Nonpatient Stakeholder Perspectives on the Use of Gamification and Financial Incentives in Mobile Health for Medication Adherence: Modified Nominal Group Technique Study
Journal of Medical Internet Research ·
Background: Medication nonadherence remains a major global health challenge, contributing to preventable disease, hospitalizations, and health care costs. Mobile health (mHealth) apps incorporating gamification and financial incentives have shown potential to improve adherence; however, most research has focused on patient perspectives, with limited understanding of how nonpatient stakeholders perceive their feasibility, risks, and implementation. Understanding nonpatient stakeholder perspectives in relation to patient viewpoints is essential for informing future policy development and establishing practical, industry-supported safeguards that protect consumers while enabling innovation. Objective: This study aimed to explore nonpatient stakeholder perspectives on the use of gamification and financial incentives in mHealth apps for medication adherence and to inform consensus-based design and policy considerations. Methods: A study was conducted using a modified virtual nominal group technique (vNGT). Nonpatient stakeholders across health care, industry, and policy sectors in Australia were recruited through purposive and convenience sampling between February and August 2025. Data collection involved a survey capturing demographics and initial perspectives, followed by online focus groups for consensus discussions. Qualitative responses were analyzed using thematic analysis supported by AI-assisted coding. Consensus statements derived from themes were rated during the focus groups. Additional probing prompts were used in the focus groups to encourage further discussion where consensus was not immediately achieved. Results from the focus groups were analyzed using descriptive statistics to summarize consensus ratings and discussions. Results: A total of 20 participants were included in the study. Nine participants reported having a health care professional background employment exclusively, while 11 reported having employment background across multiple sectors or exclusively outside health care. Six key themes were identified: tailored gamification for adherence, financial incentives as a contested motivator, designing for diversity and inclusion, usability barriers to engagement, trust through data governance, and validated and sustainable innovation. These informed 24 consensus statements, of which 54% (13/24) achieved unanimous agreement. Stakeholders strongly endorsed personalization, simplicity, and transparent data practices, while expressing nuanced concerns regarding the ethical use, sustainability, and potential unintended consequences of financial incentives. Conclusions: Nonpatient stakeholders largely reinforce patient priorities while extending them with critical perspectives on implementation, governance, and sustainability. Gamification and financial incentives are viewed as potentially effective but require careful, ethically grounded design to balance engagement with long-term motivation and trust. These findings support the development of stakeholder-informed guidelines for responsible mHealth innovation and highlight the importance of integrating patient and system-level perspectives in digital health design. Future research should prioritize co-designed longitudinal studies using apps with gamification and a range of incentive offers with clear redemption processes to evaluate the long-term impact on medication adherence across diverse patient populations.