JMIR Publications

ABSTRACT

Background:

Gamification, the application of game design elements in nongame contexts, has emerged as a promising strategy to promote engagement in mobile health (mHealth) interventions. Individuals with intellectual disabilities may benefit from gamified learning, yet evidence remains limited regarding whether gamification is essential or merely optional for learning effectiveness in this population, particularly among adults.

Objective:

This study examined whether gamification functions as a critical threshold for learning effectiveness among adults with intellectual disabilities using a gamified mHealth platform.

Methods:

We developed a gamified mHealth platform with QRcode based access that integrated Universal Design for Learning (UDL) principles with accessibility requirements of the Convention on the Rights of Persons with Disabilities (CRPD) through 3 cumulative layers: (1) Representation: AI-generated Easy Read content; (2) Action and Expression: mHealth interactive delivery; and (3) Engagement: gamification features including real-time leaderboards and point systems. Thirty-six adults with mild-to-moderate intellectual disabilities participated across 3 conditions: paper-based Easy Read only (Condition A, layer 1; n=15), mHealth platform without gamification (Condition B, layers 1-2; n=21; 101 session pairs), and gamified mHealth platform (Condition C, layers 1-3; n=18; 32 session pairs). Conditions B and C involved the same participants across an 8-session independent living skills curriculum, enabling within-subject comparison. Each session included a pretest and posttest. Because participants contributed multiple sessions, linear mixed models with a random intercept for participant were used to estimate within-condition change and to compare improvement between Conditions B and C, with a sensitivity analysis adjusting for pretest scores.

Results:

Paper-based delivery showed limited improvement, with only 1 of 8 sessions reaching significance. Without gamification, scores did not change significantly (mean change 12.9 points; P=.41; d=0.13), whereas gamified sessions showed significant improvement (mean change 59.4 points; P=.002; d=0.59). Improvement was greater in gamified than in non-gamified sessions (B=44.05, 95% CI 3.16-84.93; P=.037; d=0.41); however, this difference was not significant after adjustment for pretest scores (P=.56), which were more often at the maximum in non-gamified sessions (56.4% vs 28.1%).

Conclusions:

Among adults with intellectual disabilities, significant learning gains were observed only when gamification was added to accessible content and mHealth delivery. These findings provide preliminary support for the threshold hypothesis, but the between-condition difference was sensitive to pretest differences and ceiling effects. Randomized controlled designs with assessments that minimize ceiling effects are needed to determine whether gamification is a necessary layer for this population.