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

A Randomized Controlled Trial Comparing Loss versus Gain Incentives to Improve Adherence to an Obesity Treatment Intervention in Adolescents

BACKGROUND/OBJECTIVES

Adherence to pediatric obesity treatment can be challenging. Monetary incentives improve adherence to lifestyle interventions, with incentives framed as loss often more effective than those framed as gain. The objectives of this study were to determine if monetary incentives in the form of gift cards would improve adherence to an obesity treatment intervention and whether framing the incentive as either loss or gain affected adherence.

METHODS

Sixty adolescents with obesity (body mass index of ≥95th percentile for age and sex) were recruited from our pediatric obesity treatment program. They were randomized into one of three groups and given a monthly adherence score (AS) of up to 100 points. These points were based on completing a medical visit, reporting on diet intake, and measuring daily steps on a wearable tracker. The Gain Group (GG), N = 20, started each month with USD 0 in a virtual account and increased their monetary reward up to USD 100 depending on AS. The Loss Group (LG), N = 21, began each month with USD 100 in their virtual account, which decreased based on adherence. The Control Group (CG), N = 19, received USD 10 monthly.

RESULTS

Adherence was highest in the GG, with 66.0 points, compared to the LG, with 54.9 points, and CG, with 40.6 points, with p < 0.01. The GG had greater adherence to their step goal (14.6) and dietary reporting (18.7) compared to the LG (10.0 and 13.9) and the CG (3.9 and 8.1), p < 0.005.

CONCLUSIONS

Gain-framed incentives are superior to loss-framed ones in improving adherence to pediatric obesity treatments.

Adolescent-Preferred financial incentives to promote type 1 diabetes Self-Care: A discrete choice experiment

AIMS

This study aimed to quantify preferences for the characteristics of a financial incentives program that would motivate adolescent engagement in type 1 diabetes (T1D) self-care.

METHOD

We performed a discrete choice experiment with 12-18 year-olds with T1D from two pediatric hospital endocrinology clinics (n = 317). We identified key attributes of incentives: (1) monthly value of the reward, (2) payment structure, and (3) difficulty of incentivized behaviors. In twelve choice questions, adolescents chose the incentive option from a pair of profiles that was more likely to motivate them to increase adherence to recommended self-care. Options presented were tailored to adolescents' T1D technology use and perceived difficulty of completing each behavior. We analyzed data using a conditional logit model.

RESULTS

The value of the reward accounted for 60.8% of preferences. Adolescents were willing to accept lower value rewards when incentive payments used positive vs. negative reinforcement (-$10.88 (95% CI: -$12.60, -9.24)) and preferred higher incentives for performing hard vs. easier behaviors (+$14.92 (95% CI: +$12.66, +$17.28)).

CONCLUSIONS

Stated preferences can inform intervention design. Future research will evaluate the external validity of the discrete choice experiment-informed intervention design by assessing adolescent health and behavioral outcomes in a randomized controlled trial.

Effects of Loss and Gain Incentives on Adherence in Pediatric Weight Management: Preliminary Studies and Economic Evaluation of a Theoretical Trial

Pediatric weight management is often hampered by poor engagement and adherence. Incentives based on loss have been shown to be more effective than gain-based incentives in improving outcomes among children with health conditions other than obesity. In preparation for a clinical trial comparing loss-framed to gain-framed incentives, a survey of youth and caregiver attitudes on weight management incentives, reasons for program attendance, and an economic evaluation of a theoretical trial were conducted. Ninety of 835 (11%) surveys were completed by caregiver and child. The economic evaluation showed that loss-framed incentives had a preferable incremental cost-effectiveness ratio (a lower value is considered preferable) than gain-based incentives. Most youth and caregivers felt a gain incentive would be superior, agreed that the full incentive should go to the youth (vs. the caregiver), and identified "improving health" as a top reason for pursuing weight management.

Designing financial incentives for health behaviour change: a mixed-methods case study of weight loss in men with obesity

Aim

Designing financial incentives for health behaviour change requires choices across several domains, including value (the size of the incentive), frequency of incentives, and direction (gain or loss). However, the rationale underlying complex incentive design is infrequently reported. Transparent reporting is important if we want to understand and improve the incentive development process. This paper describes a mixed methods approach for designing financial incentives for health behaviour change which involves stakeholders throughout the design process.

Subject and methods

The mixed methods approach focuses on incentives for weight loss for men with obesity living in areas with high levels of disadvantage. The approach involves: (a) using an existing framework to identify all domains of a financial incentive scheme for which choices need to be made, deciding what criteria are relevant (such as effectiveness, acceptability and uptake) and making choices on each domain on the basis of the criteria; (b) conducting a survey of target population preferences to inform choices for domains and to design the incentive scheme; and (c) making final decisions at a stakeholder consensus workshop.

Results

The approach was implemented and an incentive scheme for weight loss for men living with obesity was developed. Qualitative interview data from men receiving the incentives in a feasibility trial endorses our approach.

Conclusion

This paper demonstrates that a mixed methods approach with stakeholder involvement can be used to design financial incentives for health behaviour change such as weight loss.

Trial registration number

NCT03040518. Date: 2 February 2017.

Frequency of persistent obesity 5 years after first time diagnosis of status asthmaticus

BACKGROUND/OBJECTIVES

When a severe asthma exacerbation occurs in an obese pediatric patient, it is unknown if this body type persists in future encounters. Persistent obesity can lead to future asthma exacerbations. The main study objective is to evaluate the persistence of a BMI percentile ≥85th in children 5 years after the first reported diagnosis of status asthmaticus. We hypothesized that a hospital admission for status asthmaticus was associated with persistence of a BMI percentile ≥85th.

METHODS

This was a long-term retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects aged 2 to 18 years of age with a diagnosis of status asthmaticus. Study population was divided into two groups based on their admission body mass index percentile: (underweight/healthy weight [<85th percentile] and overweight/obese [≥85th percentile]) and evaluated for the following outcomes: age, race, ethnicity, diagnostic codes, and BMI percentiles (initially and 5 years after diagnosis of status asthmaticus).

RESULTS

A total of 129 subjects (n%) (76 [58.9%] underweight/healthy weight and 53 [41.1%] overweight/obese) were included. Children that were initially overweight/obese with status asthmaticus had significantly increased odds of continuing to be overweight/obese 5 years after diagnosis compared to children who were underweight/healthy weight at baseline (OR = 7.50 [95% confidence interval, 3.20-17.60; p < 0.001]).

CONCLUSIONS

Overweight/obese asthmatic children are at risk of continuing to be obese several years after being diagnosed with status asthmaticus. This study reinforces the notion that when an asthmatic obese child presents with status asthmaticus, a thorough evaluation of nutrition, physical activity, and asthma control should be considered to reduce the risk of persistent obesity and possibly future asthma exacerbations.

Applying Behavioral Economics to Improve Adolescent and Young Adult Health: A Developmentally-Sensitive Approach

Each day, adolescents and young adults (AYAs) choose to engage in behaviors that impact their current and future health. Behavioral economics represents an innovative lens through which to explore decision-making among AYAs. Behavioral economics outlines a diverse set of phenomena that influence decision-making and can be leveraged to develop interventions that may support behavior change. Up to this point, behavioral economic interventions have predominantly been studied in adults. This article provides an integrative review of how behavioral economic phenomena can be leveraged to motivate health-related behavior change among AYAs. We contextualize these phenomena in the physical and social environments unique to AYAs and the neurodevelopmental changes they undergo, highlighting opportunities to intervene in AYA-specific contexts. Our review of the literature suggests behavioral economic phenomena leveraging social choice are particularly promising for AYA health. Behavioral economic interventions that take advantage of AYA learning and development have the potential to positively impact youth health and well-being over the lifespan.

Sustaining the reach of a scalable weight loss intervention through financial incentives- a pragmatic, feasibility, online randomized trial protocol

BACKGROUND

High attrition following initial enrollment in evidence-based weight loss programs is a common, challenging, and under-studied issue. A behavioral economics approach consisting of modest monetary incentives may help to engage participants beyond enrollment to close the initial attrition gap.

PURPOSE

To describe the methods and design of a pragmatic, online randomized controlled trial (RCT) of an incentivized, technology-facilitated weight loss program through an innovative research-practice partnership involving primary care, health promotion researchers, and a small business.

METHODS

This study is a four-arm (1:1:1:1) RCT that compares the efficacy of outcome-based (weight loss), process-based (weighing in), a combination of outcome- and process-based, or choice-based incentives on sustaining program reach after initial enrollment for an evidence-based weight loss program. The multicomponent weight loss program includes a website, social cognitive theory-based daily health coaching, tailored messaging delivered via email and text messaging, access to online health coaches, and objective weight assessment through a community kiosk. The study will enroll 400 individuals aged 19 and older who have a body mass index ≥25 kg/m², and have reliable access to the Internet or a smart phone. Participants will be followed for 3, 6, 9, and 12 months to assess program reach and representativeness, and continued participation after enrollment. The secondary outcomes include weight loss and program implementation costs. We will conduct participant focus groups to understand the barriers and facilitators of participation and key informant interviews focusing on clinic managers and care providers to explore the potential for future adoption and implementation of the evidence-based program.

DISCUSSION

This study possesses the potential to close the attrition gap after initial enrollment in a web-based digital weight loss intervention in the primary care and community settings. Clinicaltrials.gov registration: NCT04225234.

Adolescent and parent perspectives on the acceptability of financial incentives to promote self-care in adolescents with type 1 diabetes

BACKGROUND

An understanding of acceptability among potential intervention participants is critical to the design of successful real-world financial incentive (FI) programs. The purpose of this qualitative study was to explore adolescent and parent perspectives on the acceptability of using FI to promote engagement in diabetes self-care in adolescents with type 1 diabetes (T1D).

METHODS

Focus groups with 46 adolescents with T1D (12-17 years old) and 39 parents of adolescents with T1D were conducted in the Seattle metropolitan area. Semistructured questions addressed participants' current use of incentives to promote change in diabetes self-care and receptivity to a theoretical incentive program administered by a third-party. Qualitative data were analyzed and emergent themes identified.

RESULTS

Three thematic categories informed participant views about the acceptability of FI programs: (a) the extent to which using FIs in the context of diabetes management fit comfortably into a family's value system, (b) the perceived effectiveness for FIs to promote improved diabetes self-care, and (c) the urgent need for improved self-care due to the threat of diabetes-related health complications. These factors together led most parents and adolescents to be open to FI program participation.

CONCLUSIONS

The results from this qualitative study suggest that well-designed FI programs to support diabetes management are acceptable to families with adolescents with T1D. Additionally, the use of FIs may have the potential to support adolescents with T1D in developing strong self-care habits and ease the often-turbulent transition to independent self-care.

Using discrete choice experiments to develop and deliver patient-centered psychological interventions: a systematic review

Developing and/or tailoring psychological interventions to align with patient preferences is a critical component of patient-centered care and has the potential to improve patient engagement and treatment outcomes. Discrete choice experiments (DCEs) are a quantitative method of assessing patient preferences that offer numerous strengths (i.e., ability to account for trade-offs), but are not routinely incorporated into health psychology coursework, likely leaving many unaware of the potential benefits of this methodology. To highlight the potential applications of DCEs within health psychology, this systematic review synthesises previous efforts to utilise DCEs to inform the design of patient-centered psychological care, defined as interventions targeting psychological (e.g., depression, anxiety) or behavioural health (e.g., pain management, adherence) concerns. Literature searches were conducted in March 2017 and November 2019 for articles reporting on DCEs using the terms 'discrete choice', 'conjoint', or 'stated preference'. Thirty-nine articles met all inclusion criteria and used DCEs to understand patient preferences regarding psychosocial clinical services (n = 12), lifestyle behaviour change interventions (n = 11), HIV prevention and/or intervention services (n = 10), disease self-management programmes (n = 4), or other interventions (n = 2). Clinical implications as well as limitations and directions for future research are discussed.

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.