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Thondre PS, Butler I, Tammam J, Achebe I, Young E, Lane M, Gallagher A. Understanding the Impact of Different Doses of Reducose ® Mulberry Leaf Extract on Blood Glucose and Insulin Responses after Eating a Complex Meal: Results from a Double-Blind, Randomised, Crossover Trial. Nutrients 2024; 16:1670. [PMID: 38892603 PMCID: PMC11174565 DOI: 10.3390/nu16111670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Non-communicable diseases (NCDs) are becoming an increasingly important health concern due to a rapidly ageing global population. The fastest growing NCD, type 2 diabetes mellitus (T2DM), is responsible for over 2 million deaths annually. Lifestyle changes, including dietary changes to low glycemic response (GR) foods, have been shown to reduce the risk of developing T2DM. The aim of this study was to investigate whether three different doses of Reducose®, a mulberry leaf extract, could lower the GR and insulinemic responses (IR) to a full meal challenge in healthy individuals. A double-blind, randomised, placebo-controlled, repeat-measure, crossover design trial was conducted by the Oxford Brookes Centre for Nutrition and Health; 37 healthy individuals completed the study. Participants consumed capsules containing either 200 mg, 225 mg, 250 mg Reducose® or placebo before a test meal consisting of 150 g white bread and egg mayo filler. Capillary blood samples were collected at 15-min intervals in the first hour and at 30-min intervals over the second and third hours to determine glucose and plasma insulin levels. The consumption of all three doses of Reducose® resulted in significantly lower blood glucose and plasma insulin levels compared to placebo. All three doses of Reducose® (200 mg, 225 mg, 250 mg) significantly lowered glucose iAUC 120 by 30% (p = 0.003), 33% (p = 0.001) and 32% (p = 0.002), respectively, compared with placebo. All three doses of Reducose® (200 mg, 225 mg, 250 mg) significantly lowered the plasma insulin iAUC 120 by 31% (p = 0.024), 34% (p = 0.004) and 38% (p < 0.001), respectively. The study demonstrates that the recommended dose (250 mg) and two lower doses (200 mg, 225 mg) of Reducose® can be used to help lower the GR and IR of a full meal containing carbohydrates, fats and proteins.
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Affiliation(s)
| | - Isabel Butler
- Oxford Brookes Centre for Nutrition and Health, Oxford OX3 0BP, UK; (P.S.T.); (I.B.); (J.T.); (I.A.); (E.Y.)
- Department of Paediatrics, University of Oxford, Oxford OX3 9DU, UK
| | - Jonathan Tammam
- Oxford Brookes Centre for Nutrition and Health, Oxford OX3 0BP, UK; (P.S.T.); (I.B.); (J.T.); (I.A.); (E.Y.)
| | - Ifunanya Achebe
- Oxford Brookes Centre for Nutrition and Health, Oxford OX3 0BP, UK; (P.S.T.); (I.B.); (J.T.); (I.A.); (E.Y.)
| | - Elysia Young
- Oxford Brookes Centre for Nutrition and Health, Oxford OX3 0BP, UK; (P.S.T.); (I.B.); (J.T.); (I.A.); (E.Y.)
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Finkelstein EA, Chow MTN, Gandhi M. Are cash incentives always king? A randomized controlled trial evaluating hedonic versus cash incentives (TEH-C). Front Public Health 2024; 12:1354814. [PMID: 38745998 PMCID: PMC11091446 DOI: 10.3389/fpubh.2024.1354814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/15/2024] [Indexed: 05/16/2024] Open
Abstract
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.
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Affiliation(s)
| | - Michelle Tian Nee Chow
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Mihir Gandhi
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
- Department of Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore
- Tampere Center for Child, Adolescent, and Maternal Health Research: Global Health Group, Tampere University, Tampere, Finland
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de Buisonjé DR, Reijnders T, Cohen Rodrigues TR, Santhanam P, Kowatsch T, Breeman LD, Janssen VR, Kraaijenhagen RA, Kemps HMC, Evers AWM. Less stick more carrot? Increasing the uptake of deposit contract financial incentives for physical activity: A randomized controlled trial. PSYCHOLOGY OF SPORT AND EXERCISE 2024; 70:102532. [PMID: 37678644 DOI: 10.1016/j.psychsport.2023.102532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 06/05/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Financial incentives are a promising tool to help people increase their physical activity, but they are expensive to provide. Deposit contracts are a type of financial incentive in which participants pledge their own money. However, low uptake is a crucial obstacle to the large-scale implementation of deposit contracts. Therefore, we investigated whether (1) matching the deposit 1:1 (doubling what is deposited) and (2) allowing for customizable deposit amounts increased the uptake and short term effectiveness of a deposit contract for physical activity. METHODS In this randomized controlled trial, 137 healthy students (age M = 21.6 years) downloaded a smartphone app that provided them with a tailored step goal and then randomized them to one of four experimental conditions. The deposit contract required either a €10 fixed deposit or a customizable deposit with any amount between €1 and €20 upfront. Furthermore, the deposit was either not matched or 1:1 matched (doubled) with a reward provided by the experiment. During 20 intervention days, daily feedback on goal progress and incentive earnings was provided by the app. We investigated effects on the uptake (measured as agreeing to participate and paying the deposit) and effectiveness of behavioral adoption (measured as participant days goal achieved). FINDINGS Overall, the uptake of deposit contracts was 83.2%, and participants (n = 113) achieved 14.9 out of 20 daily step goals. A binary logistic regression showed that uptake odds were 4.08 times higher when a deposit was matched (p = .010) compared to when it was not matched. Furthermore, uptake odds were 3.53 times higher when a deposit was customizable (p = .022) compared to when it was fixed. Two-way ANCOVA showed that matching (p = .752) and customization (p = .143) did not impact intervention effectiveness. However, we did find a marginally significant interaction effect of deposit matching X deposit customization (p = .063, ηp2 = 0.032). Customization decreased effectiveness when deposits were not matched (p = .033, ηp2 = 0.089), but had no effect when deposits were matched (p = .776, ηp2 = 0.001). CONCLUSIONS We provide the first experimental evidence that both matching and customization increase the uptake of a deposit contract for physical activity. We recommend considering both matching and customization to overcome lack of uptake, with a preference for customization since matching a deposit imposes significant additional costs. However, since we found indications that customizable deposits might reduce effectiveness (when the deposits are not matched), we urge for more research on the effectiveness of customizable deposit contracts. Finally, future research should investigate which participant characteristics are predictive of deposit contract uptake and effectiveness. PRE-REGISTRATION OSF Registries, https://osf.io/cgq48.
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Affiliation(s)
- David R de Buisonjé
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands.
| | - Thomas Reijnders
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands; Department of Human-Centered Design, Faculty of Industrial Design Engineering, TU Delft, Delft, the Netherlands
| | - Talia R Cohen Rodrigues
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Prabhakaran Santhanam
- Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
| | - Tobias Kowatsch
- Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland; Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland; School of Medicine, University of St.Gallen, St.Gallen, Switzerland
| | - Linda D Breeman
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Veronica R Janssen
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Hareld M C Kemps
- Department of Cardiology, Máxima Medical Center, Veldhoven, the Netherlands; Department of Industrial Design, Eindhoven University of Technology, the Netherlands
| | - Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands; Leiden University, Technical University Delft, and Erasmus University, Rotterdam, the Netherlands
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Ostermann J, Hair NL, Moses S, Ngadaya E, Godfrey Mfinanga S, Brown DS, Noel Baumgartner J, Vasudevan L. Is the intention to vaccinate enough? Systematic variation in the value of timely vaccinations and preferences for monetary vs non-monetary incentives among pregnant women in southern Tanzania. Vaccine X 2023; 13:100266. [PMID: 36814594 PMCID: PMC9939728 DOI: 10.1016/j.jvacx.2023.100266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 03/03/2022] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
Background Globally, approximately 19.7 million children remain under-vaccinated; many more receive delayed vaccinations. Sustained progress towards global vaccination targets requires overcoming, or compensating for, incrementally greater barriers to vaccinating hard-to-reach and hard-to-vaccinate children. We prospectively assessed pregnant women's valuations of routine childhood vaccinations and preferences for alternative incentives to inform interventions aiming to increase vaccination coverage and timeliness in southern Tanzania. Methods Between August and December 2017, 406 women in their last trimester of pregnancy were enrolled from health facilities and communities in the Mtwara region of Tanzania and asked contingent valuation questions about their willingness to vaccinate their child if they were (a) given an incentive, or (b) facing a cost for each vaccination. Interval censored regressions assessed correlates of women's willingness to pay (WTP) for timely vaccinations. Participants were asked to rank monetary and non-monetary incentive options for the timely vaccination of their children. Findings All women expected to get their children vaccinated according to the recommended schedule, even without incentives. Nearly all women (393; 96.8 %) were willing to pay for vaccinations. The average WTP was Tanzania Shilling (Tsh) 3,066 (95 % confidence interval Tsh 2,523-3,610; 1 USD ∼ Tsh 2,200) for each vaccination. Women's valuations of timely vaccinations varied significantly with vaccine-related knowledge and attitudes, economic status, and rural vs urban residence. Women tended to prefer non-monetary over monetary incentives for the timely vaccination of their children. Interpretation Women placed a high value on timely childhood vaccinations, suggesting that unexpected system-level barriers rather than individual-level demand factors are likely to be the primary drivers of missed vaccinations. Systematic variation in the value of vaccinations across women reflects variation in perceived benefits and opportunity costs. In this setting, nonmonetary incentives and other interventions to increase demand and compensate for system-level barriers hold significant potential for improving vaccination coverage and timeliness. ClinicalTrialsgov Protocol NCT03252288.
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Affiliation(s)
- Jan Ostermann
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
- South Carolina Smart State Center for Healthcare Quality, University of South Carolina, Columbia, SC, USA
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Corresponding author at: Arnold School of Public Health, 915 Greene St. #351, Columbia, SC 29208, USA.
| | - Nicole L. Hair
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Sara Moses
- Muhimbili Research Centre, National Institute for Medical Research, Dar-es-Salaam, United Republic of Tanzania
| | - Esther Ngadaya
- Muhimbili Research Centre, National Institute for Medical Research, Dar-es-Salaam, United Republic of Tanzania
| | - Sayoki Godfrey Mfinanga
- Muhimbili Research Centre, National Institute for Medical Research, Dar-es-Salaam, United Republic of Tanzania
- Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, United Republic of Tanzania
- School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, United Republic of Tanzania
| | - Derek S. Brown
- Brown School of Social Work, Washington University in Saint Louis, St. Louis, MO, USA
| | - Joy Noel Baumgartner
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lavanya Vasudevan
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Allen J, Mahumane A, Riddell J, Rosenblat T, Yang D, Yu H. Teaching and Incentives: Substitutes or Complements? ECONOMICS OF EDUCATION REVIEW 2022; 91:102317. [PMID: 37560092 PMCID: PMC10408734 DOI: 10.1016/j.econedurev.2022.102317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Interventions to promote learning are often categorized into supply- and demand-side approaches. In a randomized experiment to promote learning about COVID-19 among Mozambican adults, we study the interaction between a supply and a demand intervention, respectively: teaching via targeted feedback, and providing financial incentives to learners. In theory, teaching and learner-incentives may be substitutes (crowding out one another) or complements (enhancing one another). Experts surveyed in advance predicted a high degree of substitutability between the two treatments. In contrast, we find substantially more complementarity than experts predicted. Combining teaching and incentive treatments raises COVID-19 knowledge test scores by 0.5 standard deviations, though the standalone teaching treatment is the most cost-effective. The complementarity between teaching and incentives persists in the longer run, over nine months post-treatment.
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Affiliation(s)
- James Allen
- Department of Economics, University of Michigan
- Ford School of Public Policy, University of Michigan
- Population Studies Center, University of Michigan
| | - Arlete Mahumane
- Beira Operational Research Center, National Institute of Health, Mozambique
| | - James Riddell
- Division of Infectious Diseases, University of Michigan Medical School
| | - Tanya Rosenblat
- School of Information and Department of Economics, University of Michigan
| | - Dean Yang
- Department of Economics, University of Michigan
- Ford School of Public Policy, University of Michigan
- Population Studies Center, University of Michigan
| | - Hang Yu
- National School of Development, Peking University
- Institute of South-South Cooperation and Development, Peking University
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de Buisonjé DR, Reijnders T, Cohen Rodrigues TR, Prabhakaran S, Kowatsch T, Lipman SA, Bijmolt THA, Breeman LD, Janssen VR, Kraaijenhagen RA, Kemps HMC, Evers AWM. Investigating Rewards and Deposit Contract Financial Incentives for Physical Activity Behavior Change Using a Smartphone App: Randomized Controlled Trial. J Med Internet Res 2022; 24:e38339. [PMID: 36201384 DOI: 10.2196/38339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Financial incentive interventions for improving physical activity have proven to be effective but costly. Deposit contracts (in which participants pledge their own money) could be an affordable alternative. In addition, deposit contracts may have superior effects by exploiting the power of loss aversion. Previous research has often operationalized deposit contracts through loss framing a financial reward (without requiring a deposit) to mimic the feelings of loss involved in a deposit contract. OBJECTIVE This study aimed to disentangle the effects of incurring actual losses (through self-funding a deposit contract) and loss framing. We investigated whether incentive conditions are more effective than a no-incentive control condition, whether deposit contracts have a lower uptake than financial rewards, whether deposit contracts are more effective than financial rewards, and whether loss frames are more effective than gain frames. METHODS Healthy participants (N=126) with an average age of 22.7 (SD 2.84) years participated in a 20-day physical activity intervention. They downloaded a smartphone app that provided them with a personalized physical activity goal and either required a €10 (at the time of writing: €1=US $0.98) deposit up front (which could be lost) or provided €10 as a reward, contingent on performance. Daily feedback on incentive earnings was provided and framed as either a loss or gain. We used a 2 (incentive type: deposit or reward) × 2 (feedback frame: gain or loss) between-subjects factorial design with a no-incentive control condition. Our primary outcome was the number of days participants achieved their goals. The uptake of the intervention was a secondary outcome. RESULTS Overall, financial incentive conditions (mean 13.10, SD 6.33 days goal achieved) had higher effectiveness than the control condition (mean 8.00, SD 5.65 days goal achieved; P=.002; ηp2=0.147). Deposit contracts had lower uptake (29/47, 62%) than rewards (50/50, 100%; P<.001; Cramer V=0.492). Furthermore, 2-way analysis of covariance showed that deposit contracts (mean 14.88, SD 6.40 days goal achieved) were not significantly more effective than rewards (mean 12.13, SD 6.17 days goal achieved; P=.17). Unexpectedly, loss frames (mean 10.50, SD 6.22 days goal achieved) were significantly less effective than gain frames (mean 14.67, SD 5.95 days goal achieved; P=.007; ηp2=0.155). CONCLUSIONS Financial incentives help increase physical activity, but deposit contracts were not more effective than rewards. Although self-funded deposit contracts can be offered at low cost, low uptake is an important obstacle to large-scale implementation. Unexpectedly, loss framing was less effective than gain framing. Therefore, we urge further research on their boundary conditions before using loss-framed incentives in practice. Because of limited statistical power regarding some research questions, the results of this study should be interpreted with caution, and future work should be done to confirm these findings. TRIAL REGISTRATION Open Science Framework Registries osf.io/34ygt; https://osf.io/34ygt.
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Affiliation(s)
- David R de Buisonjé
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, Netherlands
| | - Thomas Reijnders
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, Netherlands
- Department of Human-Centered Design, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
| | - Talia R Cohen Rodrigues
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, Netherlands
| | - Santhanam Prabhakaran
- Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
| | - Tobias Kowatsch
- Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
- School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Stefan A Lipman
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Tammo H A Bijmolt
- Faculty of Economics and Business, University of Groningen, Groningen, Netherlands
| | - Linda D Breeman
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, Netherlands
| | - Veronica R Janssen
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hareld M C Kemps
- Department of Cardiology, Máxima Medical Center, Veldhoven, Netherlands
| | - Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Leiden, Netherlands
- Medical Delta, Leiden University, Technical University Delft, Erasmus University, Delft, Netherlands
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Michaud TL, Estabrooks PA, You W, Ern J, Scoggins D, Gonzales K, King KM, Dai H, Su D. Effectiveness of incentives to improve the reach of health promotion programs- a systematic review and meta-analysis. Prev Med 2022; 162:107141. [PMID: 35809822 DOI: 10.1016/j.ypmed.2022.107141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 05/31/2022] [Accepted: 07/02/2022] [Indexed: 10/17/2022]
Abstract
The reach (i.e., enrollment, engagement, and retention) of health promotion evidence-based programs (EBPs) at the participant level has been challenging. Incentives based on behavioral economics may be used to improve EBP reach. We aimed to systematically review and synthesize the evidence of the effectiveness of incentives as a dissemination strategy to increase EBP reach. We conducted a literature search in PubMed, SCOPUS, EMBASE, Cochrane Review and Cochrane CENTRAL for articles published between January 2000 and March 2020 to identify incentive strategies used to increase program reach among health promotion EBPs. Inclusion criteria included studies published in English, experimental or quasi-experimental designs, comparison of incentive to non-incentive or control strategies, and reported on reach (n = 35 health promotion studies). Monetary incentives using cash and a fixed schedule of reinforcement were the most used incentive schemes (71%). Incentives alone or combined with other strategies as a multicomponent approach were effective in improving program enrollment, engagement, and retention. Specifically, incentive strategies were associated with higher odds of program enrollment (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.82-4.24; n = 10) and retention (OR, 2.54, 95% CI, 1.34-4.85; n = 9) with considerable heterogeneity (I2 = 94% and 91%, respectively). Incentives are a promising individual-level dissemination strategy to improve the reach of health promotion EBPs. However, understanding the optimal amount, type, frequency, and target of incentives, and how incentives fit in a multicomponent approach in different contexts requires further research.
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Affiliation(s)
- Tzeyu L Michaud
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA; Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Paul A Estabrooks
- Department of Health and Kinesiology, College of Health, University of Utah, Salt Lake City, UT, USA
| | - Wen You
- Department of Public Health Sciences, University of Virginia, University of Virginia Cancer Center, Charlottesville, VA, USA
| | - Jessica Ern
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dylan Scoggins
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kelly Gonzales
- College of Nursing, Omaha Division, University of Nebraska Medical Center, Omaha, NE, USA
| | - Keyonna M King
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA; Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Hongying Dai
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dejun Su
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA; Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
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Krukowski RA, Harvey JR, Naud S, Finkelstein EA, West DS. Perspectives on the Form, Magnitude, Certainty, Target, and Frequency of Financial Incentives in a Weight Loss Program. Am J Health Promot 2022; 36:996-1004. [PMID: 35377246 PMCID: PMC10369452 DOI: 10.1177/08901171221078843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Financial incentives are a promising approach to enhance weight loss outcomes; however, little guidance exists on the optimal incentive structure. DESIGN Mixed methods. SETTING An online weight management trial, combining outcome (i.e., weight loss) and behavioral (i.e., self-weighing, dietary self-monitoring, and steps) incentives over 12 months (up to $665). SUBJECTS 116 participants who completed the incentive preference assessment at the 18-month follow-up visit. METHOD Response distributions on the form, magnitude, certainty, and target of the incentives and content analysis of the qualitative responses. RESULTS Nearly all (96.6%) participants indicated they liked receiving electronic Amazon gift cards, more so than the alternatives presented. Most participants (81.0%) thought they would have lost a similar amount of weight if the incentives were smaller. Few (18.1%) indicated they would have preferred a lottery structure, but 50.8% indicated the variable incentive schedule was beneficial during the maintenance period. Most (77.6%) felt incentives were most helpful when starting to lose weight. In both phases, most participants (85.3% and 72.4%, respectively) indicated appropriate behaviors were incentivized. Participants had mixed views on whether outcome or behavioral incentives were most motivating. CONCLUSION There was notable variation in preferences for the magnitude, duration, and timing of incentives; it will be important to examine in future research whether incentive design should be tailored to individual preferences.
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Affiliation(s)
- Rebecca A Krukowski
- Department of Public Health Sciences, College of Medicine, 2358University of Virginia, Charlottesville, VA, USA
| | - Jean R Harvey
- Department of Nutrition and Food Sciences, 2092University of Vermont, Burlington, VT, USA
| | - Shelly Naud
- Biomedical Statistics, Larner College of Medicine, 2092University of Vermont, Burlington, VT, USA
| | - Eric A Finkelstein
- Duke-NUS Medical School and Duke University Global Health Institute, singapore
| | - Delia S West
- Arnold School of Public Health, 2629University of South Carolina, Columbia, SC, USA
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You W, Yuan Y, Boyle KJ, Michaud TL, Parmeter C, Seidel RW, Estabrooks PA. Examining Ways to Improve Weight Control Programs' Population Reach and Representativeness: A Discrete Choice Experiment of Financial Incentives. PHARMACOECONOMICS - OPEN 2022; 6:193-210. [PMID: 34757584 PMCID: PMC8864042 DOI: 10.1007/s41669-021-00310-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Both theoretical and empirical evidence supports the potential of modest financial incentives to increase the reach of evidence-based weight control programs. However, few studies exist that examine the best incentive design for achieving the highest reach and representativeness at the lowest cost and whether or not incentive designs may be valued differentially by subgroups that experience obesity-related health disparities. METHODS A discrete choice experiment was conducted (n = 1232 participants; over 90% of them were overweight/obese) to collect stated preference towards different financial incentive attributes, including reward amount, program location, reward contingency, and payment form and frequency. Mixed logit and conditional logit models were used to determine overall and subgroup preference ranking of attributes. Using the National Health and Nutrition Examination Survey data sample weights and the estimated models, we predicted US nationally representative participation rates by subgroups and examined the effect of offering more than one incentive design. External validity was checked by using a completed cluster randomized control trial. RESULTS There were significant subgroup differences in preference toward incentive attributes. There was also a sizable negative response to larger incentive amounts among African Americans, suggesting that higher amounts would reduce participation from this population. We also find that offering participants a menu of incentive designs to choose from would increase reach more than offering higher reward amounts. CONCLUSIONS We confirmed the existence of preference heterogeneity and the importance of subgroup-targeted incentive designs in any evidence-based weight control program to maximize population reach and reduce health disparities.
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Affiliation(s)
- Wen You
- Department of Public Health Science, School of Medicine, University of Virginia, University of Virginia Cancer Center, Charlottesville, VA USA
| | | | - Kevin J. Boyle
- Department of Agricultural and Applied Economics, Willis Blackwood Real Estate, Virginia Tech, Blacksburg, VA USA
| | - Tzeyu L. Michaud
- Department of Health Promotion, University of Nebraska Medical Center, Omaha, NE USA
| | - Chris Parmeter
- Department of Economics, University of Miami, Miami, FL USA
| | - Richard W. Seidel
- Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA USA
| | - Paul A. Estabrooks
- Department of Health Promotion, University of Nebraska Medical Center, Omaha, NE USA
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10
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West DS, Krukowski RA, Monroe CM, Stansbury ML, Carpenter CA, Finkelstein EA, Naud S, Ogden D, Harvey JR. Randomized controlled trial of financial incentives during weight-loss induction and maintenance in online group weight control. Obesity (Silver Spring) 2022; 30:106-116. [PMID: 34932889 PMCID: PMC10519100 DOI: 10.1002/oby.23322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study examined the impact of a financial incentive scheme integrating process and outcome incentives across weight-loss induction and weight maintenance on 18-month weight outcomes. METHODS This was a randomized controlled trial. Participants with overweight or obesity (n = 418; 91% female; 28% racial/ethnic minority) were randomized to an 18-month, online, group-based behavioral weight-control program (Internet-Only) or the same program with financial incentives provided for 12 months, contingent on self-regulatory weight-control behaviors (self-weighing, dietary self-monitoring, and physical activity) and weight-outcome benchmarks (Internet+Incentives). No financial incentives were provided from Months 13 to 18 to examine the durability of weight-control behaviors and outcomes without incentives. RESULTS Weight-loss induction at Month 6 was significantly greater for Internet+Incentives than Internet-Only (6.8% vs. 4.9%, respectively, p = 0.01). Individuals receiving incentives were significantly more likely to maintain weight loss ≥ 5% at Month 12 (45% in Internet+Incentives vs. 32% in Internet-Only, p < 0.02) and remain weight stable (39% vs. 27%, respectively, p < 0.01). Internet+Incentives participants also reported significantly greater behavioral engagement through Month 12. However, once incentives ceased, there were no differences in sustained weight outcomes (Month 18), and engagement declined dramatically. CONCLUSIONS Despite promoting greater treatment engagement and initial weight loss, financial incentives as offered in this study did not promote better extended weight control.
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Affiliation(s)
- Delia S. West
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Rebecca A. Krukowski
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Courtney M. Monroe
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Melissa L. Stansbury
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Chelsea A. Carpenter
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL, USA
| | - Eric A. Finkelstein
- Duke-NUS Medical School and Duke University Global Health Institute, Singapore and Durham, NC, USA
| | - Shelly Naud
- Department of Medical Biostatistics, University of Vermont, Burlington, Vermont, USA
| | - Doris Ogden
- Department of Nutrition and Food Sciences, University of Vermont, Burlington, Vermont, USA
| | - Jean R. Harvey
- Department of Nutrition and Food Sciences, University of Vermont, Burlington, Vermont, USA
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11
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Yeung KF, Gandhi M, Lam AYR, Julianty S, Chia AYM, Tan GCS, Goh SY, Ho ETL, Koh AFY, Tan GSW, Shum EJW, Finkelstein EA, Jafar TH, Teoh YL, van Dam RM, Whitton C, Thumboo J, Bee YM. The Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes (Pre-DICTED) program: study protocol for a randomized controlled trial. Trials 2021; 22:522. [PMID: 34362409 PMCID: PMC8349028 DOI: 10.1186/s13063-021-05500-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-based diabetes prevention programs varied widely in effectiveness, and the intervention strategy consisting of lifestyle interventions, stepwise addition of metformin, and financial incentives has not been studied in real-world clinical practice settings. The Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes (Pre-DICTED) trial is a pragmatic trial that aims to compare the effectiveness of a community-based stepwise diabetes prevention program with added financial incentives (intervention) versus the standard of care (control) in reducing the risk of type 2 diabetes over 3 years among overweight or obese individuals with pre-diabetes. METHODS This is an open-label, 1:1 randomized controlled trial which aims to recruit 846 adult individuals with isolated impaired fasting glucose (IFG), isolated impaired glucose tolerance (IGT), or both IFG and IGT from Singapore. Intervention arm participants attend 12 group-based sessions (2 nutrition workshops, 9 exercise sessions, and a goal-setting workshop) delivered at community sites (weeks 1 to 6), receive weekly physical activity and nutrition recommendations delivered by printed worksheets (weeks 7 to 12), and receive monthly health tips delivered by text messages (months 4 to 36). From month 6 onwards, intervention arm participants who remain at the highest risk of conversion to diabetes are prescribed metformin. Intervention arm participants are also eligible for a payment/rewards program with incentives tied to attendance at the group sessions and achievement of the weight loss target (5% of baseline weight). All participants are assessed at baseline, month 3, month 6, and every 6 months subsequently till month 36. The primary endpoint is the proportion of participants with diabetes at 3 years. Secondary endpoints include the mean change from baseline at 3 years in fasting plasma glucose, 2-hour plasma glucose, HbA1c, body weight, body mass index, physical activity, and dietary intake. DISCUSSION The Pre-DICTED trial will provide evidence of the effectiveness and feasibility of a community-based stepwise diabetes prevention program with added financial incentives for individuals with pre-diabetes in Singapore. The study will provide data for a future cost-effectiveness analysis, which will be used to inform policymakers of the value of a nationwide implementation of the diabetes prevention program. TRIAL REGISTRATION ClinicalTrials.gov NCT03503942 . Retrospectively registered on April 20, 2018. Protocol version: 5.0 Date: 1 March 2019.
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Affiliation(s)
- Kar-Fu Yeung
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Mihir Gandhi
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore.,Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore.,The Center for Child Health Research, Tampere University, Tampere, Finland
| | - Amanda Yun Rui Lam
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.,SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore
| | - Selly Julianty
- SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.,Regional Health System Office, SingHealth, Singapore, Singapore
| | | | - Gilbert Choon Seng Tan
- SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.,SingHealth Polyclinics, Singapore, Singapore
| | - Su-Yen Goh
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.,SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore
| | - Emily Tse Lin Ho
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.,Regional Health System Office, SingHealth, Singapore, Singapore
| | - Angela Fang Yung Koh
- SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.,Department of Internal Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Gavin Siew Wei Tan
- SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.,Surgical Retinal Department, Singapore National Eye Centre, Singapore, Singapore
| | | | - Eric A Finkelstein
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Tazeen H Jafar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yee Leong Teoh
- Biostatistics, Singapore Clinical Research Institute, Singapore, Singapore
| | - Rob M van Dam
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Clare Whitton
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | - Yong Mong Bee
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore. .,SingHealth Duke-NUS Diabetes Centre, Singapore, Singapore.
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12
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Okamoto S, Kamimura K, Shiraishi K, Sumita K, Komamura K, Tsukao A, Chijiki S, Kuno S. Daily steps and healthcare costs in Japanese communities. Sci Rep 2021; 11:15095. [PMID: 34301997 PMCID: PMC8302729 DOI: 10.1038/s41598-021-94553-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/09/2021] [Indexed: 11/14/2022] Open
Abstract
Physical inactivity is a pandemic that requires intensive, usually costly efforts for risk reduction of related chronic diseases. Nevertheless, it is challenging to determine the effectiveness of physical activity in healthcare cost reduction based on existing literature. Therefore, this study aimed to investigate the impact of physical activity (daily steps) on healthcare costs utilising the data retrieved from a health promotion project (the e-wellness Project, held in three municipalities in Japan). Evaluating the effects of daily steps, measured by pedometers, on healthcare costs by a quasi-experimental approach among participants aged 40–75 years (about 4000 person-years of observation, between 2009 and 2013), we found that a one-step-increase in the annual average daily step reduced outpatient healthcare costs by 16.26 JPY (≒ 0.11 GBD) in the short run. Based on the assumption of a dynamic relationship between the health statuses in multiple years, the long-run effects of daily steps on healthcare costs were estimated at 28.24 JPY (≒ 0.20 GBD). We determined the health benefits of walking in a sample of middle-aged and older Japanese adults by our findings that an increase in step counts reduced healthcare costs.
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Affiliation(s)
- Shohei Okamoto
- Research Team for Social Participation and Community Health, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo, 173-0015, Japan. .,Institute for Global Health Policy Research, National Centre for Global Health and Medicine, Tokyo, Japan.
| | | | - Kenichi Shiraishi
- Department of Social Welfare, Gunma University of Health and Welfare , Gunma, Japan
| | - Kazuto Sumita
- Department of International Economics, Toyo University , Tokyo, Japan
| | | | | | | | - Shinya Kuno
- R&D Center for Smart Wellness City Policies, University of Tsukuba , Ibaraki, Japan
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13
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Alkhoury D, Atchison J, Trujillo AJ, Oslin K, Frey KP, O'Toole RV, Castillo RC, O'Hara NN. Can financial payments incentivize short-term smoking cessation in orthopaedic trauma patients? Evidence from a discrete choice experiment. HEALTH ECONOMICS REVIEW 2021; 11:15. [PMID: 33903947 PMCID: PMC8077692 DOI: 10.1186/s13561-021-00313-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/18/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Smoking increases the risk of complications and related costs after an orthopaedic fracture. Research in other populations suggests that a one-time payment may incentivize smoking cessation. However, little is known on fracture patients' willingness to accept financial incentives to stop smoking; and the level of incentive required to motivate smoking cessation in this population. This study aimed to estimate the financial threshold required to motivate fracture patients to stop smoking after injury. METHODS This cross-sectional study utilized a discrete choice experiment (DCE) to elicit patient preferences towards financial incentives and reduced complications associated with smoking cessation. We presented participants with 12 hypothetical options with several attributes with varying levels. The respondents' data was used to determine the utility of each attribute level and the relative importance associated with each attribute. RESULTS Of the 130 enrolled patients, 79% reported an interest in quitting smoking. We estimated the financial incentive to be of greater relative importance (ri) (45%) than any of the included clinical benefits of smoking cessations (deep infection (ri: 24%), bone healing complications (ri: 19%), and superficial infections (ri: 12%)). A one-time payment of $800 provided the greatest utility to the respondents (0.64, 95% CI: 0.36 to 0.93), surpassing the utility associated with a single $1000 financial incentive (0.36, 95% CI: 0.18 to 0.55). CONCLUSIONS Financial incentives may be an effective tool to promote smoking cessation in the orthopaedic trauma population. The findings of this study define optimal payment thresholds for smoking cessation programs.
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Affiliation(s)
- Dana Alkhoury
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jared Atchison
- Department of Orthopaedics, University of Maryland School of Medicine, 110 South Paca St., Suite 300, Baltimore, MD, USA
| | - Antonio J Trujillo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kimberly Oslin
- Department of Orthopaedics, University of Maryland School of Medicine, 110 South Paca St., Suite 300, Baltimore, MD, USA
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert V O'Toole
- Department of Orthopaedics, University of Maryland School of Medicine, 110 South Paca St., Suite 300, Baltimore, MD, USA
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, 110 South Paca St., Suite 300, Baltimore, MD, USA.
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14
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Thondre PS, Lightowler H, Ahlstrom L, Gallagher A. Mulberry leaf extract improves glycaemic response and insulaemic response to sucrose in healthy subjects: results of a randomized, double blind, placebo-controlled study. Nutr Metab (Lond) 2021; 18:41. [PMID: 33858439 PMCID: PMC8047566 DOI: 10.1186/s12986-021-00571-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background There are many benefits of maintaining healthy blood glucose levels, and studies have shown that lifestyle changes such as changes to diet can successfully restore normoglycaemia in participants with dysglycaemia. Significant health-related lifestyle changes are often difficult to implement and functional ingredients that can reduce glycaemic and insulaemic responses may help at risk populations. The aim of this study was to investigate whether a mulberry leaf extract could lower the glycaemic and insulinaemic responses to 75 g sucrose in healthy individuals. Methods A double-blind, randomised, placebo-controlled, crossover design trial was conducted by the Oxford Brookes Centre for Nutrition and Health. Thirty-eight participants were recruited into the trial and, after an overnight fast, were given 75 g sucrose + white mulberry leaf extract, or 75 g sucrose alone. Capillary blood samples were collected at 15-min intervals in the first hour and at 30-min intervals over the second hour to determine glucose and plasma insulin levels. Data analysis was conducted using a paired samples T test or a Wilcoxon signed rank test. Results The addition of mulberry leaf extract to sucrose resulted in a significantly lower glycaemic response and insulinaemic response compared to a matched placebo (sucrose alone). The change in blood glucose measurements were significantly lower at 15 min (p < 0.001), 30 min (p < 0.001), 45 min (p = 0.008), and 120 min (p < 0.001) and plasma insulin measurements were significantly lower at 15 min (p < 0.001), 30 min (p < 0.001), 45 min (p < 0.001), 60 min (p = 0.001) and 120 min (p < 0.001). The glucose iAUC (− 42%, p = 0.001), insulin iAUC (− 40%, p < 0.001), peak glucose (− 40.0%, p < 0.001) and peak insulin (− 41%, p < 0.001) from baseline were significantly lower for white mulberry leaf extract compared with the placebo. White mulberry leaf extract was well tolerated and there were no reported adverse events. Conclusions Mulberry leaf extract can be used as part of lifestyle changes that may lead to healthy blood glucose levels. Trial registration: ISRCTN99601810 (23 October 2020, retrospectively registered)
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Affiliation(s)
- Pariyarath Sangeetha Thondre
- Oxford Brookes Centre for Nutrition and Health, Faculty of Health and Life Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford, OX3 0BP, UK
| | - Helen Lightowler
- Oxford Brookes Centre for Nutrition and Health, Faculty of Health and Life Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford, OX3 0BP, UK
| | - Lis Ahlstrom
- Oxford Brookes Centre for Nutrition and Health, Faculty of Health and Life Sciences, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford, OX3 0BP, UK
| | - Andrew Gallagher
- Phynova Group Ltd, 16 Fenlock Court, Blenheim Office Park, Long Hanborough, OX29 8LN, UK.
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15
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Bilger M, Shah M, Tan NC, Tan CYL, Bundoc FG, Bairavi J, Finkelstein EA. Process- and Outcome-Based Financial Incentives to Improve Self-Management and Glycemic Control in People with Type 2 Diabetes in Singapore: A Randomized Controlled Trial. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 14:555-567. [PMID: 33491116 PMCID: PMC8357673 DOI: 10.1007/s40271-020-00491-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sub-optimally controlled diabetes increases risks for adverse and costly complications. Self-management including glucose monitoring, medication adherence, and exercise are key for optimal glycemic control, yet, poor self-management remains common. OBJECTIVE The main objective of the Trial to Incentivize Adherence for Diabetes (TRIAD) study was to determine the effectiveness of financial incentives in improving glycemic control among type 2 diabetes patients in Singapore, and to test whether process-based incentives tied to glucose monitoring, medication adherence, and physical activity are more effective than outcome-based incentives tied to achieving normal glucose readings. METHODS TRIAD is a randomized, controlled, multi-center superiority trial. A total of 240 participants who had at least one recent glycated hemoglobin (HbA1c) being 8.0% or more and on oral diabetes medication were recruited from two polyclinics. They were block-randomized (blocking factor: current vs. new glucometer users) into the usual care plus (UC +) arm, process-based incentive arm, and outcome-based incentive arm in a 2:3:3 ratio. The primary outcome was the mean change in HbA1c at month 6 and was linearly regressed on binary variables indicating the intervention arms, baseline HbA1c levels, a binary variable indicating titration change, and other baseline characteristics. RESULTS Our findings show that the combined incentive arms trended toward better HbA1c than UC + , but the difference is estimated with great uncertainty (difference - 0.31; 95% confidence interval [CI] - 0.67 to 0.06). Lending credibility to this result, the proportion of participants who reduced their HbA1c is higher in the combined incentive arms relative to UC + (0.18; 95% CI 0.04, 0.31). We found a small improvement in process- relative to outcome-based incentives, but this was again estimated with great uncertainty (difference - 0.05; 95% CI - 0.42 to 0.31). Consistent with this improvement, process-based incentives were more effective at improving weekly medication adherent days (0.64; 95% CI - 0.04 to 1.32), weekly physically active days (1.37; 95% CI 0.60-2.13), and quality of life (0.04; 95% CI 0.0-0.07) than outcome-based incentives. CONCLUSION This study suggests that both incentive types may be part of a successful self-management strategy. Process-based incentives can improve adherence to intermediary outcomes, while outcome-based incentives focus on glycemic control and are simpler to administer.
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Affiliation(s)
- Marcel Bilger
- Health Economics and Policy, Vienna University of Business and Economics, Vienna, Austria.
| | - Mitesh Shah
- SingHealth Polyclinics, Singapore, Singapore
| | | | | | - Filipinas G Bundoc
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Joann Bairavi
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Eric A Finkelstein
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore.,Duke Global Health Institute, Duke University, Durham, USA
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16
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Finkelstein EA, Lim RSM, Ward DS, Evenson KR. Leveraging family dynamics to increase the effectiveness of incentives for physical activity: the FIT-FAM randomized controlled trial. Int J Behav Nutr Phys Act 2020; 17:113. [PMID: 32912260 PMCID: PMC7488241 DOI: 10.1186/s12966-020-01018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/03/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Eric Andrew Finkelstein
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
| | - Robyn Su May Lim
- Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Dianne Stanton Ward
- Center for Health Promotion and Disease Prevention, University of North Carolina Chapel Hill, 1700 Martin Luther King Jr. Boulevard #7426, Chapel Hill, NC, 27514, USA.,Department of Nutrition, Gillings School of Global Public Health, University of North Carolina Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Kelly R Evenson
- Center for Health Promotion and Disease Prevention, University of North Carolina Chapel Hill, 1700 Martin Luther King Jr. Boulevard #7426, Chapel Hill, NC, 27514, USA.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, NC, 27599-8050, USA
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17
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Sharman MJ, Ball K, Greaves S, Jose KA, Morse M, Blizzard CL, Wells G, Venn AJ, Palmer AJ, Lester D, Williams J, Harpur S, Cleland VJ. trips4health: Protocol of a single-blinded randomised controlled trial incentivising adults to use public transport for physical activity gain. Contemp Clin Trials Commun 2020; 19:100619. [PMID: 32775761 PMCID: PMC7394862 DOI: 10.1016/j.conctc.2020.100619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 12/03/2022] Open
Abstract
Background Public transport (PT) users typically accumulate more physical activity (PA) than private motor vehicle users yet redressing physical inactivity through transport-related PA (TRPA) interventions has received limited attention. Further, incentive-based strategies can increase leisure-time PA but their impact on TRPA, is unclear. This study's objective is to determine the impact of an incentive-based strategy on TRPA in a regional Australian setting. Methods trips4health is a single-blinded randomised controlled trial with a four-month intervention phase and subsequent six-month maintenance phase. Participants will be randomised to: an incentives-based intervention (bus trip credit for reaching bus trip targets, weekly text messages to support greater bus use, written PA guidelines); or an active control (written PA guidelines only). Three hundred and fifty adults (≥18 years) from southern Tasmania will be recruited through convenience methods, provide informed consent and baseline information, then be randomised. The primary outcome is change in accelerometer measured average daily step count at baseline and four- and ten-months later. Secondary outcomes are changes in: measured and self-reported travel behaviour (e.g. PT use), PA, sedentary behaviour; self-reported and measured (blood pressure, waist circumference, height, weight) health; travel behaviour perspectives (e.g. enablers/barriers); quality of life; and transport-related costs. Linear mixed model regression will determine group differences. Participant and PT provider level process evaluations will be conducted and intervention costs to the provider determined. Discussion trips4health will determine the effectiveness of an incentive-based strategy to increase TRPA by targeting PT use. The findings will enable evidence-informed decisions about the worthwhileness of such strategies. Trial registration ACTRN12619001136190. Universal trial number U1111-1233-8050.
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Affiliation(s)
- M J Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - K Ball
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, Victoria, Australia
| | - S Greaves
- Institute of Transport and Logistic Studies, The University of Sydney, Sydney, New South Wales, Australia
| | - K A Jose
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - M Morse
- Metro Tasmania, Hobart, Tasmania, Australia
| | - C L Blizzard
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - G Wells
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - A J Venn
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - A J Palmer
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - D Lester
- Local Government Association of Tasmania, Hobart, Tasmania, Australia
| | - J Williams
- Department of Health, Tasmanian Government, Hobart, Tasmania, Australia
| | - S Harpur
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - V J Cleland
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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18
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Adding Financial Incentives to Online Group-Based Behavioral Weight Control: An RCT. Am J Prev Med 2020; 59:237-246. [PMID: 32446752 PMCID: PMC8510645 DOI: 10.1016/j.amepre.2020.03.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/24/2020] [Accepted: 03/29/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Internet-delivered behavioral weight control is promising for expanding the reach and availability of weight management, but online programs produce lower weight losses than typically achieved in person. Financial incentives have been shown to increase weight losses. This study examined whether adding financial incentives for self-monitoring and achieving target weight losses increases weight losses attained in a fully online, group-based behavioral weight management program compared with the same program alone. STUDY DESIGN This study was an RCT. SETTING/PARTICIPANTS Adults with overweight and obesity (n=418; 91% female; 28% minority) were recruited from 2 clinical centers. INTERVENTION The intervention was a 24-session online group-based behavioral weight control program with weekly synchronous chat sessions (Internet-only) or the same program with weekly financial incentives for self-monitoring body weight and dietary intake daily and for achieving target weight losses at 2 and 6 months (Internet + incentives). MAIN OUTCOME MEASURES This study measured weight loss at 6 months and treatment engagement (attendance, self-monitoring of body weight, dietary intake, and physical activity). Data were collected between February 2016 and August 2018, and analyses were completed in 2019. RESULTS Participants randomized to the Internet + incentives group lost more weight (-6.4 [SD=5.5] kg) than those in the Internet-only group (-4.7 [SD=6.6] kg; p<0.01). Further, a higher proportion of the Internet + incentives group achieved ≥5% weight loss (55%) than those in the Internet-only group (40%; p<0.05). Treatment engagement was higher in the Internet + incentives condition, with greater self-monitoring of behaviors targeted by incentives, as well as higher rates of behaviors not targeted and higher self-reported physical activity. Study retention was higher among those in the Internet + incentives condition (91%) than those in the Internet-only condition (81%; p=0.003). CONCLUSIONS Adding financial incentives to a program delivered fully online increases weight losses compared with the program alone and can achieve weight losses comparable to in-person programs, offering potential for substantial geographic reach. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02688621.
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Luong MLN, Hall M, Bennell KL, Kasza J, Harris A, Hinman RS. The Impact of Financial Incentives on Physical Activity: A Systematic Review and Meta-Analysis. Am J Health Promot 2020; 35:236-249. [PMID: 32672050 DOI: 10.1177/0890117120940133] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the effects of financial incentives on physical activity (PA). DATA SOURCES MEDLINE, Embase, 7 other databases, and 2 trial registries until July 17, 2019. STUDY INCLUSION AND EXCLUSION CRITERIA Randomized controlled trials with adults aged ≥18 years assessing the effect of financial incentives on PA. Any comparator was eligible provided the only difference between groups was the incentive strategy. DATA EXTRACTION Two independent reviewers extracted data and assessed study quality. Of 5765 records identified, 57 records (51 unique trials; n = 17 773 participants) were included. DATA SYNTHESIS Random-effects models pooling data for each of the 5 PA domains. RESULTS Financial incentives increase leisure time PA (gym or class attendance; standardized mean difference [95% CI], 0.46 [0.28-0.63], n = 5057) and walking behavior (steps walked; 0.25 [0.13-0.36], n = 3254). No change in total minutes of PA (0.52 [-0.09 to 1.12], n = 968), kilocalories expended (0.19 [-0.06 to 0.44], n = 247), or the proportion of participants meeting PA guidelines (risk ratio [95% CI] 1.53 [0.53-4.44], n = 650) postintervention was observed. After intervention has ceased, incentives sustain a slight increase in leisure time PA (0.10 [0.02-0.18], n = 2678) and walking behavior (0.11 [0.00-0.22], n = 2425). CONCLUSIONS Incentives probably improve leisure time PA and walking at intervention end, and small improvements may be sustained over time once incentives have ceased. They lead to little or no difference in kilocalories expended or minutes of PA. It is uncertain whether incentives change the likelihood of meeting PA guidelines because the certainty of the evidence is low.
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Affiliation(s)
- My-Linh Nguyen Luong
- Department of Physiotherapy, 549319Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Victoria, Australia
| | - Michelle Hall
- Department of Physiotherapy, 549319Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Victoria, Australia
| | - Kim L Bennell
- Department of Physiotherapy, 549319Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Victoria, Australia
| | - Jessica Kasza
- Biostatistics Unit, 161667School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Anthony Harris
- Centre for Health Economics, Monash Business School, Monash University, Victoria, Australia
| | - Rana S Hinman
- Department of Physiotherapy, 549319Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Victoria, Australia
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Bilger M, Wong TT, Lee JY, Howard KL, Bundoc FG, Lamoureux EL, Finkelstein EA. Using Adherence-Contingent Rebates on Chronic Disease Treatment Costs to Promote Medication Adherence: Results from a Randomized Controlled Trial. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:841-855. [PMID: 31317511 PMCID: PMC6885505 DOI: 10.1007/s40258-019-00497-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Poor adherence to medications is a global public health concern with substantial health and cost implications, especially for chronic conditions. In the USA, poor adherence is estimated to cause 125,000 deaths and cost $US100 billion annually. The most successful adherence-promoting strategies that have been identified so far have moderate effect, are relatively costly, and raise availability, feasibility, and/or scalability issues. OBJECTIVE The main objective of SIGMA (Study on Incentives for Glaucoma Medication Adherence) was to measure the effectiveness on medication adherence of a novel incentive strategy based on behavioral economics that we refer to as adherence-contingent rebates. These rebates offered patients a near-term benefit while leveraging loss aversion and regret and increasing the salience of adherence. METHODS SIGMA is a 6-month randomized, controlled, open-label, single-center superiority trial with two parallel arms. A total of 100 non-adherent glaucoma patients from the Singapore National Eye Centre were randomized into intervention (adherence-contingent rebates) and usual care (no rebates) arms in a 1:1 ratio. The primary outcome was the mean change from baseline in percentage of adherent days at Month 6. The trial registration number is NCT02271269 and a detailed study protocol has been published elsewhere. FINDINGS We found that participants who were offered adherence-contingent rebates were adherent to all their medications on 73.1% of the days after 6 months, which is 12.2 percentage points (p = 0.027) higher than in those not receiving the rebates after controlling for baseline differences. This better behavioral outcome was achieved by rebates averaging 8.07 Singapore dollars ($US5.94 as of 2 November 2017) per month during the intervention period. CONCLUSION This study shows that simultaneously leveraging several insights from behavioral economics can significantly improve medication adherence rates. The relatively low cost of the rebates and significant health and cost implications of medication non-adherence suggest that this strategy has the potential to cost-effectively improve health outcomes for many conditions.
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Affiliation(s)
- Marcel Bilger
- Health Economics and Policy, Vienna University of Business and Economics, Welthandelsplatz 1, Building D4, 1020, Vienna, Austria.
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore.
| | - Tina T Wong
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Jia Yi Lee
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Kaye L Howard
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Filipinas G Bundoc
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Ecosse L Lamoureux
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Eric A Finkelstein
- Health Services & Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, NC, USA
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Rummo PE, Elbel B. Using Multiple Financial Incentive Structures to Promote Sustainable Changes in Health Behaviors. JAMA Netw Open 2019; 2:e199859. [PMID: 31441932 DOI: 10.1001/jamanetworkopen.2019.9859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Pasquale E Rummo
- Section on Health Choice, Policy and Evaluation, Department of Population Health, New York University School of Medicine, New York
| | - Brian Elbel
- Section on Health Choice, Policy and Evaluation, Department of Population Health, New York University School of Medicine, New York
- Wagner Graduate School of Public Service, New York University, New York
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