***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Cognitive behavior therapy ( CBT ) is the first-line of treatment for overweight and obesity patients whose problems originate in maladaptive eating habits ( e.g. , emotional eating ) . However , in-person CBT is currently difficult to access by large segments of the population . The proposed SIGMA intervention ( i.e. , the Self-help , Integrated , and Gamified Mobile-phone Application ) is a mHealth intervention based on CBT principles . It specifically targets overweight young adults with underlying maladaptive behaviors and cognitions regarding food . The SIGMA app was design ed as a serious game and intended to work as a st and alone app for weight maintenance or alongside a calorie-restrictive diet for weight loss . It uses a complex and novel scoring system that allows points earned within the game to be supplemented by points earned during outdoor activities with the help of an embedded pedometer . Methods / design The efficacy of the SIGMA mHealth intervention will be investigated within a r and omized , placebo-controlled trial . The intervention will be set to last 2 months with a 3-month follow-up . Selected participants will be young overweight adults with non- clinical maladaptive eating habits embodied by food cravings , binge eating , and emotional eating . The primary outcomes will be represented by changes in ( 1 ) self-reported maladaptive thoughts related to eating and body weight , ( 2 ) self-reported maladaptive eating behaviors in the range of urgent food cravings , emotional eating or binge eating , ( 3 ) as well as biased attentional processing of food items as indexed by reaction times . Secondary outcomes will be represented by changes in weight , Body Mass Index , general mood , and physical activity as indexed by the number of steps per day . Discussion Through an evidence -based cognitive behavioral approach and a user-friendly game interface , the SIGMA intervention offers a significant contribution to the development of a cost-effective and preventive self-help tool for young overweight adults with maladaptive eating habits . Trial registration IS RCT N , ID : 70907354 . Registered on 6 February 2017 . The IS RCT N registration is in line with the World Health Organization Trial Registration Data Set . The present paper represents the original version of the protocol . Any changes to the protocol will be communicated to IS RCT Background Prevention and management of work-related stress and related mental problems is a great challenge . Mobile applications are a promising way to integrate prevention strategies into the everyday lives of citizens . Objective The objectives of this study was to study the usage , acceptance , and usefulness of a mobile mental wellness training application among working-age individuals , and to derive preliminary design implication s for mobile apps for stress management . Methods Oiva , a mobile app based on acceptance and commitment therapy ( ACT ) , was design ed to support active learning of skills related to mental wellness through brief ACT-based exercises in the daily life . A one-month field study with 15 working-age participants was organized to study the usage , acceptance , and usefulness of Oiva . The usage of Oiva was studied based on the usage log files of the application . Changes in wellness were measured by three vali date d question naires on stress , satisfaction with life ( SWLS ) , and psychological flexibility ( AAQ-II ) at the beginning and at end of the study and by user experience question naires after one week ’s and one month ’s use . In-depth user experience interviews were conducted after one month ’s use to study the acceptance and user experiences of Oiva . Results Oiva was used actively throughout the study . The average number of usage sessions was 16.8 ( SD 2.4 ) and the total usage time per participant was 3 hours 12 minutes ( SD 99 minutes ) . Significant pre-post improvements were obtained in stress ratings ( mean 3.1 SD 0.2 vs mean 2.5 SD 0.1 , P=.003 ) and satisfaction with life scores ( mean 23.1 SD 1.3 vs mean 25.9 SD 0.8 , P=.02 ) , but not in psychological flexibility .  Oiva was perceived easy to use , acceptable , and useful by the participants . A r and omized controlled trial is ongoing to evaluate the effectiveness of Oiva on working-age individuals with stress problems . Conclusions A feasibility study of Oiva mobile mental wellness training app showed good acceptability , usefulness , and engagement among the working-age participants , and provided increased underst and ing on the essential features of mobile apps for stress management . Five design implication s were derived based on the qualitative findings : ( 1 ) provide exercises for everyday life , ( 2 ) find proper place and time for challenging content , ( 3 ) focus on self-improvement and learning instead of external rewards , ( 4 ) guide gently but do not restrict choice , and ( 5 ) provide an easy and flexible tool for self-reflection Our recent work ( Boyle , Earle , LaBrie , & Smith , 2017 ) showed that the efficacy of personalized normative feedback-based ( PNF ) college alcohol interventions can be improved through the addition of gamified elements including points , chance , competition , and personal avatars . However , participants in that study were compensated with subject pool credit . In the current study , we piloted an up grade d , smartphone-based version of the game , which was design ed to be truly self-sustaining ( i.e. , engaging enough that students play voluntarily without the presence of external motivators ) . First-year students were invited to play the game weekly for six rounds , with participants su bmi tting and voting on their own questions each week and receiving a novel type of feedback in addition to st and ard descriptive PNF : opposite peers ' judgments of participants ' self-reported drinking behavior , or reflective norms . With no play-based incentives , 222 first-year college students voluntarily played the game , CampusG AND R. ANCOVA models revealed that , relative to participants r and omized to receive feedback on control topics during the three intervention rounds , those who received both descriptive and reflective feedback on peer alcohol use had significantly reduced normative perceptions and reduced alcohol use two months post intervention . This was especially true among heavy drinkers . The results suggest that our gamified " G AND R " approach shows promise as a self-sustaining intervention and , further , that high-risk drinkers may benefit disproportionately from this methodology . Thus , self-sustaining interventions represent an encouraging avenue for future research and development and may hold the potential to impact  risky college drinking  on a large scale Gamified interventions exploit the motivational characteristics of a game in order to provide prevention information and promote behavior change . Despite the modest effect sizes observed in increasingly popular web-based personalized normative feedback ( PNF ) alcohol interventions for college students , previous research has yet to consider how gamification might be used to enhance efficacy . This study examines whether a novel , gamified PNF intervention format , which includes a point-based reward system , the element of chance , and personal icons to visually represent users , is more effective in reducing short-term alcohol use than the st and ard web-based style of PNF currently used on college campuses . Two-hundred and thirty-seven college students were r and omly assigned to receive either a st and ard brief , web-based PNF alcohol intervention or the same alcohol intervention components delivered within a Facebook-connected social game called CampusG AND R ( Gamified Alcohol Norm Discovery and Readjustment ) . In both study conditions participants answered identical questions about their perceptions of peer drinking norms and own drinking and then received the same PNF slides . Two weeks following PNF delivery , participants again reported their perceptions of peers ' alcohol use and own drinking . Students in the CampusG AND R condition reported significantly reduced peer drinking norms and alcohol use at the two-week follow-up relative to students who received identical PNF delivered by st and ard online survey . Further , a mediation model demonstrated that this effect was driven by larger reductions in perceived drinking norms among participants assigned to receive CampusG AND R , relative to control . As web-based PNF is becoming an increasingly universal prevention strategy , findings from this study suggest gamification may represent one method by which intervention efficacy could be substantially improved . The potential method ological and economic benefits associated with gamified PNF interventions are emphasized and directions for future research are discussed Background Virtual reality ( VR ) is not commonly used in clinical rehabilitation , and commercial VR gaming systems may have mixed effects in patients with stroke . Therefore , we developed RehabMaster ™ , a task-specific interactive game-based VR system for post-stroke rehabilitation of the upper extremities , and assessed its usability and clinical efficacy . Methods A participatory design and usability tests were carried out for development of RehabMaster with representative user groups . Two clinical trials were then performed . The first was an observational study in which seven patients with chronic stroke received 30 minutes of  RehabMaster intervention per day for two weeks . The second was a r and omised controlled trial of 16 patients with acute or subacute stroke who received 10 sessions of conventional occupational therapy only ( OT-only group ) or conventional occupational therapy plus 20 minutes of RehabMaster intervention ( RehabMaster + OT group ) . The Fugl-Meyer Assessment score ( FMA ) , modified Barthel Index ( MBI ) , adverse effects , and drop-out rate were recorded . Results The requirements of a VR system for stroke rehabilitation were established and incorporated into RehabMaster . The reported advantages from the usability tests were improved attention , the immersive flow experience , and individualised intervention . The first clinical trial showed that the RehabMaster intervention improved the FMA ( P = .03 ) and MBI ( P = .04 ) across evaluation times . The second trial revealed that the addition of RehabMaster intervention tended to enhance the improvement in the FMA ( P = .07 ) but did not affect the improvement in the MBI . One patient with chronic stroke left the trial , and no adverse effects were reported . Conclusions The RehabMaster is a feasible and safe VR system for enhancing upper extremity function in patients with stroke In recent years , there has been increasing discussion of the limitations of traditional r and omized controlled trial ( RCT ) method ologies for the evaluation of eHealth and mHealth interventions , and in particular , the requirement that these interventions be locked down during evaluation . Locking down these interventions locks in defects and eliminates the opportunities for quality improvement and adaptation to the changing technological environment , often leading to validation of tools that are out date d by the time that trial results are published . Furthermore , because behavioral intervention technologies change frequently during real-world deployment , even if a tested intervention were deployed in the real world , its shelf life would be limited . We argue that RCTs will have greater scientific and public health value if they focus on the evaluation of intervention principles ( rather than a specific locked-down version of the intervention ) , allowing for ongoing quality improvement modifications to the behavioral intervention technology based on the core intervention principles , while continuously improving the functionality and maintaining technological currency . This paper is an initial proposal of a framework and methodology for the conduct of trials of intervention principles ( TIPs ) aim ed at minimizing the risks of in-trial changes to intervention technologies and maximizing the potential for knowledge acquisition . The focus on evaluation of intervention principles using clinical and usage outcomes has the potential to provide more generalizable and durable information than trials focused on a single intervention technology Background Virtual reality exposure therapy ( VRET ) has been shown to be as effective as traditional forms of in vivo exposure therapy for the treatment of specific phobias . However , as with in vivo exposure , VRET still involves relatively high costs and limited accessibility which makes it prohibitive for a large part of the population . Innovative methods using smartphone applications ( apps ) may improve accessibility and scalability of VRET . The aim of this study is to evaluate 0Phobia , a gamified self-guided VRET for acrophobia that is delivered through a smartphone app in combination with rudimentary cardboard virtual reality ( VR ) goggles . Methods / design Participants ( N = 180 , aged 18–65 years ) with acrophobia symptoms will be recruited from the Dutch general population and r and omized to either 0Phobia ( n = 90 ) or a waitlist control condition ( n = 90 ) .  0Phobia will be delivered over a period of 3 weeks and includes psychoeducation , VR exposure , cognitive techniques , monitoring of symptoms , and relapse prevention . The primary outcome measure will be the Acrophobia Question naire . Secondary outcome measures will include user-friendliness , symptoms of anxiety , depression , and mastery . Assessment s will take place online at baseline , directly after the intervention ( post test ) and at follow-up ( 3 months ) . Discussion This study capitalizes on novel technology and recent scientific advances to develop an affordable and scalable treatment modality . Trial registration Netherl and s Trial Register : NTR6442 . Registered on 29 June 2017 
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The most commonly observed gamification elements were levels or progress feedback , points or scoring , rewards or prizes , narrative or theme , personalization , and customization ; the least commonly observed elements were artificial assistance , unlockable content , social cooperation , exploratory or open-world approach , artificial challenge , and r and omness .
The most commonly observed mental health and well-being domains were anxiety disorders and well-being , whereas the least commonly observed domains were conduct disorder and bipolar disorders .
Conclusions Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature .
We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks .