Enhancing Child Digital Dietary Self-Monitoring Via Positive Reinforcement: Proof-of-Concept Trial

Background

Dietary self-monitoring (DSM) is an essential behavior change strategy used in pediatric nutrition intervention, but adherence is poor. One strategy for improving DSM is positive reinforcement (PR).

Purpose

To examine the usability, acceptability, and preliminary efficacy of a digital DSM log implementing two PR strategies, caregiver praise and gamification, to improve child DSM.

Methods

The study consisted of two phases: formative testing and a subsequent proof-of-concept trial. Children 8-12 years and their adult caregivers were eligible to participate. For formative testing, families (n = 5) attended a single in-person session to provide feedback on function and design. For the proof-of-concept trial, a 2x2 factorial design was used to test the effects of assignment to caregiver praise and/or gamification on DSM frequency (number of days with tracking) and timing (proportion of items logged on day of intake and number of logging sessions). Effects on intrinsic motivation were also examined. For the proof-of-concept trial, families (n = 19) were randomly assigned to BASIC, PRAISE, GAME, or PRAISE+GAME condition. Children tracked their intake of fruits, vegetables, sweet and salty snack foods, and sugar-sweetened beverages for 4 weeks.

Results

Formative results indicated the log was generally acceptable, and minor changes were made based on qualitative analysis. For the proof-of-concept trial, participants tracked on 23.6 ± 4.6 of 28 days, recorded 69.3% ± 45.1% of items on the day of intake, and completed 23.1 ± 8.2 logging sessions. Analysis revealed that gamification was significantly better implemented than caregiver praise. Caregivers assigned to praise responded to praise check-ins on 12.2 ± 5.8 of 28 days, whereas children assigned to gamification received ≥1 point on 20.8 ± 12.3 of 28 days. No significant effects of PR assignment on DSM frequency, DSM timing, or intrinsic motivation were found. However, gamification exhibited medium to large effect sizes on DSM frequency and intrinsic motivation.

Discussion

Gamification, which relies on automation to provide immediate, consistent, and convenient PR may provide unique advantages for reinforcing child behaviors compared to praise, which relies on caregiver implementation. Future research should examine reinforcement of DSM in intervention settings to determine effects on treatment outcomes.