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

Rationale, design, and baseline characteristics of WalkIT Arizona: A factorial randomized trial testing adaptive goals and financial reinforcement to increase walking across higher and lower walkable neighborhoods

Little change over the decades has been seen in adults meeting moderate-to-vigorous physical activity (MVPA) guidelines. Numerous individual-level interventions to increase MVPA have been designed, mostly static interventions without consideration for neighborhood context. Recent technologies make adaptive interventions for MVPA feasible. Unlike static interventions, adaptive intervention components (e.g., goal setting) adjust frequently to an individual's performance. Such technologies also allow for more precise delivery of "smaller, sooner incentives" that may result in greater MVPA than "larger, later incentives". Combined, these factors could enhance MVPA adoption. Additionally, a central tenet of ecological models is that MVPA is sensitive to neighborhood environment design; lower-walkable neighborhoods constrain MVPA adoption and maintenance, limiting the effects of individual-level interventions. Higher-walkable neighborhoods are hypothesized to enhance MVPA interventions. Few prospective studies have addressed this premise. This report describes the rationale, design, intervention components, and baseline sample of a study testing individual-level adaptive goal-setting and incentive interventions for MVPA adoption and maintenance over 2 years among adults from neighborhoods known to vary in neighborhood walkability. We scaled these evidenced-based interventions and tested them against static-goal-setting and delayed-incentive comparisons in a 2 × 2 factorial randomized trial to increase MVPA among 512 healthy insufficiently-active adults. Participants (64.3% female, M age = 45.5 ± 9.1 years, M BMI = 33.9 ± 7.3 kg/m2, 18.8% Hispanic, 84.0% White) were recruited from May 2016 to May 2018 from block groups ranked on GIS-measured neighborhood walkability and socioeconomic status (SES) and classified into four neighborhood types: "high walkable/high SES," "high walkable/low SES," "low walkable/high SES," and "low walkable/low SES." Results from this ongoing study will provide evidence for some of the central research questions of ecological models.

Behavioral economic insights to improve medication adherence in adults with chronic conditions: a scoping review protocol

OBJECTIVE

The objective of this review is to map the evidence on the use of behavioral economic insights to improve medication adherence in adults with chronic conditions.

INTRODUCTION

Medication non-adherence is a barrier to effectively managing chronic conditions, leading to poorer patient outcomes and placing an additional financial burden on healthcare systems. As the population ages and the prevalence of chronic disease increases, new ways to influence patient behavior are needed. Approaches that use insights from behavioral economics may help improve medication adherence, thus reducing morbidity, mortality and financial costs of unmanaged chronic diseases.

INCLUSION CRITERIA

Eligible studies will include adults taking medication for a chronic condition. All interventions relevant to high-income settings using insights from behavioral economics to improve medication adherence in adults will be considered. Contexts may include, but are not limited to, primary health care, corporate wellness programs and health insurance schemes. Any study design published in English will be considered. Studies in facilities where medication is administered to patients will be excluded.

METHODS

PubMed, Embase, Scopus, PsycINFO, EconLit and CINAHL will be searched from database inception to present. Gray literature will be searched using Google Scholar, OpenGrey and the Grey Literature Report. One reviewer will review titles, and then two reviewers will independently review abstracts to identify eligible studies. One reviewer will extract data on study characteristics, study design and study outcomes. A second reviewer will validate 25% of the extracted information. The results of the data extraction will be presented in a table, and a narrative summary will be presented.

Advances in the Management of Peripheral Artery Disease

PURPOSE OF REVIEW

This paper provides a concise update on the management of peripheral artery disease (PAD).

RECENT FINDINGS

PAD continues to denote a population at high risk for mortality but represents a threat for limb loss only when associated with foot ulcers, gangrene, or infections. Performing either angiogram or non-invasive testing for all patients with foot ulcers, gangrene, or foot infections will help increase the detection of PAD, and refined revascularization strategies may help optimize wound healing in this patient group. Structured exercise programs are becoming available to more patients with claudication as methods to improve adherence to community-based exercise programs will improve. Finally, ensuring more patients with PAD receive aspirin therapy and statins may improve long-term survival, while further research will help determine if adding newer antiplatelet or anticoagulant medications may reduce leg amputations in selected patients. Clinicians should have a low threshold to obtain an angiogram and to pursue revascularization in patients with foot ulcers, gangrene, or foot infections. In patients with claudication, clinicians should maximize the benefits derived from exercise therapy and medical management before offering percutaneous or surgical revascularization.

Effectiveness and cost-effectiveness of incentives as a tool for prevention of non-communicable diseases: A systematic review

The rising epidemic of non-communicable diseases (NCDs) poses substantial health and economic challenges to both individuals and society. Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs. Yet, whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematically addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal. In this systematic review we aim to determine whether there is an evidence base for any of these strategies. Forty-eight published randomized controlled trials (70 contrasts) evaluating the effectiveness of incentive-based strategies for improvements in NCD risk-factors were reviewed. Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy. More evidence for long-term effectiveness and cost-effectiveness is needed to justify third party funding of any incentive based strategy.

Ecological Momentary Assessment of Factors Associated with Water Intake among Adolescents with Kidney Stone Disease

PURPOSE

Maintaining high water intake decreases kidney stone recurrence but is difficult to do. Strategies to reduce stone recurrence among adolescents are lacking. We conducted an ecological momentary assessment study to identify factors associated with water intake in adolescents with nephrolithiasis.

MATERIALS AND METHODS

The study population consisted of 15 female and 10 male patients 12 to 18 years old with at least 1 prior kidney stone. For 7 days participants used "smart" bottles to self-monitor water intake and received questionnaires randomly 4 times daily, which were completed in real time on mobile devices. The questionnaires ascertained awareness of water intake volume, awareness of water intake goals, perceived need to drink, access to water, alternative beverage consumption and attitudes toward bathrooms. Linear mixed effects models were fit to estimate the association between momentary responses and daily water intake.

RESULTS

During 175 person-days 595 assessments (85%) were completed. Median daily water intake was 1,304 ml (IQR 848-1,832) and 20% of participants met their intake goal for 4 days or more. Unawareness of water intake volume was associated with drinking 690 ml less water per day (p = 0.04). A strong self-perceived need to drink more was associated with drinking 1,954 ml less water each day compared to no self-perceived need to drink more (p <0.01). Unawareness of intake goals was weakly associated with drinking 1,129 ml less water each day (p = 0.1). Access to water, alternative beverage consumption and bathroom aversion were not associated with water intake.

CONCLUSIONS

Unawareness of water volume consumed and low responsiveness to perceived need to drink more were associated with low water intake. Interventions that help adolescents recognize when and identify how to increase water intake may be effective in decreasing stone recurrence.

Modeling lottery incentives for daily adherence

Many health issues require adherence to recommended daily activities, such as taking medication to manage a chronic condition, walking a certain distance to promote weight loss, or measuring weights to assess fluid balance in heart failure. The cost of nonadherence can be high, with respect to both individual health outcomes and the healthcare system. Incentivizing adherence to daily activities can promote better health in patients and populations and potentially provide long‐term cost savings.

Multiple incentive structures are possible. We focus here on a daily lottery incentive in which payment occurs when both the participant's lottery number matches the number drawn and the participant adheres to the targeted daily behavior.

Our objective is to model the lottery's effect on participants' probability to complete the targeted task, particularly over the short term. We combine two procedures for analyzing such binary time series: a parameter‐driven regression model with an autocorrelated latent process and a comparative interrupted time series. We use the output of the regression model as the control generator for the comparative time series in order to create a quasi‐experimental design.

Mobile health interventions to promote physical activity and reduce sedentary behaviour in the workplace: A systematic review

Objective

This systematic review aimed to assess the effectiveness, feasibility and acceptability of mobile health (mHealth) technology (including wearable activity monitors and smartphone applications) for promoting physical activity (PA) and reducing sedentary behaviour (SB) in workplace settings.

Methods

Systematic searches were conducted in seven electronic databases (MEDLINE, SPORTDiscus, Scopus, EMBASE, PsycINFO, Web of Science and the Cochrane library). Studies were included if mHealth was a major intervention component, PA/SB was a primary outcome, and participants were recruited and/or the intervention was delivered in the workplace. Study quality was assessed using the Effective Public Health Practice Project (EPHPP) tool. Interventions were coded for behaviour change techniques (BCTs) using the Coventry, Aberdeen and London - Refined (CALO-RE) taxonomy.

Results

Twenty-five experimental and quasi-experimental studies were included. Studies were highly heterogeneous and only one was rated as 'strong' methodological quality. Common BCTs included self-monitoring, feedback, goal-setting and social comparison. A total of 14/25 (56%) studies reported a significant increase in PA, and 4/10 (40%) reported a significant reduction in sedentary time; 11/16 (69%) studies reported a significant impact on secondary outcomes including reductions in weight, systolic blood pressure and total cholesterol. While overall acceptability was high, a large decline in technology use and engagement was observed over time.

Conclusions

While methodological quality was generally weak, there is reasonable evidence for mHealth in a workplace context as a feasible, acceptable and effective tool to promote PA. The impact in the longer term and on SB is less clear. Higher quality, mixed methods studies are needed to explore the reasons for decline in engagement with time and the longer-term potential of mHealth in workplace interventions.Protocol registration: The review protocol was registered with PROSPERO: CRD42017058856.

Assessment of Parents' Preferences for Incentives to Promote Engagement in Family-Based Childhood Obesity Treatment

Importance

Family-based treatment (FBT) is recommended for childhood obesity, but even when sought, attrition is high. Extrinsic incentives, which have been effective for improving adult health, could improve FBT engagement.

Objective

To assess parents' preferences for FBT incentives.

Design, Setting, and Participants

Survey study of parents of children aged 6 to 17 years with obesity (body mass index in ≥95th percentile for age and sex). Parents' preferences for FBT incentive program attributes were assessed in a discrete choice experiment conducted using a nationally representative, web-based survey in March 2018. Attributes included (1) the monetary value of the incentive, (2) the payment structure, (3) the goal being incentivized, and (4) the person(s) being incentivized. A fractional factorial design was used to create a set of profiles representing hypothetical FBT incentives. Parents were presented with 10 pairs of profiles and asked which would most motivate them in FBT. Parents were also asked about preferences between a small, guaranteed incentive and a lottery for a large incentive. Analyses used a hierarchical Bayesian model and linear regressions.

Main Outcomes and Measures

Parents' preference for different incentive program attributes and levels.

Results

The nationally representative survey had a 41.4% eligibility rate (n = 339) and a 89.7% completion rate (n = 304). A total of 53.3% of respondents (weighted percentage) were non-Hispanic white, 42.6% had an annual household income less than $50 000, and 28.3% had a bachelor's degree. Parents preferred higher incentives, although they were willing to accept lower-value incentives if both the parent and the child (vs the child alone) were required to meet the goal (mean difference [MD], -$108; 95% CI, -$132 to -$84), if the incentive used a gain-framed vs loss-framed payment structure (MD, -$72; 95% CI, -$85 to -$59), and if physical activity goals were incentivized over weight loss (MD, -$63; 95% CI, -$82 to -$44) or dietary monitoring (MD, -$5; 95% CI, -$1 to $28). Only 20.6% of parents preferred a lottery over a guaranteed payment. Preferences did not vary among demographic or health subgroups.

Conclusions and Relevance

In this study, parent-stated preferences did not align with FBT best practices or behavioral economic theory. A randomized clinical trial could examine whether aligning incentives with preferences or best practices would maximize FBT engagement and behavior change.

A Move-A-Thon Event: A Workplace Demonstration of a Proposed Alternative Strategy to Incentivize Workers to Engage in Physical Activity

Motivating employees to increase their physical activity is a health promotion challenge. A Move-A-Thon (MAT) event approach was implemented as an alternative incentive to help workers to optimize their physical activity levels. We implemented a demonstration project in which workers were incentivized for their participation through monetized donations to charity. Their steps were monitored over the 2-week demonstration period. The MAT goal was for participants to achieve a minimum of 3,000 daily steps for 2 weeks, for which they could earn a total donation of up to US$20. Participants walking at least once with up to five different "exercise buddies" could earn up to US$2 more per buddy for donation. Of 10 workers invited, nine enrolled and eight completed participation by logging their monitored steps across an average of 13.75 full MAT participation days. Participants averaged 9,330.8 steps per day-more than triple the lower threshold required for a maximum US$20 charitable donation. The eight participants walked with a total of 21 "exercise buddies." They were receptive to future MAT events of longer duration. In total, the monetized donation to charity made by those eight participants was US$202. The MAT event participants were successful at promoting physical activity among a small group of workers for 2 weeks. Future worksite health promotion projects with this type of incentive strategy are indicated.

Examining the use of loyalty point incentives to encourage health and fitness centre participation

A unique financial incentive intervention was conducted in Canada, where YMCA members were offered loyalty points (Air Miles Reward Miles) to encourage visits to YMCA Health and Fitness Centres. The purpose of this evaluation study was to determine if YMCA members would participate in a loyalty point incentive program and if the weekly YMCA visit rates differed between Air Miles collectors and non-collectors. YMCA swipe data were collected from 2012 to 2016, including 12 months pre-program (baseline data), 36 months during the intervention period, and 3 months post-program. The final analyses, conducted in 2017, included 459,146 participants from 13 YMCA locations. Quasi-Poisson regression models were used to compare the weekly visit rates between Air Miles collectors and non-collectors. Of the 459,146 participants, 6.4% (n = 29,449) registered their Air Miles card with their YMCA membership (Air Miles collectors). Average weekly visit rates over the entire study period were significantly higher (1.37 to 3.84 times) among the Air Miles collector group than those in the non-collector group, but there was no evidence that incentives were associated with increased YMCA visits when adjusting for the pre-program period. This research demonstrated that incentives are a practical and acceptable public health strategy in Canada. More research is needed into how to harness the reach of loyalty point providers such as Air Miles, and how incentive-based programs should be optimally designed and delivered (e.g., type, timing, and magnitude of incentive).

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Loyalty points are popular and are a less expensive type of financial incentive.

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Air Miles Reward Miles were offered to YMCA members to increase visits to Health and Fitness Centers.

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Average weekly visit rates significantly higher among Air Miles collectors both prior to and during the incentive period.

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No association was found between adoption of the Air Miles incentive and increased YMCA visits when adjusting for baseline.

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More research is needed into how incentive programs should be optimally designed and delivered.

A Cluster-Randomized Trial on Small Incentives to Promote Physical Activity

INTRODUCTION

There has been limited research investigating whether small financial incentives can promote participation, behavior change, and engagement in physical activity promotion programs. This study evaluates the effects of two types of small financial incentives within a physical activity promotion program of a Swiss health insurance company.

STUDY DESIGN

Three-arm cluster-randomized trial comparing small personal financial incentives and charity financial incentives (10 Swiss Francs, equal to US$10.40) for each month with an average step count of >10,000 steps per day to control. Insureds' federal state of residence was the unit of randomization. Data were collected in 2015 and analyses were completed in 2018.

SETTING/PARTICIPANTS

German-speaking insureds of a large health insurer in Switzerland were invited. Invited insureds were aged ≥18 years, enrolled in complementary insurance plans and registered on the insurer's online platform.

MAIN OUTCOME MEASURES

Primary outcome was the participation rate. Secondary outcomes were steps per day, the proportion of participant days in which >10,000 steps were achieved and non-usage attrition over the first 3 months of the program.

RESULTS

Participation rate was 5.94% in the personal financial incentive group (OR=1.96, 95% CI=1.55, 2.49) and 4.98% in the charity financial incentive group (OR=1.59, 95% CI=1.25, 2.01) compared with 3.23% in the control group. At the start of the program, the charity financial group had a 12% higher chance of walking 10,000 steps per day than the control group (OR=1.68, 95% CI=1.23, 2.30), but this effect dissipated after 3 months. Steps per day and non-usage attrition did not differ significantly between the groups.

CONCLUSIONS

Small personal and charity financial incentives can increase participation in physical activity promotion programs. Incentives may need to be modified in order to prevent attrition and promote behavior change over a longer period of time.

TRIAL REGISTRATION

This study is registered at www.isrctn.com ISRCTN24436134.

Investigating Intervention Components and Exploring States of Receptivity for a Smartphone App to Promote Physical Activity: Protocol of a Microrandomized Trial

Background

Smartphones enable the implementation of just-in-time adaptive interventions (JITAIs) that tailor the delivery of health interventions over time to user- and time-varying context characteristics. Ideally, JITAIs include effective intervention components, and delivery tailoring is based on effective moderators of intervention effects. Using machine learning techniques to infer each user’s context from smartphone sensor data is a promising approach to further enhance tailoring.

Objective

The primary objective of this study is to quantify main effects, interactions, and moderators of 3 intervention components of a smartphone-based intervention for physical activity. The secondary objective is the exploration of participants’ states of receptivity, that is, situations in which participants are more likely to react to intervention notifications through collection of smartphone sensor data.

Methods

In 2017, we developed the Assistant to Lift your Level of activitY (Ally), a chatbot-based mobile health intervention for increasing physical activity that utilizes incentives, planning, and self-monitoring prompts to help participants meet personalized step goals. We used a microrandomized trial design to meet the study objectives. Insurees of a large Swiss insurance company were invited to use the Ally app over a 12-day baseline and a 6-week intervention period. Upon enrollment, participants were randomly allocated to either a financial incentive, a charity incentive, or a no incentive condition. Over the course of the intervention period, participants were repeatedly randomized on a daily basis to either receive prompts that support self-monitoring or not and on a weekly basis to receive 1 of 2 planning interventions or no planning. Participants completed a Web-based questionnaire at baseline and postintervention follow-up.

Results

Data collection was completed in January 2018. In total, 274 insurees (mean age 41.73 years; 57.7% [158/274] female) enrolled in the study and installed the Ally app on their smartphones. Main reasons for declining participation were having an incompatible smartphone (37/191, 19.4%) and collection of sensor data (35/191, 18.3%). Step data are available for 227 (82.8%, 227/274) participants, and smartphone sensor data are available for 247 (90.1%, 247/274) participants.

Conclusions

This study describes the evidence-based development of a JITAI for increasing physical activity. If components prove to be efficacious, they will be included in a revised version of the app that offers scalable promotion of physical activity at low cost.

Trial Registration

ClinicalTrials.gov NCT03384550; https://clinicaltrials.gov/ct2/show/NCT03384550 (Archived by WebCite at http://www.webcitation.org/74IgCiK3d)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11540

Using Behavioral Economics to Encourage Parent Behavior Change: Opportunities to Improve Clinical Effectiveness

Pediatric clinical practice often involves improving child health by changing parents' behavior. Strategies from behavioral economics-a field that leverages predictable patterns in human decision making to overcome barriers to behavior change-can improve health outcomes in adults. Although more research is needed, the application of these approaches to parent behavior change in pediatric settings has the potential to improve the clinical effectiveness of child health care. We review the foundational concepts of behavioral economics and identify the unique role of pediatricians in motivating parent behavior change. We then discuss how to apply 4 key strategies in practice-message framing, use of defaults, enhanced active choice, and harnessing social forces-to support parent decision making to improve child health. Leveraging behavioral economic principles around parental decision making has the potential to supercharge program effectiveness and improve patient and family health.

Association of Medicaid Healthy Behavior Incentive Programs With Smoking Cessation, Weight Loss, and Annual Preventive Health Visits

IMPORTANCE

Several states have implemented Healthy Behavior Incentive Programs (HBIPs) in Medicaid through Section 1115 demonstration waivers. These programs use financial incentives to encourage positive behavior changes, such as greater use of preventive services, smoking cessation, and weight loss.

OBJECTIVE

To test for an association between the introduction of HBIPs and the rates of smoking cessation, weight loss, and annual preventive health visits in states that have adopted behavior-specific programs compared with states that have not.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study using a difference-in-differences analysis of the 2011-2016 Behavioral Risk Factor Surveillance Survey Interview Results data, adjusting for demographic conditions, state unemployment rates, state Medicaid expansion, national secular trends, and time invariant state-specific factors, was conducted. Two sets of participants were considered: adults aged 18 to 64 years who had a reported annual household income of less than $25 000 (n = 442 089) or adults aged 18 to 64 years who had completed high school education or less (n = 676 883).

EXPOSURES

Changes in health behavior outcomes in 4 states (Florida, Indiana, Iowa, and Michigan) that implemented behavior-specific HBIPs targeting smoking, obesity, and annual health checkups through a Section 1115 waiver, against changes in control states, including Washington, DC, that did not introduce an HBIP (n = 44).

MAIN OUTCOMES AND MEASURES

Rate of smoking, obesity, and attendance at annual preventive health visits.

RESULTS

Of Behavioral Risk Factor Surveillance Service respondents used for the less than $25 000 annual household income cohort (n = 442 089), the mean (SD) age was 43.1 (0.8) years, and the mean (SD) percentage of women was 58.4% (2.5%). For the cohort of high school education or less (n = 676 883) population, the mean (SD) age was 41.6 (1.1) years, and the mean (SD) percentage of women was 46.6% (0.9%). During a 2-year period after implementation, there were no improvements in smoking and obesity in individuals with a household income of less than $25 000 (2.49 percentage points, 95% CI, 1.75-3.23 percentage points; P < .001 and -1.94 percentage points, 95% CI, -4.42 to 0.55 percentage points; P = .12, respectively) as well as in the population holding a high school education or less (1.74 percentage points, 95% CI, 0.64-2.85 percentage points; P = .003 and -0.73 percentage points, 95% CI, -1.84 to 0.38 percentage points; P = .19). An association was noted between an increase in preventive health visit rates among states adopting behavior-specific HBIPs relative to control states in the less than $25 000 household income population (3.89 percentage points, 95% CI, 2.64-5.14 percentage points; P < .001). However, these associations were substantively small and not robust across the high school education or less population (1.8 percentage points, 95% CI, -0.12 to 3.71 percentage points; P = .07).

CONCLUSIONS AND RELEVANCE

Early postimplementation assessment may indicate that HBIPs were not associated with substantive improvements in incentivized healthy behaviors among populations likely to be Medicaid beneficiaries. The value, format, and timing of the incentive, complexity in delivery, and lack of awareness of incentives among target beneficiaries and clinicians may limit the usefulness of programs even over a longer follow-up period.

Social Incentives and Gamification to Promote Weight Loss: The LOSE IT Randomized, Controlled Trial

BACKGROUND

Social networks influence obesity patterns, but interventions to leverage social incentives to promote weight loss have not been well evaluated.

OBJECTIVE

To test the effectiveness of gamification interventions designed using insights from behavioral economics to enhance social incentives to promote weight loss.

DESIGN

The Leveraging Our Social Experiences and Incentives Trial (LOSE IT) was a 36-week randomized, controlled trial with a 24-week intervention and 12-week follow-up.

PARTICIPANTS

One hundred and ninety-six obese adults (body mass index ≥ 30) comprising 98 two-person teams.

INTERVENTIONS

All participants received a wireless weight scale, used smartphones to track daily step counts, formed two-person teams with a family member or friend, and selected a weight loss goal. Teams were randomly assigned to control or one of two gamification interventions for 36 weeks that used points and levels to enhance collaborative social incentives. One of the gamification arms also had weight and step data shared regularly with each participant's primary care physician (PCP).

MAIN OUTCOME MEASURES

The primary outcome was weight loss at 24 weeks. Secondary outcomes included weight loss at 36 weeks.

KEY RESULTS

At 24 weeks, participants lost significant weight from baseline in the control arm (mean: - 3.9 lbs; 95% CI: - 6.1 to - 1.7; P < 0.001), the gamification arm (mean: - 6.6 lbs; 95% CI: - 9.4 to - 3.9; P < 0.001), and the gamification arm with PCP data sharing (mean: - 4.8 lbs; 95% CI: - 7.4 to - 2.3; P < 0.001). At 36 weeks, weight loss from baseline remained significant in the control arm (mean: - 3.5 lbs; 95% CI: - 6.1 to - 0.8; P = 0.01), the gamification arm (mean: - 6.3 lbs; 95% CI: - 9.2 to - 3.3; P < 0.001), and the gamification arm with PCP data sharing (mean: - 5.2 lbs; 95% CI: - 8.5 to - 2.0; P < 0.01). However, in the main adjusted model, there were no significant differences in weight loss between each of the intervention arms and control at either 12, 24, or 36 weeks.

CONCLUSIONS

Using digital health devices to track behavior with a partner led to significant weight loss through 36 weeks, but the gamification interventions were not effective at promoting weight loss when compared to control.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: 02564445.

Physical activity after commitment lotteries: examining long-term results in a cluster randomized trial

To overcome self-control difficulties, people can commit to their health goals by voluntarily accepting deadlines with consequences. In a commitment lottery, the winners are drawn from all participants, but can only claim their prize if they also attained their gym-attendance goals. In a 52-week, three-arm trial across six company gyms, we tested if commitment lotteries with behavioral economic underpinnings would promote physical activity among overweight adults. In previous work, we presented an effective 26-week intervention. In the present paper we analyzed maintenance of goal attainment at 52-week follow-up and the development of weight over time. We compared weight and goal attainment (gym attendance ≥ 2 per week) between three arms that-in the intervention period- consisted of (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 lottery-deadlines. After a successful 26-week intervention, goal attainment declined between weeks 27 and 52 in the long-term lottery arm, but remained higher than in the control group. Goal attainment did not differ between the short-term lottery arm and control arm. Weight declined slightly in all arms in the first 13 weeks of the trial and remained stable from there on. Commitment lotteries can support regular gym attendance up to 52 weeks, but more research is needed to achieve higher levels of maintenance and weight loss.

Gamification Use and Design in Popular Health and Fitness Mobile Applications

PURPOSE

To evaluate the presence of gamification in popular mobile applications and whether principles from behavioral economics were incorporated in the design.

DESIGN

The top 50 ranked free health and fitness applications were downloaded. Gamification elements were predetermined through literature review, and applications were evaluated for their presence.

SETTING

App Store by Apple Inc.

MEASURES

Presence of gamification, type of game element, and use of behavioral economic principles.

ANALYSIS

We classified the types and frequencies of targeted behaviors and features of gamification. Use of behavioral economic principles focused on designing rewards or points using loss aversion (allocated upfront and could be lost), variable reinforcement (not allocated constantly), and probability inflation (using drawings or lottery designs).

RESULTS

Gamification was used by 64% of mobile applications. Most applications that included gamification (97%) targeted behaviors related to physical activity and weight loss. Applications focused on other areas such as reproductive health, meditation, and sleep used gamification less often (11%). Game elements used most commonly included goal setting (78%), social influences (78%), and challenges (63%), while less common elements included points (6%) and levels (3%). No applications incorporated behavioral economics principles specified in the study.

CONCLUSIONS

Gamification was commonly used by popular health and fitness mobile applications, but none used the specified behavioral economic principles to design rewards or points. Mobile applications could potentially improve their use if their design better leveraged principles from behavioral economics.

Comparative effectiveness of novel nonmonetary incentives to promote HIV testing

OBJECTIVE

To assess the comparative effectiveness of alternative incentive-based interventions to promote HIV testing among men.

DESIGN

Randomized clinical trial.

METHODS

We enumerated four Ugandan parishes and enrolled men at least 18 years. Participants were randomized to six groups that received incentives of varying type and amount for HIV testing at a 13-day community health campaign. Incentive types were: gain-framed (control): participants were told they would receive a prize for testing; loss-framed: participants were told they had won a prize, shown several prizes, asked to select one, then told they would lose the prize if they did not test; lotteries: those who tested had a chance to win larger prizes. Each incentive type had a low and high amount (∼US$1 and US$5/participant). The primary outcome was HIV-testing uptake at the community health campaign.

RESULTS

Of 2532 participants, 1924 (76%) tested for HIV; 7.6% of those tested were HIV-positive. There was no significant difference in testing uptake in the two lottery groups (78%; P = 0.076) or two loss-framed groups (77%; P = 0.235) vs. two gain-framed groups (74%). Across incentive types, testing did not differ significantly in high-cost (76%) vs. low-cost (75%; P = 0.416) groups. Within low-cost groups, testing uptake was significantly higher in the lottery (80%) vs. gain-framed (72%; P = 0.009) group.

CONCLUSION

Overall, neither offering incentives via lotteries nor framing incentives as losses resulted in significant increases in HIV testing compared with standard gain-framed incentives. However, when offering low-cost incentives to promote HIV testing, providing lottery-based rewards may be a better strategy than gain-framed incentives.

Loss-Framed Financial Incentives and Personalized Goal-Setting to Increase Physical Activity Among Ischemic Heart Disease Patients Using Wearable Devices: The ACTIVE REWARD Randomized Trial

BACKGROUND

Regular physical activity reduces the risk of cardiovascular events, but most ischemic heart disease (IHD) patients do not obtain enough.

METHODS AND RESULTS

ACTIVE REWARD (A Clinical Trial Investigating Effects of a Randomized Evaluation of Wearable Activity Trackers with Financial Rewards) was a 24-week home-based, remotely monitored, randomized trial with a 16-week intervention (8-week ramp-up incentive phase and 8-week maintenance incentive phase) and an 8-week follow-up. Patients used wearable devices to track step counts and establish a baseline. Patients in control received no other interventions. Patients in the incentive arm received personalized step goals and daily feedback for all 24 weeks. In the ramp-up incentive phase, daily step goals increased weekly by 15% from baseline with a maximum of 10 000 steps and then remained fixed. Each week, $14 was allocated to a virtual account; $2 could be lost per day for not achieving step goals. The primary outcome was change in mean daily steps from baseline to the maintenance incentive phase. Ischemic heart disease patients had a mean (SD) age of 60 (11) years and 70% were male. Compared with control, patients in the incentive arm had a significantly greater increase in mean daily steps from baseline during ramp-up (1388 versus 385; adjusted difference, 1061 [95% confidence interval, 386-1736]; P<0.01), maintenance (1501 versus 264; adjusted difference, 1368 [95% confidence interval, 571-2164]; P<0.001), and follow-up (1066 versus 92; adjusted difference, 1154 [95% confidence interval, 282-2027]; P<0.01).

CONCLUSIONS

Loss-framed financial incentives with personalized goal setting significantly increased physical activity among ischemic heart disease patients using wearable devices during the 16-week intervention, and effects were sustained during the 8-week follow-up.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02531022.

Exploring parent attitudes around using incentives to promote engagement in family-based weight management programs

Incentives can promote adult wellness. We sought to examine whether incentives might help overcome barriers to engagement in child weight management programs and the ideal value, type and recipient of incentives. In 2017, we conducted semi-structured phone interviews with parents of children ≤17 years old, formerly or currently affected by obesity, who had (n = 11) or had never (n = 12) participated in family-based behavioral treatment (FBT) for obesity. Interviews explored the range and type of incentives families would be willing to accept. Interview transcripts were coded and data were analyzed using a thematic analysis. We found that some parents were skeptical about receiving cash incentives. However, once treatment-related costs were identified, some became more interested in reimbursement for out of pocket expenditures. Most parents felt up to $100/month would be adequate and that incentives should be tied to changing behaviors, not BMI. Some interviewees expressed preferences for non-cash incentives (e.g. a gift card) over cash incentives. Parents were willing to share incentives with adolescents, up to $50/month, but there was concern about incentives affecting a child's intrinsic motivation for behavior change. All parents acknowledged that moderate incentives alone couldn't overcome the realities of structural and familial barriers to engaging in weight management programs. In summary, we identified aspects of an incentive program to promote engagement in FBT that would be desirable and feasible to implement. Future quantitative work can reveal the value and structure of incentives that are effective for improving obesogenic health behaviors and outcomes.

Using financial incentives to promote physical activity in American Indian adolescents: A randomized controlled trial

American Indians (AI) have high prevalence of diabetes in youth and may benefit from increasing physical activity as a strategy to improve metabolic health. We tested whether financial incentives would elicit greater frequency and/or duration of exercise in AI youth at high risk for developing diabetes. Overweight/obese AI boys and girls, 11-20 years old, were instructed to exercise on 3 days/week for 48 weeks at a tribal wellness center. The program was divided into three, 16-week-long phases to test different financial incentive strategies. Within each phase participants were randomly assigned to one of two groups that received different payments for exercise. Phase 1 was designed to test whether the size of the incentive would affect exercise frequency. In Phase 1, the number of exercise sessions did not differ between the group receiving a modest fixed-value payment per exercise session and the group receiving enhanced incentives to exercise more frequently (26 ± 3 versus 28 ± 2 sessions, respectively, p = 0.568). In Phase 2, the provision of an enhanced financial incentive to increase exercise duration resulted longer sessions, as the incentivized and standard payment groups exercised 38 ± 2 versus 29 ± 1 minutes per session (p = 0.002), respectively. In Phase 3, the effect of reducing the incentives on maintenance of exercise behaviors was inconclusive due to high participant withdrawal. Aerobic fitness increased 10% during Phase 1 but was unchanged thereafter. Insulin sensitivity and body composition were unchanged during the study. In conclusion, enhanced financial incentives increased the duration of exercise sessions, but had minimal effects on exercise participation. These results indicate that financial incentives hold promise in motivating previously sedentary, overweight/obese adolescents to exercise longer, but motivating them to sustain an exercise program remains the major challenge.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01848353.

Attitudes on technological, social, and behavioral economic strategies to reduce cellphone use among teens while driving

OBJECTIVE

The majority of U.S. teens admit to handheld cellphone use while driving, an increasingly common cause of crashes. Attitudes toward novel cellphone applications and settings that block use while driving are poorly understood, potentially limiting uptake. We examined teens' willingness to reduce cellphone use while driving and perceptions of potential strategies to limit this behavior.

METHODS

Teen drivers (n = 153) aged 16-17 who owned smartphones and admitted to texting while driving completed an online survey. Survey instruments measured willingness to give up cellphone use and perceptions of technological and behavioral economic strategies to reduce cellphone use while driving. We used chi-square tests to test the hypothesis that willingness to give up certain types of cellphone use while driving and the perceptions of strategies to reduce cellphone use while driving would differ by self-reported frequency of texting while driving in the past 30 days (low [1-5 days] vs. high [6 or more days]).

RESULTS

Most teens were willing or somewhat willing to give up reading texts (90%), sending texts (95%), and social media (99%) while driving. However, they were not willing to give up navigation (59%) and music applications (43%). Those who engaged in high-frequency texting while driving were more likely to say that they were not willing to give up navigation applications (73 vs. 44%, P <.001), music applications (54 vs. 32%, P <.001), and reading texts (15 vs. 4%, P =.029). Overall, the following strategies where rated as likely to be very effective for reducing texting while driving: gain-framed financial incentives (75%), loss-framed financial incentives (63%), group-based financial incentives (58%), insurance discounts (53%), automatic phone locking while driving (54%), e-mail notifications to parents (47%), automated responses to incoming texts (42%), peer concern (18%), and parental concern (15%). Those who engaged in high-frequency texting while driving were less likely to say that following strategies would be very effective: automated responses to incoming texts (33 vs. 53%, P =.016), peer concern (9 vs. 29%, P =.002), and parental concern (9 vs. 22%, P =.025). The strongest perceived benefit of cellphone blocking apps was decreasing distraction (86%). The predominant reason for not wanting to use this technology was not wanting parents to monitor their behavior (60%).

CONCLUSIONS

Promising strategies for increasing acceptance of cellphone blocking technology among teen drivers include automated screen locking and permitting hands-free navigation and music combined with behavioral economic incentives to sustain engagement.

Cost-Effectiveness of a Community-Based Diabetes Prevention Program with Participation Incentives for Medicaid Beneficiaries

OBJECTIVE

To examine the cost-effectiveness of a community-based Diabetes Prevention Program (DPP) for Medicaid beneficiaries from the perspective of the health care sector.

DATA SOURCES/STUDY SETTING

A total of 847 Medicaid enrollees at high risk for type 2 diabetes participating in a community-based DPP.

STUDY DESIGN

Pre- and post clinical outcome and cost data were used as inputs into a validated diabetes simulation model. The model was used to evaluate quality-adjusted life years (QALYs) and health care costs over a 40-year time horizon from the perspective of the health care sector.

DATA COLLECTION/EXTRACTION METHODS

Clinical outcome and cost data were derived from a study examining the effect of financial incentives on weight loss.

PRINCIPAL FINDINGS

Study participants lost an average of 4.2 lb (p < .001) and increased high-density lipoprotein cholesterol by 1.75 mg/dl (p = .002). Intervention costs, which included financial incentives for participation and weight loss, were $915 per participant. The incremental cost-effectiveness ratio was estimated to be $14,011 per QALY but was sensitive to the time horizon studied.

CONCLUSIONS

Widespread adoption of community-based DPP has the potential to reduce diabetes and cardiovascular-related morbidity and mortality for low-income persons at high risk for diabetes and may be a cost-effective investment for Medicaid programs.

Paying people to lose weight: the effectiveness of financial incentives provided by health insurers for the prevention and management of overweight and obesity - a systematic review

Curbing the obesity epidemic is likely to require a suite of interventions targeting the obesogenic environment as well as individual behaviour. Evidence suggests that the effectiveness of behaviour modification programmes can be enhanced by financial incentives that immediately reward weight loss behaviour. This systematic review investigated the effectiveness of incentives with a focus on assessing the relative effectiveness of incentives that target different behaviours as well as factors of importance when implementing these programmes in real-world settings (health insurer settings). A narrative review of the academic and grey literature including a variety of study designs was undertaken. Twenty studies met inclusion criteria and were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results suggest that incentivizing weight loss is effective in the short term while the incentives are in place. There are various incentive designs, and although the relative effectiveness of each of these on weight loss is not clear, it appears that positive incentives increase the uptake into programmes and may reduce dropouts. As with other weight loss initiatives, there is a need to explore ways to maintain weight loss in the longer term - incentives for weight maintenance could play a role.

Are Financial Incentives for Lifestyle Behavior Change Informed or Inspired by Behavioral Economics? A Mapping Review

OBJECTIVE

To identify the behavioral economics (BE) conceptual underpinnings of lifestyle financial incentive (FI) interventions.

DATA SOURCE

A mapping review of peer-reviewed literature was conducted by searching electronic databases.

STUDY INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria were real-world FI interventions explicitly mentioning BE, targeting individuals, or populations with lifestyle-related behavioral outcomes. Exclusion criteria were hypothetical studies, health professional focus, clinically oriented interventions.

DATA EXTRACTION

Study characteristics were tabulated according to purpose, categorization of BE concepts and FI types, design, outcome measures, study quality, and findings.

DATA SYNTHESIS AND ANALYSIS

Financial incentives were categorized according to type and payment structure. Behavioral economics concepts explicitly used in the intervention design were grouped based on common patterns of thinking. The interplay between FI types, BE concepts, and outcome was assessed.

RESULTS

Seventeen studies were identified from 1452 unique records. Analysis showed 76.5% (n = 13) of studies explicitly incorporated BE concepts. Six studies provided clear theoretical justification for the inclusion of BE. No pattern in the type of FI and BE concepts used was apparent.

CONCLUSIONS

Not all FI interventions claiming BE inclusion did so. For interventions that explicitly included BE, the degree to which this was portrayed and woven into the design varied. This review identified BE concepts common to FI interventions, a first step in providing emergent and pragmatic information to public health and health promotion program planners.

Financial Incentives and Health Coaching to Improve Physical Activity Following Total Knee Replacement: A Randomized Controlled Trial

OBJECTIVE

Most persons who undergo total knee replacement (TKR) do not increase their physical activity following surgery. We assessed whether financial incentives and health coaching would improve physical activity in persons undergoing TKR.

METHODS

We designed a factorial randomized controlled trial among persons undergoing TKR for osteoarthritis. Subjects underwent normal perioperative procedures, including postoperative physical therapy, and were assigned to 1 of 4 arms: attention control, telephonic health coaching (THC), financial incentives (FI), or THC + FI. We objectively measured step counts and minutes of physical activity using a commercial accelerometer (Fitbit Zip) and compared the changes from pre-TKR to 6 months post-TKR across the 4 study arms.

RESULTS

Of the 202 randomized subjects, 150 (74%) provided both pre-TKR and 6 months post-TKR accelerometer data. Among completers, the mean ± SE daily step count at 6 months ranged from 5,619 ± 381 in the THC arm to 7,152 ± 407 in the THC + FI arm (adjusting for baseline values). Daily step count 6 months post-TKR increased by 680 (95% confidence interval [95% CI] -94, 1,454) in the control arm, 274 (95% CI -473, 1,021) in the THC arm, 826 (95% CI 89, 1,563) in the FI arm, and 1,808 (95% CI 1,010, 2,606) in the THC + FI arm. Weekly physical activity increased by mean ± SE 14 ± 10, 14 ± 10, 16 ± 10, and 39 ± 11 minutes in the control, THC, FI, and THC + FI arms, respectively.

CONCLUSION

A dual THC + FI intervention led to substantial improvements in step count and physical activity following TKR.

Evaluating the Impact of Physical Activity Apps and Wearables: Interdisciplinary Review

Background

Although many smartphone apps and wearables have been designed to improve physical activity, their rapidly evolving nature and complexity present challenges for evaluating their impact. Traditional methodologies, such as randomized controlled trials (RCTs), can be slow. To keep pace with rapid technological development, evaluations of mobile health technologies must be efficient. Rapid alternative research designs have been proposed, and efficient in-app data collection methods, including in-device sensors and device-generated logs, are available. Along with effectiveness, it is important to measure engagement (ie, users’ interaction and usage behavior) and acceptability (ie, users’ subjective perceptions and experiences) to help explain how and why apps and wearables work.

Objectives

This study aimed to (1) explore the extent to which evaluations of physical activity apps and wearables: employ rapid research designs; assess engagement, acceptability, as well as effectiveness; use efficient data collection methods; and (2) describe which dimensions of engagement and acceptability are assessed.

Method

An interdisciplinary scoping review using 8 databases from health and computing sciences. Included studies measured physical activity, and evaluated physical activity apps or wearables that provided sensor-based feedback. Results were analyzed using descriptive numerical summaries, chi-square testing, and qualitative thematic analysis.

Results

A total of 1829 abstracts were screened, and 858 articles read in full. Of 111 included studies, 61 (55.0%) were published between 2015 and 2017. Most (55.0%, 61/111) were RCTs, and only 2 studies (1.8%) used rapid research designs: 1 single-case design and 1 multiphase optimization strategy. Other research designs included 23 (22.5%) repeated measures designs, 11 (9.9%) nonrandomized group designs, 10 (9.0%) case studies, and 4 (3.6%) observational studies. Less than one-third of the studies (32.0%, 35/111) investigated effectiveness, engagement, and acceptability together. To measure physical activity, most studies (90.1%, 101/111) employed sensors (either in-device [67.6%, 75/111] or external [23.4%, 26/111]). RCTs were more likely to employ external sensors (accelerometers: P=.005). Studies that assessed engagement (52.3%, 58/111) mostly used device-generated logs (91%, 53/58) to measure the frequency, depth, and length of engagement. Studies that assessed acceptability (57.7%, 64/111) most often used questionnaires (64%, 42/64) and/or qualitative methods (53%, 34/64) to explore appreciation, perceived effectiveness and usefulness, satisfaction, intention to continue use, and social acceptability. Some studies (14.4%, 16/111) assessed dimensions more closely related to usability (ie, burden of sensor wear and use, interface complexity, and perceived technical performance).

Conclusions

The rapid increase of research into the impact of physical activity apps and wearables means that evaluation guidelines are urgently needed to promote efficiency through the use of rapid research designs, in-device sensors and user-logs to assess effectiveness, engagement, and acceptability. Screening articles was time-consuming because reporting across health and computing sciences lacked standardization. Reporting guidelines are therefore needed to facilitate the synthesis of evidence across disciplines.

A Randomized, Controlled Trial of Lottery-Based Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults

PURPOSE

To evaluate the effect of lottery-based financial incentives in increasing physical activity.

DESIGN

Randomized, controlled trial.

SETTING

University of Pennsylvania Employees.

PARTICIPANTS

A total of 209 adults with body mass index ≥27.

INTERVENTIONS

All participants used smartphones to track activity, were given a goal of 7000 steps per day, and received daily feedback on performance for 26 weeks. Participants randomly assigned to 1 of the 3 intervention arms received a financial incentive for 13 weeks and then were followed for 13 weeks without incentives. Daily lottery incentives were designed as a "higher frequency, smaller reward" (1 in 4 chance of winning $5), "jackpot" (1 in 400 chance of winning $500), or "combined lottery" (18% chance of $5 and 1% chance of $50).

MEASURES

Mean proportion of participant days step goals were achieved.

ANALYSIS

Multivariate regression.

RESULTS

During the intervention, the unadjusted mean proportion of participant days that goal was achieved was 0.26 in the control arm, 0.32 in the higher frequency, smaller reward lottery arm, 0.29 in the jackpot arm, and 0.38 in the combined lottery arm. In adjusted models, only the combined lottery arm was significantly greater than control ( P = .01). The jackpot arm had a significant decline of 0.13 ( P < .001) compared to control. There were no significant differences during follow-up.

CONCLUSIONS

Combined lottery incentives were most effective in increasing physical activity.

Use and effectiveness of behavioural economics in interventions for lifestyle risk factors of non-communicable diseases: a systematic review with policy implications

AIM

There is limited evidence on what behavioural economics strategies are effective and can be used to inform non-communicable diseases (NCDs) public health policies designed to reduce overeating, excessive drinking, smoking, and physical inactivity. The aim of the review is to examine the evidence on the use and effectiveness of behavioural economics insights on reducing NCDs lifestyle risk factors.

METHODS

Medline, Embase, PsycINFO, and EconLit were searched for studies published between January 2002 and July 2016 and reporting empirical, non-pharmacological, interventional research focusing on reducing at least one NCDs lifestyle risk factor by employing a behavioural economics perspective.

RESULTS

We included 117 studies in the review; 67 studies had a low risk of bias and were classified as strong or very strong, 37 were moderate, and 13 were weak. We grouped studies by NCDs risk factors and conducted a narrative synthesis. The most frequent behavioural economics precepts used were incentives, framing, and choice architecture. We found inconclusive evidence regarding the success of behavioural economics strategies to reduce alcohol consumption, but we identified several strategies with policy-level implications which could be used to reduce smoking, improve nutrition, and increase physical activity.

CONCLUSION

Most studies targeting tobacco consumption, physical activity levels, and eating behaviours from a behavioural economics perspective had promising results with potential impact on NCDs health policies. We recommend future studies to be implemented in real-life settings and on large samples from diverse populations.

Can financial incentives help people trying to establish new habits? Experimental evidence with new gym members

Can financial incentives aid habit formation in people attempting to establish a positive health behavior? We provide evidence on this question from a randomized controlled trial of modest-sized incentives to attend the gym among new members of a fitness facility. Our experiment randomized 690 participants into a control group that received a $30 payment unconditionally or one of 3 incentive groups that received a payment for attending the gym at least 9 times over the first 6 weeks of membership. Two incentive treatment arms offered monetary payments of $30 and $60. The third incentive treatment, motivated by the endowment effect, offered a physical item worth $30. All three incentives had only small impacts on attendance during members' first 6 weeks and no effect on their post-incentive visit trajectories. We document substantial overconfidence among new members about their likely visits and discuss how overconfidence may undermine the effectiveness of incentive programs.

The impact of financial incentives on physical activity in adults: a systematic review protocol

BACKGROUND

Most adults fail to meet global physical activity guidelines set out by the World Health Organization. In recent years, behavioural economic principles have been used to design novel interventions that increase physical activity. Immediate financial rewards, for instance, can motivate an individual to change physical activity behaviour by lowering the opportunity costs of exercise. This systematic review will summarise the evidence about the effectiveness of financial incentive interventions for improving physical activity in adults.

METHODS

We will search MEDLINE, Embase, Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, PsycINFO, EconLit, SPORTDiscus, the National Health Service Economic Evaluation Database, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform from inception using a comprehensive, electronic search strategy. The search strategy will include terms related to 'financial incentive' and 'physical activity'. Only randomised controlled trials that investigate the effect of financial incentives on physical activity in adult populations and that are written in the English language will be included. Two review authors will independently screen abstracts and titles, complete full text reviews and extract data on objective and self-reported physical activity outcomes. The authors will also assess the study quality using the Cochrane risk of bias tool and provide a systematic presentation and synthesis of the included studies' characteristics and results. If more than two studies are sufficiently similar in population, settings and interventions, we will pool the data to conduct a meta-analysis. If we are unable to perform a meta-analysis, we will conduct a narrative synthesis of the results and produce forest plots for individual studies. Our subgroup analyses will examine the differential effects of an intervention in healthy populations compared to populations with disease pathology and compare the effects of interventions using financial rewards to interventions using financial penalties.

DISCUSSION

This systematic review will determine the effectiveness of positive and negative financial incentives on physical activity in adults. Findings will help inform the development of public health interventions and research in this field.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2017: CRD42017068263.

Recent Approaches to Improve Medication Adherence in Patients with Coronary Heart Disease: Progress Towards a Learning Healthcare System

PURPOSE OF REVIEW

Non-adherence to medications for the secondary prevention of myocardial infarction (MI) is a major contributor to morbidity and mortality in these patients. This review describes recent advances in promoting adherence to therapies for coronary artery disease (CAD).

RECENT FINDINGS

Two large randomized controlled trials to "incentivize" adherence were somewhat disappointing; neither financial incentives nor "peer pressure" successfully increased rates of adherence in the post-MI population. Patient education and provider engagement appear to be critical aspects of improving adherence to CAD therapies, where the provider is a physician, pharmacist, or nurse and follow-up is performed in person or by telephone. Fixed-dose combinations of CAD medications, formulated as a so-called "polypill," have shown some early efficacy in increasing adherence. Technological advances that automate monitoring and/or encouragement of adherence are promising but seem universally dependent on patient engagement. For example, medication reminders via text message perform better if patients are required to respond. Multifaceted interventions, in which these and other interventions are combined together, appear to be most effective. There are several available types of proven interventions through which providers, and the health system at large, can advance patient adherence to CAD therapies. No single intervention to promote adherence will be successful in all patients. Further study of multifaceted interventions and the interactions between different interventions will be important to advancing the field. The goal is a learning healthcare system in which a network of interventions responds and adapts to patients' needs over time.

Effect of Financial Incentives on Glucose Monitoring Adherence and Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes: A Randomized Clinical Trial

IMPORTANCE

Glycemic control often deteriorates during adolescence and the transition to young adulthood for patients with type 1 diabetes. The inability to manage type 1 diabetes effectively during these years is associated with poor glycemic control and complications from diabetes in adult life.

OBJECTIVE

To determine the effect of daily financial incentives on glucose monitoring adherence and glycemic control in adolescents and young adults with type 1 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

The Behavioral Economic Incentives to Improve Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes (BE IN CONTROL) study was an investigator-blinded, 6-month, 2-arm randomized clinical trial conducted between January 22 and November 2, 2016, with 3-month intervention and follow-up periods. Ninety participants (aged 14-20) with suboptimally controlled type 1 diabetes (hemoglobin A1c [HbA1c] >8.0%) were recruited from the Diabetes Center for Children at the Children's Hospital of Philadelphia.

INTERVENTIONS

All participants were given daily blood glucose monitoring goals of 4 or more checks per day with 1 or more level within the goal range (70-180 mg/dL) collected with a wireless glucometer. The 3-month intervention consisted of a $60 monthly incentive in a virtual account, from which $2 was subtracted for every day of nonadherence to the monitoring goals. During a 3-month follow-up period, the intervention was discontinued.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in HbA1c levels at 3 months. Secondary outcomes included adherence to glucose monitoring and change in HbA1c levels at 6 months. All analyses were by intention to treat.

RESULTS

Of the 181 participants screened, 90 (52 [57.8%] girls) were randomized to the intervention (n = 45) or control (n = 45) arms. The mean (SD) age was 16.3 (1.9) years. The intervention group had significantly greater adherence to glucose monitoring goals in the incentive period (50.0% vs 18.9%; adjusted difference, 27.2%; 95% CI, 9.5% to 45.0%; P = .003) but not in the follow-up period (15.3% vs 8.7%; adjusted difference, 3.9%; 95% CI, -2.0% to 9.9%; P = .20). The change in HbA1c levels from baseline did not differ significantly between groups at 3 months (adjusted difference, -0.08%; 95% CI, -0.69% to 0.54%; P = .80) or 6 months (adjusted difference, 0.03%; 95% CI, -0.55% to 0.60%; P = .93).

CONCLUSIONS AND RELEVANCE

Among adolescents and young adults with type 1 diabetes, daily financial incentives improved glucose monitoring adherence during the incentive period but did not significantly improve glycemic control.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02568501.

Implementation of a workplace intervention using financial rewards to promote adherence to physical activity guidelines: a feasibility study

Background

We designed and implemented the Brigham and Women’s Wellness Initiative (B-Well), a single-arm study to examine the feasibility of a workplace program that used individual and team-based financial incentives to increase physical activity among sedentary hospital employees.

Methods

We enrolled sedentary, non-clinician employees of a tertiary medical center who self-reported low physical activity. Eligible participants formed or joined teams of three members and wore Fitbit Flex activity monitors for two pre-intervention weeks followed by 24 weeks during which they could earn monetary rewards. Participants were rewarded for increasing their moderate-to-vigorous physical activity (MVPA) by 10% from the previous week or for meeting the Centers for Disease Control and Prevention (CDC) physical activity guidelines (150 min of MVPA per week). Our primary outcome was the proportion of participants meeting weekly MVPA goals and CDC physical activity guidelines. Secondary outcomes included Fitbit-wear adherence and factors associated with meeting CDC guidelines more consistently.

Results

B-Well included 292 hospital employees. Participants had a mean age of 38 years (SD 11), 83% were female, 38% were obese, and 62% were non-Hispanic White. Sixty-three percent of participants wore the Fitbit ≥4 days per week for ≥20 weeks. Two-thirds were satisfied with the B-Well program, with 79% indicating that they would participate again. Eighty-six percent met either their personal weekly goal or CDC physical activity guidelines for at least 6 out of 24 weeks, and 52% met their goals or CDC physical activity guidelines for at least 12 weeks. African Americans, non-obese subjects, and those with lower impulsivity scores reached CDC guidelines more consistently.

Conclusions

Our data suggest that a financial incentives-based workplace wellness program can increase MVPA among sedentary employees. These results should be reproduced in a randomized controlled trial.

Trial registration

Clinicaltrials.gov, NCT02850094. Registered July 27, 2016 [retrospectively registered].

Meteorologic and Geographic Barriers to Physical Activity in a Workplace Wellness Program

BACKGROUND

Inclement weather and home environment can act as barriers to physical activity. However, it is unclear if they reduce the activity of persons participating in activity-promoting programs.

METHODS

Data from a 6-month workplace financial incentives program were used to establish the association between meteorologic (temperature, rain, snow, and wind) and geographic factors (urban/nonurban home location and distance between home and work) and moderate to vigorous physical activity (MVPA). Multivariable models were built to estimate mean weekly minutes of MVPA adjusting for demographic factors, clinical factors, and impulsivity.

RESULTS

The 292 participants had a mean age of 38 (SD = 11) years. Eighty-three percent were female and 62% were white. Twenty-nine percent lived within 3 miles of work, and 35% lived in urban areas. Participants who lived more than 3 miles from work averaged 75 [95% confidence interval (CI), 65-84] minutes of weekly MVPA compared with 105 (95% CI, 88-122) minutes for those who lived within 3 miles of work. Urban participants averaged 70 (95% CI, 57-83) minutes of MVPA compared with 91 (95% CI, 80-102) minutes for nonurban participants. Colder temperatures were associated with decreased MVPA, and impulsivity modified the effect.

CONCLUSIONS

Colder temperatures, greater distance from work, and an urban residence are associated with fewer minutes of MVPA.

Effect of a Game-Based Intervention Designed to Enhance Social Incentives to Increase Physical Activity Among Families: The BE FIT Randomized Clinical Trial

IMPORTANCE

Gamification, the application of game design elements such as points and levels in nongame contexts, is often used in digital health interventions, but evidence on its effectiveness is limited.

OBJECTIVE

To test the effectiveness of a gamification intervention designed using insights from behavioral economics to enhance social incentives within families to increase physical activity.

DESIGN, SETTING, AND PARTICIPANTS

The Behavioral Economics Framingham Incentive Trial (BE FIT) was a randomized clinical trial with a 12-week intervention period and a 12-week follow-up period. The investigation was a community-based study between December 7, 2015, and August 14, 2016. Participants in the modified intent-to-treat analysis were adults enrolled in the Framingham Heart Study, a long-standing cohort of families.

INTERVENTIONS

All participants tracked daily step counts using a wearable device or a smartphone, established a baseline, selected a step goal increase, and received daily individual feedback on goal performance by text message or email for 24 weeks. Families in the gamification arm could earn points and progress through levels based on physical activity goal achievement during the 12-week intervention. The game design was meant to enhance collaboration, accountability, and peer support.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of participant-days that step goals were achieved during the intervention period. Secondary outcomes included the proportion of participant-days that step goals were achieved during the follow-up period and the change in the mean daily steps during the intervention and follow-up periods.

RESULTS

Among 200 adults comprising 94 families, the mean age was 55.4 years, and 56.0% (n = 112) were female. During the intervention period, participants in the gamification arm achieved step goals on a significantly greater proportion of participant-days (0.53 vs 0.32; adjusted difference, 0.27; 95% CI, 0.20-0.33; P < .001) and had a significantly greater increase in the mean daily steps compared with baseline (1661 vs 636; adjusted difference, 953; 95% CI, 505-1401; P < .001) than the control arm. During the follow-up period, physical activity in the gamification arm declined but remained significantly greater than that in the control arm for the proportion of participant-days achieving step goals (0.44 vs 0.33; adjusted difference, 0.12; 95% CI, 0.05-0.19; P < .001) and the mean daily steps compared with baseline (1385 vs 798; adjusted difference, 494; 95% CI, 170-818; P < .01).

CONCLUSIONS AND RELEVANCE

Gamification designed to leverage insights from behavioral economics to enhance social incentives significantly increased physical activity among families in the community.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02531763.

Healthy Beyond Pregnancy, a Web-Based Intervention to Improve Adherence to Postpartum Care: Randomized Controlled Feasibility Trial

Background

During the postpartum visit, health care providers address issues with short- and long-term implications for maternal and child health. Women with Medicaid insurance are less likely to return for a postpartum visit compared with women with private insurance. Behavioral economics acknowledges that people do not make exclusively rational choices, rather immediate gratification, cognitive and psychological biases, and social norms influence decision making. Drawing on insights from decision science, behavioral economists have examined how these biases can be modulated through carefully designed interventions. We have developed a Web-based tool, Healthy Beyond Pregnancy, that incorporates empirically derived concepts of behavioral economics to improve adherence rates to the postpartum visit.

Objectives

The primary objectives of this pilot study were to (1) refine and assess the usability of Healthy Beyond Pregnancy and (2) assess the feasibility of a randomized controlled trial (RCT) of the intervention.

Methods

We used a multistep process and multidisciplinary team of maternal-fetal medicine physicians, a behavioral economist, and researchers with expertise in behavioral interventions to design Healthy Beyond Pregnancy. We assessed the usability of the program with the Post-Study System Usability Questionnaire (PSSUQ), a validated 7-point scale, and semistructured interviews with postpartum women. We then conducted a feasibility trial to determine the proportion of eligible women who were willing to participate in an RCT of Healthy Beyond Pregnancy and the proportion of women willing to complete the Web-based program. Exploratory outcomes of the pilot trial included attendance at the postpartum visit, uptake of long-acting reversible contraception, and uptake of any contraception.

Results

The median PSSUQ score for Healthy Beyond Pregnancy was 6.5 (interquartile range: 6.1-7) demonstrating high usability. Semistructured interviews (n=10) provided in-depth comments about users’ experience and further improved the program. A total of 34 postpartum women with Medicaid insurance were approached for the pilot trial, and 30 (88%) were consented and randomized. All women randomized to Healthy Beyond Pregnancy completed the Web-based program, had text-enabled cell phones, and were willing to receive text messages from the study team. Women in the Healthy Beyond Pregnancy arm were more likely to return for a postpartum visit compared with women in the control arm with 85% of women in Healthy Beyond Pregnancy returning versus 53% in the control arm (odds ratio in the Healthy Beyond Pregnancy group: 5.3; 95% CI 0.9-32.0; P=.06).

Conclusions

We have developed a highly usable and acceptable Web-based program designed to increase attendance at the postpartum visit. Our pilot trial demonstrates that women are willing and able to participate in a randomized trial of a Web-based program and text messaging system.

Trial Registration

Clinicaltrials.gov NCT03296774; https://clinicaltrials.gov/ct2/show/NCT03296774 (Archived by WebCite at http://www.webcitation.org/6tpgXFzyk)

A Scoping Review of Behavioral Economic Interventions for Prevention and Treatment of Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

The purpose of this paper was to review studies of behavioral economic interventions (financial incentives, choice architecture modifications, or commitment devices) to prevent type 2 diabetes mellitus (T2DM) among at-risk patients or improve self-management among patients with T2DM.

RECENT FINDINGS

We found 15 studies that used varied study designs and outcomes to test behavioral economic interventions in clinical, workplace, or health plan settings. Of four studies that focused on prevention of T2DM, two found that financial incentives increased weight loss and completion of a fasting blood glucose test, and two choice architecture modifications had mixed effects in encouraging completion of tests to screen for T2DM. Of 11 studies that focused on improving self-management of T2DM, four of six tests of financial incentives demonstrated increased engagement in recommended care processes or improved biometric measures, and three of five tests of choice architecture modifications found improvements in self-management behaviors. Though few studies have tested behavioral economic interventions for prevention or treatment of T2DM, those that have suggested such approaches have the potential to improve patient behaviors and such approaches should be tested more broadly.

Effect of Electronic Reminders, Financial Incentives, and Social Support on Outcomes After Myocardial Infarction: The HeartStrong Randomized Clinical Trial

IMPORTANCE

Adherence to medications prescribed after acute myocardial infarction (AMI) is low. Wireless technology and behavioral economic approaches have shown promise in improving health behaviors.

OBJECTIVE

To determine whether a system of medication reminders using financial incentives and social support delays subsequent vascular events in patients following AMI compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Two-arm, randomized clinical trial with a 12-month intervention conducted from 2013 through 2016. Investigators were blinded to study group, but participants were not. Design was a health plan-intermediated intervention for members of several health plans. We recruited 1509 participants from 7179 contacted AMI survivors (insured with 5 large US insurers nationally or with Medicare fee-for-service at the University of Pennsylvania Health System). Patients aged 18 to 80 years were eligible if currently prescribed at least 2 of 4 study medications (statin, aspirin, β-blocker, antiplatelet agent), and were hospital inpatients for 1 to 180 days and discharged home with a principal diagnosis of AMI.

INTERVENTIONS

Patients were randomized 2:1 to an intervention using electronic pill bottles combined with lottery incentives and social support for medication adherence (1003 patients), or to usual care (506 patients).

MAIN OUTCOMES AND MEASURES

Primary outcome was time to first vascular rehospitalization or death. Secondary outcomes were time to first all-cause rehospitalization, total number of repeated hospitalizations, medication adherence, and total medical costs.

RESULTS

A total of 35.5% of participants were female (n = 536); mean (SD) age was 61.0 (10.3) years. There were no statistically significant differences between study arms in time to first rehospitalization for a vascular event or death (hazard ratio, 1.04; 95% CI, 0.71 to 1.52; P = .84), time to first all-cause rehospitalization (hazard ratio, 0.89; 95% CI, 0.73 to 1.09; P = .27), or total number of repeated hospitalizations (hazard ratio, 0.94; 95% CI, 0.60 to 1.48; P = .79). Mean (SD) medication adherence did not differ between control (0.42 [0.39]) and intervention (0.46 [0.39]) (difference, 0.04; 95% CI, -0.01 to 0.09; P = .10). Mean (SD) medical costs in 12 months following enrollment did not differ between control ($29 811 [$74 850]) and intervention ($24 038 [$66 915]) (difference, -$5773; 95% CI, -$13 682 to $2137; P = .15).

CONCLUSIONS AND RELEVANCE

A compound intervention integrating wireless pill bottles, lottery-based incentives, and social support did not significantly improve medication adherence or vascular readmission outcomes for AMI survivors.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01800201.