Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial

Hourly step recommendations to achieve daily goals for working and older adults

BACKGROUND

The widespread use of physical activity trackers enables the collection of high-resolution health data, such as hourly step counts, to evaluate health promotion programmes. We aim to investigate how participants meet their daily step goals.

METHODS

We used 24-h steps data from the National Steps ChallengeTM Season 3, wherein participants were rewarded with vouchers when achieving specified goals of 5000, 7500, and 10,000 steps per day. We extracted data from 3075 participants' including a total of 52,346 participant-days. We modelled the hourly step counts using a two-part model, in which the distribution for step counts was allowed to depend on the sum of step counts up to the previous hour and participant demographics.

RESULTS

Participants have a mean age of 44.2 years (standard deviation = 13.9), and 40.4% are males. We show that on weekdays, the hourly mean step counts among participants aged 60 and above are higher than participants aged 30 to 59 from the start of the day till 6 p.m. We also find that participants who accumulate at least 7000 steps by 7 p.m. are associated with higher success of achieving 10,000 steps.

CONCLUSIONS

We provide recommendations on the hourly targets to achieve daily goals, based on different participants' characteristics. Future studies could experimentally test if prompts and nudges at the recommended times of day could promote reaching step goals.

Evaluation of the "15 Minute Challenge": A Workplace Health and Wellbeing Program

The 15 Minute Challenge is an mHealth workplace wellness initiative, employing gamification to promote physical activity, aiming to enhance health outcomes and overall well-being. This retrospective cohort study evaluated the effectiveness of the program among employees at various Australian, New Zealand, and UK workplaces. Real-world data from 11,575 participants across 73 companies were analyzed. The program encouraged daily 15 min physical activity sessions over six weeks. Participants self-reported their physical activity and fitness, energy, overall health, sleep quality, and mood at baseline and 6 weeks. Program satisfaction, engagement rates, and adherence to the program were also assessed. Effectiveness was evaluated using multi-level mixed-effects linear regression analyses. The intervention showed significant increases in physical activity, with 95% of participants meeting or exceeding international physical activity guidelines, up from 57% at baseline (p < 0.05). Self-reported fitness, energy, overall health, sleep quality, and mood significantly improved (between 7.1 and 14.0% improvement; all p < 0.05). High satisfaction was reported, with 92% of participants recommending the program. The 15 Minute Challenge effectively increased physical activity levels and improved self-reported health outcomes among participating employees. The high satisfaction rates and significant health improvements highlight the potential of workplace wellness programs to combat sedentary behavior and promote a healthier, more active lifestyle.

Could nudges reduce health literacy disparities in CVD prevention? An experiment using alternative messages for CVD risk assessment screening

OBJECTIVE

To explore the effect of SMS nudge messages amongst people with varying health literacy on their intention to get a Heart Health Check.

METHODS

A 3 (Initial SMS: scarcity, regret, or control nudge) x 2 (Reminder SMS: social norm or control nudge) factorial design was used in a hypothetical online experiment. 705 participants eligible for Heart Health Checks were recruited. Outcomes included intention to attend a Heart Health Check and psychological responses.

RESULTS

In the control condition, people with lower health literacy had lower behavioural intentions compared to those with higher health literacy (p = .011). Scarcity and regret nudges closed this gap, resulting in similar intention levels for lower and higher health literacy. There was no interactive effect of the reminder nudge and health literacy (p = .724).

CONCLUSION

Scarcity and regret nudge messages closed the health literacy gap in behavioural intentions compared to a control message, while a reminder nudge had limited additional benefit. Health literacy should be considered in behavioural intervention evaluations to ensure health equity is addressed.

PRACTICE IMPLICATIONS

Results informed a national screening program using a universal precautions approach, where messages with higher engagement for lower health literacy groups were used in clinical practice.

Dyad and group-based interventions in physical activity, diet, and weight loss: a systematic review of the evidence

Studies show that interpersonal relations impact behavior change. Yet, a comprehensive review of their efficacy remains unclear. This systematic review examines the efficacy of dyadic and group-based studies that intervened on primary endpoints: diet, PA, and weight loss in adults and their networks. We searched five databases for eligible articles published from 1980 to present. Final inclusion and risk of bias were independently determined and agreed upon by two of the paper's co-authors. Nine dyads and twelve group-based studies were eligible. Of the studies, 36% (4/11) of PA studies, 60% (3/5) of diet studies and 57% (8/14) of studies with weight loss as primary outcomes, reported significant findings. Compared to dyadic interventions, a greater proportion of group-based interventions demonstrated efficacy in PA gain and weight loss as outcomes. Approximately 43% of studies demonstrated low to moderate methodological quality. This systematic review synthesized the evidence of dyadic and group studies that intervened on PA, diet, and weight in adults from the same network. Moderately-high risk of bias and lack of diverse representation restricts inferences around efficacy. High-quality rigorous research is needed to understand the efficacy of dyadic and group-based interventions in addressing these co-occurring endpoints of interest.

Effect of Gamification, Financial Incentives, or Both to Increase Physical Activity Among Patients at High Risk of Cardiovascular Events: The BE ACTIVE Randomized Controlled Trial

BACKGROUND

Physical activity is associated with a lower risk of major adverse cardiovascular events, but few individuals achieve guideline-recommended levels of physical activity. Strategies informed by behavioral economics increase physical activity, but their longer-term effectiveness is uncertain. We sought to determine the effect of behaviorally designed gamification, loss-framed financial incentives, or their combination on physical activity compared with attention control over 12-month intervention and 6-month postintervention follow-up periods.

METHODS

Between May 2019 and January 2024, participants with clinical atherosclerotic cardiovascular disease or a 10-year risk of myocardial infarction, stroke, or cardiovascular death of ≥7.5% by the Pooled Cohort equation were enrolled in a pragmatic randomized clinical trial. Participants received a wearable device to track daily steps, established a baseline, selected a step goal increase, and were randomly assigned to control (n=151), behaviorally designed gamification (n=304), loss-framed financial incentives (n=302), or gamification+financial incentives (n=305). The primary outcome of the trial was the change in mean daily steps from baseline through the 12-month intervention period.

RESULTS

A total of 1062 patients (mean±SD age, 67±8; 61% female; 31% non-White) were enrolled. Compared with control subjects, participants had significantly greater increases in mean daily steps from baseline during the 12-month intervention in the gamification arm (adjusted difference, 538.0 [95% CI, 186.2-889.9]; P=0.0027), financial incentives arm (adjusted difference, 491.8 [95% CI, 139.6-844.1]; P=0.0062), and gamification+financial incentives arm (adjusted difference, 868.0 [95% CI, 516.3-1219.7]; P<0.0001). During the 6-month follow-up, physical activity remained significantly greater in the gamification+financial incentives arm than in the control arm (adjusted difference, 576.2 [95% CI, 198.5-954]; P=0.0028), but it was not significantly greater in the gamification (adjusted difference, 459.8 [95% CI, 82.0-837.6]; P=0.0171) or financial incentives (adjusted difference, 327.9 [95% CI, -50.2 to 706]; P=0.09) arms after adjustment for multiple comparisons.

CONCLUSIONS

Behaviorally designed gamification, loss-framed financial incentives, and the combination of both increased physical activity compared with control over a 12-month intervention period, with the largest effect in gamification+financial incentives. These interventions could be a useful component of strategies to reduce cardiovascular risk in high-risk patients.

REGISTRATION

URL: https://clinicaltrials.gov; Unique Identifier: NCT03911141.

What are the important factors influencing the physical activity level of junior high school students: a cross-sectional survey

Background

Engaging in regular physical activity has been consistently linked to improved physical health and academic performance. Despite its known benefits, there is a concerning trend of decreased physical activity among children globally. The study primarily aims to investigate the level of physical activity among junior high school students in Taiyuan and analyse the main affecting factors from a socio-ecological perspective.

Methods

A cross-sectional study was conducted, involving 650 junior high school students from 7 schools in Taiyuan, and 648 valid questionnaires were ultimately collected. The data on students' physical activity levels were collected through the Children's Leisure Activities Study Survey Questionnaire, and the data on factors affecting students' physical activity were collected through the Student Perceived Factors Affecting Physical Activity Questionnaire.

Results

In this study, students from the 7th, 8th, and 9th grades participated in physical activities, averaging 214.500 min per week in moderate-intensity and 25.000 min in high-intensity activities, cumulatively averaging 280.000 min weekly. Notably, a significant disparity (p = 0.012) was observed in the combined duration of moderate and high-intensity activities, with male students engaging more time compared to their female counterparts (307.500 vs. 255.000 min). This variance extended across different grades, particularly evident in 8th graders who recorded the highest weekly high-intensity activity duration (31.000 min) and overall physical activity time (320.500 min), surpassing the 7th graders(p = 0.007 for high-intensity activities). Furthermore, an exploratory factor analysis of a 32-item questionnaire, designed to identify determinants of physical activity, revealed six principal components. These components were found to positively correlate with both moderate and high-intensity physical activities.

Conclusion

Results emphasize that educational institutions and community programs should collaborate to offer engaging weekend physical activity programs. Schools should develop and implement tailored physical education curricula addressing gender and grade differences. Furthermore, schools and local governments should invest in high-quality sports equipment and facilities.

Are cash incentives always king? A randomized controlled trial evaluating hedonic versus cash incentives (TEH-C)

Introduction

Physical inactivity is a risk factor for obesity and non-communicable diseases. Despite myriad health and non-health benefits resulting from physical activity (PA), most individuals do not meet PA recommendations. Providing an incentive for meeting activity goals may increase activity levels. Classical economists argue that cash is the best incentive. Behavioral economists have posited that hedonic (pleasurable) incentives (e.g., massages, restaurant meals) may be superior to cash when incentives are offered over multiple time periods. To date, no studies have directly compared the effectiveness of cash versus hedonic incentives in promoting PA across multiple time periods.

Methods

We conducted a two-arm, parallel, 4-month randomized controlled trial with healthy adults in Singapore where participants were randomized to either cash or hedonic incentives. Participants could earn up to SGD50 (≈USD37) in cash or hedonic incentives each month they met the study's step target of 10,000 steps daily on at least 20/25 days out of the first 28 days of a month. The primary objective was to compare the mean proportion of months that participants met the step target between the two arms.

Results

By month 4, participants in the cash (N = 154) and hedonic incentive (N = 156) arms increased their mean daily steps by 870 (p < 0.001) and 1,000 steps (p < 0.001), respectively. The mean proportion of months the step target was achieved was 90.53 and 88.34 for participants in the cash and hedonic incentive arms respectively, but differences across arms were small and not statistically significant for this or any outcome assessed.

Conclusion

Our findings suggest that both cash and hedonic incentives are effective at promoting physical activity but that neither strategy is clearly superior.Clinical trial registration: ClinicalTrials.gov, NCT04618757 registered on November 6, 2020.

Incentivised physical activity intervention promoting daily steps among university employees in the workplace through a team-based competition

Introduction

The benefits of walking on health and well-being is well established and regarded as the most accessible form of physical activity (PA) that most individuals can incorporate into their lives. Despite the benefits, the impact of a competitive walking intervention combined with a prize incentive in the workplace is yet to be established. The aim of this intervention was to promote PA among university employees through teams-based competition with a prize incentive targeted towards the recommended 10,000 steps per day.

Methods

A total of 49 employees participated and formed eight departmental teams ranging from Senior Admin management, Educational & Social work, Nursing & Midwifery, Sport & Exercise, Health Sciences, Admin Assistant, Library, and IT to compete in a walking intervention. Each team was handed an ActiGraph wGT3X-BT from Monday to Friday to record their walking steps. Steps. Post intervention participants completed an open-ended survey to provide their views about the intervention.

Results

The ActiGraph findings determined that steps increased by 4,799 per day from daily baseline of 5,959 to 10,758 throughout this intervention. The themes from qualitative data showed that the prize incentive and competitive nature of this intervention has motivated staff to walk more, changed their behaviour, enjoyed the team-based competition, and improved perceived productivity in the workplace.

Discussion and conclusion

This intervention increased employees' daily steps by 4,799 and met the 10,000 steps guideline. The 'Health Sciences' team recorded the highest steps 531,342 followed by the 'Education and Social Work' accumulating 498,045 steps throughout this intervention. This intervention with prize incentive demonstrated a positive impact on employees personal and work-based outcomes as well as contributed to the workplace PA, health, and wellbeing literature, and more specifically, to the scarce research focused on university settings.

Harnessing technology and gamification to increase adult physical activity: a cluster randomized controlled trial of the Columbia Moves pilot

BACKGROUND

The use of health technologies and gamification to promote physical activity has increasingly been examined, representing an opportunistic method for harnessing social support inherent within existing social ties. However, these prior studies have yielded mixed findings and lacked long-term follow-up periods. Thus, a pilot cluster randomized controlled trial was conducted to gauge the feasibility and preliminary efficacy of a digital gamification-based physical activity promotion approach among teams of insufficiently active adults with existing social ties.

METHODS

Teams (N = 24; 116 total participants) were randomized to either a 12-week intervention (Fitbit, step goals, app, feedback; TECH) or the same program plus gamification (TECH + Gamification). Mixed effects models were used to compare group differences in treatment adherence, and changes in social support, steps, and moderate-to-vigorous physical activity at 12 weeks and 52 weeks from baseline, adjusted for sociodemographic characteristics and team size.

RESULTS

TECH had a lower mean number of days of Fitbit self-monitoring versus TECH + Gamification during the intervention (adjusted difference: -.30; 95% CI, -.54 to -.07; P = .01). Post-intervention, TECH had 47% lower odds of self-monitoring 7 days per week versus TECH + Gamification (.53; 95% CI, .31 to .89; P = .02). No differences were observed between TECH + Gamification and TECH in increases in social support (0.04; 95% CI, -.21 to .29; P = .76), ActiGraph-measured daily steps (-425; 95% CI, -1065 to 215; P = .19), or moderate-to-vigorous physical activity minutes (-3.36; 95% CI, -8.62 to 1.91; P = .21) from baseline to 12 weeks or in the regression of these improvements by 1 year (Ps > .05). Although not significant in the adjusted models (Ps > .05), clinically meaningful differences in Fitbit-measured daily steps (TECH, 7041 ± 2520; TECH + Gamification, 7988 ± 2707) and active minutes (TECH, 29.90 ± 29.76; TECH + Gamification, 36.38 ± 29.83) were found during the intervention.

CONCLUSIONS

A gamified physical activity intervention targeting teams of adults with existing social ties was feasible and facilitated favorable, clinically meaningful additive physical activity effects while in place but did not drive enhanced, long-term physical activity participation. Future investigations should explore optimal team dynamics and more direct ways of leveraging social support (training teams; gamifying social support).

TRIAL REGISTRATION

Clinicaltrials.gov ( NCT03509129 , April 26, 2018).

A randomized controlled trial of gamification, financial incentives, or both to increase physical activity among patients with elevated risk for cardiovascular disease: rationale and design of the be active study

BACKGROUND

Higher levels of physical activity are associated with improvements in cardiovascular health, and consensus guidelines recommend that individuals with or at risk for atherosclerotic cardiovascular disease (ASCVD) participate in regular physical activity. However, most adults do not achieve recommended levels of physical activity. Concepts from behavioral economics have been used to design scalable interventions that increase physical activity over short time periods, but the longer-term efficacy of these strategies is uncertain.

STUDY DESIGN AND OBJECTIVES

BE ACTIVE (NCT03911141) is a pragmatic, virtual, randomized controlled trial designed to evaluate the effectiveness of 3 strategies informed by behavioral economic concepts to increase daily physical activity in patients with established ASCVD or 10-year ASCVD risk > 7.5% who are seen in primary care and cardiology clinics affiliated with the University of Pennsylvania Health System. Patients are contacted by email or text message, and complete enrollment and informed consent on the Penn Way to Health online platform. Patients are then provided with a wearable fitness tracker, establish a baseline daily step count, set a goal to increase daily step count by 33% to 50%, and are randomized 1:2:2:2 to control, gamification, financial incentives, or both gamification and financial incentives. Interventions continue for 12 months, with follow-up for an additional 6 months to evaluate the durability of behavior change. The trial has met its enrollment goal of 1050 participants, with a primary endpoint of change from baseline in daily steps over the 12-month intervention period. Key secondary endpoints include change from baseline in daily steps over the 6-month post-intervention follow-up period and change in moderate to vigorous physical activity over the intervention and follow-up periods. If the interventions prove effective, their effects on life expectancy will be compared with their costs in cost-effectiveness analysis.

CONCLUSIONS

BE ACTIVE is a virtual, pragmatic randomized clinical trial powered to demonstrate whether gamification, financial incentives, or both are superior to attention control in increasing physical activity. Its results will have important implications for strategies to promote physical activity in patients with or at risk for ASCVD, as well as for the design and implementation of pragmatic virtual clinical trials within health systems.

Evaluation of the Effectiveness of Behavioral Economic Incentive Programs for Goal Achievement on Healthy Diet, Weight Control and Physical Activity: A Systematic Review and Network Meta-analysis

BACKGROUND

Healthy diet, weight control and physical activity to reduce obesity can be motivated by financial incentives (FI). Behavioral-economic approaches may improve the incentivization effectiveness. This study compares and ranks the effectiveness of standard and behavioral incentivization for healthy diet, weight control, and physical activity promotion.

PURPOSE

To investigate whether behavioral-economic insights improve incentivization effectiveness.

METHODS

A systematic search of Medline and Scopus was performed from database inception to December 2020. Study characteristics, program designs, and risk ratio (RR) were extracted. A two-stage network meta-analysis pooled and ranked intervention effects.

RESULTS

There were 35 eligible RCTs. For diet-weight control, standard FI, deposit contract (deposit), lottery-based incentive (lottery), and standard-FI + lottery increased goal achievement compared to no-FI but only deposit was statistically significant with pooled RRs and 95% confidence intervals (CI) of 1.21 (0.94, 1.56), 1.79 (1.04, 3.05), 1.45 (0.99, 2.13), and 1.73 (0.83, 3.63). For physical activity, standard-FI, deposit, and lottery significantly increased goal achievement compared to no-FI, with pooled RRs of 1.38 (1.13, 1.68), 1.63 (1.24, 2.14) and 1.43 (1.14, 1.80), respectively. In a follow-up period for physical activity, only deposit significantly increased goal achievement compared to no-FI, with pooled RRs of 1.39 (1.11, 1.73).

CONCLUSION

Deposit, followed by lottery, were best for motivating healthy diet, weight control and physical activity at program end. Post-intervention, deposit then standard-FI were best for motivating physical activity. Behavioral insights can improve incentivization effectiveness, although lottery-based approaches may offer only short-term benefit regarding physical activity. However, the imprecise intervention effects were major concerns.

Feasibility and outcomes from using a commitment device and text message reminders to increase adherence to time-restricted eating: A randomized trial

BACKGROUND

Obesity is strongly associated with cardiovascular disease, particularly through its effects on blood pressure. Though maintaining a negative caloric balance leads to weight loss, many patients struggle to adhere to low calorie diets over the long term. Time-restricted eating, a subtype of intermittent fasting (IF), may be an easier dietary pattern for patients to initiate and maintain. We tested the feasibility of a bidirectional texting strategy to help patients with obesity and hypertension initiate and maintain time-restricted eating, and whether a commitment device, a pledge to behave in a certain way in the future while making nonadherence costlier, would increase adherence beyond bidirectional texting.

METHODS

Patients with obesity and hypertension seen in cardiology clinics were provided education on time-restricted eating and randomized to a commitment device versus attention control. Attention control consisted of daily bidirectional text messages asking whether patients adhered to IF and weekly text messages asking participants to send their weight and blood pressure. The commitment device involved the same text messages as attention control, plus a commitment contract, setting of implementation intentions with respect to details of time-restricted eating, and involvement of a support partner who received weekly updates on the participant's adherence to time-restricted eating. The intervention lasted 12 weeks, followed by a 6-week follow-up period. The primary outcome was days per week adherent to time-restricted eating over the 18-week study period, measured by daily self-report. We also compared change from baseline weight and blood pressure between randomized groups.

RESULTS

A total of 37 patients were randomized and started the study-20 to attention control and 17 to the commitment device. Mean age was 60 years old, and mean BMI was 38.4 kg/m2. Over the 18-week study period, the mean ± standard deviation (SD) number of days per week adherent to time-restricted eating was 4.7 ± 1.9 in the control arm and 5.4 ± 1.7 in the intervention arm (P = .23). Mean systolic blood pressure declined from 135 to 128 mm Hg among all participants (P = .006) with no difference between groups in change from baseline blood pressure (P = .74). Weight decreased from 229 to 223 pounds among all participants (P = .25) with no significant difference between groups in change from baseline weight (P = .84).

CONCLUSIONS

A bidirectional texting strategy was feasible for helping patients with obesity and hypertension initiate and adhere to time-restricted eating. Adding a commitment device to bidirectional texting did not increase adherence to time-restricted eating compared with attention control, nor were there significant between group changes in blood pressure or weight, but these comparisons were underpowered. A larger randomized trial of the effect of this scalable intervention, compared with usual care, on blood pressure and weight among patients with obesity and hypertension is warranted.

CLINICAL TRIALS REGISTRATION

clinicaltrials.gov; unique identifier: NCT04836312.

Physical Activity Trends Among Adults in a National Mobile Health Program: A Population-Based Cohort Study of 411,528 Adults

Physical inactivity is a global public health challenge, and effective, large-scale interventions are needed. We examined the effectiveness of a population-wide mobile health (mHealth) intervention in Singapore, National Steps Challenge Season 3 (NSC3) and 2 booster challenges (Personal Pledge and Corporate Challenge). The study includes 411,528 participants. We used regression discontinuity design and difference-in-difference with fixed-effects regression to examine the association of NSC3 and the additional booster challenges on daily step counts. Participants tended to be female (58.5%), with an average age of 41.5 years (standard deviation, 13.9) and body mass index (weight (kg)/height (m)2) of 23.8 (standard deviation, 4.5). We observed that NSC3 was associated with a mean increase of 1,437 steps (95% confidence interval (CI): 1,408, 1,467) per day. Enrollments in Personal Pledge and Corporate Challenge were associated with additional mean increases of 1,172 (95% CI: 1,123, 1,222) and 896 (95% CI: 862, 930) steps per day, respectively. For NSC3, the associated mean increase in the step counts across different sex and age groups varied, with greater increases for female participants and those in the oldest age group. We provide real-world evidence suggesting that NSC3 was associated with improvements in participants' step counts. Results suggest NSC3 is an effective and appealing population-wide mHealth physical activity intervention.

Lottery incentives for smoking cessation at the workplace: design and protocol of the smoke-free lottery - a cluster randomized trial

BACKGROUND

Smoking is the leading behavioral risk factor for the loss of healthy life years. Many smokers want to quit, but have trouble doing so. Financial incentives in workplace settings have shown promising results in supporting smokers and their design influences their impact. Lotteries that leverage behavioral economic insights might improve the effectiveness of workplace cessation support.

METHODS AND DESIGN

We examine in a cluster randomized trial if a workplace cessation group training paired with lottery deadlines will increase continuous abstinence rates over and above the cessation training alone. Organizations are randomized to either the control arm or lottery arm. The lotteries capitalize regret aversion by always informing winners at the deadline, but withholding prizes if they smoked. In the lottery-arm, winners are drawn out of all participants within a training group, regardless of their smoking status. In weeks 1-13 there are weekly lotteries. Winners are informed about their prize (€50), but can only claim it if they did not smoke that week, validated biochemically. After 26 weeks, there is a long-term lottery where the winners are informed about their prize (vacation voucher worth €400), but can only claim it if they were abstinent between weeks 13 and 26. The primary outcome is continuous abstinence 52 weeks after the quit date.

DISCUSSION

There is a quest for incentives to support smoking cessation that are considered fair, affordable and effective across different socioeconomic groups. Previous use of behavioral economics in the design of lotteries have shown promising results in changing health behavior. This cluster randomized trial aims to demonstrate if these lotteries are also effective for supporting smoking cessation. Therefore the study design and protocol are described in detail in this paper. Findings might contribute to the application and development of effective cessation support at the workplace.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NL8463 . Date of registration: 17-03-2020.

Do physical activity interventions combining self-monitoring with other components provide an additional benefit compared with self-monitoring alone? A systematic review and meta-analysis

Objective

To determine the net effect of different physical activity intervention components on step counts in addition to self-monitoring.

Design

A systematic review with meta-analysis and meta-regression.

Data sources

Five databases (PubMed, Scopus, Web of Science, ProQuest and Discus) were searched from inception to May 2022. The database search was complemented with backward and forward citation searches and search of the references from relevant systematic reviews.

Eligibility criteria

Randomised controlled trials comparing an intervention using self-monitoring (active control arm) with an intervention comprising the same treatment PLUS any additional component (intervention arm).

Data extraction and synthesis

The effect measures were mean differences in daily step count. Meta-analyses were performed using random-effects models, and effect moderators were explored using univariate and multivariate meta-regression models.

Results

Eighty-five studies with 12 057 participants were identified, with 75 studies included in the meta-analysis at postintervention and 24 at follow-up. At postintervention, the mean difference between the intervention and active control arms was 926 steps/day (95% CI 651 to 1201). At a follow-up, the mean difference was 413 steps/day (95% CI 210 to 615). Interventions with a prescribed goal and involving human counselling, particularly via phone/video calls, were associated with a greater mean difference in the daily step count than interventions with added print materials, websites, smartphone apps or incentives.

Conclusion

Physical activity interventions that combine self-monitoring with other components provide an additional modest yet sustained increase in step count compared with self-monitoring alone. Some forms of counselling, particularly remote phone/video counselling, outperformed other intervention components, such as websites and smartphone apps.

PROSPERO registered number

CRD42020199482.

Measuring “Nudgeability”: Development of a Scale on Susceptibility to Physical Activity Nudges among College Students

Background: The current college lifestyle create more opportunities for students to develop unhealthy behaviors, especially physical inactivity. Nudging could be an effective tool to improve physical activity behaviors by changing college settings. One-nudge-fits-all leads to ineffective nudges, so it is necessary to develop a reliable and valid instrument capable of measuring the “nudgeability” of physical activity nudges for college students, which is for a higher level of nudge efficacy. Method: Developing the College Physical Activity Nudges Susceptibility Scale (CPANSS) that integrated the nudge method with the Likert scale, which is the first attempt to measure the susceptibility to nudges directly by a scale. There are four steps for developing CPANSS, including Scale Dimensions, Item Generation, Exploratory Factor Analysis (n = 294), and Confirmatory Factor Analysis (n = 293) with appropriate procedures. Results: The five-factor 21-item CPANSS with good reliability and validity fitted the data reasonably well. Conclusion: The CPANSS was to provide a new tool for policymakers to design effective nudges in changing and promoting physical activity in college settings, and to provide a method for scholars to promote other healthy behaviors for different target groups.

Economic evaluation of an incentive-based program to increase physical activity and reduce sedentary behaviour in middle-aged adults

BACKGROUND

Incentive-based programs represent a promising approach for health insurers to encourage health-promoting behaviours. However, little is known about the value for money of such programs. This study aimed to determine the cost-effectiveness of the ACHIEVE (Active CHoices IncEntiVE) program designed to incentivise increased physical activity and reduced sedentary behaviour in middle-aged adults.

METHODS

 A within-trial cost-efficacy analysis was conducted. Benefits were assessed by evaluating paired t-tests from participants' pre- and post- trial Body Mass Index (BMI) (kg/m2), sitting time (minutes/day) and metabolic equivalents (METS) minutes. A health sector perspective was adopted for the assessment of costs. Pathway analysis was used to determine the resource use associated with the intervention, with costs expressed in Australian dollars (A$) for the 2015 reference year. A long-term cost-effectiveness analysis was undertaken which extended the analysis time horizon and the trial population to the relevant eligible Australian population. Within this analysis, the 16-week intervention was modelled for roll-out across Australia over a 1-year time horizon targeting people with private health insurance who are insufficiently active and highly sedentary. Improved health related quality of life quantified in Health-Adjusted Life Years (HALYs) (based on the health impacts of increased metabolic equivalent (MET) minutes and reduced body mass index (BMI) and cost-offsets (resulting from reductions in obesity and physical inactivity-related diseases) were tracked until the cohort reached age 100 years or death. A 3% discount rate was used and all outcomes were expressed in 2010 values. Simulation modelling techniques were used to present 95% uncertainty intervals around all outputs.

RESULTS

 The within-trial cost-efficacy analysis indicated that the ACHIEVE intervention cost approximately A$77,432. The cost per participant recruited was A$944. The incremental cost-effectiveness ratio (ICER) for MET increase per person per week was A$0.61; minute of sedentary time reduced per participant per day was A$5.15 and BMI unit loss per participant was A$763. The long-term cost effectiveness analysis indicated that if the intervention was scaled-up to all eligible Australians, approximately 265,095 participants would be recruited to the program at an intervention cost of A$107.4 million. Health care cost savings were A$33.4 million. Total HALYs gained were 2,709. The mean ICER was estimated at A$27,297 per HALY gained which is considered cost-effective in the Australian setting.

CONCLUSION

 The study findings suggest that financial incentives to promote physical activity and reduce sedentary behaviour are likely to be cost-effective.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12616000158460 (10/02/2016).

Nudges used to promote physical activity and to reduce sedentary behaviour in the workplace: Results of a scoping review

Physical inactivity is one of the most important risk factors for non-communicable diseases. Workplace health promotion is therefore of growing interest to support an active day using nudges. The scoping review aims to (a) analyse how frequently nudges are applied in workplace health promotion to increase physical activity and/or reduce sedentary behaviour, and (b) characterise the nudges used. A systematic database search was conducted for the period 2009 to June 2020. According to predefined inclusion and exclusion criteria, studies promoting physical activity and/or reducing sedentary behaviour using nudges were included. Nudges were classified according to MINDSPACE and TIPPME. A study protocol was previously published. Of the 256 studies identified, 26 used nudges. Most studies were conducted in Europe (n = 12) and the USA (n = 8). N = 18 studies targeted physical activity and n = 8 studies targeted sedentary behaviour. In most studies promoting physical activity, prompts were given to climb stairs (n = 11). Interventions targeting sedentary behaviour were more diverse, using digital interventions or mixed approaches (n = 8). Although nudges can help increase physical activity and reduce sedentary behaviour, there are still gaps in terms of their effective and efficient use. There is a lack of long-term studies that analyse habituation and behavioural changes beyond the intervention period. In addition, the potential of digital and mixed approaches is not yet fully exploited. Further studies from low- and middle-income countries with different climates and working conditions are needed to investigate the feasibility of approaches and advance the fight against physical inactivity.

Predicting changes in glycemic control among adults with prediabetes from activity patterns collected by wearable devices

The use of wearables is increasing and data from these devices could improve the prediction of changes in glycemic control. We conducted a randomized trial with adults with prediabetes who were given either a waist-worn or wrist-worn wearable to track activity patterns. We collected baseline information on demographics, medical history, and laboratory testing. We tested three models that predicted changes in hemoglobin A1c that were continuous, improved glycemic control by 5% or worsened glycemic control by 5%. Consistently in all three models, prediction improved when (a) machine learning was used vs. traditional regression, with ensemble methods performing the best; (b) baseline information with wearable data was used vs. baseline information alone; and (c) wrist-worn wearables were used vs. waist-worn wearables. These findings indicate that models can accurately identify changes in glycemic control among prediabetic adults, and this could be used to better allocate resources and target interventions to prevent progression to diabetes.

Association between behavioral phenotypes and sustained use of smartphones and wearable devices to remotely monitor physical activity

Smartphones and wearable devices can be used to remotely monitor health behaviors, but little is known about how individual characteristics influence sustained use of these devices. Leveraging data on baseline activity levels and demographic, behavioral, and psychosocial traits, we used latent class analysis to identify behavioral phenotypes among participants randomized to track physical activity using a smartphone or wearable device for 6 months following hospital discharge. Four phenotypes were identified: (1) more agreeable and conscientious; (2) more active, social, and motivated; (3) more risk-taking and less supported; and (4) less active, social, and risk-taking. We found that duration and consistency of device use differed by phenotype for wearables, but not smartphones. Additionally, "at-risk" phenotypes 3 and 4 were more likely to discontinue use of a wearable device than a smartphone, while activity monitoring in phenotypes 1 and 2 did not differ by device type. These findings could help to better target remote-monitoring interventions for hospitalized patients.

The Role of Behavioral Economics in Improving Cardiovascular Health Behaviors and Outcomes

PURPOSE OF REVIEW

Behavioral economics represents a promising set of principles to inform the design of health-promoting interventions. Techniques from the field have the potential to increase quality of cardiovascular care given suboptimal rates of guideline-directed care delivery and patient adherence to optimal health behaviors across the spectrum of cardiovascular care delivery.

RECENT FINDINGS

Cardiovascular health-promoting interventions have demonstrated success in using a wide array of principles from behavioral economics, including loss framing, social norms, and gamification. Such approaches are becoming increasingly sophisticated and focused on clinical cardiovascular outcomes in addition to health behaviors as a primary endpoint. Many approaches can be used to improve patient decisions remotely, which is particularly useful given the shift to virtual care in the context of the COVID-19 pandemic. Numerous applications for behavioral economics exist in the cardiovascular care delivery space, though more work is needed before we will have a full understanding of ways to best leverage such applications in each clinical context.

Effect of Goal-Setting Approaches Within a Gamification Intervention to Increase Physical Activity Among Economically Disadvantaged Adults at Elevated Risk for Major Adverse Cardiovascular Events: The ENGAGE Randomized Clinical Trial

Importance

Health promotion efforts commonly communicate goals for healthy behavior, but the best way to design goal setting among high-risk patients has not been well examined.

Objective

To test the effectiveness of different ways to set and implement goals within a behaviorally designed gamification intervention to increase physical activity.

Design, Setting, and Participants

Evaluation of the Novel Use of Gamification With Alternative Goal-setting Experiences was conducted from January 15, 2019, to June 1, 2020. The 24-week randomized clinical trial included a remotely monitored 8-week introductory intervention period, 8-week maintenance intervention period, and 8-week follow-up period. A total of 500 adults from lower-income neighborhoods in and around Philadelphia, Pennsylvania, who had either an atherosclerotic cardiovascular disease (ASCVD) condition or a 10-year ASCVD risk score greater than or equal to 7.5% were enrolled. Participants were paid for enrolling in and completing the trial.

Interventions

All participants used a wearable device to track daily steps, established a baseline level, and were then randomly assigned to an attention control or 1 of 4 gamification interventions that varied only on how daily step goals were set (self-chosen or assigned) and implemented (immediately or gradually).

Main Outcome Measures

The primary outcome was change in mean daily steps from baseline to the 8-week maintenance intervention period. Other outcomes included changes in minutes of moderate to vigorous physical activity. All randomly assigned participants were included in the intention-to-treat analysis.

Results

Of the 500 participants, 331 individuals (66.2%) were Black, 114 were White (22.8%), and 348 were women (69.6%). Mean (SD) age was 58.5 (10.8) years and body mass index was 33.2 (7.8). A total of 215 participants (43.0%) had an ASCVD condition. Compared with the control arm, participants with self-chosen and immediate goals had significant increases in the number of daily steps during the maintenance intervention period (1384; 95% CI, 805-1963; P < .001) that were sustained during the 8-week follow-up (1391; 95% CI, 785-1998; P < .001). This group also had significant increases in daily minutes of moderate to vigorous physical activity during the maintenance intervention (4.1; 95% CI, 1.8-6.4; P < .001) that were sustained during follow-up (3.5; 95% CI, 1.1-5.8; P = .004). No other gamification arms had consistent increases in physical activity compared with the control arm. No major adverse events were reported.

Conclusions and Relevance

In this trial among economically disadvantaged adults at elevated risk for major adverse cardiovascular events, a gamification intervention led to increases in physical activity that were sustained during 8 weeks of follow-up when goals were self-chosen and implemented immediately.

Trial Registration

ClinicalTrials.gov Identifier: NCT03749473.

Dissemination and implementation of national physical activity, sedentary behaviour, and/or sleep guidelines among community-dwelling adults aged 18 years and older: a systematic scoping review and suggestions for future reporting and research

Strategies for dissemination (purposive distribution of a guideline to specific audiences) and implementation (actions to support the general public in meeting guideline recommendations/behavioural benchmarks) of national movement guidelines (physical activity (PA), sedentary behaviour, and sleep) have yet to be synthesized. The purpose of this systematic scoping review was to identify strategies for dissemination and implementation of national PA, sedentary behaviour, and/or sleep guidelines among community-dwelling adults (aged >18 years) and/or stakeholders in Canada and analogous countries. Five search approaches (e.g., published literature, grey literature, targeted web-based, custom Google, and content expert consultation) identified records (e.g., empirical studies, organizational reports, website pages, or guideline messages) that discussed and/or evaluated dissemination or implementation strategies for a prespecified list of guidelines. A modified strategy classification system was developed to chart the data. Forty-seven reports met inclusion criteria. Dissemination strategies (n = 42) were more frequently reported than implementation strategies (n = 24). Implementation strategies were more frequently evaluated (n = 13 vs. 7 dissemination strategies) and associated with positive outcomes. The 13 studies that evaluated strategies were at high or serious risk of bias. We identified limited information about the dissemination and implementation of national movement guidelines and identified strategies were rarely evaluated. Greater efforts are required to increase the impact of guidelines among the general public and stakeholders and to build the evidence base in this field. (Open Science Framework registration: https://osf.io/4tyw3.) Novelty An adapted movement guideline dissemination and implementation strategy classification framework is provided. Knowledge translation efforts should be documented and evaluated to advance science and practice in the movement guideline field.

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.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03563027.

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

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

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

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

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02961192.

Do low-cost economic incentives motivate healthy behavior?

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

Engineering a mobile platform to promote sleep in the pediatric primary care setting

Study Objectives

Pediatricians lack tools to support families at home for the promotion of childhood sleep. We are using the Multiphase Optimization Strategy (MOST) framework to guide the development of a mobile health platform for childhood sleep promotion. The objective of this study is to demonstrate feasibility of a mobile health platform towards treating children with insufficient sleep.

Methods

Children aged 10–12 years were enrolled (Study #1: N = 30; Study #2: N = 43). Participants wore a sleep tracker to measure sleep duration. Data were retrieved by a mobile health platform, programmed to send introductory messages during run-in (2 weeks) and goal achievement messages during intervention (7 weeks) periods. In study #1, participants were randomized to control, gain-framed incentive or loss-framed incentive arms. In study #2, participants were randomized to control, loss-framed incentive, normative feedback or loss-framed incentive plus normative feedback arms.

Results

In study #1, 1514 nights of data were captured (69%) and sleep duration during the intervention was higher by an average of 21 (95% CI: −8, 51) and 34 (95% CI: 7, 61) minutes per night for the gain-framed and loss-framed arms, respectively, compared to controls. In study #2, 2,689 nights of data were captured (81%), with no major differences in average sleep duration between the control and the loss-framed or normative feedback arms.

Conclusions

We have developed and deployed a mobile health platform that can capture sleep data and remotely communicate with families. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework.

Clinical Trials

Both studies included in this manuscript were registered at clinicaltrials.gov:

-Study #1: NCT03263338

-Study #2: NCT03426644

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Do smartphone applications and activity trackers increase physical activity in adults? Systematic review, meta-analysis and metaregression

OBJECTIVE

To determine the effectiveness of physical activity interventions involving mobile applications (apps) or trackers with automated and continuous self-monitoring and feedback.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed and seven additional databases, from 2007 to 2020.

STUDY SELECTION

Randomised controlled trials in adults (18-65 years old) without chronic illness, testing a mobile app or an activity tracker, with any comparison, where the main outcome was a physical activity measure. Independent screening was conducted.

DATA EXTRACTION AND SYNTHESIS

We conducted random effects meta-analysis and all effect sizes were transformed into standardised difference in means (SDM). We conducted exploratory metaregression with continuous and discrete moderators identified as statistically significant in subgroup analyses.

MAIN OUTCOME MEASURES

Physical activity: daily step counts, min/week of moderate-to-vigorous physical activity, weekly days exercised, min/week of total physical activity, metabolic equivalents.

RESULTS

Thirty-five studies met inclusion criteria and 28 were included in the meta-analysis (n=7454 participants, 28% women). The meta-analysis showed a small-to-moderate positive effect on physical activity measures (SDM 0.350, 95% CI 0.236 to 0.465, I²=69%, T ²=0.051) corresponding to 1850 steps per day (95% CI 1247 to 2457). Interventions including text-messaging and personalisation features were significantly more effective in subgroup analyses and metaregression.

CONCLUSION

Interventions using apps or trackers seem to be effective in promoting physical activity. Longer studies are needed to assess the impact of different intervention components on long-term engagement and effectiveness.

Peer effects in smoking cessation: An instrumental variables analysis of a worksite intervention in Thailand

While smoking is widely acknowledged to be a social activity, limited evidence exists on the extent to which friends influence each other during worksite-based tobacco cessation interventions. Drawing on data from adult smokers (N = 1823) in a large, cluster randomized controlled trial in worksites in Thailand, this study examines the presence of social spillovers in the decision to abstain from smoking. We leverage a unique aspect of social network structure in these data-the existence of non-overlapping friendship networks-to address the challenge of isolating the effects of peers on smoking behavior from the confounding effects of endogenous friend selection and bidirectional peer influence. We find that individuals with workplace friends who have abstained from smoking during the trial are significantly more likely to abstain themselves. Instrumental variables estimates suggest that abstinence after 3 and 12 months increases 26 and 32 percentage points, respectively, for each additional workplace friend who abstains. These findings highlight the potential for workplace interventions to use existing social networks to magnify the effect of individual-level behavior change, particularly in low- and middle-income countries where tobacco cessation support tends to be limited.

Adding team-based financial incentives to the Carrot Rewards physical activity app increases daily step count on a population scale: a 24-week matched case control study

Background

Mobile health applications (mHealth apps) targeting physical inactivity have increased in popularity yet are usually limited by low engagement. This study examined the impact of adding team-based incentives (Step Together Challenges, STCs) to an existing mHealth app (Carrot Rewards) that rewarded individual physical activity achievements.

Methods

A 24-week quasi-experimental study (retrospective matched pairs design) was conducted in three Canadian provinces (pre-intervention: weeks 1–12; intervention: weeks 13–24). Participants who used Carrot Rewards and STCs (experimental group) were matched with those who used Carrot Rewards only (controls) on age, gender, province and baseline mean daily step count (±500 steps/d). Carrot Rewards users earned individual-level incentives (worth $0.04 CAD) each day they reached a personalized daily step goal. With a single partner, STC users could earn team incentives ($0.40 CAD) for collaboratively reaching individual daily step goals 10 times in seven days (e.g., Partner A completes four goals and Partner B completes six goals in a week).

Results

The main analysis included 61,170 users (mean age = 32 yrs.; % female = 64). Controlling for pre-intervention mean daily step count, a significant difference in intervention mean daily step count favoured the experimental group (p < 0.0001; η_p² = 0.024). The estimated marginal mean group difference was 537 steps per day, or 3759 steps per week (about 40 walking min/wk). Linear regression suggested a dose-response relationship between the number of STCs completed (app engagement) and intervention mean daily step count (adjusted R² = 0.699) with each new STC corresponding to approximately 200 more steps per day.

Conclusion

Despite an explosion of physical activity app interest, low engagement leading to small or no effects remains an industry hallmark. In this paper, we found that adding modest team-based incentives to the Carrot Rewards app increased mean daily step count, and importantly, app engagement moderated this effect. Others should consider novel small-teams based approaches to boost engagement and effects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-020-01043-1.

Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial

RATIONALE & OBJECTIVE

Although maintaining high fluid intake is an effective low-risk intervention for the secondary prevention of urinary stone disease, many patients with stones do not increase their fluid intake.

STUDY DESIGN

We describe the rationale and design of the Prevention of Urinary Stones With Hydration (PUSH) Study, a randomized trial of a multicomponent behavioral intervention program to increase and maintain high fluid intake. Participants are randomly assigned (1:1 ratio) to the intervention or control arm. The target sample size is 1,642 participants.

SETTING & PARTICIPANTS

Adults and adolescents 12 years and older with a symptomatic stone history and low urine volume are eligible. Exclusion criteria include infectious or monogenic causes of urinary stone disease and comorbid conditions precluding increased fluid intake.

INTERVENTIONS

All participants receive usual care and a smart water bottle with smartphone application. Participants in the intervention arm receive a fluid intake prescription and an adaptive program of behavioral interventions, including financial incentives, structured problem solving, and other automated adherence interventions. Control arm participants receive guideline-based fluid instructions.

OUTCOMES

The primary end point is recurrence of a symptomatic stone during 24 months of follow-up. Secondary end points include changes in radiographic stone burden, 24-hour urine output, and urinary symptoms.

LIMITATIONS

Periodic 24-hour urine volumes may not fully reflect daily behavior.

CONCLUSIONS

With its highly novel features, the PUSH Study will address an important health care problem.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT03244189.

Engineering a Mobile Platform to Promote Sleep in the Pediatric Primary Care Setting

Background

Pediatricians lack tools to support families at home for the promotion of childhood sleep. We are using the Multiphase Optimization Strategy (MOST) framework to guide the development of a mobile health platform for childhood sleep promotion.

Purpose

Under the preparation phase of the MOST framework, to demonstrate feasibility of a mobile health platform towards treating children with insufficient sleep.

Methods

Children aged 10-12y were enrolled (Study #1: N=30; Study #2: N=43). Participants wore a sleep tracker to measure sleep duration. Data were retrieved by a mobile health platform, programmed to send introductory messages during run-in (2 weeks) and goal achievement messages during intervention (7 weeks) periods. In study #1, participants were randomized to control, gain-framed incentive or loss-framed incentive arms. In study #2, participants were randomized to control, loss-framed incentive, normative feedback or loss-framed incentive plus normative feedback arms.

Results

In study #1, 1,514 nights of data were captured (69%) and sleep duration during the intervention was higher by an average of 21 (95% CI: -8, 51) and 34 (95% CI: 7, 61) minutes per night for the gain-framed and loss-framed arms, respectively, compared to controls. In study #2, 2,689 nights of data were captured (81%), with no major differences in average sleep duration between the control and the loss-framed or normative feedback arms.

Conclusion

We have developed and deployed a mobile health platform that can capture sleep data and remotely communicate with families. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework.

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

OBJECTIVE

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

STUDY DESIGN

Two-arm, parallel-group randomised controlled trial.

SETTING/PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

UMIN000033276.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Incentive programmes for smoking cessation: cluster randomized trial in workplaces in Thailand

OBJECTIVE

To compare several monetary incentive programmes for promoting smoking abstinence among employees who smoke at workplaces in a middle income country.

DESIGN

Parallel group, open label, assessor blinded, cluster randomized controlled trial.

SETTING

Large industrial workplaces in metropolitan Bangkok, Thailand.

PARTICIPANTS

Employees who smoked cigarettes and planned to quit within six months recruited from 101 worksite clusters (84 different companies).

INTERVENTIONS

Worksites were digitally cluster randomized by an independent investigator to usual care or usual care plus one of eight types of incentive programmes. Usual care consisted of one time group counseling and cessation support through a 28 day text messaging programme. The incentive programmes depended on abstinence at three months and varied on three intervention components: refundable deposits, assignment to a teammate, and bonus size ($20 (£15; €17) or $40).

MAIN OUTCOME MEASURES

The primary outcome was biochemically verified seven day point prevalence smoking abstinence at 12 months. Secondary outcomes were programme acceptance at enrollment and smoking abstinence at three months (end of intervention) and at six months. All randomized participants who had complete baseline information were included in intention-to-treat analyses; participants with missing outcomes were coded as continuing smokers.

RESULTS

Between April 2015 and August 2016, the trial enrolled 4190 participants. Eighteen were omitted because of missing baseline covariates and death before the primary endpoint, therefore 4172 participants were included in the intention-to-treat analyses. Programme acceptance was relatively high across all groups: 58.7% (2451/4172) overall and 61.3% (271/442) in the usual care group. Abstinence rates at 12 months did not differ among deposit programmes (336/2253, 14.9%) and non-deposit programmes (280/1919, 14.6%; adjusted difference 0.8 points, 95% confidence interval -2.7 to 4.3, P=0.65), but were somewhat lower for team based programmes (176/1348, 13.1%) than individual based programmes (440/2824, 15.6%; -3.2 points, -6.6 to -0.2, P=0.07), and higher for $40 bonus programmes (322/1954, 16.5%) than programmes with no bonus (148/1198, 12.4%; 5.9 points, 2.1 to 9.7, P=0.002). The $40 individual bonus was the most efficacious randomization group at all endpoints. Intervention components did not strongly interact with each other.

CONCLUSIONS

Acceptance of monetary incentive programmes for promoting smoking abstinence was high across all groups. The $40 individual bonus programmes increased long term smoking abstinence compared with usual care, although several other incentive designs did not, such as team based programmes and deposit programmes. Incentive design in workplace wellness programmes might influence their effectiveness at reducing smoking rates in low resource settings.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02421224).

Leveraging family dynamics to increase the effectiveness of incentives for physical activity: the FIT-FAM randomized controlled trial

BACKGROUND

Insufficient physical activity is a global public health concern. Research indicates incentives can increase physical activity levels of children but has not tested whether incentives targeted at children can be leveraged to increase physical activity levels of their parents. This study evaluates whether a novel incentive design linking children's incentives to both their and their parent's physical activity levels can increase parent's physical activity.

METHODS

We conducted a two-arm, parallel, open-labelled randomized controlled trial in Singapore where parent-child dyads were randomly assigned to either (1) rewards to child contingent on child's physical activity (child-based) or (2) rewards to child contingent on both child's and parent's physical activity (family-based). Parents had to be English-speaking, computer-literate, non-pregnant, full-time employees, aged 25-65 years, and with a participating child aged 7-11 years. Parent-child dyads were randomized within strata (self-reported low vs high weekly physical activity) into study arms in a 1:1 ratio. Participants were given activity trackers to assess daily steps. The outcome of interest was the between-arm difference in the change from baseline in parent's mean steps/day measured by accelerometry at months 6 and 12 (primary endpoint).

RESULTS

Overall, 159 and 157 parent-child dyads were randomized to the child-based or family-based arms, respectively. Outcomes were evaluated on an intent-to-treat basis. At month 6, there was a 613 steps/day (95% CI: 54-1171) differential in favour of family-based parents. At month 12, our primary endpoint, the differential was reduced to 369 steps/day (95% CI: - 88-1114) and was no longer statistically significant.

CONCLUSIONS

Our findings suggest that novel incentive designs that take advantage of group dynamics may be effective. However, in this design, the effectiveness of the family-based incentive to increase parent's physical activity was not sustained through one year.

TRIAL REGISTRATION

NCT02516345 (ClinicalTrials.gov) registered on August 5, 2015.

The physical activity at work (PAW) study protocol: a cluster randomised trial of a multicomponent short-break intervention to reduce sitting time and increase physical activity among office workers in Thailand

BACKGROUND

High levels of sedentary behaviour (SB) are associated with non-communicable diseases. In 2016, the estimated total healthcare expenditure from physical activity (PA) in Thailand added up to $190 million in international dollars. The challenge to reduce SB and increase PA among office workers is more urgent now than ever as Thailand is transforming itself from a predominantly rural country to an increasingly urban one. This study will investigate the effectiveness of a multicomponent short break intervention on the reduction of SB during office hours.

METHODS/DESIGN

This two-armed Physical Activity at Work (PAW) cluster randomised controlled trial will recruit 360 office workers from 18 offices in the Thailand's Ministry of Public Health (MOPH). Offices will be randomised to either the intervention group or the control group. The multicomponent intervention is informed by the Social Ecological Model and Behaviour Change Techniques (BCTs) and contains four components: (i) organisational, including heads of the participating divisions leading exercises, sending encouragement text messages and acknowledging efforts; (ii) social, including team movement breaks and team-based incentives; (iii) environmental, including posters to encourage exercise; and (iv) individual components including real-time PA feedback via an individual device. The main intervention component will be a short break intervention. The primary outcome of this study is the sedentary time of office workers. Secondary outcomes include time spent on PA, cardiometabolic outcomes, work productivity, musculoskeletal pain, and quality of life. The study also includes process and economic evaluations from the individual and societal perspective.

DISCUSSION

The study will be the first experimental study in Thailand to investigate the effect of a short-break intervention at the workplace on SBs of office workers and health outcomes. The study will also include a cost-effectiveness analysis to inform investments on short break interventions under the Universal Healthcare Coverage in Thailand, which includes health promotion and disease prevention component.

TRIAL REGISTRATION

The PAW study has been registered at the Thai Clinical Trials Registry (TCTR) under the study ID TCTR20200604007 . Registered 02 June 2020,.

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

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

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

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

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

A randomized, controlled, behavioral intervention to promote walking after abdominal organ transplantation: results from the LIFT study

Kidney transplant recipients (KTRs) and liver transplant recipients (LTRs) have significant post-transplant weight gain and low physical activity. We conducted a home-based, remotely monitored intervention using wearable accelerometer devices to promote post-transplant physical activity. We randomized 61 KTRs and 66 LTRs within 24 months of transplant to: (i) control, (ii) accelerometer or (iii) intervention: accelerometer paired with financial incentives and health engagement questions to increase steps by 15% from baseline every 2 weeks. The primary outcome was weight change. A co-primary outcome for the two accelerometer arms was steps. Participants were recruited at a median of 9.5 [3-17] months post-transplant. At 3 months, there were no significant differences in weight change across the three arms. The intervention arm was more likely to achieve ≥7000 steps compared to control with device (OR 1.99, 95% CI: 1.03-3.87); effect remained significant after adjusting for demographics, allograft, time from transplant and baseline weight. Adherence to target step goals was 74% in the intervention arm, 84% of health engagement questions were answered correctly. A pilot study with financial incentives and health engagement questions was feasible and led KTRs and LTRs to walk more, but did not affect weight. A definitive trial is warranted.

A Mobile Health Team Challenge to Promote Stepping and Stair Climbing Activities: Exploratory Feasibility Study

Background

Mobile health (mHealth) approaches are growing in popularity as a means of addressing low levels of physical activity (PA).

Objective

This study aimed to determine the validity of wearables in measuring step count and floor count per day and assess the feasibility and effects of a 6-week team challenge intervention delivered through smartphone apps.

Methods

Staff and students from a public university were recruited between 2015 and 2016. In phase 1, everyone wore a Fitbit tracker (Charge or Charge HR) and an ActiGraph for 7 days to compare daily step count estimated by the two devices under free-living conditions. They were also asked to climb 4 bouts of floors in an indoor stairwell to measure floor count which was compared against direct observation. In phase 2, participants were allocated to either a control or intervention group and received a Fitbit tracker synced to the Fitbit app. Furthermore, the intervention group participants were randomized to 4 teams and competed in 6 weekly (Monday to Friday) real-time challenges. A valid day was defined as having 1500 steps or more per day. The outcomes were as follows: (1) adherence to wearing the Fitbit (ie, number of days in which all participants in each group were classified as valid users aggregated across the entire study period), (2) mean proportion of valid participants over the study period, and (3) the effects of the intervention on step count and floor count determined using multiple linear regression models and generalized estimating equations (GEEs) for longitudinal data analysis.

Results

In phase 1, 32 of 40 eligible participants provided valid step count data, whereas all 40 participants provided valid floor count data. The Fitbit trackers demonstrated high correlations (step count: Spearman ρ=0.89; P<.001; floor count: Spearman ρ=0.98; P<.001). The trackers overestimated step count (median absolute error: 17%) but accurately estimated floor count. In phase 2, 20 participants each were allocated to an intervention or control group. Overall, 24 participants provided complete covariates and valid PA data for analyses. Multiple linear regressions revealed that the average daily steps was 15.9% higher for the intervention group (95% CI −8.9 to 47.6; P=.21) during the final two intervention weeks; the average daily floors climbed was 39.4% higher (95% CI 2.4 to 89.7; P=.04). GEE results indicated no significant interaction effects between groups and the intervention week for weekly step count, whereas a significant effect (P<.001) was observed for weekly floor count.

Conclusions

The consumer wearables used in this study provided acceptable validity in estimating stepping and stair climbing activities, and the mHealth-based team challenge interventions were feasible. Compared with the control group, the participants in the intervention group climbed more stairs, so this can be introduced as an additional PA promotion target in the context of mHealth strategies. Methodologically rigorous studies are warranted to further strengthen this study’s findings.

Effects of Bluetooth-Enabled Desk Ellipticals on Office Work Performance: Rationale, Design, and Protocol for a Randomized Trial With Overweight and Obese Adults

Background

Workplaces that provide opportunities for physical activity without requiring extra time for activity could help counteract the obesity epidemic. Desk ellipticals can contribute to activity-supportive workplace environments; however, the feasibility of engaging employees in pedaling ellipticals during simultaneous office work has not been well evaluated.

Objective

We aim to present the rationale and methods from an ongoing randomized trial with overweight and obese employees that will evaluate (1) the effects of pedaling a compact desk elliptical on work performance and (2) the influence of different incentive types and schedules on desk pedaling quantity.

Methods

Overweight and obese medical center employees are being recruited in dyads for a 2 (gift card type: healthier food vs Amazon) by 3 (gift card schedule: immediate incentive contingent on individual pedaling quantity; immediate incentive partially contingent on dyads’ joint pedaling quantity; and delayed noncontingent pedaling incentive) cluster randomized within-subjects factorial trial. All participants receive a Bluetooth-enabled desk elliptical for 4 weeks and access to a mobile app that provides real-time pedaling feedback. The primary aims are to assess (1) change in employee work performance from pre- to postelliptical installation via employee and supervisor ratings and (2) effects of gift card type and schedule on quantity of objectively measured desk pedaling completed.

Results

Data collection is ongoing. We expect to complete main outcome analyses in 2020.

Conclusions

This trial represents one of the earliest attempts to assess the effects of desk pedaling and pedaling-incentive types in real-world offices. It could help bridge the research-to-practice gap by providing evidence on whether desk pedaling can be sustained without compromising work performance.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16275