Framing Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults: A Randomized, Controlled Trial

Effect of Gamification With and Without Financial Incentives to Increase Physical Activity Among Veterans Classified as Having Obesity or Overweight: A Randomized Clinical Trial

IMPORTANCE

Gamification is increasingly being used for health promotion but has not been well tested with financial incentives or among veterans.

OBJECTIVE

To test the effectiveness of gamification with social support, with and without a loss-framed financial incentive, to increase physical activity among veterans classified as having overweight and obesity.

DESIGN, SETTING, AND PARTICIPANTS

This 3-group randomized clinical trial had a 12-week intervention period and an 8-week follow-up period. Participants included veterans with a body mass index greater than or equal to 25 who were receiving care from a single site in Philadelphia, Pennsylvania. Participants underwent a remotely monitored intervention from March 19, 2019, to August 9, 2020. Data analyses were conducted between October 1, 2020, and November 14, 2020.

INTERVENTIONS

All participants received a wearable device to track step counts and selected a step goal. The control group received feedback from their devices only. Participants in the 2 gamification groups were entered into a 12-week game with points and levels designed using behavioral economic principles and selected a support partner to receive weekly updates. Participants in the loss-framed financial incentive group had $120 allocated to a virtual account and lost $10 if weekly goals were not achieved.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in mean daily steps from baseline during the intervention. Secondary outcomes include proportion of days goals were achieved and changes during follow-up.

RESULTS

A total of 180 participants were randomized, 60 to the gamification with social support group, 60 to the gamification with social support and loss-framed financial incentives group, and 60 to the control group. The participants had a mean (SD) age of 56.5 (12.9) years and a mean (SD) body mass index of 33.0 (5.6); 71 participants (39.4%) were women, 90 (50.0%) were White, and 67 (37.2%) were Black. During the intervention period, compared with control group participants, participants in the gamification with financial incentives group had a significant increase in mean daily steps from baseline (adjusted difference, 1224 steps; 95% CI, 451 to 1996 steps; P = .005), but participants in the gamification without financial incentives group did not (adjusted difference, 433 steps; 95% CI, -337 to 1203 steps; P = .81). The increase for the gamification with financial incentives group was not sustained during the follow-up period, and the step count was not significantly different than that of the control group (adjusted difference, 564 steps; 95% CI, -261 to 1389 steps; P = .37). Compared with the control group, participants in the intervention groups had a significantly higher adjusted proportion of days meeting their step goal during the main intervention and follow-up period (gamification with social support group, adjusted difference from control, 0.21 participant-day; 95% CI, 0.18-0.24 participant-day; P < .001; gamification with social support and loss-framed financial incentive group, adjusted difference from control, 0.34 participant-day; 95% CI, 0.31-0.37 participant-day; P < .001).

CONCLUSIONS AND RELEVANCE

Among veterans classified as having overweight and obesity, gamification with social support combined with loss-framed financial incentives was associated with a modest increase in physical activity during the intervention period, but the increase was not sustained during follow-up. Gamification without incentives did not significantly change physical activity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03563027.

Financial incentives and wearable activity monitors to increase ambulation after cystectomy: A randomized controlled trial

OBJECTIVES

Financial incentive programs are effective in increasing physical activity for overweight, ambulatory adults. We sought to determine the potential effect size and direction of financial incentives on ambulation after radical cystectomy.

MATERIALS AND METHODS

We performed a pilot randomized controlled trial of daily financial incentives to meet postoperative step goals among adults with Eastern Cooperative Oncology Group performance status ≤2 who underwent radical cystectomy for bladder cancer at a single center. Step counts were measured over a 3- to 14-day preoperative period and 30-day postoperative period using a wearable activity monitor. Postoperative daily step goals of 10%, 25%, 40%, and 55% of mean preoperative daily step counts were set for postoperative weeks 1 through 4, respectively. The primary outcome was the number of postoperative days on which the step goals were met. Secondary outcomes included the number of daily postoperative steps taken and the length of stay. Participants randomized to the intervention arm received $1.50 for every day the goal was met with a 20% chance of a $100 reward if the step goal was met on >75% of the first 30 postoperative days. Questionnaires assessing self-reported physical activity, disability, and social support were administered preoperatively at 30 days postoperatively.

RESULTS

Thirty-three patients were analyzed, 11 in the control and 22 in the intervention arms. There were no statistically significant differences between incentive and control arms for the primary outcome (4.5/30 days vs. 9/30 days, P = 0.53). Results after adjusting for differences in baseline characteristics were similar (RR 1.00, 95% CI 0.24-4.19, P = 1.00). There were also no differences in average daily postoperative steps (median 979 vs. 1191, 95% CI -810 to 1,400, P = 0.59), length of stay (7.5 vs. 7, 95% CI -2.7 to 5.1, P = 0.56), or self-reported measures of disability, activity, and social support.

CONCLUSIONS

While this trial was a pilot study and not powered to detect a difference between groups, there was no suggestion of any clinically important impact of this financial incentive on postoperative ambulation. While a fully-powered trial is feasible, given the small range of plausible benefit, such a trial would be unlikely to influence clinical practice.

Creating Exercise Habits Using Incentives: The Tradeoff between Flexibility and Routinization

Habits involve regular, cue-triggered routines. In a field experiment, we tested whether incentivizing exercise routines-paying participants each time they visit the gym within a planned, daily two-hour window-leads to more persistent exercise than offering flexible incentives-paying participants each day they visit the gym, regardless of timing. Routine incentives generated fewer gym visits than flexible incentives, both during our intervention and after incentives were removed. Even among sub-groups that were experimentally induced to exercise at similar rates during our intervention, recipients of routine incentives exhibited a larger decrease in exercise after the intervention than recipients of flexible incentives.

Leveraging insights from behavioral economics to improve mobility for adults with stroke: Design and rationale of the BE Mobile clinical trial

Physical inactivity post-stroke can negatively impact long-term health outcomes and contribute to cardiovascular deconditioning, muscle loss, and increased risk for recurrent stroke. The limited number of interventions designed to improve daily physical activity post-stroke have lacked precision in step goals, are resource intensive, and difficult to scale. The purpose of the Leveraging Insights from Behavioral Economics to Improve Mobility for Adults with Stroke (BE Mobile) trial is to examine the preliminary effectiveness of a novel gamification with social incentives intervention for improving physical activity post-stroke. This trial includes adults who have experienced an ischemic or hemorrhagic stroke ≥3 months prior to the time of recruitment who are randomized to a control or gamification arm. All participants receive a Fitbit Inspire 2 wearable device to quantify daily steps and complete a 2-week baseline run-in period followed by an 8-week intervention period. All participants select a daily step goal and the gamification arm is enrolled in a game with loss-framed points and levels to help participants achieve their daily step goal. Participants in the gamification arm also select a support partner who receives weekly updates on their progress in the game. The primary outcome is change in daily steps from baseline during the intervention period. The secondary outcome is difference in the proportion of days participants achieved their daily step goal. Results from this trial will inform future, larger studies that leverage insights from behavioral economics to help improve daily physical activity post-stroke. Trial registration: NCT #04607811.

Effect of Group Contingency Type on Walking: Comparisons of Effectiveness and Cost Efficiency

Group contingency (GC) is an effective and cost-efficient strategy that can be successfully applied to technology-based interventions. This study examined the relative effectiveness and cost efficiency of three types of technology-based group contingencies on walking among adults. Seventy two students were divided into teams of three. Each team was randomly assigned to one of three GC conditions (independent, interdependent, or dependent) and underwent 66 days of technology-based group contingency intervention. Sixty five participants completed the intervention and 61 completed the follow-up assessment 2 months later. Step counts and self-reported walking activity increased after the intervention under all three conditions. The proportion of participants that met the target step counts was significantly higher under the dependent group contingency condition. However, 2 months later, intervention effects were not maintained under any condition. For cost efficiency, the increase in step count per point was significantly higher under the interdependent group contingency condition. Group cohesion and social validity (point satisfaction and point utility) were significantly higher under the dependent group contingency condition. Finally, the clinical implications and limitations of this study are discussed.

One Size Does Not Fit All: Financial Incentives Needed to Change Physical Exercise Levels for Different Groups

This study estimated the distribution of willingness to accept (WTA) for a physical activity behavior change intervention entailing the completion of 10,000 steps/day to shed light on which levels of incentives trigger a change in behavior for different proportions of the population and for more at-risk subgroups. An online contingent valuation (CV) survey was administered to 1,130 respondents in the Basque Autonomous Community, Spain. The survey queried respondents about their physical activity levels and intention to engage in physical activity before presenting the WTA questions. Nonparametric WTA values were estimated for the whole sample and for subsamples of active, inactive, and overweight and obese people. One-quarter of respondents would engage with the hypothetical program even without payment, but if a monetary incentive was offered them, they would take it. The median WTA for committing to complete 10,000 steps/day is €0.23 for the full sample, €0.21 for active, €0.25 for inactive, and €0.23 for overweight and obese people. The WTA at 75th percentile is €4 for the full sample, €1.70 for active, €10.80 for inactive, and €5 for overweight and obese respondents. WTA is positively affected by a person's lack of disposable time to increase their physical activity and, for inactive people, by their poor intention to become physically active.

Effect of Behaviorally Designed Gamification With Social Incentives on Lifestyle Modification Among Adults With Uncontrolled Diabetes: A Randomized Clinical Trial

IMPORTANCE

Gamification is increasingly being used to promote healthy behaviors. However, it has not been well tested among patients with chronic conditions and over longer durations.

OBJECTIVE

To test the effectiveness of behaviorally designed gamification interventions to enhance support, collaboration, or competition to promote physical activity and weight loss among adults with uncontrolled type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

A 4-arm randomized clinical trial with a 1-year intervention was conducted from January 23, 2017, to January 27, 2020, with remotely monitored intervention. Analyses were conducted between February 10 and October 6, 2020. Participants included 361 adults with type 2 diabetes with hemoglobin A1c levels greater than or equal to 8% and body mass index greater than or equal to 25.

INTERVENTIONS

All participants received a wearable device, smart weight scale, and laboratory testing. Participants in the control group received feedback from their devices but no other interventions. Participants in the gamification arms conducted goal setting and were entered into a 1-year game designed using insights from behavioral economics with points and levels for achieving step goals and weight loss targets. The game varied by trial arm to promote either support, collaboration, or competition.

MAIN OUTCOMES AND MEASURES

Co-primary outcomes included daily step count, weight, and hemoglobin A1c level. Secondary outcome was low-density lipoprotein cholesterol level. Intention-to-treat analysis was used.

RESULTS

Participants had a mean (SD) age of 52.5 (10.1) years; hemoglobin A1c level, 9.6% (1.6%); daily steps, 4632 (2523); weight, 107.4 kg (20.8 kg); and body mass index, 37.1 (6.6). Of the 361 participants, 202 (56.0%) were women, 143 (39.6%) were White, and 185 (51.2%) were Black; with 87 (24.1%) randomized to control; 92 (25.4%) randomized to gamification with support and intervention; 95 (26.3%) randomized to gamification with collaboration; and 87 (24.1%) randomized to gamification with competition. Compared with the control group over 1 year, there was a significant increase in mean daily steps from baseline among participants receiving gamification with support (adjusted difference relative to control group, 503 steps; 95% CI, 103 to 903 steps; P = .01) and competition (606 steps; 95% CI, 201 to 1011 steps; P = .003) but not collaboration (280 steps; 95% CI, -115 to 674 steps; P = .16). All trial arms had significant reductions in weight and hemoglobin A1c levels from baseline, but there were no significant differences between any of the intervention arms and the control arm. There was only 1 adverse event reported that may have been related to the trial (arthritic knee pain).

CONCLUSIONS AND RELEVANCE

Among adults with uncontrolled type 2 diabetes, a behaviorally designed gamification intervention in this randomized clinical trial significantly increased physical activity over a 1-year period when designed to enhance either support or competition but not collaboration. No differences between intervention and control groups were found for other outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02961192.

Do low-cost economic incentives motivate healthy behavior?

We conducted a field experiment to test the effectiveness of a conditional, low-cost, and recurring financial incentive in motivating recreation center visits. Results indicate that the financial incentive did not motivate students' recreation center visits. However, it was successful in increasing the frequency of recreation center visits for female students who had an established exercise habit. For a payout of $0.50, we estimate an increase of 0.4 visits per week for female students with established exercise habits. This provides modest evidence that the financial incentive structure was able to increase the behavioral response at the intensive margin. Our results show that the design of our financial incentive was not effective on the extensive margin. There was also no effect of the financial incentive on the recreation center visits for male students.

Randomized controlled trials of self-monitoring interventions with or without incentives for diet and exercise among individuals with overweight or obesity: Psychological and behavioural effects

OBJECTIVES

To test the effects of three behavioural interventions (daily monetary incentives + self-monitoring, delayed lump sum monetary incentives + self-monitoring, and self-monitoring only) on psychological constructs and fruit and vegetable consumption or physical activity behaviour change among a sample of adults with overweight or obesity.

DESIGN

A pair of 3-arm longitudinal randomized controlled trials compared daily monetary incentives + self-monitoring, delayed lump sum monetary incentives + self-monitoring, and self-monitoring only interventions for either fruit and vegetable consumption or physical activity.

METHODS

Individuals reporting elevated weight status and insufficient engagement in one of the target behaviours were randomly assigned to one of three 3-week interventions. All three interventions involved daily self-monitoring of the behaviour, and two provided monetary incentives contingent upon reported behaviour. Participants completed measures of psychological constructs and reported behaviour at baseline, the end of the intervention, and two and four weeks post-intervention.

RESULTS

Participants across all three intervention conditions demonstrated increased engagement in the target behaviour from pre- to post-intervention and reported behaviour remained above baseline levels at both follow-up time points. Increases in reported behaviour during the intervention were associated with increases in self-efficacy, and this enhanced self-efficacy prospectively predicted sustained reported behaviour at follow-up. However, contrary to hypotheses, the incentive interventions including self-monitoring were not more efficacious than self-monitoring alone, and increased reported behaviour was not associated with enhancements in attitudes.

CONCLUSIONS

Self-monitoring interventions can aid behaviour change efforts, and behavioural practice during these interventions can increase self-efficacy. However, among adults with overweight or obesity who are seeking behaviour change interventions, incentive-based self-monitoring approaches may not be superior to self-monitoring alone in driving behaviour change and maintenance.

Effect of Behaviorally Designed Gamification With a Social Support Partner to Increase Mobility After Hospital Discharge: A Randomized Clinical Trial

IMPORTANCE

Hospitalization is associated with decreased mobility and functional decline. Behaviorally designed gamification can increase mobility in community settings but has not been tested among patients at risk for functional decline during a high-risk transition period after hospitalization.

OBJECTIVE

To test a behaviorally designed gamification intervention with a social support partner to increase patient mobility after hospital discharge.

DESIGN, SETTING, AND PARTICIPANTS

This study is a randomized clinical trial of a 12-week intervention without follow-up. Enrollment occurred from January 2018 to June 2019 at a referral hospital with a remote at-home monitoring intervention among patients living predominantly in 3 states (Pennsylvania, New Jersey, and Delaware). Participants included adult patients discharged from general medicine and oncology units to home. Data analysis was performed from October 2019 to March 2020.

INTERVENTIONS

All participants received a wearable device to track daily steps. The control group received feedback from the device but no other interventions. The intervention group entered into a 12-week game informed by behavioral economics to assign points and levels for achieving step goals and reinforced by a support partner who received updates on participant progress.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in mean daily steps from baseline through the 12-week intervention. Secondary measures were change in functional status and urgent care utilization (ie, emergency department visits and hospital readmissions) within this period.

RESULTS

A total of 232 participants were enrolled in the study (118 randomized to control and 114 randomized to the intervention). Participants had a mean (SD) age of 40 (14) years, 141 (61%) were female, 101 (43%) were White, and 103 (44%) had an annual household income less than $50 000. Daily step counts increased from 3795 to 4652 steps (difference, 857 steps; 95% CI, 488 to 1224 steps) among intervention participants and increased from 3951 to 4499 steps (difference, 548 steps; 95% CI, 193 to 903 steps) among control participants. The change in mean daily step count from baseline was not significantly different for participants in the intervention group vs the control group (adjusted difference, 270 steps; 95% CI, -214 to 754 steps; P = .27). Among the subgroup of 76 participants with higher levels of social engagement, post hoc exploratory analyses showed a significant increase in mobility for intervention vs control (adjusted difference, 1125 steps; 95% CI, 409 to 1841 steps; P = .002). Fewer participants in this subgroup experienced functional decline (1 of 36 participants [4%] in the intervention group vs 5 of 40 participants [12%] in the control group) and hospital readmission at 30 days (3 of 36 participants [8%] in the intervention group vs 6 of 40 participants [15%] in the control group), but the differences were not statistically significant. There were no significant differences in these secondary outcomes for the overall sample.

CONCLUSIONS AND RELEVANCE

Gamification with social incentives did not affect mobility or functional decline in all participants, but post hoc analysis suggests positive findings for both outcomes for patients with higher social engagement.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03321279.

Stepping into survivorship pilot study: Harnessing mobile health and principles of behavioral economics to increase physical activity in ovarian cancer survivors

OBJECTIVE

Physical activity improves physical function, quality of life, and mental health, yet fewer than 80% of ovarian cancer survivors meet activity guidelines. This pilot intervention study aimed to increase physical activity in ovarian cancer survivors by leveraging principles of behavioral economics, gamification, and social support.

METHODS

This 24-week study (12-week intervention; 12-week follow-up) enrolled women with ovarian cancer after completion of first-line treatment with a self-selected "teammate." Participants used Fitbits to measure daily steps, select an increased step goal, and enroll in a collaborative game, including points and levels for achieving step goals. Primary outcomes were feasibility (defined a priori as ≥60% approach-to-consent ratio and ≥ 70% adherence to Fitbit), acceptability (≤20% of participants reporting burden or regret for participation) and preliminary efficacy (≥70% reporting increased motivation); exploratory outcomes included change in steps.

RESULTS

We recruited 24 participants (mean age = 63 years, range = 37-79 years) with a 94% approach-to-consent ratio. All participants completed the intervention with 94% tracker adherence. At 24-week follow-up, 1/24 (≤5%) of participants reported burden; 0/24 (0%) reported regret for study participation; and 22/24 (>90%) agreed/strongly agreed that "the study motivated me to increase activity levels." Participants' mean daily steps were 6210.7 (±3328.1) at baseline and increased to 7643 (± 3610.9) steps (p < 0.001) during the 12-week intervention.

CONCLUSIONS

This pilot study demonstrated feasibility, acceptability, and preliminary efficacy, justifying a larger randomized clinical trial to test efficacy at increasing activity levels. Future studies should examine strategies for maintaining increased activity levels in survivors over time.

Improving centre-based group exercise participation of older adults using the behaviour change wheel

An emphasis on active ageing could help to delay the onset of frailty. In Singapore, Senior Activity Centres provide free and guided group exercise sessions for older adults. However, one such centre had very low participation rates among community-dwelling older adults despite running standardised programmes. Based on a needs analysis from a prior project, this paper reports on strategies implemented to improve the daily centre-based group exercise participation rate among community-dwelling older adults. Using the behaviour change wheel model, participant motivation domains were identified as primary gaps, while the psychological capability and physical opportunity were categorised as secondary gaps. A logic model was used to design a project to respond to these identified gaps and guide the evaluation approach. Three strategies were implemented over a 4-week period and reviewed at 6 months: (1) promotion of the exercise classes, (2) delayed rewards for participation and (3) health ambassadors. Evaluation findings highlighted that more resources were needed for the training of community-dwelling older adult healthcare ambassadors in the use of motivational interviewing. The interventions were found to be efficacious in increasing daily group exercise participation rate at the centre, from an average of three to nine participants per day over the 4 weeks. Furthermore, more than 60% of these participants achieved the WHO's weekly minimum exercise recommendation for older adults (150 min moderate-intensity physical activity). To increase the engagement of older adults in physical activity or exercise participation, we recommend the use of behaviour change wheel model and the use of community-based health ambassadors. In conclusion, the project found improved daily centre-based group physical exercise participation rates when all the domains in the behaviour change wheel model were addressed.

Project Step: A Randomized Controlled Trial Investigating the Effects of Frequent Feedback and Contingent Incentives on Physical Activity

BACKGROUND

Financial incentives and feedback on behavior offer promise for promoting physical activity. However, evidence for the effect of each of these techniques is inadequate. The present study evaluated the effects of daily versus weekly feedback and incentives contingent on reaching a daily walking goal versus noncontingent incentives in a 2 × 2 trial.

METHODS

Participants (N = 57) had a body mass index >25 kg/m2 and were insufficiently active. Participants received a daily walking goal that adapted weekly.

RESULTS

Participants receiving daily feedback increased daily steps (P = .03) more than those receiving weekly feedback. Participants receiving contingent incentives did not significantly increase steps (P = .12) more than those receiving noncontingent incentives. A trend-level effect (P = .09) suggested that there may be an interaction such that the combination of daily feedback and contingent incentives is most effective.

CONCLUSIONS

Results indicate that feedback is an important component of remotely delivered PA interventions and that evaluating each component of low-intensity interventions may help to improve efficacy. Moreover, results indicate that possible synergistic effects of feedback and rewards should be investigated further to help optimize interventions.

Unraveling Mobile Health Exercise Interventions for Adults: Scoping Review on the Implementations and Designs of Persuasive Strategies

Background

It is unclear why some physical activity (PA) mobile health (mHealth) interventions successfully promote PA whereas others do not. One possible explanation is the variety in PA mHealth interventions—not only do interventions differ in the selection of persuasive strategies but also the design and implementation of persuasive strategies can vary. However, limited studies have examined the different designs and technical implementations of strategies or explored if they indeed influenced the effectiveness of the intervention.

Objective

This scoping review sets out to explore the different technical implementations and design characteristics of common and likely most effective persuasive strategies, namely, goal setting, monitoring, reminders, rewards, sharing, and social comparison. Furthermore, this review aims to explore whether previous mHealth studies examined the influence of the different design characteristics and technical operationalizations of common persuasive strategies on the effectiveness of the intervention to persuade the user to engage in PA.

Methods

An unsystematic snowball and gray literature search was performed to identify the literature that evaluated the persuasive strategies in experimental trials (eg, randomized controlled trial, pre-post test). Studies were included if they targeted adults, if they were (partly) delivered by a mobile system, if they reported PA outcomes, if they used an experimental trial, and when they specifically compared the effect of different designs or implementations of persuasive strategies. The study methods, implementations, and designs of persuasive strategies, and the study results were systematically extracted from the literature by the reviewers.

Results

A total of 29 experimental trials were identified. We found a heterogeneity in how the strategies are being implemented and designed. Moreover, the findings indicated that the implementation and design of the strategy has an influence on the effectiveness of the PA intervention. For instance, the effectiveness of rewarding was shown to vary between types of rewards; rewarding goal achievement seems to be more effective than rewarding each step taken. Furthermore, studies comparing different ways of goal setting suggested that assigning a goal to users might appear to be more effective than letting the user set their own goal, similar to using adaptively tailored goals as opposed to static generic goals. This study further demonstrates that only a few studies have examined the influence of different technical implementations on PA behavior.

Conclusions

The different implementations and designs of persuasive strategies in mHealth interventions should be critically considered when developing such interventions and before drawing conclusions on the effectiveness of the strategy as a whole. Future efforts are needed to examine which implementations and designs are most effective to improve the translation of theory-based persuasive strategies into practical delivery forms.

A Web-Based Multidomain Lifestyle Intervention for Older Adults: The eMIND Randomized Controlled Trial

Importance/Objective: To describe the feasibility and acceptability of a 6-month web-based multidomain lifestyle training intervention for community-dwelling older people and to test the effects of the intervention on both function- and lifestyle-related outcomes.

DESIGN

6-month, parallel-group, randomized controlled trial (RCT).

SETTING

Toulouse area, South-West, France.

PARTICIPANTS

Community-dwelling men and women, ≥ 65 years-old, presenting subjective memory complaint, without dementia.

INTERVENTION

The web-based multidomain intervention group (MIG) received a tablet to access the multidomain platform and a wrist-worn accelerometer measuring step counts; the control group (CG) received only the wrist-worn accelerometer. The multidomain platform was composed of nutritional advices, personalized exercise training, and cognitive training. Main outcomes and measures: Feasibility, defined as the proportion of people connecting to ≥75% of the prescribed sessions, and acceptability, investigated through content analysis from recorded semi-structured interviews. Secondary outcomes included clinical (eg, cognitive function, mobility, health-related quality of life (HRQOL)) and lifestyle (eg, step count, food intake) measurements.

RESULTS

Among the 120 subjects (74.2 ±5.6 years-old; 57.5% women), 109 completed the study (n=54, MIG; n=55, CG). 58 MIG subjects connected to the multidomain platform at least once; among them, adherers of ≥75% of sessions varied across multidomain components: 37 people (63.8% of 58 participants) for cognitive training, 35 (60.3%) for nutrition, and three (5.2%) for exercise; these three persons adhered to all multidomain components. Participants considered study procedures and multidomain content in a positive way; the most cited weaknesses were related to exercise: too easy, repetitive, and slow progression. Compared to controls, the intervention had a positive effect on HRQOL; no significant effects were observed across the other clinical and lifestyle outcomes.

CONCLUSIONS AND RELEVANCE

Providing multidomain lifestyle training through a web-platform is feasible and well-accepted, but the training should be challenging enough and adequately progress according to participants' capabilities to increase adherence. Recommendations for a larger on-line multidomain lifestyle training RCT are provided.

Ethically incentivising healthy behaviours: views of parents and adolescents with type 1 diabetes

BACKGROUND

To assess ethical concerns associated with participation in a financial incentive (FI) programme to help adolescents with type 1 diabetes improve diabetes self-management.

METHODS

Focus groups with 46 adolescents with type 1 diabetes ages 12-17 and 38 of their parents were conducted in the Seattle, Washington metropolitan area. Semistructured focus group guides addressed ethical concerns related to the use of FI to promote change in diabetes self-management. Qualitative data were analysed and emergent themes identified.

RESULTS

We identified three themes related to the ethical issues adolescents and parents anticipated with FI programme participation. First, FI programmes may variably change pressure and conflict in different families in ways that are not necessarily problematic. Second, the pressure to share FIs in some families and how FI payments are structured may lead to unfairness in some cases. Third, some adolescents may be likely to fabricate information in any circumstances, not simply because of FIs, but this could compromise the integrity of FI programmes relying on measures that cannot be externally verified.

CONCLUSIONS

Many adolescents with type 1 diabetes and their parents see positive potential of FIs to help adolescents improve their self-management. However, ethical concerns about unfairness, potentially harmful increases in conflict/pressure and dishonesty should be addressed in the design and evaluation of FI programmes.

Contingency management for individuals with chronic health conditions: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Contingency management (CM) interventions involve providing reinforcement for engaging in a desired behavior, and have been shown to increase treatment adherence and promote abstinence in the treatment of substance use disorders. This review was conducted to systematically review the literature on the effectiveness of CM when applied to a range of medical conditions outside of substance use disorders.

METHOD

The authors identified a total of 24 randomized studies examining the effects of CM on four outcomes: weight change, physical activity, medication/device adherence, and viral load that were included in the qualitative summary, and 20 studies included in the meta-analysis.

RESULTS

CM was associated with positive outcomes for physical activity and medication/device adherence compared to control conditions. Findings with weight loss and viral load were more mixed, and evidence for publication bias was found for both outcomes. The effects of CM tend to dissipate when the contingency is removed. Heterogeneity was observed across most outcomes.

LIMITATIONS AND CONCLUSIONS

This review provides preliminary support for the use of CM in increasing physical activity and improving adherence to medication for chronic health conditions while reinforcement is ongoing. Future studies should examine potential moderators and identify strategies to maintain these changes over time.

Effect of a financial incentive (shopping point) on increasing the number of daily walking steps among community-dwelling adults in Japan: a randomised controlled trial

OBJECTIVE

The aim of this study was to investigate the effect of a financial incentive on the number of daily walking steps among community-dwelling adults in Japan.

STUDY DESIGN

Two-arm, parallel-group randomised controlled trial.

SETTING/PARTICIPANTS

We recruited physically inactive community-dwelling adults from Sendai city, Japan. Eligible participants were randomly allocated to an intervention or a wait list control group. Pedometers were used to assess the mean number of daily steps in three periods: baseline (weeks 1-3), intervention (weeks 4-6) and follow-up (weeks 7-9).

INTERVENTION

The intervention group was offered a financial incentive (shopping points) to meet the target number of increased daily steps in the intervention period.

MAIN OUTCOME MEASURES

The primary outcome was an increase in the mean number of daily steps in the intervention and follow-up periods compared with baseline.

RESULTS

Seventy-two participants (69.4% women; mean age, 61.2±16.2 years; mean number of daily steps at baseline, 6364±2804) were randomised to the intervention (n=36) and control groups (n=36). During the intervention period, the increase in mean daily steps was significantly higher in the intervention group (1650, 95% CI=1182 to 2119) than in the control group (514, 95% CI=136 to 891; p<0.001). However, the difference between groups was not significant at follow-up after the incentives were removed (p=0.311). In addition, compared with controls, a significantly higher proportion of participants in the intervention group showed an increase in mean daily steps of ≥1000 (69.4% vs 30.6%, respectively; OR=5.17, 95% CI=1.89 to 14.08). There were no adverse effects from the intervention.

CONCLUSIONS

The present results suggest that financial incentives are effective in promoting short-term increases in physical activity.

TRIAL REGISTRATION NUMBER

UMIN000033276.

Behavior Change

Despite rapid growth in the empirical research on behavior change, modern science has yet to produce a coherent set of recommendations for individuals and organizations eager to align everyday actions with enduringly valued goals. We propose the process model of behavior change as a parsimonious framework for organizing strategies according to where they have their primary impact in the generation of behavioral impulses. To begin, individuals exist in objective situations, only certain features of which attract attention, which in turn lead to subjective appraisals, then finally give rise to response tendencies. Unhealthy habits develop when conflicting impulses are consistently resolved in favor of momentary temptations instead of valued goals. To change behavior for the better, we can strategically modify objective situations, where we pay attention, how we construct appraisals, and how we enact responses. Crucially, behavior change strategies can be initiated either by the individual (i.e., self-control) or by others (e.g., a benevolent employer).

The effects of financial incentives on diabetes prevention program attendance and weight loss among low-income patients: the We Can Prevent Diabetes cluster-randomized controlled trial

BACKGROUND

Penetration and participation of real life implementation of lifestyle change programs to prevent type 2 diabetes has been challenging. This is particularly so among low income individuals in the United States. The purpose of this study is to examine the effectiveness of financial incentives on attendance and weight loss among Medicaid beneficiaries participating in the 12-month Diabetes Prevention Program (DPP).

METHODS

This is a cluster-randomized controlled trial with two financial incentive study arms and an attention control study arm. Medicaid beneficiaries with prediabetes from 13 primary care clinics were randomly assigned to individually earned incentives (IND; 33 groups; n = 309), a hybrid of individual- and group-earned incentives (GRP; 30 groups; n = 259), and an attention control (AC; 30 groups; n = 279). Up to $520 in incentives could be earned for attaining attendance and weight loss goals over 12 months. Outcomes are percent weight loss from baseline, achieving 5% weight loss from baseline, and attending 75% of core and 75% of maintenance DPP sessions. Linear mixed models were used to examine weight change and attendance rates over the 16 weeks and 12 months.

RESULTS

The percent weight change at 16 weeks for the IND, GRP, and AC participants were similar, at - 2.6, - 3.1%, and - 3.4%, respectively. However, participants achieving 5% weight loss in the IND, GRP, and AC groups was 21.5, 24.0% (GRP vs AC, P < 0.05), and 15.2%. Attendance at 75% of the DPP core sessions was significantly higher among IND (60.8%, P < 0.001) and GRP (64.0%, P < 0.001) participants than among AC (38.6%) participants. Despite substantial attrition over time, attendance at 75% of the DPP maintenance sessions was also significantly higher among IND (23.0%, P < 0.001) and GRP (26.1%, P < 0.001) participants than among AC (11.0%) participants.

CONCLUSIONS

Financial incentives can improve the proportion of Medicaid beneficiaries attending the 12-month DPP and achieving at least 5% weight loss.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02422420 ; retrospectively registered April 21, 2015.

Factors Associated With Participation in the Chronic Disease Self-Management Program: Findings From the SUCCEED Trial

BACKGROUND AND PURPOSE

Self-management programs may improve quality of life and self-efficacy for stroke survivors, but participation is low. In a randomized controlled trial of a complex, multidisciplinary, team-based secondary stroke prevention intervention, we offered participants Chronic Disease Self-Management Program (CDSMP) workshops in addition to clinic visits and home visits. To enhance participation, workshops were facilitated by community health workers who were culturally and linguistically concordant with most participants and scheduled CDSMP sessions at convenient venues and times. Over time, we implemented additional strategies such as free transportation and financial incentives. In this study, we aimed to determine factors associated with CDSMP participation and attendance.

METHODS

From 2014 to 2018, 18 CDSMP workshop series were offered to 241 English and Spanish-speaking individuals (age ≥40 years) with recent stroke or transient ischemic attack. Zero-inflated Poisson regression was used to identify factors associated with participation and attendance (ie, number of sessions attended) in CDSMP. Missing values were imputed using multiple imputation methods.

RESULTS

Nearly one-third (29%) of intervention subjects participated in CDSMP. Moderate disability and more clinic/home visits were associated with participation. Participants with higher numbers of clinic and home visits (incidence rate ratio [IRR], 1.06 [95% CI, 1.01-1.12]), severe (IRR, 2.34 [95% CI, 1.65-3.31]), and moderately severe disability (IRR, 1.55 [95% CI, 1.07-2.23]), and who enrolled later in the study (IRR, 1.12 [95% CI, 1.08-1.16]) attended more sessions. Individuals with higher chaos scores attended fewer sessions (IRR, 0.97 [95% CI, 0.95-0.99]).

CONCLUSIONS

Less than one-third of subjects enrolled in the SUCCEED (Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities) intervention participated in CDSMP; however, participation improved as transportation and financial barriers were addressed. Strategies to address social determinants of health contributing to chaos and engage individuals in healthcare may facilitate attendance. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01763203.

Text messaging and financial incentives to encourage weight loss in men with obesity: the Game of Stones feasibility RCT

Background

In 2016, 26% of UK men were estimated to be obese. Systematic reviews suggest that few men engage in formal weight loss interventions that support weight reduction and improve health.

Objective

To co-produce, with patient and public involvement, an acceptable and feasible randomised controlled trial design to test a men-only weight management intervention.

Design

This was a two-phase feasibility study. Phase 1 was the development of intervention components, study procedures and materials including a discrete choice experiment with survey questions. Phase 2 was an individually randomised three-arm feasibility trial over 12 months. Qualitative interviews were conducted at 3 and 12 months.

Setting

The setting was two sites in Scotland that had disadvantaged urban and rural areas and differed in employment levels and ethnic groups.

Participants

In phase 1, 1045 men with obesity were recruited by Ipsos MORI (London, UK; www.ipsos.com/ipsos-mori/en-uk) to represent the UK population. In phase 2, 105 men with obesity were recruited in the community or through general practice obesity registers. Qualitative interviews were conducted with 50 men at 3 months and with 33 men at 12 months.

Interventions

The trial arms were narrative short message service (SMS) for 12 months (SMS only), financial endowment incentive informed by loss aversion and linked to achievement of weight loss targets plus narrative SMS for 12 months (SMS + I), and waiting list control group for 12 months followed by 3 months of an alternative SMS style developed based on feedback from men who had received the narrative SMS (control).

Main outcome measures

The main outcome measures were acceptability and feasibility of recruitment, retention, engagement, intervention components and trial procedures. Outcomes were assessed by examining procedural, quantitative and qualitative data at 3, 6 and 12 months.

Results

The most acceptable incentive strategy, based on the discrete choice experiment results, was to verify weight loss of 5% at 3 months, verify weight loss of 10% at 6 months and maintain weight loss of 10% at 12 months. Overall, 105 men with obesity from across the socioeconomic spectrum were successfully recruited to target, 59% of whom lived in more disadvantaged areas. Retention at 12 months was acceptable (74%) and was higher among individuals from disadvantaged areas. Narrative SMS were acceptable to many men, with a minority reporting negative reactions. Incentives were acceptable but were not the primary motivation for behaviour change. Twelve men in the incentive arm (33%) secured at least some money and three (8%) secured the full amount. Both intervention arms lost some weight, with greater weight loss in the arm that received SMS and incentives. The alternative SMS based on men’s feedback received no strong negative reactions.

Limitations

Fewer participants from the SMS + I arm (64%) completed the study at 12 months than did those in the SMS-only (79%) and control (83%) arms. The reasons for this difference were complex.

Conclusions

The men-only weight management intervention consisting of narrative SMS and financial incentives was acceptable and feasible, meeting the progression criteria for a full trial. Tailoring of SMS may improve acceptability and retention.

Future work

Minor refinements to the intervention components based on the study findings will be made prior to testing in a multisite definitive randomised controlled trial.

Trial registration

ClinicalTrials.gov NCT03040518.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.

Monetary incentives for improving smartphone-measured oral hygiene behaviors in young children: A randomized pilot trial

AIMS

To assess feasibility, acceptability, and early efficacy of monetary incentive-based interventions on fostering oral hygiene in young children measured with a Bluetooth-enabled toothbrush and smartphone application.

DESIGN

A stratified, parallel-group, three-arm individually randomized controlled pilot trial.

SETTING

Two Los Angeles area Early Head Start (EHS) sites.

PARTICIPANTS

36 parent-child dyads enrolled in an EHS home visit program for 0-3 year olds.

INTERVENTIONS

Eligible dyads, within strata and permuted blocks, were randomized in equal allocation to one of three groups: waitlist (delayed monetary incentive) control group, fixed monetary incentive package, or lottery monetary incentive package. The intervention lasted 8 weeks.

OUTCOMES

Primary outcomes were a) toothbrushing performance: mean number of Bluetooth-recorded half-day episodes per week when the child's teeth were brushed, and b) dental visit by the 2-month follow-up among children with no prior dental visit. The a priori milestone of 20% more frequent toothbrushing identified the intervention for a subsequent trial. Feasibility and acceptability measures were also assessed, including frequency of parents syncing the Bluetooth-enabled toothbrush to the smartphone application and plaque measurement from digital photographs.

FINDINGS

Digital monitoring of toothbrushing was feasible. Mean number of weekly toothbrushing episodes over 8 weeks was 3.9 in the control group, 4.1 in the fixed incentive group, and 6.0 in the lottery incentive group. The lottery group had 53% more frequent toothbrushing than the control group and 47% more frequent toothbrushing than the fixed group. Exploratory analyses showed effects concentrated among children ≤24 months. Follow-up dental visit attendance was similar across groups. iPhone 7 more reliably captured evaluable images than Photomed Cannon G16.

CONCLUSIONS

Trial protocol and outcome measures were deemed feasible and acceptable. Results informed the study protocol for a fully powered trial of lottery incentives versus a delayed control using the smart toothbrush and remote digital incentive program administration.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03862443.

Leveraging goals to incentivize healthful behaviors across adulthood

Despite abundant evidence for the benefits of physical activity on aging trajectories, older Americans remain largely inactive. The present study was designed to examine age differences in responsiveness to financial incentives to increase walking. Grounded in socioemotional selectivity theory, we examined the effectiveness of financial incentives that varied in prosociality. Three types of incentives were presented to community-residing adults 18-92 years of age (N = 450). Participants were randomly assigned to 1 of 5 conditions: personal, loved one, charity, choice, or a no-incentive control group. Average daily step counts were measured using pedometers during a baseline week, during the incentivized period, and after the incentivized period ended. Overall, financial incentives significantly increased walking compared to a control group. Whereas personal incentives were effective regardless of age, incentives to earn for charities were starkly more effective in older adults than younger adults. Moreover, 1 week after the incentivized period ended, older participants were more likely to maintain increased step counts, whereas younger people reverted to baseline step counts. Findings suggest that financial incentives can increase walking in a wide age range and that charitable incentives may be especially effective in health interventions targeting older adults. The importance of aligning incentives with age-related goals is discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Framing Social Comparison Feedback With Financial Incentives for Physical Activity Promotion: A Randomized Trial

Background: Social comparison feedback is often used in physical activity interventions but the optimal design of feedback is unknown. Methods: This 4-arm, randomized trial consisted of a 13-week intervention period and 13-week follow-up period. During the intervention, 4-person teams were entered into a weekly lottery valued at about $1.40/day and contingent on the team averaging ≥7000 steps per day. Social comparison feedback on performance was delivered weekly for 26 weeks, and varied by reference point (50th vs 75th percentile) and forgiveness in use of activity data (all 7 d or best 5 of 7 d). The primary outcome was the mean proportion of participant-days achieving the 7000-step goal. Results: During the intervention period, the unadjusted mean proportion of participant-days that the goal was achieved was 0.47 (95% confidence interval [CI]: 0.38 to 0.56) in the 50th percentile arm, 0.38 (95% CI: 0.30 to 0.37) in the 75th percentile arm, 0.40 (95% CI: 0.31 to 0.49) in the 50th percentile with forgiveness arm, and 0.47 (95% CI: 0.38 to 0.55) in the 75th percentile with forgiveness arm. In adjusted models during the intervention and follow-up periods, there were no significant differences between arms. Conclusions: Changing social comparison feedback did not impact physical activity.

A pilot randomized trial of incentive strategies to promote HIV retesting in rural Uganda

Background

Retesting for HIV is critical to identifying newly-infected persons and reinforcing prevention efforts among at-risk adults. Incentives can increase one-time HIV testing, but their role in promoting retesting is unknown. We sought to test feasibility and acceptability of incentive strategies, including commitment contracts, to promote HIV retesting among at-risk adults in rural Uganda.

Methods

At-risk HIV-negative adults were enrolled in a pilot trial assessing feasibility and acceptability of incentive strategies to promote HIV retesting three months after enrollment. Participants were randomized (1:1:3) to: 1) no incentive; 2) standard cash incentive (~US$4); and 3) commitment contract: participants could voluntarily make a low- or high-value deposit that would be returned with added interest (totaling ~US$4 including the deposit) upon retesting or lost if participants failed to retest. Contracts sought to promote retesting by leveraging loss aversion and addressing present bias via pre-commitment. Outcomes included acceptability of trial enrollment, contract feasibility (proportion of participants making deposits), and HIV retesting uptake.

Results

Of 130 HIV-negative eligible adults, 123 (95%) enrolled and were randomized: 74 (60%) to commitment contracts, 25 (20%) to standard incentives, and 24 (20%) to no incentive. Of contract participants, 69 (93%) made deposits. Overall, 93 (76%) participants retested for HIV: uptake was highest in the standard incentive group (22/25 [88%]) and lowest in high-value contract (26/36 [72%]) and no incentive (17/24 [71%]) groups.

Conclusion

In a randomized trial of strategies to promote HIV retesting among at-risk adults in Uganda, incentive strategies, including commitment contracts, were feasible and had high acceptability. Our findings suggest use of incentives for HIV retesting merits further comparison in a larger trial.

Trial registration

ClinicalTrials.gov identifier: NCT:02890459

Using Nudges to Enhance Clinicians' Implementation of Shared Decision Making With Patient Decision Aids

Background. Although effective interventions for shared decision making (SDM) exist, there is a lack of uptake of these tools into clinical practice. “Nudges,” which draw on behavioral economics and target automatic thinking processes, are used by policy makers to influence population-level behavior change. Nudges have not been applied in the context of SDM interventions but have potential to influence clinician motivation, a primary barrier to long-term adoption of SDM tools. Objective. Describe, evaluate, and propose recommendations for the use of a behavioral economics framework (MINDSPACE) on clinician motivation and behavior during implementation of a validated decision aid (DA) for left ventricular assist device at nine hospitals. Methods. Qualitative thematic analysis of process notes from stakeholder meetings during the first 6 months of implementation to identify examples of how the MINDSPACE framework was operationalized. Quantitative implementation progress was evaluated using the RE-AIM framework. Results. MINDSPACE components were translated into concrete approaches that leveraged influential stakeholders, fostered ownership over the DA and positive emotional associations, spread desirable norms across sites, and situated the DA within established default processes. DA reach to eligible patients increased from 9.8% in the first month of implementation to 70.0% in the sixth month. Larger gains in reach were observed following meetings using MINDSPACE approaches. Limitations. The MINDSPACE framework does not capture all possible influences on behavior and responses to nudges may differ across populations. Conclusions. Behavioral economics can be applied to implementation science to foster uptake of SDM tools by increasing clinician motivation. Our recommendations can help other researchers effectively apply these approaches in real-world settings when there are often limited incentives and opportunities to change organizational- or structural-level factors.

Couple-based collaborative management model of type 2 diabetes mellitus for community-dwelling older adults in China: protocol for a hybrid type 1 randomized controlled trial

BACKGROUND

China's limited health care resources cannot meet the needs of chronic disease treatment and management of its rapid growing ageing population. The improvement and maintenance of patient's self-management is essential to disease management. Given disease management mainly occurs in the context of family, this study proposes to validate a Couple-based Collaborative Management Model of chronic diseases that integrates health professionals and family supporters; such as to empower the couples with disease management knowledge and skills, and to improve the couples' health and quality of life.

METHODS

The proposed study will validate a couple-based collaborative management model of Type 2 Diabetes Mellitus (T2DM) in a community-based multicenter, two-arm, randomized controlled trial of block design in Guangzhou, China. Specifically, 194 T2DM patients aged ≥55 and their partners recruited from community health care centers will be randomized at the patient level for each center at a 1:1 ratio into the couple-based intervention arm and the individual-based control arm. For the intervention arm, both the patients and their spouses will receive four-weekly structured group education & training sessions and 2 months of weekly tailored behavior change boosters; while these interventions will be only provided to the patients in the control group. Behavior change incentives will be targeted at the couples or only at the patient respectively. Treatment effects on patients' hemoglobin, spouses' quality of life, alongside couples' behavior outcomes will be compared between arms. Study implementation will be evaluated considering its Reach, Effectiveness, Adoption, Implementation and Maintenance following the RE-AIM framework.

DISCUSSION

This study will generate a model of effective collaboration between community health professionals and patients' family, which will shield light on chronic disease management strategy for the increasing ageing population.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1900027137, Registered 1st Nov. 2019.

Using Behavioral Economics and Technology to Improve Outcomes in Cardio-Oncology

Patients with cancer are often at elevated risk for cardiovascular disease due to overlapping risk factors and cardiotoxic anticancer treatments. Their cancer diagnoses may be the predominant focus of clinical care, with less of an emphasis on concurrent cardiovascular risk management. Widely adopted technology platforms, including electronic health records and mobile devices, can be leveraged to improve the cardiovascular outcomes of these patients. These technologies alone may be insufficient to change behavior and may have greater impact if combined with behavior change strategies. Behavioral economics is a scientific field that uses insights from economics and psychology to help explain why individuals are often predictably irrational. Combining insights from behavioral economics with these scalable technology platforms can positively impact medical decision-making and sustained healthy behaviors. This review focuses on the principles of behavioral economics and how "nudges" and scalable technology can be used to positively impact clinician and patient behaviors.

Game of Stones: feasibility randomised controlled trial of how to engage men with obesity in text message and incentive interventions for weight loss

OBJECTIVES

To examine the acceptability and feasibility of narrative text messages with or without financial incentives to support weight loss for men.

DESIGN

Individually randomised three-arm feasibility trial with 12 months' follow-up.

SETTING

Two sites in Scotland with high levels of disadvantage according to Scottish Index for Multiple Deprivation (SIMD).

PARTICIPANTS

Men with obesity (n=105) recruited through community outreach and general practitioner registers.

INTERVENTIONS

Participants randomised to: (A) narrative text messages plus financial incentive for 12 months (short message service (SMS)+I), (B) narrative text messages for 12 months (SMS only), or (C) waiting list control.

OUTCOMES

Acceptability and feasibility of recruitment, retention, intervention components and trial procedures assessed by analysing quantitative and qualitative data at 3, 6 and 12 months.

RESULTS

105 men were recruited, 60% from more disadvantaged areas (SIMD quintiles 1 or 2). Retention at 12 months was 74%. Fewer SMS+I participants (64%) completed 12-month assessments compared with SMS only (79%) and control (83%). Narrative texts were acceptable to many men, but some reported negative reactions. No evidence emerged that level of disadvantage was related to acceptability of narrative texts. Eleven SMS+I participants (31%) successfully met or partially met weight loss targets. The cost of the incentive per participant was £81.94 (95% CI £34.59 to £129.30). Incentives were acceptable, but improving health was reported as the key motivator for weight loss. All groups lost weight (SMS+I: -2.51 kg (SD=4.94); SMS only: -1.29 kg (SD=5.03); control: -0.86 kg (SD=5.64) at 12 months).

CONCLUSIONS

This three-arm weight management feasibility trial recruited and retained men from across the socioeconomic spectrum, with the majority from areas of disadvantage, was broadly acceptable to most participants and feasible to deliver.

TRIAL REGISTRATION NUMBER

NCT03040518.

Effectiveness of the Fun for Wellness Web-Based Behavioral Intervention to Promote Physical Activity in Adults With Obesity (or Overweight): Randomized Controlled Trial

BACKGROUND

Insufficient physical activity in the adult population is a global pandemic. Fun for Wellness (FFW) is a self-efficacy theory- and Web-based behavioral intervention developed to promote growth in well-being and physical activity by providing capability-enhancing opportunities to participants.

OBJECTIVE

This study aimed to evaluate the effectiveness of FFW to increase physical activity in adults with obesity in the United States in a relatively uncontrolled setting.

METHODS

This was a large-scale, prospective, double-blind, parallel-group randomized controlled trial. Participants were recruited through an online panel recruitment company. Adults with overweight were also eligible to participate, consistent with many physical activity-promoting interventions for adults with obesity. Also consistent with much of the relevant literature the intended population as simply adults with obesity. Eligible participants were randomly assigned to the intervention (ie, FFW) or the usual care (ie, UC) group via software code that was written to accomplish equal allocations to the FFW and UC groups. Data collection was Web based, fully automated, and occurred at three time points: baseline, 30 days after baseline (T2), and 60 days after baseline (T3). Participants (N=461) who were assigned to the FFW group (nFFW=219) were provided with 30 days of 24-hour access to the Web-based intervention. A path model was fit to the data consistent with the FFW conceptual model for the promotion of physical activity.

RESULTS

There was evidence for a positive direct effect of FFW on transport-related physical activity self-efficacy (beta=.22, P=.02; d=0.23), domestic-related physical activity self-efficacy (beta=.22, P=.03; d=0.22), and self-efficacy to regulate physical activity (beta=.16, P=.01; d=0.25) at T2. Furthermore, there was evidence for a positive indirect effect of FFW on physical activity at T3 through self-efficacy to regulate physical activity at T2 (beta=.42, 95% CI 0.06 to 1.14). Finally, there was evidence for a null direct effect of FFW on physical activity (beta=1.04, P=.47; d=0.07) at T3.

CONCLUSIONS

This study provides some initial evidence for both the effectiveness (eg, a positive indirect effect of FFW on physical activity through self-efficacy to regulate physical activity) and the ineffectiveness (eg, a null direct effect of FFW on physical activity) of the FFW Web-based behavioral intervention to increase physical activity in adults with obesity in the United States. More broadly, FFW is a scalable Web-based behavioral intervention that may effectively, although indirectly, promote physical activity in adults with obesity and therefore may be useful in responding to the global pandemic of insufficient physical activity in this at-risk population. Self-efficacy to regulate physical activity appears to be a mechanism by which FFW may indirectly promote physical activity in adults with obesity.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT03194854; https://clinicaltrials.gov/ct2/show/NCT03194854.

Effectiveness of the Fun for Wellness Web-Based Behavioral Intervention to Promote Physical Activity in Adults With Obesity (or Overweight): Randomized Controlled Trial

Background

Insufficient physical activity in the adult population is a global pandemic. Fun for Wellness (FFW) is a self-efficacy theory- and Web-based behavioral intervention developed to promote growth in well-being and physical activity by providing capability-enhancing opportunities to participants.

Objective

This study aimed to evaluate the effectiveness of FFW to increase physical activity in adults with obesity in the United States in a relatively uncontrolled setting.

Methods

This was a large-scale, prospective, double-blind, parallel-group randomized controlled trial. Participants were recruited through an online panel recruitment company. Adults with overweight were also eligible to participate, consistent with many physical activity–promoting interventions for adults with obesity. Also consistent with much of the relevant literature the intended population as simply adults with obesity. Eligible participants were randomly assigned to the intervention (ie, FFW) or the usual care (ie, UC) group via software code that was written to accomplish equal allocations to the FFW and UC groups. Data collection was Web based, fully automated, and occurred at three time points: baseline, 30 days after baseline (T2), and 60 days after baseline (T3). Participants (N=461) who were assigned to the FFW group (nFFW=219) were provided with 30 days of 24-hour access to the Web-based intervention. A path model was fit to the data consistent with the FFW conceptual model for the promotion of physical activity.

Results

There was evidence for a positive direct effect of FFW on transport-related physical activity self-efficacy (beta=.22, P=.02; d=0.23), domestic-related physical activity self-efficacy (beta=.22, P=.03; d=0.22), and self-efficacy to regulate physical activity (beta=.16, P=.01; d=0.25) at T2. Furthermore, there was evidence for a positive indirect effect of FFW on physical activity at T3 through self-efficacy to regulate physical activity at T2 (beta=.42, 95% CI 0.06 to 1.14). Finally, there was evidence for a null direct effect of FFW on physical activity (beta=1.04, P=.47; d=0.07) at T3.

Conclusions

This study provides some initial evidence for both the effectiveness (eg, a positive indirect effect of FFW on physical activity through self-efficacy to regulate physical activity) and the ineffectiveness (eg, a null direct effect of FFW on physical activity) of the FFW Web-based behavioral intervention to increase physical activity in adults with obesity in the United States. More broadly, FFW is a scalable Web-based behavioral intervention that may effectively, although indirectly, promote physical activity in adults with obesity and therefore may be useful in responding to the global pandemic of insufficient physical activity in this at-risk population. Self-efficacy to regulate physical activity appears to be a mechanism by which FFW may indirectly promote physical activity in adults with obesity.

Trial Registration

ClinicalTrials.gov, identifier: NCT03194854; https://clinicaltrials.gov/ct2/show/NCT03194854.

Evaluating the Feasibility, Acceptability, and Effects of Deposit Contracts With and Without Daily Feedback to Promote Physical Activity

Background: Despite interest in financial incentive programs, evidence regarding the feasibility, acceptability, and effectiveness of deposit contracts (ie, use of participants’ own money as a financial reward) for increasing physical activity (PA) is limited. Furthermore, evidence regarding the use of feedback within incentive programs is limited. Purpose: To evaluate: (1) the feasibility and acceptability of deposit contracts for increasing objectively measured PA and (2) the effects of deposit contracts with or without ongoing feedback on PA. Methods: Participants (n = 24) were exposed to 3 conditions (1) self-monitoring, (2) incentive, and (3) incentive with feedback in an ABACABAC design, with the order of incentive conditions counterbalanced across participants. Results: Effect sizes suggest that individuals had a modest increase in PA during the incentive conditions compared with self-monitoring. Presentation order moderated results, such that individuals exposed to incentives with feedback first performed more poorly across both incentive conditions. In addition, individuals often cited the deposit contract as a reason for not enrolling, and those who did participate reported inadequate acceptability of the incentives and feedback. Conclusions: Results suggest that while deposit contracts may engender modest increases in PA, this type of incentive may not be feasible or acceptable for promoting PA.

A qualitative study to examine how differences in motivation can inform the development of targeted physical activity interventions for African American women

Self-Determination Theory proposes that some people are motivated to initiate physical activity by externally-controlled reasons (e.g., physical appearance, approval from others), whereas others feel compelled by more autonomous sources of motivation (e.g., enjoyment, personal importance). This study used qualitative methods to examine whether individual differences in autonomous motivation offers a useful framework for developing targeted intervention programs for African American women. Focus groups (k = 6) were conducted to examine how different levels of autonomous motivation for physical activity related to differences in physical activity barriers and facilitators among African American women (N = 31). Sessions were audiotaped, transcribed, and coded by independent raters (r = 0.70). QSR NVivo 11 was used to analyze data, and themes were identified separately for women with low, medium, or high autonomous motivation. Those with high autonomous motivation focused on themes of wanting novelty, excitement, and competition, whereas those with low autonomous motivation focused on themes of wanting instrumental support and financial incentives for increasing engagement in physical activity. Implications for developing physical activity intervention programs for African American women that are targeted toward differences in autonomous motivation are discussed.

Effectiveness of Behaviorally Designed Gamification Interventions With Social Incentives for Increasing Physical Activity Among Overweight and Obese Adults Across the United States: The STEP UP Randomized Clinical Trial

IMPORTANCE

Gamification, the use of game design elements in nongame contexts, is increasingly being used in workplace wellness programs and digital health applications. However, the best way to design social incentives in gamification interventions has not been well examined.

OBJECTIVE

To assess the effectiveness of support, collaboration, and competition within a behaviorally designed gamification intervention to increase physical activity among overweight and obese adults.

DESIGN, SETTING, AND PARTICIPANTS

This 36-week randomized clinical trial with a 24-week intervention and 12-week follow-up assessed 602 adults from 40 states with body mass indexes (calculated as weight in kilograms divided by height in meters squared) of 25 or higher from February 12, 2018, to March 17, 2019.

INTERVENTIONS

Participants used a wearable device to track daily steps, established a baseline, selected a step goal increase, were randomly assigned to a control (n = 151) or to 1 of 3 gamification interventions (support [n = 151], collaboration [n = 150], and competition [n = 150]), and were remotely monitored. The control group received feedback from the wearable device but no other interventions for 36 weeks. The gamification arms were entered into a 24-week game designed using insights from behavioral economics with points and levels for achieving step goals. No gamification interventions occurred during follow-up.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in mean daily steps from baseline through the 24-week intervention period.

RESULTS

A total of 602 participants (mean [SD] age, 39 [10] years; mean [SD] body mass index, 30 [5]; 427 [70.9%] male) were included in the study. Compared with controls, participants had a significantly greater increase in mean daily steps from baseline during the intervention in the competition arm (adjusted difference, 920; 95% CI, 513-1328; P < .001), support arm (adjusted difference, 689; 95% CI, 267-977; P < .001), and collaboration arm (adjusted difference, 637; 95% CI, 258-1017; P = .001). During follow-up, physical activity remained significantly greater in the competition arm than in the control arm (adjusted difference, 569; 95% CI, 142-996; P = .009) but was not significantly greater in the support (adjusted difference, 428; 95% CI, 19-837; P = .04) and collaboration (adjusted difference, 126; 95% CI, -248 to 468; P = .49) arms than in the control arm.

CONCLUSIONS AND RELEVANCE

All 3 gamification interventions significantly increased physical activity during the 24-week intervention, and competition was the most effective. Physical activity was lower in all arms during follow-up and only remained significantly greater in the competition arm than in the control arm.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03311230.

Remotely Monitored Gamification and Social Incentives to Improve Glycemic Control Among Adults With Uncontrolled Type 2 Diabetes (iDiabetes): Protocol for a Randomized Controlled Trial

Background

Type 2 diabetes is a significant cause of morbidity and mortality in the United States. Lifestyle modifications including increasing physical activity and losing weight have been demonstrated to improve glycemic control. However, most patients struggle to make these changes. Many stakeholders are interested in using gamification and social incentives to increase engagement in healthy behaviors. However, these approaches often do not appropriately leverage insights from behavioral economics that could be used to address predictable barriers to behavior change.

Objective

This study aimed to describe the protocol for the Influencing DIabetics to Adapt Behaviors related to Exercise and weighT by Enhancing Social incentives (iDiabetes) trial, which aimed to evaluate the effectiveness of gamification interventions that leverage insights from behavioral economics to enhance supportive, competitive, or collaborative social incentives to improve glycemic control, promote weight loss, and increase physical activity among overweight and obese adults with type 2 diabetes.

Methods

We are conducting a one-year four-arm randomized controlled trial of 361 overweight and obese patients with type 2 diabetes and a glycated hemoglobin (HbA_1c) level ≥8.0. Wireless weight scales and wearable devices are provided to remotely monitor weight and physical activity and transmit data to the study team. Patients are recruited by email, following which they establish a baseline measure of weight, daily step count, HbA_1c level, and low-density lipoprotein cholesterol level and then repeat these measures at 6 and 12 months. The control arm receives no other interventions. Patients randomized to one of the three intervention arms are entered into a game designed using insights from behavioral economics to enhance supportive, competitive, or collaborative social incentives. To examine predictors of strong or poor performance, participants completed validated questionnaires on a range of areas including their personality, risk preferences, and social network.

Results

Enrollment of 361 patients was completed in January 2019. Results are expected in 2020.

Conclusions

The iDiabetes trial represents a scalable model to remotely monitor the daily health behaviors of adults with type 2 diabetes. Results from this trial will help provide insights into how to improve management of patients with type 2 diabetes.

Trial Registration

ClinicalTrials.gov NCT02961192; https://clinicaltrials.gov/ct2/show/NCT02961192

International Registered Report Identifier (IRRID)

DERR1-10.2196/14180

Commitment Lotteries Promote Physical Activity Among Overweight Adults-A Cluster Randomized Trial

Background

The World Health Organization has identified physical inactivity as the fourth leading risk factor for global mortality. People often intend to engage in physical activity on a regular basis, but have trouble doing so. To realize their health goals, people can voluntarily accept deadlines with consequences that restrict undesired future behaviors (i.e., commitment devices).

Purpose

We examined if lottery-based deadlines that leverage regret aversion would help overweight individuals in attaining their goal of attending their gym twice per week. At each deadline a lottery winner was drawn from all participants. The winners were only eligible for their prize if they attained their gym-attendance goals. Importantly, nonattending lottery winners were informed about their forgone prize. The promise of this counterfactual feedback was designed to evoke anticipated regret and emphasize the deadlines.

Methods

Six corporate gyms with a total of 163 overweight participants were randomized to one of three arms. We compared (i) weekly short-term lotteries for 13 weeks; (ii) the same short-term lotteries in combination with an additional long-term lottery after 26 weeks; and (iii) a control arm without lotteries.

Results

After 13 weeks, participants in the lottery arms attained their attendance goals more often than participants in the control arm. After 26 weeks, we observe a decline in goal attainment in the short-term lottery arm and the highest goal attainment in the long-term lottery arm.

Conclusions

With novel applications, the current research adds to a growing body of research that demonstrates the effectiveness of commitment devices in closing the gap between health goals and behavior.

Clinical Trial information

This trial is registered in the Dutch Trial Register. Identifier: NTR5559

Mobile Health Advances in Physical Activity, Fitness, and Atrial Fibrillation: Moving Hearts

The growing recognition that "health" takes place outside of the hospital and clinic, plus recent advances in mobile and wearable devices, have propelled the field of mobile health (mHealth). Cardiovascular disease and prevention are major opportunities for mHealth, as mobile devices can monitor key physiological signals (e.g., physical activity, heart rate and rhythm) for promoting healthy behaviors, detecting disease, and aid in ongoing care. In this review, the authors provide an update on cardiovascular mHealth by highlighting recent progress and challenges with mobile and wearable devices for assessing and promoting physical activity and fitness, and for monitoring heart rate and rhythm for the detection and management of atrial fibrillation.

Effect of Different Financial Incentive Structures on Promoting Physical Activity Among Adults: A Randomized Clinical Trial

IMPORTANCE

Few adults engage in recommended levels of physical activity. Financial incentives can promote physical activity, but little is known about how the structure of these incentives influences their effectiveness (eg, how incentives are disbursed over time).

OBJECTIVE

To determine if it is more effective to disburse fixed total financial incentives at a constant, increasing, or decreasing rate to encourage physical activity.

DESIGN, SETTING, AND PARTICIPANTS

A 2-week randomized clinical trial was conducted from June 2 to 15, 2014, using an online platform that automatically records daily steps of pedometer-wearing users and awards points redeemable for cash. The study population comprised 3515 adult users of the online platform in the lower 70th percentile of steps taken among all users before treatment. Data analyses were performed from August 20, 2014, to February 1, 2018. Analysis was performed on an intent-to-treat basis.

INTERVENTIONS

Participants were randomized to either a control group or to 1 of 3 intervention groups during the 2 weeks of the study. Participants in the control group received a constant daily rate of $0.00001 per step. The 3 intervention groups received a 20-fold incentive increase ($0.00020 per step) distributed differently during the 2 weeks of the study: at a constant, increasing, or decreasing rate. Reminder emails explaining incentive schedules were sent the day before the intervention and halfway through the 2-week intervention.

MAIN OUTCOMES AND MEASURES

Change in mean daily steps during the 2-week intervention and 3 weeks after the intervention. The study had 80% power to detect a difference of 280 steps per day during the intervention at α = .05.

RESULTS

The study included 3515 participants (879 in the control condition, 879 in the constant incentive condition, 881 in the increasing incentive condition, and 876 in the decreasing incentive condition). During the intervention, compared with participants in the control group, participants receiving constant incentives logged 306.7 more steps per day (95% CI, 91.5-521.9 steps; P = .005), those receiving decreasing incentives logged 96.9 more steps per day (95% CI, 15.3-178.5 steps; P = .02), and those receiving increasing incentives logged no significant change in steps per day (1.5 steps per day; 95% CI, -81.6 to 84.7 steps; P = .97). One week after the intervention, compared with participants in the control group, only participants receiving constant incentives logged significantly more steps per day (329.5; 95% CI, 20.6-638.4; P = .04). Two and 3 weeks after the intervention, there were no significant differences compared with participants in the control group. Overall, for each $1 spent, participants in the constant incentives group logged 475.4 more steps than those in the increasing incentives group and 429.3 more steps than those in the decreasing incentives group.

CONCLUSIONS AND RELEVANCE

This study found that financial incentives for physical activity were more effective during a payment period when they were offered at a constant rate rather than an increasing or decreasing rate. However, this effectiveness dissipated shortly after the incentives were removed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02154256.

Medicaid and CHIP Child Health Beneficiary Incentives: Program Landscape and Stakeholder Insights

OBJECTIVES

To describe the landscape of Medicaid and the Children's Health Insurance Program beneficiary incentive programs for child health and garner key stakeholder insights on incentive program rationale, child and family engagement, and program evaluation.

METHODS

We identified beneficiary health incentive programs from 2005 to 2018 through a search of peer-reviewed and publicly available documents and through semistructured interviews with 80 key stakeholders (Medicaid and managed-care leadership, program evaluators, patient advocates, etc). This study highlights insights from 23 of these stakeholders with expertise on programs targeting child health (<18 years old) to understand program rationale, beneficiary engagement, and program evaluation.

RESULTS

We identified 82 child health-targeted beneficiary incentive programs in Medicaid and the Children's Health Insurance Program. Programs most commonly incentivized well-child checks (n = 77), preventive screenings (n = 30), and chronic disease management (n = 30). All programs included financial incentives (eg, gift cards, premium incentives); some also offered incentive material prizes (n = 12; eg, car seats). Loss-framed incentives were uncommon (n = 1; eg, lost benefits) and strongly discouraged by stakeholders. Stakeholders suggested family engagement strategies including multigenerational incentives or incentives addressing social determinants of health. Regarding evaluation, stakeholders suggested incentivizing evidence-based preventive services (eg, vaccinations) rather than well-child check attendance, and considering proximal measures of child well-being (eg, school functioning).

CONCLUSIONS

As the landscape of beneficiary incentive programs for child health evolves, policy makers have unique opportunities to leverage intergenerational and social approaches for family engagement and to more effectively increase and evaluate programs' impact.

Race Differences in Physical Activity Uptake Within a Workplace Wellness Program: A Comparison of Black and White Employees

PURPOSE

To examine differences in physical activity (PA) uptake between black and white employees during a financial incentive-based workplace intervention.

DESIGN

Prospective cohort study from July 2014 to June 2015 (NCT02850094).

SETTING

Tertiary academic medical center.

PARTICIPANTS

Forty-three black and 182 white nonclinical employees.

INTERVENTION

Participants self-selected or were assigned to teams. Participants completed a 24-week intervention receiving rewards for meeting weekly PA goals (increasing moderate-to-vigorous PA [MVPA] by 10% from previous week or meeting Guidelines threshold of 150 minutes of MVPA).

MEASURES

Outcomes included weekly MVPA in minutes, average daily step counts, number of weeks meeting personal goals and the Guidelines, and Fitbit adherence in days and weeks.

ANALYSIS

We performed an analysis of covariance for each outcome, with race as the primary independent variable of interest, adjusting for demographic and health-related covariates.

RESULTS

During the intervention, blacks walked 9128 steps per day while whites walked 7826 steps per day, a difference of approximately 1300 steps (P < .05). Blacks also demonstrated a greater uptake in both steps and MVPA from baseline than did whites, resulting in similar MVPA throughout the intervention.

CONCLUSIONS

Findings suggest that workplace PA interventions using financial incentives may result in similar engagement in MVPA among white and black employees, while black employees walk more steps during the intervention. Limitations include a primarily white female sample which may not generalize.

Prediction using a randomized evaluation of data collection integrated through connected technologies (PREDICT): Design and rationale of a randomized trial of patients discharged from the hospital to home

BACKGROUND

Hospital readmission prediction models often perform poorly. A critical limitation is that they use data collected up until the time of discharge but do not leverage information on patient behaviors at home after discharge.

METHODS

PREDICT is a two-arm, randomized trial comparing ways to use remotely-monitored patient activity levels after hospital discharge to improve hospital readmission prediction models. Patients are randomly assigned to use a wearable device or smartphone application to track physical activity data. The study collects also validated assessments on patient characteristics as well as disparate data on credit scores and medication adherence. Patients are followed for 6 months. We evaluate whether these data sources can improve prediction compared to standard modelling approaches.

CONCLUSION

The PREDICT Trial tests a novel method of remotely-monitoring patient behaviors after hospital discharge. Findings from the trial could inform new ways to improve the identification of patients at high-risk for hospital readmission.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02983812.

Behavioral economics implementation: Regret lottery improves mHealth patient study adherence

Background

Nonadherence to study protocols reduces the generalizability, validity, and statistical power of longitudinal studies.

Purpose

To determine whether an automated electronically-delivered regret lottery would improve adherence to an intensive mHealth self-monitoring protocol as part of a longitudinal observational study.

Methods

We enrolled 77 adults into a 52-week study requiring five daily ecologic momentary assessments (EMA) of stress and daily accelerometer use. We performed a pre/post single-arm study to evaluate the efficacy of a lottery intervention in improving adherence to this protocol. Midway through the study, participants were invited to enter a weekly regret lottery ($50 prize, expected value <$1) in which prize collection was contingent upon meeting adherence thresholds for the prior week. Study protocol adherence before and after lottery initiation were compared using mixed models repeated measures analysis of variance.

Results

62 participants consented to lottery participation. In the 12 weeks prior to lottery initiation, weekly adherence was declining (slope −1.4%/week). The weekly per-participant probability of adherence was higher after lottery initiation when comparing the 4-week (32% pre-lottery vs 50% post-lottery, p < 0.001), 8-week (37% vs 49%, p < 0.001), and 12-week periods (39% vs 45%, p = 0.001) before and after lottery initiation. However, the rate of decline in adherence over time was unchanged.

Conclusion

The implementation of an automated, electronically-delivered weekly regret lottery improved adherence with an intensive self-monitoring study protocol. Regret lotteries may represent a cost-effective tool to improve adherence and reduce bias caused by dropout or nonadherence.