Digital nudges and gamification: how the China state promotes citizens to manage chronic diseases in neighborhoods

BACKGROUND: Chronic diseases pose a growing threat to public health and have raised widespread social concern in China. In response, the Chinese government has rolled out chronic disease management campaigns at the community level to curb disease incidence. However, low public participation constrains their effectiveness. Although campaign-style mobilization has been widely studied, less is known about how digital nudges, particularly gamification, enhance citizen engagement in Chinese communities. METHODS: To address this gap, we conducted in-depth interviews with sixty Chinese stakeholders to examine how the Chinese state nudged individuals toward proactive chronic disease management using gamified mechanics. RESULTS: We identify four core gamification elements, including dramatization, level-up progression, rewards, and socialization, that function as digital nudges. These gamified interventions can significantly reduce participants' cognitive burden, amplify their perceived benefits of self-care, enhanced individual agency, and foster supportive social networks. However, the sustainability of these gamified interventions is undermined by misaligned reward structures, standardized level-up progression systems, and unresolved intra-community conflicts. CONCLUSIONS: To overcome these obstacles, we propose implementing culturally attuned reward mechanisms, dynamically tailored challenge pathways, and robust online community governance to foster enduring public engagement. By revealing China's neighborhood-level digital nudge approaches, this research not only enriches global understanding of gamified chronic disease management but also provides transferable design principles for public health interventions worldwide.