IMPORTANCE: Gamification, the application of game design elements such as points and levels in nongame contexts, is often used in digital health interventions, but evidence on its effectiveness is limited. OBJECTIVE: To test the effectiveness of a gamification intervention designed using insights from behavioral economics to enhance social incentives within families to increase physical activity. DESIGN, SETTING, AND PARTICIPANTS: The Behavioral Economics Framingham Incentive Trial (BE FIT) was a randomized clinical trial with a 12-week intervention period and a 12-week follow-up period. The investigation was a community-based study between December 7, 2015, and August 14, 2016. Participants in the modified intent-to-treat analysis were adults enrolled in the Framingham Heart Study, a long-standing cohort of families. INTERVENTIONS: All participants tracked daily step counts using a wearable device or a smartphone, established a baseline, selected a step goal increase, and received daily individual feedback on goal performance by text message or email for 24 weeks. Families in the gamification arm could earn points and progress through levels based on physical activity goal achievement during the 12-week intervention. The game design was meant to enhance collaboration, accountability, and peer support. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of participant-days that step goals were achieved during the intervention period. Secondary outcomes included the proportion of participant-days that step goals were achieved during the follow-up period and the change in the mean daily steps during the intervention and follow-up periods. RESULTS: Among 200 adults comprising 94 families, the mean age was 55.4 years, and 56.0% (n = 112) were female. During the intervention period, participants in the gamification arm achieved step goals on a significantly greater proportion of participant-days (0.53 versus 0.32; adjusted difference 0.27; 95% CI 0.20 to 0.33; p < 0.001) and had a significantly greater increase in the mean daily steps compared with baseline (1,661 versus 636; adjusted difference 953; 95% CI 505 to 1,401; p < 0.001) than the control arm. During the follow-up period, physical activity in the gamification arm declined but remained significantly greater than that in the control arm for the proportion of participant-days achieving step goals (0.44 versus 0.33; adjusted difference 0.12; 95% CI 0.05 to 0.19; p < 0.001) and the mean daily steps compared with baseline (1,385 versus 798; adjusted difference 494; 95% CI 170 to 818; p < 0.01). CONCLUSIONS AND RELEVANCE: Gamification designed to leverage insights from behavioral economics to enhance social incentives significantly increased physical activity among families in the community. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02531763.

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