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Heckman CJ, Mitarotondo A, Lin Y, Khavjou O, Riley M, Manne SL, Yaroch AL, Niu Z, Glanz K. Digital Interventions to Modify Skin Cancer Risk Behaviors in a National Sample of Young Adults: Randomized Controlled Trial. J Med Internet Res 2024; 26:e55831. [PMID: 38954433 PMCID: PMC11252624 DOI: 10.2196/55831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/01/2024] [Accepted: 04/10/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Young adults engage in behaviors that place them at risk for skin cancer. Dissemination of digital health promotion interventions via social media is a potentially promising strategy to modify skin cancer risk behaviors by increasing UV radiation (UVR) protection and skin cancer examinations. OBJECTIVE This study aimed to compare 3 digital interventions designed to modify UVR exposure, sun protection, and skin cancer detection behaviors among young adults at moderate to high risk of skin cancer. METHODS This study was a hybrid type II effectiveness-implementation randomized controlled trial of 2 active interventions, a digital skin cancer risk reduction intervention (UV4.me [basic]) compared with an enhanced version (UV4.me2 [enhanced]), and an electronic pamphlet (e-pamphlet). Intervention effects were assessed over the course of a year among 1369 US young adults recruited primarily via Facebook and Instagram. Enhancements to encourage intervention engagement and behavior change included more comprehensive goal-setting activities, ongoing proactive messaging related to previously established mediators (eg, self-efficacy) of UVR exposure and protection, embedded incentives for module completion, and ongoing news and video updates. Primary outcome effects assessed via linear regression were UVR exposure and sun protection and protection habits. Secondary outcome effects assessed via logistic regression were skin self-exams, physician skin exams, sunscreen use, indoor tanning, and sunburn. RESULTS The active interventions increased sun protection (basic: P=.02; enhanced: P<.001) and habitual sun protection (basic: P=.04; enhanced P=.01) compared with the e-pamphlet. The enhanced intervention increased sun protection more than the basic one. Each active intervention increased sunscreen use at the 3-month follow-up (basic: P=.03; enhanced: P=.01) and skin self-exam at 1 year (basic: P=.04; enhanced: P=.004), compared with the e-pamphlet. Other intervention effects and differences between the Basic and Enhanced Intervention effects were nonsignificant. CONCLUSIONS The active interventions were effective in improving several skin cancer risk and skin cancer prevention behaviors. Compared with the basic intervention, the enhanced intervention added to the improvement in sun protection but not other behaviors. Future analyses will explore intervention engagement (eg, proportion of content reviewed). TRIAL REGISTRATION ClinicalTrials.gov NCT03313492; http://clinicaltrials.gov/ct2/show/NCT03313492.
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Affiliation(s)
| | | | - Yong Lin
- Rutgers School of Public Health, Piscataway, NJ, United States
| | - Olga Khavjou
- RTI International, Research Triangle Park, NC, United States
| | | | - Sharon L Manne
- Rutgers Cancer Institute, New Brunswick, NJ, United States
| | - Amy L Yaroch
- Gretchen Swanson Center for Nutrition, Omaha, NE, United States
| | - Zhaomeng Niu
- Rutgers School of Health Professions, Piscataway, NJ, United States
| | - Karen Glanz
- University of Pennsylvania, Philadelphia, PA, United States
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Linnemayr S, Odiit M, Mukasa B, Ghai I, Stecher C. INcentives and ReMINDers to Improve Long-Term Medication Adherence (INMIND): impact of a pilot randomized controlled trial in a large HIV clinic in Uganda. J Int AIDS Soc 2024; 27:e26306. [PMID: 38923298 PMCID: PMC11197960 DOI: 10.1002/jia2.26306] [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: 02/07/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Habits are a common strategy for successfully countering medication non-adherence, yet existing interventions do not support participants during the long habit formation period, resulting in high attrition. We test a novel intervention combining text messages and incentives with anchoring to support antiretroviral therapy (ART) pill-taking habits. METHODS In a randomized, parallel controlled trial, a sample of 155 participants 18 years and older who initiated ART within 3 months were recruited at Mildmay Uganda between October 2021 and April 2022. All participants were educated on the anchoring strategy and chose an anchor, that is existing routines, to pair with pill-taking. Participants were randomized to either usual care (C = 49), daily text message reminders to follow their anchoring plan (Messages group; T1 = 49) or messages and incentives conditional on pill-taking in line with their anchor (Incentives group; T2 = 57). Assessments occurred at baseline, month 3 (end of intervention) and month 9 (end of observation period). The primary outcomes are electronically measured mean adherence and pill-taking consistent with participants' anchor time. RESULTS The primary outcome of pill-taking in line with the anchoring plan was higher in the Incentives group during the 3-month intervention (12.2 p.p. [95% CI: 2.2 22.2; p = .02]), and remained significantly higher after the incentives were withdrawn (months 4-6 (14.2 p.p. [95% CI 1.1 27.2; p = .03]); months 7-9 (14.1 p.p. [95% CI -0.2 28.5; p = .05])). Mean adherence was higher in both treatment groups relative to the control group during the intervention (T1 vs. C, p = .06; T2 vs. C, p = .06) but not post-intervention. CONCLUSIONS The promising approach of using incentives to support habit formation among ART treatment initiators needs to be evaluated in a fully powered study to further our understanding of the habit formation process and to evaluate its cost-effectiveness.
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Affiliation(s)
| | | | | | | | - Chad Stecher
- College of Health SolutionsArizona State UniversityPhoenixArizonaUSA
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Corrêa R, Tabak BM. The Influence of Behavioral Sciences on Adherence to Physical Activity and Weight Loss in Overweight and Obese Patients: A Systematic Review of Randomized Controlled Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:630. [PMID: 38791844 PMCID: PMC11121225 DOI: 10.3390/ijerph21050630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024]
Abstract
In recent years, weight gain and reduced physical activity in the general population have contributed to the development of obesity and other health problems; on the other hand, studies in behavioral sciences have been used to modify behaviors for a healthier life, so the objective of this study was to identify the evidence of interventions in behavioral sciences on adherence to physical activity and weight loss in obese patients. This systematic review study is based on a search of the electronic databases PubMed, Web of Science, Scopus, and Cochrane. Studies assessed the evidence from intervention studies that assessed the influence of intervention studies of behavioral sciences on public health. The articles were published between 2013 and 2023. The systematic search of the databases identified 2951 articles. The review analyzed 10 studies. Behavioral science interventions presented evidence through strategies such as multicomponent interventions, lottery and financial incentives, message framing, message framing with financial incentive and physical activity, and psychological satisfaction, demonstrating results in weight loss and maintenance and increased physical activity. This study presents scientific evidence through healthy behavior change methodologies, and future studies can explore these strategies in conjunction with public health technologies in the search for public-private partnerships to promote physical activity in adults.
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Affiliation(s)
- Rafael Corrêa
- School of Public Policy and Government, Getulio Vargas Foundation, SGAN 602 Módulos A,B,C, Asa Norte, Brasília 70830-020, Brazil;
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Stecher C, Chen CH, Codella J, Cloonan S, Hendler J. Combining anchoring with financial incentives to increase physical activity: a randomized controlled trial among college students. J Behav Med 2024:10.1007/s10865-024-00492-4. [PMID: 38704776 DOI: 10.1007/s10865-024-00492-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 04/16/2024] [Indexed: 05/07/2024]
Abstract
The purpose of this study was to: (1) compare the relative efficacy of different combinations of three behavioral intervention strategies (i.e., personalized reminders, financial incentives, and anchoring) for establishing physical activity habits using an mHealth app and (2) to examine the effects of these different combined interventions on intrinsic motivation for physical activity and daily walking habit strength. A four-arm randomized controlled trial was conducted in a sample of college students (N = 161) who had a self-reported personal wellness goal of increasing their physical activity. Receiving cue-contingent financial incentives (i.e., incentives conditional on performing physical activity within ± one hour of a prespecified physical activity cue) combined with anchoring resulted in the highest daily step counts and greatest odds of temporally consistent walking during both the four-week intervention and the full eight-week study period. Cue-contingent financial incentives were also more successful at increasing physical activity and maintaining these effects post-intervention than traditional non-cue-contingent incentives. There were no differences in intrinsic motivation or habit strength between study groups at any time point. Financial incentives, particularly cue-contingent incentives, can be effectively used to support the anchoring intervention strategy for establishing physical activity habits. Moreover, mHealth apps are a feasible method for delivering the combined intervention technique of financial incentives with anchoring.
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Wernimont SA, Fleener D, Summers KM, Deonovic B, Syrop CH, Andrews JI. The Effect of Financial Incentives on Adherence to Glucose Self-Monitoring during Pregnancy among Patients with Insulin-Requiring Diabetes: A Randomized Clinical Trial. Am J Perinatol 2024; 41:e259-e266. [PMID: 35777732 PMCID: PMC11093650 DOI: 10.1055/a-1889-7765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/03/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Glucose self-monitoring is critical for the management of diabetes in pregnancy, and increased adherence to testing is associated with improved obstetrical outcomes. Incentives have been shown to improve adherence to diabetes self-management. We hypothesized that use of financial incentives in pregnancies complicated by diabetes would improve adherence to glucose self-monitoring. STUDY DESIGN We conducted a single center, randomized clinical trial from May 2016 to July 2019. In total, 130 pregnant patients, <29 weeks with insulin requiring diabetes, were recruited. Participants were randomized in a 1:1:1 ratio to one of three payment groups: control, positive incentive, and loss aversion. The control group received $25 upon enrollment. The positive incentive group received 10 cents/test, and the loss aversion group received $100 for >95% adherence and "lost" payment for decreasing adherence. The primary outcome was percent adherence to recommended glucose self-monitoring where adherence was reliably quantified using a cellular-enabled glucometer. Adherence, calculated as the number of tests per day divided by the number of recommended tests per day×100%, was averaged from time of enrollment until admission for delivery. RESULTS We enrolled 130 participants and the 117 participants included in the final analysis had similar baseline characteristics across the three groups. Average adherence rates in the loss aversion, control and positive incentive groups were 69% (SE=5.12), 57% (SE = 4.60), and 58% (SE=3.75), respectively (p=0.099). The loss aversion group received an average of $50 compared with $38 (positive incentive) and $25 (control). CONCLUSION In this randomized clinical trial, loss aversion incentives tended toward higher adherence to glucose self-monitoring among patients whose pregnancies were complicated by diabetes, though did not reach statistical significance. Further studies are needed to determine whether use of incentives improve maternal and neonatal outcomes. KEY POINTS · Self-glucose monitoring is a critical part of diabetes management in pregnancy.. · Loss aversion financial incentives may increase adherence to glucose self-monitoring in pregnancy.. · The impact of testing incentives on maternal and neonatal outcomes requires further investigation..
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Affiliation(s)
- Sarah A Wernimont
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota
- Division of Molecular Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Diedre Fleener
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Karen M Summers
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Benjamin Deonovic
- Department of Biostatistics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Craig H Syrop
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Janet I Andrews
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota
- Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Berardi V, Phillips CB, McEntee ML, Stecher C, Todd M, Adams MA. The Impact of Monetary Incentives on Delay Discounting Within a Year-Long Physical Activity Intervention. Ann Behav Med 2024; 58:341-352. [PMID: 38507617 PMCID: PMC11008587 DOI: 10.1093/abm/kaae009] [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] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Delay discounting is the depreciation in a reward's perceived value as a function of the time until receipt. Monetary incentive programs that provide rewards contingent on meeting daily physical activity (PA) goals may change participants' delay discounting preferences. PURPOSE Determine if monetary incentives provided in close temporal proximity to meeting PA goals changed delay discounting, and if such changes mediated intervention effects. METHODS Inactive adults (n = 512) wore accelerometers during a 12-month intervention where they received proximal monetary incentives for meeting daily moderate-to-vigorous PA (MVPA) goals or delayed incentives for study participation. Delay discount rate and average MVPA were assessed at baseline, end of intervention, and a 24-month follow-up. Using structural equation modeling, we tested effects of proximal versus delayed rewards on delay discounting and whether any changes mediated intervention effects on MVPA. PA self-efficacy was also evaluated as a potential mediator, and both self-efficacy and delay discounting were assessed as potential moderators of intervention effects. RESULTS Proximal rewards significantly increased participants' delay discounting (β = 0.238, confidence interval [CI]: -0.078, 0.380), indicating greater sensitivity to reinforcement timing. This change did not mediate incentive-associated increases in MVPA at the end of the 12-month intervention (β = -0.016, CI: -0.053, 0.019) or at a 24-month follow-up (β = -0.020, CI: -0.059, 0.018). Moderation effects were not found. CONCLUSIONS Incentive-induced increases in delay discounting did not deleteriously impact MVPA. This finding may help assuage concerns about using monetary incentives for PA promotion, but further research regarding the consequences of changes in delay discounting is warranted.
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Affiliation(s)
- Vincent Berardi
- Department of Psychology, Chapman University, Orange, CA, USA
| | | | - Mindy L McEntee
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Michael Todd
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Marc A Adams
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
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Robinson L, Arden MA, Dawson S, Walters SJ, Wildman MJ, Stevenson M. A machine-learning assisted review of the use of habit formation in medication adherence interventions for long-term conditions. Health Psychol Rev 2024; 18:1-23. [PMID: 35086431 DOI: 10.1080/17437199.2022.2034516] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/21/2022] [Indexed: 12/20/2022]
Abstract
Adherence to medication in long-term conditions is around 50%. The key components of successful interventions to improve medication adherence remain unclear, particularly when examined over prolonged follow-up periods. Behaviour change theories are increasingly interested in the utility of habit formation for the maintenance of health behaviour change, but there is no documentation on how habit has been conceptualised in the medication adherence intervention literature, or what effect the key technique identified in habit formation theory (context dependent repetition) has in these studies. To examine this, a machine-learning assisted review was conducted. Searches of MEDLINE, EMBASE and PSYCInfo and the reference list of a comprehensive systematic review of medication adherence interventions yielded 5973 articles. Machine learning-assisted title and abstract screening identified 15 independent RCTs published between 1976 and 2021, including 18 intervention comparisons of interest. Key findings indicate that conceptualisations of habit in the medication adherence literature are varied and behaviour change technique coding identified only six studies which explicitly described using habit formation. Future work should aim to develop this evidence base, drawing on contemporary habit theory and with explicit demonstration of what techniques have been used to promote habit formation.
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Affiliation(s)
- L Robinson
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - M A Arden
- Centre for Behavioural Science and Applied Psychology, Sheffield Hallam University, Sheffield, UK
| | - S Dawson
- Wolfson Adult Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, City Hospital, Nottingham, UK
| | - S J Walters
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - M J Wildman
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - M Stevenson
- Department of Computer Science, The University of Sheffield, Sheffield, UK
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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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Worthington A, Gillies N, Hannaford R, Roy R, Braakhuis A. Implementing multicomponent, eHealth-based behaviour change support within a dietary intervention trial improves adherence to study-related behaviours in healthy young adults. BMC Nutr 2023; 9:134. [PMID: 37990250 PMCID: PMC10664496 DOI: 10.1186/s40795-023-00798-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Behaviour change science is proposed to improve participant retention and enhance the validity of trials. However, researchers seldom systematically consider and implement behaviour change strategies within trials for this purpose. The objective of this article is to evaluate how an eHealth behaviour change support (BCS) program enhances young adults' adherence to behaviours required within a dietary intervention. METHODS The Nine Principles framework was used to develop BCS to implement across both arms of a 10-week randomised parallel-group intervention to enhance adherence to (i) eating healthily and (ii) reporting dietary intake. Key components of the BCS included access to a dietitian-led Facebook group, text reminders, and food delivery. Effectiveness was measured using the following analyses of the 78 participants who completed the study; pre-post change in targeted dietary habits over time using a subscore of the Healthy Diet Habits Index, questionnaire to assess change in perception of barriers to eating healthily over time, Facebook group engagement, and impact evaluation of the BCS. Participants received a dietary reporting score out of 100 to assess adherence across the 10 weeks. RESULTS The total Healthy Diet Habits Index subscore out of 16 significantly increased from baseline to week 10 (10.6 ± 2.6 to 11.2 ± 2.6, p value < 0.05), driven primarily by an increase in vegetable consumption. Overall adherence to reporting was high across the 10 weeks, with the total population mean reporting score 90.4 ± 14.6 out of 100. Relatively low Facebook engagement was observed. Adding objects to the environment, prompts/cues and removing reward appeared to be effective components of the BCS for enhancing adherence to the target behaviours. CONCLUSION Using a behaviour change framework to support the design of randomised trials is a promising way to enhance participant adherence to study requirements that are typically considered burdensome, such as dietary reporting. It also enables researchers to identify and replicate effective components of BCS, including behaviour change techniques and modes of delivery. Further research into the use of different behaviour change frameworks for this purpose is warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04869163; https://clinicaltrials.gov/ct2/show/NCT04869163 . (03/05/2021).
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Affiliation(s)
- Anna Worthington
- Discipline of Nutrition, School of Medical Sciences, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
| | - Nicola Gillies
- Discipline of Nutrition, School of Medical Sciences, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Rina Hannaford
- Bioinformatics & Statistics Team, AgResearch Ltd, Palmerston North, New Zealand
| | - Rajshri Roy
- Discipline of Nutrition, School of Medical Sciences, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Andrea Braakhuis
- Discipline of Nutrition, School of Medical Sciences, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Pinho-Gomes AC, Mullins E. Inequalities in smoking among pregnant women in North West London. J Public Health (Oxf) 2023; 45:e518-e521. [PMID: 37099756 PMCID: PMC10788838 DOI: 10.1093/pubmed/fdad040] [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: 01/31/2023] [Revised: 03/11/2023] [Accepted: 03/27/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND London has the lowest smoking prevalence among pregnant women in England. However, it was unclear whether the low overall prevalence masked inequalities. This study investigated the prevalence of smoking among pregnant women in North West London stratified by ethnicity and deprivation. METHODS Data regarding smoking status, ethnicity and deprivation were extracted from electronic health records collected by maternity services at Imperial Healthcare NHS Trust between January 2020 and August 2022. RESULTS A total of 25 231 women were included in this study. At the time of booking of antenatal care (mean of 12 weeks), 4% of women were current smokers, 17% were ex-smokers and 78% never smokers. There were marked differences in the smoking prevalence between ethnic groups. Women of Mixed-White and Black Caribbean ethnicity and White Irish women had the highest prevalence of smoking (12 and 9%, respectively). There was an over 4-fold increase in the prevalence of smoking between the most and the least deprived groups (5.6 versus 1.3%). CONCLUSIONS Even in a population with an overall low prevalence of smoking in pregnancy, women experiencing deprivation and from certain ethnic backgrounds have a high smoking prevalence and hence are the most likely to benefit from smoking cessation interventions.
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Affiliation(s)
- Ana-Catarina Pinho-Gomes
- The George Institute for Global Health, Imperial College London, Fourth Floor Translation and Innovation Hub, London W12 0BZ, UK
- Institute of Health Informatics, University College London, London NW1 2DA, UK
| | - Edward Mullins
- The George Institute for Global Health, Imperial College London, Fourth Floor Translation and Innovation Hub, London W12 0BZ, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London W12 0BZ, UK
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Jackson MA, Brown AL, Baker AL, Bonevski B, Haber P, Bonomo Y, Blandthorn J, Attia J, Perry N, Barker D, Gould GS, Dunlop AJ. Tobacco treatment incorporating contingency management, nicotine replacement therapy, and behavioral counseling for pregnant women who use substances: a feasibility trial. Front Psychiatry 2023; 14:1207955. [PMID: 37654991 PMCID: PMC10467262 DOI: 10.3389/fpsyt.2023.1207955] [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: 04/18/2023] [Accepted: 07/17/2023] [Indexed: 09/02/2023] Open
Abstract
Introduction Most pregnant women with substance use problems smoke, and few will quit during their pregnancy. Tobacco treatment is often overlooked, with the focus usually placed on other substance use. Additionally, few targeted effective treatments for this group exist. To address this, the feasibility of an intensive tobacco treatment incorporating contingency management (CM) that featured non-face-to-face delivery was examined. Methods A single-arm pre-post design feasibility trial was conducted in three antenatal services that support women who use substances in metropolitan Australia. Participants were over the age of 15, had <33-week gestation, and smoked tobacco daily. They received financial incentives for daily carbon monoxide-verified smoking abstinence or reduction through an internet-based CM programme, nicotine replacement therapy (NRT) posted to women and partners or household members who smoked and telephone-delivered behavioral counseling from study enrolment to birth. Results Of the 101 referrals, 46 women (46%) consented. The mean (SD) age was 31(±6) years, and the gestation period was 22(±6) weeks. Nineteen (41%) of those enrolled were retained for 12-week postpartum. Of 46 women, 32 (70%) utilized CM; 32 (70%) used NRT for ≥2 weeks; 23 (50%) attended ≥1 counseling session; and 15 (22%) received NRT for partners/household members. Fifteen (33%) were verified abstinent from tobacco at delivery after a median (IQR) period of abstinence of 65(36-128) days. All non-smokers at birth utilized NRT and financial incentives, and 9/15 (60%) utilized counseling. Four (9%) were abstinent at 12-week postpartum. Median cigarettes smoked/day reduced from baseline to delivery (10(6-20) to 1(0-6) p =< 0.001). Women who quit smoking had more education (72% vs. 33% p =< 0.02), completed more CO samples (median (IQR) 101(59-157) vs. 2(0-20) p =< 0.001), and received more incentives (median (IQR) $909($225-$1980) vs. $34($3-$64) p =< 0.001). Intervention acceptability was rated favorably by participants (9 items rated 0-10 with scores >5 considered favorable). Discussion This study demonstrated the feasibility and acceptability of a consumer-informed, non-face-to-face intensive tobacco treatment, highlighting the potential of remotely delivered technology-based CM to reduce the health impact of tobacco smoking in high-priority populations. The intervention demonstrates scale-up potential. Future studies should extend treatment into the postpartum period, utilizing new technologies to enhance CM delivery and improve counseling provision and partner support. Clinical trial registration https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374196, ACTRN1261800056224.
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Affiliation(s)
- Melissa A. Jackson
- Hunter New England Health Local Health District, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Drug and Alcohol Clinical Research Improvement Network, St. Leonards, NSW, Australia
| | - Amanda L. Brown
- Hunter New England Health Local Health District, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Amanda L. Baker
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Billie Bonevski
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Paul Haber
- Drug and Alcohol Clinical Research Improvement Network, St. Leonards, NSW, Australia
- Edith Collins Centre, Sydney Local Health District, Camperdown, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Yvonne Bonomo
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Women's Alcohol and Drug Service, The Royal Women's Hospital, Parkville, VIC, Australia
| | - Julie Blandthorn
- Women's Alcohol and Drug Service, The Royal Women's Hospital, Parkville, VIC, Australia
| | - John Attia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Natasha Perry
- Hunter New England Health Local Health District, Newcastle, NSW, Australia
| | - Daniel Barker
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Gillian S. Gould
- Faculty of Health, Southern Cross University, Coffs Harbour, NSW, Australia
| | - Adrian J. Dunlop
- Hunter New England Health Local Health District, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Drug and Alcohol Clinical Research Improvement Network, St. Leonards, NSW, Australia
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12
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Silverman AL, Boggs JM, Eberle JW, Baldwin M, Behan HC, Baglione A, Paolino V, Vela de la Garza Evia ÁF, Boukhechba M, Barnes L, Funk DH, Teachman BA. Minimal Effect of Messaging on Engagement in a Digital Anxiety Intervention. PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2023; 54:252-263. [PMID: 37868738 PMCID: PMC10586207 DOI: 10.1037/pro0000496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
This study evaluated the effectiveness of different recruitment messages for encouraging enrollment in a digital mental health intervention (DMHI) for anxiety among 1,600 anxious patients in a large healthcare system. Patients were randomly assigned to receive a standard message, or one of five messages designed to encourage enrollment: Three messages offered varying financial incentives, one message offered coaching, and one message provided consumer testimonials. Patients could then click a link in the message to visit the DMHI website, enroll, and start the first session. We examined the effects of message features and message length (short vs. long) on rates of site clicks, enrollment, and starting the first session. We also tested whether demographic and clinical factors derived from patients' electronic health records were associated with rates of enrollment and starting the first session to understand the characteristics of patients most likely to use DMHIs in this setting. Across messages, 19.4% of patients clicked a link to visit the DMHI website, but none of the messages were significantly associated with rates of site clicks, enrollment, or starting the first session. Females (vs. males) had a greater probability of enrollment. No other demographic or clinical variables were significantly associated with enrollment or starting the first session. Findings provide guidance for resource allocation decisions in larger scale DMHI implementations in healthcare settings.
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Affiliation(s)
| | | | | | - Megan Baldwin
- Institute for Health Research, Kaiser Permanente Colorado
| | | | - Anna Baglione
- Department of Engineering Systems and Environment, University of Virginia
| | | | | | - Medhi Boukhechba
- Department of Engineering Systems and Environment, University of Virginia
| | - Laura Barnes
- Department of Engineering Systems and Environment, University of Virginia
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Stecher C, Cloonan S, Linnemayr S, Huberty J. Combining Behavioral Economics-Based Incentives With the Anchoring Strategy: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e39930. [PMID: 37115610 PMCID: PMC10182474 DOI: 10.2196/39930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 02/20/2023] [Accepted: 03/16/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Chronic (ie, long-term) elevated stress is associated with a number of mental and physical health conditions. Mindfulness meditation mobile apps are a promising tool for stress self-management that can overcome several barriers associated with in-person interventions; however, to date, poor app-based intervention adherence has limited the efficacy of these mobile health tools. Anchoring, or pairing, a new behavior with an existing routine has been shown to effectively establish habits that are maintained over time, but this strategy typically only works for those with high initial motivation and has yet to be tested for maintaining meditation with a mobile app. OBJECTIVE This study will test novel combinations of behavioral economics-based incentives with the anchoring strategy for establishing and maintaining adherence to an effective dose of meditation with a mobile app. METHODS This 16-week study will use a 5-arm, parallel, partially blinded (participants only), randomized controlled design. We will implement a fractional factorial study design that varies the use of self-monitoring messages and financial incentives to support participants' use of their personalized anchoring strategy for maintaining adherence to a ≥10 minute-per-day meditation prescription during an 8-week intervention period, followed by an 8-week postintervention observation period. Specifically, we will vary the use of self-monitoring messages of either the target behavior (ie, meditation tracking) or the outcome associated with the target behavior (ie, mood symptom tracking). We will also vary the use of financial incentives conditional on either meditation at any time of day or meditation performed at approximately the same time of day as participants' personalized anchors. RESULTS Continuous meditation app use data will be used to measure weekly meditation adherence over the 16-week study period as a binary variable equal to 1 if participants complete ≥10 minutes of meditation for ≥4 days per week and 0 otherwise. We will measure weekly anchoring plan adherence as a binary variable equal to 1 if participants complete ≥10 minutes of meditation within +1 or -1 hour of the timing of their chosen anchor on ≥4 days per week and 0 otherwise. In addition to these primary measures of meditation and anchoring plan adherence, we will also assess the secondary measures of stress, anxiety, posttraumatic stress disorder, sleep disturbance, and meditation app habit strength at baseline, week 8, and week 16. CONCLUSIONS This study will fill an important gap in the mobile health literature by testing novel intervention approaches for establishing and maintaining adherence to app-based mindfulness meditation. If successful, this study will identify an accessible and scalable stress self-management intervention that can help combat stress in the United States. TRIAL REGISTRATION ClinicalTrials.gov NCT05217602; https://clinicaltrials.gov/ct2/show/NCT05217602. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/39930.
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Affiliation(s)
- Chad Stecher
- Arizona State University, Phoenix, AZ, United States
| | - Sara Cloonan
- Arizona State University, Phoenix, AZ, United States
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14
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Hunter LA, Wyman S, Packel LJ, Facente SN, Li Y, Harte A, Nicolette G, Di Germanio C, Busch MP, Reingold AL, Petersen ML. Monitoring SARS-CoV-2 incidence and seroconversion among university students and employees: a longitudinal cohort study in California, June-August 2020. BMJ Open 2023; 13:e063999. [PMID: 37024253 PMCID: PMC10083519 DOI: 10.1136/bmjopen-2022-063999] [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] [Indexed: 04/08/2023] Open
Abstract
OBJECTIVES To identify incident SARS-CoV-2 infections and inform effective mitigation strategies in university settings, we piloted an integrated symptom and exposure monitoring and testing system among a cohort of university students and employees. DESIGN Prospective cohort study. SETTING A public university in California from June to August 2020. PARTICIPANTS 2180 university students and 738 university employees. PRIMARY OUTCOME MEASURES At baseline and endline, we tested participants for active SARS-CoV-2 infection via quantitative PCR (qPCR) test and collected blood samples for antibody testing. Participants received notifications to complete additional qPCR tests throughout the study if they reported symptoms or exposures in daily surveys or were selected for surveillance testing. Viral whole genome sequencing was performed on positive qPCR samples, and phylogenetic trees were constructed with these genomes and external genomes. RESULTS Over the study period, 57 students (2.6%) and 3 employees (0.4%) were diagnosed with SARS-CoV-2 infection via qPCR test. Phylogenetic analyses revealed that a super-spreader event among undergraduates in congregate housing accounted for at least 48% of cases among study participants but did not spread beyond campus. Test positivity was higher among participants who self-reported symptoms (incidence rate ratio (IRR) 12.7; 95% CI 7.4 to 21.8) or had household exposures (IRR 10.3; 95% CI 4.8 to 22.0) that triggered notifications to test. Most (91%) participants with newly identified antibodies at endline had been diagnosed with incident infection via qPCR test during the study. CONCLUSIONS Our findings suggest that integrated monitoring systems can successfully identify and link at-risk students to SARS-CoV-2 testing. As the study took place before the evolution of highly transmissible variants and widespread availability of vaccines and rapid antigen tests, further research is necessary to adapt and evaluate similar systems in the present context.
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Affiliation(s)
- Lauren A Hunter
- School of Public Health, University of California, Berkeley, California, USA
| | - Stacia Wyman
- Innovative Genomics Institute, University of California, Berkeley, California, USA
| | - Laura J Packel
- School of Public Health, University of California, Berkeley, California, USA
| | - Shelley N Facente
- School of Public Health, University of California, Berkeley, California, USA
- Facente Consulting, Richmond, California, USA
| | - Yi Li
- School of Public Health, University of California, Berkeley, California, USA
| | - Anna Harte
- University Health Services, University of California, Berkeley, California, USA
| | - Guy Nicolette
- University Health Services, University of California, Berkeley, California, USA
| | | | - Michael P Busch
- Vitalant Research Institute, San Francisco, California, USA
- Department of Laboratory Medicine, University of California, San Francisco, California, USA
| | - Arthur L Reingold
- School of Public Health, University of California, Berkeley, California, USA
| | - Maya L Petersen
- School of Public Health, University of California, Berkeley, California, USA
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15
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Liu JX, Vallin J, Chiu C, Cabrera FA, Hunter LA, Rao A, Njau P, McCoy SI. Designing for two: How enhancing human-centered design with behavioral nudges unlocked breakthroughs to promote young women's psychological safety and access to reproductive care in Tanzania. Soc Sci Med 2023; 320:115683. [PMID: 36709692 PMCID: PMC10798268 DOI: 10.1016/j.socscimed.2023.115683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/16/2023]
Abstract
Adolescent girls and young women (AGYW; ages 15-24) in sub-Saharan Africa face many barriers to accessing preventive sexual and reproductive health (SRH) services. We drew upon the strengths of two complementary approaches, human-centered design and behavioral economics, to craft a holistic, highly-tailored, and empathetic intervention to motivate AGYW to seek contraception and HIV self-test kits at community drug shops. To encourage engagement, we embedded "nudge" strategies at different opportunity points (uncovered during our design research) along the care-seeking and service delivery journey. Our Malkia Klabu intervention is a loyalty program designed to enhance drug shops' role as SRH providers through which AGYW earned punches for shop purchases redeemable for small prizes; free SRH products could be requested at any time. From our 4-month pilot in Shinyanga, Tanzania, we assess the extent to which different behavioral nudge strategies motivated behaviors as predicted by synthesizing findings from (1) in-depth interviews with AGYW and shopkeepers, (2) shop program records, (3) shop observations, and (4) customer exit surveys. Overall, we find that AGYW and shopkeepers were motivated by many intervention features as intended and consistent with hypothesized mechanisms. We found strong evidence of social norms for helping to spread awareness of Malkia Klabu among peers, prize incentives for drawing AGYW back to shops, and the opt-out default membership gift of an HIV self-test kit for encouraging testing uptake and exploration of contraceptives. Shopkeepers in both arms noted increased community status from distributing HIV self-testing kits (ego). Malkia Klabu shopkeepers experienced increased customer traffic and business revenues (incentives), which reduced shopkeepers' gatekeeping tendencies and earned them additional recognition as champions of AGYW well-being. Integrating human-centered design and behavioral economics was effective for developing an innovative and effective intervention that simultaneously met the different needs of economic actors in support of public health priorities.
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Affiliation(s)
- Jenny X Liu
- Institute for Health and Aging; Bixby Center for Global Reproductive Health; University of California, San Francisco, 490 Illinois St. 123J, San Francisco, CA 94158, USA.
| | - Janelli Vallin
- Institute for Health and Aging; Bixby Center for Global Reproductive Health; University of California, San Francisco, 490 Illinois St. 123J, San Francisco, CA 94158, USA.
| | - Calvin Chiu
- School of Public Health; University of California, Berkeley; 2121 Berkeley Way, Berkeley, CA, 94704, USA.
| | - F Abigail Cabrera
- Center for Excellence in Primary Care; University of California, San Francisco; Zuckerberg San Francisco General Hospital; 995 Potrero Ave, Ward 83, San Francisco, CA, 94110, USA.
| | - Lauren A Hunter
- School of Public Health; University of California, Berkeley; 2121 Berkeley Way, Berkeley, CA, 94704, USA.
| | - Aarthi Rao
- Behavioral Insights and Program Design; Cityblock Health; 86 Laws Brook Rd, Concord, MA 01742, USA.
| | - Prosper Njau
- National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly and Children; Government City - Mtumba, Afya Road, P.O. Box 743, 40478 Dodoma, United Republic of Tanzania.
| | - Sandra I McCoy
- School of Public Health; University of California, Berkeley; 2121 Berkeley Way, Berkeley, CA, 94704, USA.
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16
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Buis L, Lee U. Loss-Framed Adaptive Microcontingency Management for Preventing Prolonged Sedentariness: Development and Feasibility Study. JMIR Mhealth Uhealth 2023; 11:e41660. [PMID: 36705949 PMCID: PMC9919499 DOI: 10.2196/41660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/30/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND A growing body of evidence shows that financial incentives can effectively reinforce individuals' positive behavior change and improve compliance with health intervention programs. A critical factor in the design of incentive-based interventions is to set a proper incentive magnitude. However, it is highly challenging to determine such magnitudes as the effects of incentive magnitude depend on personal attitudes and contexts. OBJECTIVE This study aimed to illustrate loss-framed adaptive microcontingency management (L-AMCM) and the lessons learned from a feasibility study. L-AMCM discourages an individual's adverse health behaviors by deducting particular expenses from a regularly assigned budget, where expenses are adaptively estimated based on the individual's previous responses to varying expenses and contexts. METHODS We developed a mobile health intervention app for preventing prolonged sedentary lifestyles. This app delivered a behavioral mission (ie, suggesting taking an active break for a while) with an incentive bid when 50 minutes of uninterrupted sedentary behavior happened. Participants were assigned to either the fixed (ie, deducting the monotonous expense for each mission failure) or adaptive (ie, deducting varying expenses estimated by the L-AMCM for each mission failure) incentive group. The intervention lasted 3 weeks. RESULTS We recruited 41 participants (n=15, 37% women; fixed incentive group: n=20, 49% of participants; adaptive incentive group: n=21, 51% of participants) whose mean age was 24.0 (SD 3.8; range 19-34) years. Mission success rates did not show statistically significant differences by group (P=.54; fixed incentive group mean 0.66, SD 0.24; adaptive incentive group mean 0.61, SD 0.22). The follow-up analysis of the adaptive incentive group revealed that the influence of incentive magnitudes on mission success was not statistically significant (P=.18; odds ratio 0.98, 95% CI 0.95-1.01). On the basis of the qualitative interviews, such results were possibly because the participants had sufficient intrinsic motivation and less sensitivity to incentive magnitudes. CONCLUSIONS Although our L-AMCM did not significantly affect users' mission success rate, this study configures a pioneering work toward adaptively estimating incentives by considering user behaviors and contexts through leveraging mobile sensing and machine learning. We hope that this study inspires researchers to develop incentive-based interventions.
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Affiliation(s)
| | - Uichin Lee
- School of Computing, Korea Advanced Institute of Science & Technology, Daejeon, Republic of Korea
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17
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Ebinger JE, Ghai I, Barajas D, Vallejo R, Blyler CA, Morales M, Garcia N, Joung S, Palimaru A, Linnemayr S. Behavioural Economics to Improve Antihypertensive Therapy Adherence (BETA): protocol for a pilot randomised controlled trial in Los Angeles. BMJ Open 2023; 13:e066101. [PMID: 36697048 PMCID: PMC9884869 DOI: 10.1136/bmjopen-2022-066101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Non-adherence to antihypertensive therapy is one of the major barriers to reducing the risk of cardiovascular disease. Several interventions have targeted higher medication adherence, yet most do not result in sustained adherence. Routinisation has emerged as a potential method for mitigating this problem, but requires high motivation during the relatively long habit formation phase. This pilot randomised controlled trial aims to test the feasibility, acceptability, and preliminary efficacy of behavioural economics-based incentives and text messages to support the routinisation of the medication-taking behaviour for promoting long-term medication adherence. METHODS AND ANALYSIS This study will recruit and randomly assign 60 adult patients seeking care for hypertension at the Cedars-Sinai Medical Center in Los Angeles to one of the three groups, Control (n=20), Messages (n=20) and Incentives (n=20) in a 1:1:1 ratio. All participants will receive information about the importance of routinisation and will select an existing behavioural routine ('anchor') to which they will tie their pill-taking to, and the corresponding time. Additionally, participants in the Messages group will receive daily text messages reminding them of the importance of routines, while those in the Incentives group will receive daily text messages and conditional prize drawings. The interventions will be delivered over three months. Participants will be followed for six months post-intervention to measure behavioural persistence. Surveys will be administered at baseline, month-3 and month-9 visits. Primary outcomes include: (1) electronically measured mean medication adherence during the intervention period and (2) post-intervention period; and (3) mean timely medication adherence based around the time of the participants' anchor during the intervention period, and (4) post-intervention period. ETHICS AND DISSEMINATION The study was approved by the Cedars-Sinai Institutional Review Board (Study ID: Pro00057764). Findings will be published in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04029883.
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Affiliation(s)
- Joseph E Ebinger
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ishita Ghai
- Frederick S. Pardee RAND Graduate School, RAND Corporation, Santa Monica, California, USA
| | - Denisse Barajas
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rocío Vallejo
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ciantel A Blyler
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle Morales
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nairy Garcia
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sandy Joung
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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18
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Carter EW, Vadari HS, Stoll S, Rogers B, Resnicow K, Heisler M, Herman WH, Kim HM, McEwen LN, Volpp KG, Kullgren JT. Study protocol: Behavioral economics and self-determination theory to change diabetes risk (BEST Change). Contemp Clin Trials 2023; 124:107038. [PMID: 36460265 PMCID: PMC10259647 DOI: 10.1016/j.cct.2022.107038] [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: 09/14/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND The Diabetes Prevention Program (DPP) and metformin can prevent or delay the onset of type 2 diabetes mellitus (T2DM) among patients with prediabetes. Yet, even when these evidence-based strategies are accessible and affordable, uptake is low. Thus, there is a critical need for effective, scalable, and sustainable approaches to increase uptake and engagement in these interventions. METHODS In this randomized controlled trial, we will test whether financial incentives and automated messaging to promote autonomous motivation for preventing T2DM can increase DPP participation, metformin use, or both among adults with prediabetes. Participants (n = 380) will be randomized to one of four study arms. Control Arm participants will receive usual care and educational text messages about preventing T2DM. Incentives Arm participants will receive the Control Arm intervention plus financial incentives for DPP participation or metformin use. Tailored Messages Arm participants will receive the Control Arm intervention plus tailored messages promoting autonomous motivation for preventing T2DM. Combined Arm participants will receive the Incentives Arm and Tailored Messages Arm interventions plus messages to increase the personal salience of financial incentives. The primary outcome is change in hemoglobin A1c from baseline to 12 months. Secondary outcomes are change in body weight, DPP participation, and metformin use. DISCUSSION If effective, these scalable and sustainable approaches to increase patient motivation to prevent T2DM can be deployed by health systems, health plans, and employers to help individuals with prediabetes lower their risk for developing T2DM.
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Affiliation(s)
- Eli W Carter
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America.
| | - Harita S Vadari
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Shelley Stoll
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Baylee Rogers
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, United States of America
| | - Kenneth Resnicow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, United States of America
| | - Michele Heisler
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America; Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, United States of America; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States of America
| | - William H Herman
- Departments of Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, MI, United States of America
| | - H Myra Kim
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, United States of America
| | - Laura N McEwen
- University of Michigan, Department of Internal Medicine- Metabolism, Endocrinology, and Diabetes, United States of America
| | - Kevin G Volpp
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, United States of America; Departments of Medicine and Health Care Management, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jeffrey T Kullgren
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States of America; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, United States of America
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19
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Chao GF, Kullgren JT, Ross R, Bonham AJ, Ghaferi AA. Financial Incentives to Improve Patient Follow-up and Weight Loss After Bariatric Surgery. Ann Surg 2023; 277:e70-e77. [PMID: 34171878 DOI: 10.1097/sla.0000000000005013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine effects of a financial incentives program on follow-up and weight loss after bariatric surgery. SUMMARY BACKGROUND DATA Consistent follow-up may improve weight loss and other health outcomes after bariatric surgery. Yet, rates of follow-up after surgery are often low. METHODS Patients from 3 practices within a statewide collaborative were invited to participate in a 6-month financial incentives program. Participants received incentives for attending postoperative appointments at 1, 3, and 6 months which doubled when participants weighed less than their prior visit. Participants were matched with contemporary patients from control practices by demographics, starting body mass index and weight, surgery date, and procedure. Preintervention estimates used matched historic patients from the same program and control practices with the criteria listed above. Patients between the 2 historic groups were additionally matched on surgery date to ensure balance on matched variables. We conducted differ-ence-in-differences analyses to examine incentives program effects. Follow-up attendance and percent excess weight loss were measured postoperative months 1, 3, 6, and 12. RESULTS One hundred ten program participants from January 1, 2018 to July 31, 2019 were matched to 203 historic program practice patients (November 20 to December 27, 2017). The control group had 273 preinter-vention patients and 327 postintervention patients. In difference-in-differ-ences analyses, the intervention increased follow-up rates at 1 month (+14.8%, P <0.0001), 3months (+29.4%, P <0.0001), and 6 months (+16.4%, P <0.0001), but not at 12 months. There were no statistically significant differences in excess weight loss. CONCLUSIONS A financial incentives program significantly increased follow-up after bariatric surgery for up to 6 months, but did not increase weight loss. Our study supports use of incentivized approaches as one way to improve postoperative follow-up, but may not translate into greater weight loss without additional supports.
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Affiliation(s)
- Grace F Chao
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jeffrey T Kullgren
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
- Departments of internal Medicine and Health Management and Policy, University of Michigan, Ann Arbor, MI
- Michigan Bariatric Surgery Collaborative, Ann Arbor, Ml
| | - Rachel Ross
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Aaron J Bonham
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Amir A Ghaferi
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Michigan Bariatric Surgery Collaborative, Ann Arbor, Ml
- Department of Surgery, University of Michigan, Ann Arbor, MI
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20
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Jose KA, Sharman MJ, Stanesby O, Greaves S, Venn AJ, Blizzard L, Palmer A, Cooper K, Williams J, Cleland VJ. Incentivising public transport use for physical activity gain: process evaluation of the COVID-19 disrupted trips4health randomised controlled trial. Int J Behav Nutr Phys Act 2022; 19:157. [PMID: 36550500 PMCID: PMC9772596 DOI: 10.1186/s12966-022-01394-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Partnering with a public transport (PT) provider, state government, and local government, the single-blinded randomised controlled trial, trips4health, investigated the impact of PT use incentives on transport-related physical activity (PA) in Tasmania, Australia. The intervention involved 16-weeks of incentives (bus trip credits) for achieving weekly PT use targets, supported by weekly text messages. This study objective was to conduct a process evaluation of the COVID-19 disrupted trips4health study. METHODS The Medical Research Council UK's framework for complex public health interventions guided the process evaluation. Participant reach, acceptability, fidelity and feasibility were evaluated. Administrative and post-intervention survey data were analysed descriptively. Semi-structured interviews with intervention participants (n = 7) and PT provider staff (n = 4) were analysed thematically. RESULTS Due to COVID-19, trips4health was placed on hold (March 2020) then stopped (May 2020) as social restrictions impacted PT use. At study cessation, 116 participants (approximately one third of target sample) had completed baseline measures, 110 were randomised, and 64 (n = 29 in the intervention group; n = 35 in the control group) completed post-intervention measures. Participants were 18 - 80 years (average 44.5 years) with females (69%) and those with tertiary education (55%) over-represented. The intervention was delivered with high fidelity with 96% of bus trip credits and 99% of behavioural text messages sent as intended. Interviewed PT staff said implementation was highly feasible. Intervention participant acceptability was high with 90% reporting bus trip incentives were helpful and 59% reporting the incentives motivated them to use PT more. From a total of 666 possible bus trip targets, 56% were met with 38% of intervention participants agreeing and 41% disagreeing that 'Meeting the bus trip targets was easy'. Interviews and open-ended survey responses from intervention participants revealed incentives motivated bus use but social (e.g., household member commitments) and systemic (e.g., bus availability) factors made meeting bus trip targets challenging. CONCLUSIONS trips4health demonstrated good acceptability and strong fidelity and feasibility. Future intervention studies incentivising PT use will need to ensure a broader demographic is reached and include more supports to meet PT targets. TRIAL REGISTRATION ACTRN12619001136190 .
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Affiliation(s)
- K. A. Jose
- grid.1009.80000 0004 1936 826XMenzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania Australia
| | - M. J. Sharman
- grid.1009.80000 0004 1936 826XMenzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania Australia
| | - O. Stanesby
- grid.1009.80000 0004 1936 826XMenzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania Australia
| | - S. Greaves
- grid.1013.30000 0004 1936 834XInstitute of Transport and Logistic Studies, The University of Sydney, Butlin Avenue, Darlington, Camperdown, New South Wales 2006 Australia
| | - A. J. Venn
- grid.1009.80000 0004 1936 826XMenzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania Australia
| | - L. Blizzard
- grid.1009.80000 0004 1936 826XMenzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania Australia
| | - A. Palmer
- grid.1009.80000 0004 1936 826XMenzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania Australia
| | - K. Cooper
- Metro Tasmania, 212 Main Road, Moonah, Hobart, Tasmania 7009 Australia
| | - J. Williams
- Public Health Services, Department of Health, Tasmanian Government, 2/25 Argyle Street, Hobart, 7001 Australia
| | - V. J. Cleland
- grid.1009.80000 0004 1936 826XMenzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania Australia
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21
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Designing financial incentives for health behaviour change: a mixed-methods case study of weight loss in men with obesity. J Public Health (Oxf) 2022. [DOI: 10.1007/s10389-022-01785-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Abstract
Aim
Designing financial incentives for health behaviour change requires choices across several domains, including value (the size of the incentive), frequency of incentives, and direction (gain or loss). However, the rationale underlying complex incentive design is infrequently reported. Transparent reporting is important if we want to understand and improve the incentive development process. This paper describes a mixed methods approach for designing financial incentives for health behaviour change which involves stakeholders throughout the design process.
Subject and methods
The mixed methods approach focuses on incentives for weight loss for men with obesity living in areas with high levels of disadvantage. The approach involves: (a) using an existing framework to identify all domains of a financial incentive scheme for which choices need to be made, deciding what criteria are relevant (such as effectiveness, acceptability and uptake) and making choices on each domain on the basis of the criteria; (b) conducting a survey of target population preferences to inform choices for domains and to design the incentive scheme; and (c) making final decisions at a stakeholder consensus workshop.
Results
The approach was implemented and an incentive scheme for weight loss for men living with obesity was developed. Qualitative interview data from men receiving the incentives in a feasibility trial endorses our approach.
Conclusion
This paper demonstrates that a mixed methods approach with stakeholder involvement can be used to design financial incentives for health behaviour change such as weight loss.
Trial registration number
NCT03040518. Date: 2 February 2017.
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22
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Hollenberg E, Bani-Fatemi A, Durbin A, Castle D, Kozloff N, Ziegler C, Stergiopoulos V. Using financial incentives to improve health service engagement and outcomes of adults experiencing homelessness: A scoping review of the literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e3406-e3434. [PMID: 35912903 DOI: 10.1111/hsc.13944] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/26/2022] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
People experiencing homelessness (PEH) have high rates of acute and chronic health conditions, complex support needs and often face multiple barriers to accessing health services. Financial incentive (FI) interventions have been found effective in improving service engagement and health outcomes for a range of health conditions, populations and settings, but little is known about their impact on PEH. We conducted a scoping review to explore the impact of FI interventions on treatment retention, adherence and other health outcomes of PEH. We searched seven electronic databases from inception to September 2021 to identify peer-reviewed published English language studies that used FI interventions with adult PEH. A scoping review methodology was used to chart relevant data uniformly. Descriptive statistics and narrative syntheses were used to describe outcomes. Thirty-three quantitative articles related to 29 primary studies were published between 1990 and 2021 and met inclusion criteria. Studies targeted three areas of health behaviour change: decreasing substance use or increasing abstinence rates, preventing or treating infectious diseases or promoting lifestyle/general health goal attainment. A variety of FIs were used (cash/non-cash, escalating/fixed schedule, larger/smaller amounts, some/all behaviours rewarded, certain/uncertain reward) across studies. Twenty-six of the primary studies reported significantly better outcomes for the participants receiving FI compared to controls. There were mixed findings about the efficacy of cash versus non-cash FIs, non-cash FIs versus other interventions and higher versus lower value of incentives. Furthermore, there was limited research about long-term outcomes and impacts. FIs have promise in increasing abstinence from substances, engagement in infectious disease treatment, retention in health services and general lifestyle modifications for PEH. Future research should examine long-term impacts and the contribution of co-interventions and intermediary lifestyle behaviour changes.
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Affiliation(s)
- Elisa Hollenberg
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Ali Bani-Fatemi
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Anna Durbin
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Unity Health Toronto, Toronto, Ontario, Canada
| | - David Castle
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Kozloff
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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23
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Hulbert LR, Michael SL, Charter-Harris J, Atkins C, Skeete RA, Cannon MJ. Effectiveness of Incentives for Improving Diabetes-Related Health Indicators in Chronic Disease Lifestyle Modification Programs: a Systematic Review and Meta-Analysis. Prev Chronic Dis 2022; 19:E66. [PMID: 36302383 PMCID: PMC9616129 DOI: 10.5888/pcd19.220151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction We examined the effectiveness of providing incentives to participants in lifestyle modification programs to improve diabetes-related health indicators: body weight, body mass index (BMI), blood pressure, cholesterol, and hemoglobin A1C (HbA1C). We also examined the potential effect of 4 different incentive domains (ie, type, monetary value, attainment certainty, and schedule) on those indicators. Methods We searched Medline, Embase, PsycINFO, and Cochrane Library to identify relevant studies published from January 2008 through August 2021. We used a random-effects model to pool study results and examine between-study heterogeneity by using the I2 statistic and the Cochran Q test. We also conducted moderator analyses by using a mixed-effects model to examine differences between subgroups of incentive domains (eg, incentive type [cash vs other types]). Results Our search yielded 10,965 articles, of which 19 randomized controlled trials met our selection criteria. The random-effects model revealed that, relative to the control group, the incentive group had significant reductions in weight (−1.85kg; 95% CI, −2.40 to −1.29; P < .001), BMI (−0.47kg/m2; 95% CI, −0.71 to −0.22; P < .001), and both systolic blood pressure (−2.59 mm HG; 95% CI, −4.98 to −0.20; P = .03) and diastolic blood pressure (−2.62 mm Hg; 95% CI, −4.61 to −0.64; P = .01). A reduction in cholesterol level was noted but was not significant (−2.81 mg/dL; 95% CI, −8.89 to −3.28; P = .37). One study found a significant reduction in hemoglobin A1c (−0.17%; 95% CI, −0.30% to −0.05%; P < .05). The moderator analyses showed that the incentive effect did not vary significantly between the subgroups of the incentive domains, except on weight loss for the attainment certainty domain, suggesting that a variety of incentive subgroups could be equally useful. Conclusion Providing incentives in lifestyle modification programs is a promising strategy to decrease weight, BMI, and blood pressure.
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Affiliation(s)
- LaShonda R. Hulbert
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- CyberData Technologies, Inc, Herndon, Virginia
| | - Shannon L. Michael
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jasmine Charter-Harris
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Charisma Atkins
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Michael J. Cannon
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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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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25
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Mitchell JT, Burns CM, Atkinson B, Cottrell M, Frye JK, McKellar MS, Kashuba ADM, McClernon FJ, Okeke NL. Feasibility, Acceptability, and Preliminary Efficacy of a Gamified Mobile Health Contingency Management Intervention for PrEP Adherence Among Black MSM. AIDS Behav 2022; 26:3311-3324. [PMID: 35416595 PMCID: PMC9474612 DOI: 10.1007/s10461-022-03675-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2022] [Indexed: 11/01/2022]
Abstract
Oral HIV pre-exposure prophylaxis (PrEP) is effective at preventing HIV. However, low adherence is common and undermines these protective effects. This is particularly relevant for groups with disproportionately higher rates of HIV, including Black men who have sex with men (MSM). The current study tested the feasibility, acceptability, and preliminary efficacy of a gamified mobile health contingency management intervention for PrEP adherence-called mSMART (Mobile App-Based Personalized Solutions for Medication Adherence of Rx Pill Tool). Fifteen Black MSM already prescribed PrEP in the community completed baseline and follow-up assessments separated by 8 weeks of using mSMART. Regarding feasibility, there was no study attrition, no mSMART functional difficulties that significantly interfered with use, and a mean rate of 82% daily mSMART use. Acceptability ratings were in the moderately to extremely satisfied range for factors such as willingness to recommend mSMART to others and user-friendliness, and in the low range for ratings on difficulty learning how to use mSMART. Scores on a system usability measure were in the acceptable range for 73% of the sample. Qualitative analysis of follow-up interviews identified individual components of mSMART that could be modified in future iterations to make it more engaging. PrEP composite adherence scores from biomarkers indicated an improvement from baseline to follow-up with a medium effect size, as well as a decrease in the number of perceived barriers to medication adherence. Findings indicate a future efficacy trial is needed to examine the effects of this gamified mobile health contingency management intervention on PrEP adherence.
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Affiliation(s)
- John T Mitchell
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, 2608 Erwin Road, Pavilion East, Suite 300, Durham, NC, 27705, USA.
- Duke Center for Addiction Science and Technology, Durham, NC, USA.
| | - Charles M Burns
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Breyah Atkinson
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Mackenzie Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin K Frye
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Mehri S McKellar
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - F Joseph McClernon
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, 2608 Erwin Road, Pavilion East, Suite 300, Durham, NC, 27705, USA
- Duke Center for Addiction Science and Technology, Durham, NC, USA
| | - Nwora Lance Okeke
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
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Wyckmans F, Banerjee N, Saeremans M, Otto R, Kornreich C, Vanderijst L, Gruson D, Carbone V, Bechara A, Buchanan T, Noël X. The modulation of acute stress on model-free and model-based reinforcement learning in gambling disorder. J Behav Addict 2022; 11:831-844. [PMID: 36112488 PMCID: PMC9872530 DOI: 10.1556/2006.2022.00059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/19/2022] [Accepted: 07/25/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND AIMS Experiencing acute stress is common in behavioral addictions such as gambling disorder. Additionally, like most substance-induced addictions, aberrant decision-making wherein a reactive habit-induced response (conceptualized as a Model-free [MF] in reinforcement learning) suppresses a flexible goal-directed response (conceptualized as a Model-based [MB]) is also common in gambling disorder. In the current study we investigated the influence of acute stress on the balance between habitual response and the goal-directed system. METHODS A sample of N = 116 problem gamblers (PG) and healthy controls (HC) performed an acute stress task - the Socially Evaluated Cold pressure task (SECPT) - or a control task. Self-reported stress and salivary cortisol were collected as measures of acute stress. Following the SECPT, participants performed the Two-Step Markov Task to account for the relative contribution of MB and MF strategies. Additionally, verbal working memory and IQ measures were collected to account for their mediating effects on the orchestration between MB/MF and the impact of stress. RESULTS Both groups had comparable baseline and stress-induced cortisol response to the SECPT. Non-stressed PG displayed lower MB learning than HC. MANOVA and regression analyses showed a deleterious effect of stress-induced cortisol response on the orchestration between MB and MF learning in HC but not in PG. These effects remained when controlling for working memory and IQ. DISCUSSION AND CONCLUSIONS We found an abnormal pattern of modulation of stress on the orchestration between MB and MF learning among PG. Several interpretations and future research directions are discussed.
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Affiliation(s)
- Florent Wyckmans
- Psychological Medicine Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Nilosmita Banerjee
- Psychological Medicine Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Mélanie Saeremans
- Psychiatric Institute, Universitary Hospital Brugmann, Brussels, Belgium
| | - Ross Otto
- Department of Psychology, McGill University, Montréal, Canada
| | - Charles Kornreich
- Psychological Medicine Laboratory, Université Libre de Bruxelles, Brussels, Belgium,Psychiatric Institute, Universitary Hospital Brugmann, Brussels, Belgium
| | - Laetitia Vanderijst
- Psychological Medicine Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Damien Gruson
- Department of Laboratory Medicine, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Vincenzo Carbone
- Department of Laboratory Medicine, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Antoine Bechara
- Faculty of Psychology, University of Southern California, Los Angeles, USA
| | - Tony Buchanan
- Department of Psychology, Saint Louis University, USA
| | - Xavier Noël
- Psychological Medicine Laboratory, Université Libre de Bruxelles, Brussels, Belgium,Corresponding author. E-mail:
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Stecher C, Ghai I, Lunkuse L, Wabukala P, Odiit M, Nakanwagi A, Linnemayr S. INcentives and ReMINDers to Improve Long-term Medication Adherence (INMIND): Protocol for a Pilot Randomized Controlled Trial in Uganda (Preprint). JMIR Res Protoc 2022; 11:e42216. [DOI: 10.2196/42216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 09/20/2022] [Accepted: 09/24/2022] [Indexed: 11/13/2022] Open
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Predictors of Counseling Participation Among Low-Income People Offered an Integrated Intervention Targeting Financial Distress and Tobacco Use. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2022; 24:525-534. [PMID: 35932394 PMCID: PMC9361947 DOI: 10.1007/s11121-022-01416-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 11/04/2022]
Abstract
Introduction Although prevalence of smoking in the USA has been decreasing for decades, smoking rates among low-income individuals remain elevated. Theories from behavioral economics and prior research suggest that financial stress may contribute to the difficulty that low-income smokers face in quitting. The present work is a secondary analysis of a randomized controlled trial that incorporated financial coaching and social services referrals into smoking cessation treatment. Primary analyses showed that participants randomized to the intervention (N = 208) were significantly more likely not to smoke, to have lower financial stress, and to be able to afford leisure activities (p < .05) than were control participants (N = 202). Methods This paper investigates subgroup discrepancies in attendance of intervention sessions and in uptake of various components of this intervention through exploratory analysis. Results Analysis using logistic regression indicated that decreased age, not having received higher education, and having income less than $1000 per month were predictive of decreased counseling attendance (p < .05). Few demographic factors were predictive of uptake of counseling components among those who attended counseling. Conclusions These results can guide future efforts to increase participant engagement in the intervention. Trial Registration ClinicalTrials.gov Identifier: NCT03187730.
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Macaulay L, O'Dolan C, Avenell A, Carroll P, Cotton S, Dombrowski S, Elders A, Goulao B, Gray C, Harris FM, Hunt K, Kee F, MacLennan G, McDonald MD, McKinley M, Skinner R, Torrens C, Tod M, Turner K, van der Pol M, Hoddinott P. Effectiveness and cost-effectiveness of text messages with or without endowment incentives for weight management in men with obesity (Game of Stones): study protocol for a randomised controlled trial. Trials 2022; 23:582. [PMID: 35869503 PMCID: PMC9306253 DOI: 10.1186/s13063-022-06504-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obesity increases the risk of type 2 diabetes, heart disease, stroke, mobility problems and some cancers, and its prevalence is rising. Men engage less than women in existing weight loss interventions. Game of Stones builds on a successful feasibility study and aims to find out if automated text messages with or without endowment incentives are effective and cost-effective for weight loss at 12 months compared to a waiting list comparator arm in men with obesity. METHODS A 3-arm, parallel group, assessor-blind superiority randomised controlled trial with process evaluation will recruit 585 adult men with body mass index of 30 kg/m2 or more living in and around three UK centres (Belfast, Bristol, Glasgow), purposively targeting disadvantaged areas. Intervention groups: (i) automated, theory-informed text messages daily for 12 months plus endowment incentives linked to verified weight loss targets at 3, 6 and 12 months; (ii) the same text messages and weight loss assessment protocol; (iii) comparator group: 12 month waiting list, then text messages for 3 months. The primary outcome is percentage weight change at 12 months from baseline. Secondary outcomes at 12 months are as follows: quality of life, wellbeing, mental health, weight stigma, behaviours, satisfaction and confidence. Follow-up includes weight at 24 months. A health economic evaluation will measure cost-effectiveness over the trial and over modelled lifetime: including health service resource-use and quality-adjusted life years. The cost-utility analysis will report incremental cost per quality-adjusted life years gained. Participant and service provider perspectives will be explored via telephone interviews, and exploratory mixed methods process evaluation analyses will focus on mental health, multiple long-term conditions, health inequalities and implementation strategies. DISCUSSION The trial will report whether text messages (with and without cash incentives) can help men to lose weight over 1 year and maintain this for another year compared to a comparator group; the costs and benefits to the health service; and men's experiences of the interventions. Process analyses with public involvement and service commissioner input will ensure that this open-source digital self-care intervention could be sustainable and scalable by a range of NHS or public services. TRIAL REGISTRATION ISRCTN 91974895 . Registered on 14/04/2021.
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Affiliation(s)
- Lisa Macaulay
- NMAHP Research Unit, Stirling University, Pathfoot Building, Stirling, FK9 4LA, UK.
| | - Catriona O'Dolan
- NMAHP Research Unit, Stirling University, Pathfoot Building, Stirling, FK9 4LA, UK
| | - Alison Avenell
- Health Services Research Unit, 3Rd Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Paula Carroll
- Department Sport & Exercise Science, Waterford Institute of Technology, Main Campus Cork RoadCo. Waterford, Waterford City, Ireland
| | - Seonaidh Cotton
- CHaRT, HRSU, 3Rd Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Stephan Dombrowski
- Faculty of Kinesiology, University of New Brunswick, 3 Bailey Drive, P.O. Box 4400, Fredericton, NB, E3B 5A3, Canada
| | - Andrew Elders
- NMAHP Research Unit, Glasgow Caledonian University, Govan Mbeki Building, Cowcaddens Road, G4 0BA, Glasgow, UK
| | - Beatriz Goulao
- CHaRT, HRSU, 3Rd Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Cindy Gray
- School of Social and Political Sciences, University of Glasgow, 25-29 Bute Gardens, Glasgow, G12 8RS, UK
| | - Fiona M Harris
- School of Health & Life Sciences, University of the West of Scotland, High Street, Paisley, Renfrewshire, PA1 2BE, UK
| | - Kate Hunt
- Institute for Social Marketing and Health, Pathfoot Building, University of Stirling, Stirling, FK9 4LA, UK
| | - Frank Kee
- Centre for Public Health, UKCRC Centre of Excellence for Public Health Research (NI), Institute Clinical Sciences A, Grosvenor Road, Belfast, BT12 6BJ, Northern Ireland
| | - Graeme MacLennan
- CHaRT, HRSU, 3Rd Floor Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | | | - Michelle McKinley
- Queen's University Belfast, University Road, Belfast, BT7 1NN, Northern Ireland
| | | | - Claire Torrens
- NMAHP Research Unit, Stirling University, Pathfoot Building, Stirling, FK9 4LA, UK
| | - Martin Tod
- Men's Health Forum, 49-51 East Rd, Hoxton, London, N1 6AH, UK
| | - Katrina Turner
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Marjon van der Pol
- Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Pat Hoddinott
- NMAHP Research Unit, Stirling University, Pathfoot Building, Stirling, FK9 4LA, UK
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Siersbaek R, Parker S, Kavanagh P, Ford JA, Burke S. How and why do financial incentives contribute to helping people stop smoking? A realist review protocol. BMJ Open 2022; 12:e060457. [PMID: 35705352 PMCID: PMC9204444 DOI: 10.1136/bmjopen-2021-060457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Smoking is harmful to human health and programmes to help people stop smoking are key public health efforts that improve individual and population health outcomes. Research shows that financial incentives improve the success of stop smoking programmes. However, a better understanding of how they work is needed to better inform policy and to support building capability for implementation.The aims of this study: (1) To review the international literature to understand: How, why, in what circumstances and for whom financial incentives improve the success of stop smoking interventions among general population groups and among pregnant women. (2) To provide recommendations for how to best use financial incentives in efforts to promote smoking cessation. METHODS AND ANALYSIS A realist review of published international literature will be undertaken to understand how, why, for whom and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women. Systematic searches were undertaken on 16 February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Iterative searching using citation tracking and of grey literature will be undertaken as needed. Using Pawson and Tilley's iterative realist review approach, data collected will be screened, selected, coded, analysed and synthesised into a set of explanatory theoretical findings. ETHICS AND DISSEMINATION Ethical approval is not required for this review as data sources to be included are previously published. The study will provide important findings for policy-makers and health system leaders to guide the development of stop smoking services which use incentives, for example, as part of the Health Service Executive's Tobacco Free Programme in Ireland. Understanding how contextual factors impact implementation and programmatic success is key to developing a more effective public health approach to stop smoking. Our dissemination strategy will be developed with our stakeholders. PROSPERO REGISTRATION NUMBER CRD42022298941.
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Affiliation(s)
- Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin 2, Ireland
| | - Sarah Parker
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin 2, Ireland
| | - Paul Kavanagh
- National Health Intelligence Unit, Strategy and Research, Jervis House, Jervis St, Health Service Executive, Dublin 1, Ireland
- Department of Public Health and Epidemiology, Centre for Population Health and Health Services Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sara Burke
- Centre for Health Policy and Management, Trinity College Dublin School of Medicine, Dublin 2, Ireland
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Triyana M, White JS. Non-monetary incentives for tobacco prevention among youth in Indonesia. JOURNAL OF HEALTH ECONOMICS 2022; 83:102620. [PMID: 35487104 DOI: 10.1016/j.jhealeco.2022.102620] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 02/25/2022] [Accepted: 03/31/2022] [Indexed: 06/14/2023]
Abstract
We provide evidence on the effectiveness of a school-based program that uses a non-monetary penalty and regular monitoring to prevent risky behavior among adolescents in Indonesia. The field experiment invited students to sign a pledge to abstain from tobacco use and a similar pledge for parents to monitor their children. To test group incentives, a subset of treated schools also competed against each other for the highest tobacco abstinence rates. We find that the individual pledge increases biochemically verified tobacco abstinence by 5 percentage points. This effect is sustained 3 months after the program ended. School competition has no additional impact on tobacco abstinence. Our findings highlight the effectiveness of non-monetary incentives to curb risky behaviors among adolescents who face limited self-control and peer pressure.
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Affiliation(s)
| | - Justin S White
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, United States.
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Baeli V, Hichy Z, Sciacca F, De Pasquale C. Comparing the Relative Importance of Predictors of Intention to Use Bicycles. Front Psychol 2022; 13:840132. [PMID: 35250782 PMCID: PMC8891601 DOI: 10.3389/fpsyg.2022.840132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/28/2022] [Indexed: 11/16/2022] Open
Abstract
The use of bicycles for active commuting is an important target to reach because of the importance of increasing physical activity among the population and improving the air quality in cities. Among the models that have been utilized in previous studies, the Theory of Planned Behavior (TPB) has shown good results in terms of the total variance obtained. However, establishing the relative importance of the TPB variables is difficult. In the present study, which was carried out in the Italian context, the authors sought to establish the weight of the proposed variables based on the dominance analysis approach. Considering the initiatives, which the Italian government carries out, and the particular period in which the study was developed, the authors included two variables in addition to the classical factors: financial incentives and daily commuting habits. A survey was administered to 294 Italians (222 females and 72 males, from 18 to 77 years old) through social networks from July to September 2020. The results have shown how the main predictor of bicycle use was use habits, followed almost at the same level by financial incentives and attitude, while norms and perceived behavioral control (PBC) present low relative importance among the variables considered. Limits of the study have been discussed, and suggestions for future research have been proposed.
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Affiliation(s)
- Valentina Baeli
- Department of Educational Science, University of Catania, Catania, Italy
| | - Zira Hichy
- Department of Educational Science, University of Catania, Catania, Italy
| | - Federica Sciacca
- Department of Educational Science, University of Catania, Catania, Italy
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Yeung K, Ulloa E. Incentivizing Prescription Drug Switching to Reduce Patient and Health Plan Spending: A Microsimulation Model. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:427-434. [PMID: 35227455 DOI: 10.1016/j.jval.2021.08.012] [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: 04/08/2021] [Revised: 07/16/2021] [Accepted: 08/18/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Most spending for prescription drugs is on branded drugs that do not have direct generic equivalents but many of these drugs do have therapeutic alternatives within class. We estimate the potential savings from providing patients a financial incentive to switch from a higher cost drug to a lower cost, therapeutic alternative drug. METHODS We used individual state-transition microsimulations to model medication use and spending with and without financial incentives over a 12-month time horizon with a healthcare sector perspective. Costs and utilization inputs were from individuals on branded insulins or multiple sclerosis drugs enrolled in a regional mixed-model health maintenance organization. Base-case model used a one-time financial incentive of $83 and $250 offered to patients on higher cost insulin and multiple sclerosis treatments, respectively, to switch to lower cost drugs within class. RESULTS Savings per individual offered an incentive in the insulin and multiple sclerosis classes were, respectively, $84 (95% CI $46-$122) and $2,127 (95% CI $267-$3,987). Varying the incentive size and switch probability resulted in maximum savings of $712 at elasticity of 0.2 and incentive size $250 for the insulin drug class. For the multiple sclerosis drug class, maximum savings of $5945 was at elasticity of 0.2 and incentive size of $1000. Short time horizon makes our savings estimates conservative. CONCLUSIONS If programs such as financial incentives could encourage even a small proportion of patients to switch among drugs within therapeutic class, then substantial savings could be generated.
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Affiliation(s)
- Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; The Comparative Health Outcomes, Policy, and Economics Institute, University of Washington, Seattle, WA, USA; Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Ernesto Ulloa
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
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MacFarlane D, Hurlstone MJ, Ecker UKH, Ferraro PJ, Linden S, Wan AKY, Veríssimo D, Burgess G, Chen F, Hall W, Hollands GJ, Sutherland WJ. Reducing demand for overexploited wildlife products: Lessons from systematic reviews from outside conservation science. CONSERVATION SCIENCE AND PRACTICE 2022. [DOI: 10.1111/csp2.627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Douglas MacFarlane
- Conservation Science Group, Department of Zoology University of Cambridge Cambridge UK
- School of Psychological Science University of Western Australia Crawley Western Australia Australia
| | - Mark J. Hurlstone
- School of Psychological Science University of Western Australia Crawley Western Australia Australia
- Department of Psychology Lancaster University Lancaster UK
| | - Ullrich K. H. Ecker
- School of Psychological Science University of Western Australia Crawley Western Australia Australia
| | - Paul J. Ferraro
- Carey Business School and the Department of Environmental Health and Engineering, A Joint Department of the Bloomberg School of Public Health and the Whiting School of Engineering Johns Hopkins University Baltimore Maryland USA
| | - Sander Linden
- Department of Psychology, Social Decision‐Making Laboratory University of Cambridge Cambridge UK
| | - Anita K. Y. Wan
- Socio‐Ecological and Conservation Science Laboratory, School of Life Sciences, Sun Yat‐Sen University Guangzhou Guangdong China
| | - Diogo Veríssimo
- Oxford Martin Program on the Illegal Wildlife Trade, Oxford University Oxford UK
- Department of Zoology University of Oxford Oxford UK
| | - Gayle Burgess
- TRAFFIC, The Wildlife Trade Monitoring Network Cambridge UK
| | - Frederick Chen
- Department of Economics Wake Forest University Winston‐Salem North Carolina USA
| | - Wayne Hall
- National Centre for Youth Substance Use Research, University of Queensland Brisbane Queensland Australia
| | - Gareth J. Hollands
- Behaviour and Health Research Unit, University of Cambridge Cambridge UK
| | - William J. Sutherland
- Conservation Science Group, Department of Zoology University of Cambridge Cambridge UK
- BioRISC, St. Catharine's College Cambridge UK
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35
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Fang S, Huang J. Financial incentives for health should be standard practice. BMJ 2022; 376:o179. [PMID: 35074862 DOI: 10.1136/bmj.o179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Shu Fang
- School of Sociology and Psychology, Central University of Finance and Economics, Beijing, China
| | - Jin Huang
- Saint Louis University and Washington University in St Louis, St Louis, MO, USA
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The effectiveness of nudging: A meta-analysis of choice architecture interventions across behavioral domains. Proc Natl Acad Sci U S A 2022; 119:2107346118. [PMID: 34983836 PMCID: PMC8740589 DOI: 10.1073/pnas.2107346118] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 12/20/2022] Open
Abstract
Changing individuals’ behavior is key to tackling some of today’s most pressing societal challenges such as the COVID-19 pandemic or climate change. Choice architecture interventions aim to nudge people toward personally and socially desirable behavior through the design of choice environments. Although increasingly popular, little is known about the overall effectiveness of choice architecture interventions and the conditions under which they facilitate behavior change. Here we quantitatively review over a decade of research, showing that choice architecture interventions successfully promote behavior change across key behavioral domains, populations, and locations. Our findings offer insights into the effects of choice architecture and provide guidelines for behaviorally informed policy making. Over the past decade, choice architecture interventions or so-called nudges have received widespread attention from both researchers and policy makers. Built on insights from the behavioral sciences, this class of behavioral interventions focuses on the design of choice environments that facilitate personally and socially desirable decisions without restricting people in their freedom of choice. Drawing on more than 200 studies reporting over 450 effect sizes (n = 2,149,683), we present a comprehensive analysis of the effectiveness of choice architecture interventions across techniques, behavioral domains, and contextual study characteristics. Our results show that choice architecture interventions overall promote behavior change with a small to medium effect size of Cohen’s d = 0.45 (95% CI [0.39, 0.52]). In addition, we find that the effectiveness of choice architecture interventions varies significantly as a function of technique and domain. Across behavioral domains, interventions that target the organization and structure of choice alternatives (decision structure) consistently outperform interventions that focus on the description of alternatives (decision information) or the reinforcement of behavioral intentions (decision assistance). Food choices are particularly responsive to choice architecture interventions, with effect sizes up to 2.5 times larger than those in other behavioral domains. Overall, choice architecture interventions affect behavior relatively independently of contextual study characteristics such as the geographical location or the target population of the intervention. Our analysis further reveals a moderate publication bias toward positive results in the literature. We end with a discussion of the implications of our findings for theory and behaviorally informed policy making.
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Köhler J, Singh JA, Stuart R, Samuelson J, Reis AA. Ethical implications of economic compensation for voluntary medical male circumcision for HIV prevention and epidemic control. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001361. [PMID: 36962919 PMCID: PMC10021191 DOI: 10.1371/journal.pgph.0001361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Despite tremendous efforts in fighting HIV over the last decades, the estimated annual number of new infections is still a staggering 1.5 million. There is evidence that voluntary medical male circumcision (VMMC) provides protection against men's heterosexual acquisition of HIV-1 infection. Despite good progress, most countries implementing VMMC for HIV prevention programmes are challenged to reach VMMC coverage rates of 90%. Particularly for men older than 25 years, a low uptake has been reported. Consequently, there is a need to identify, study and implement interventions that could increase the uptake of VMMC. Loss of income and incurred transportation costs have been reported as major barriers to uptake of VMMC. In response, it has been suggested to use economic compensation in order to increase VMMC uptake. In this discussion paper, we present and review relevant arguments and concerns to inform decision-makers about the ethical implications of using economic compensation, and to provide a comprehensive basis for policy and project-related discussions and decisions.
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Affiliation(s)
- Johannes Köhler
- Department of Anesthesiology and Critical Care Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Jerome Amir Singh
- School of Law, University of KwaZulu-Natal, Durban, South Africa
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Rennie Stuart
- UNC Bioethics Center, Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Julia Samuelson
- Global Programmes on HIV, Hepatitis, STIs, World Health Organization, Geneva, Switzerland
| | - Andreas Alois Reis
- Health Ethics and Governance Unit, World Health Organization, Geneva, Switzerland
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Breen RJ, Palmer MA, Frandsen M, Ferguson SG. OUP accepted manuscript. Nicotine Tob Res 2022; 24:1661-1668. [PMID: 35165733 PMCID: PMC9575978 DOI: 10.1093/ntr/ntac042] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 01/27/2022] [Accepted: 02/11/2022] [Indexed: 11/14/2022]
Abstract
Introduction Financial incentive programs promote smoking cessation. However, the incentive amount which should be provided—and how this may interact with other program characteristics—is unknown. The objective of this study was to evaluate the influence of the design of incentive programs for smoking cessation on current smokers’ perceptions of programs and willingness to enroll. Method An online discrete choice experiment was conducted amongst adult current smokers residing in the United Kingdom (N = 430). Hypothetical incentive programs were described using five attributes (incentive amount, incentive type, frequency of sessions, reward schedules, program location). Participants responded to a series of choice sets comprised of two hypothetical programs. For each set, participants selected their preferred program. They then specified whether they would enroll in their preferred program if it were available. Analyses also considered the effect of participant income on preferences. Results Overall, participants preferred higher amounts over lower amounts, cash over vouchers, healthcare settings over workplaces, and consistent amounts over an escalating schedule. One session per week was the most preferred session frequency. Willingness to enroll increased quadratically with the incentive amount, although this increase slowed for higher amounts. Although middle- and high-income smokers preferred slightly higher amounts (cf. low-income participants), enrollment choices did not differ by income. Conclusion The characteristics of incentive programs influence smokers’ perceptions of programs and willingness to enroll. Higher amounts may encourage greater enrollment rates, but there will likely be a ceiling point beyond which increasing the incentive amount does not meaningfully increase enrollments. Implications There is increasing evidence incentive programs aid smoking cessation. Yet, the variety in previous program designs means how to best structure programs, including optimal incentive amount and the impact of the design on potential enrollment rates, remains unclear. This study suggests enrollments may be highest when incentive amounts are higher, rewards of a consistent amount in cash are provided, and sessions occur once per week in a healthcare setting. Although higher-income participants may desire higher incentive amounts compared to lower-income participants, this may not translate into differences in willingness to enroll.
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Affiliation(s)
- Rachel J Breen
- Corresponding Author: Rachel Breen, BPsych (Hons), College of Health and Medicine University of Tasmania Locked Bag 1342 Launceston, Tasmania 7250, Australia. E-mail:
| | - Matthew A Palmer
- College of Health & Medicine, University of Tasmania, Tasmania, Australia
| | - Mai Frandsen
- College of Health & Medicine, University of Tasmania, Tasmania, Australia
| | - Stuart G Ferguson
- College of Health & Medicine, University of Tasmania, Tasmania, Australia
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Huang G. Does Warm Glow Promote Physical Activity? Examining the Relative Effectiveness of Self-Benefiting versus Other-Benefiting Incentives in Motivating Fitness App Use by Corporate Sponsorship Programs. HEALTH COMMUNICATION 2021; 36:1719-1730. [PMID: 32698621 DOI: 10.1080/10410236.2020.1794548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Despite an essential step in the self-regulation process, the feature of offering rewards - in particular, offering tangible rewards - is underdeveloped in most fitness mobile apps. The present study addressed this issue by harnessing the contributions of corporations in the form of providing incentives to fitness app users as part of their corporate social responsibility initiatives. This study investigated the dual mechanisms through which incentive type and functional congruence shape consumers' intention to use a fitness app and their attitudes toward the sponsor, respectively. Through a 2 (self-benefiting vs. other-benefiting incentives) by 2 (low vs. high congruence) experiment, this study found that when using other-benefiting incentives, incentives provided by high-congruence sponsors elicited more favorable attitude toward the incentive than those provided by low-congruence sponsors and, in turn, increased users' propensity to use the app. But this indirect effect was not in play when using self-benefiting incentives. From the sponsor's perspective, in the low-congruence condition, other-benefiting incentives were more effective in leading users to attribute altruistic motives to the sponsorship, resulting in more favorable attitudes toward the sponsor; however, the mediating mechanism failed to operate under the high-congruence condition. Taken together, this research shed light on the mediating mechanisms and boundary conditions of strategies of partnering sponsorship with fitness apps, making this type of partnership a win-win initiative for both the app users and the corporations involved.
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Affiliation(s)
- Guanxiong Huang
- Department of Media and Communication, City University of Hong Kong
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40
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Das SK, Bukhari AS, Taetzsch AG, Ernst AK, Rogers GT, Gilhooly CH, Hatch-McChesney A, Blanchard CM, Livingston KA, Silver RE, Martin E, McGraw SM, Chin MK, Vail TA, Lutz LJ, Montain SJ, Pittas AG, Lichtenstein AH, Allison DB, Dickinson S, Chen X, Saltzman E, Young AJ, Roberts SB. Randomized trial of a novel lifestyle intervention compared with the Diabetes Prevention Program for weight loss in adult dependents of military service members. Am J Clin Nutr 2021; 114:1546-1559. [PMID: 34375387 DOI: 10.1093/ajcn/nqab259] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/14/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Lifestyle interventions are the first-line treatment for obesity, but participant weight loss is typically low. OBJECTIVES We evaluated the efficacy of an alternative lifestyle intervention [Healthy Weight for Living (HWL)] compared with a modified Diabetes Prevention Program (m-DPP). HWL was based on a revised health behavior change model emphasizing hunger management and the development of healthy food preferences. m-DPP was a standard Diabetes Prevention Program implemented with counselor time matched to HWL. Participants were adult dependents of military personnel and had overweight or obesity. METHODS Participants were randomly assigned to HWL (n = 121) or m-DPP (n = 117), delivered primarily by group videoconference with additional midweek emails. The primary outcome was 12-mo weight change. Secondary outcomes included 6-mo changes in cardiometabolic risk factors and diet. Intention-to-treat (ITT) and complete case (CC) analyses were performed using linear mixed models. RESULTS Retention did not differ between groups (72% and 66% for HWL and m-DPP at 12 mo, respectively; P = 0.30). Mean ± SE adjusted 12-mo weight loss in the ITT cohort was 7.46 ± 0.85 kg for HWL and 7.32 ± 0.87 kg for m-DPP (P = 0.91); in the CC cohort, it was 7.83 ± 0.82 kg for HWL and 6.86 ± 0.88 kg for m-DPP (P = 0.43). Thirty-eight percent of HWL and 30% of m-DPP completers achieved ≥10% weight loss (P = 0.32). Improvements in systolic blood pressure, LDL cholesterol, triglycerides, fasting glucose, general health, sleep, and mood were similar across groups; improvements in diastolic blood pressure were greater in m-DPP. Adjusted group mean reductions in energy intake were not significantly different between groups, but HWL participants were more adherent to their dietary prescription for lower glycemic index and high fiber and protein (P = 0.05 to <0.001 for ITT). CONCLUSIONS HWL and m-DPP showed equivalent and clinically impactful mean weight loss with cardiometabolic benefits. These results identify an alternative approach for behavioral treatment of overweight and obesity.This trial was registered at clinicaltrials.gov as NCT02348853.
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Affiliation(s)
- Sai Krupa Das
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA.,Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Asma S Bukhari
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Amy G Taetzsch
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Amy K Ernst
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Gail T Rogers
- Biostatistics and Data Management Unit, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Cheryl H Gilhooly
- Metabolic Research Unit, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Adrienne Hatch-McChesney
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Caroline M Blanchard
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Kara A Livingston
- Nutritional Epidemiology, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Rachel E Silver
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA.,Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Edward Martin
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Susan M McGraw
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Meghan K Chin
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Taylor A Vail
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Laura J Lutz
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Scott J Montain
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Anastassios G Pittas
- Division of Endocrinology, Diabetes and Metabolism, Tufts Medical Center, Boston, MA, USA
| | - Alice H Lichtenstein
- Cardiovascular Nutrition, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - David B Allison
- Department of Epidemiology, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Stephanie Dickinson
- Department of Epidemiology, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Xiwei Chen
- Department of Epidemiology, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Edward Saltzman
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Andrew J Young
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Susan B Roberts
- Energy Metabolism, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA.,Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
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Hene N, Wood P, Schwellnus M, Jordaan E, Laubscher R. Repeated Annual Health Risk Assessments With Intervention Did Not Reduce 10-year Cardiovascular Disease Risk: A 4-year Longitudinal Study in 13,737 Financial Sector Employees. J Occup Environ Med 2021; 63:881-888. [PMID: 34074955 DOI: 10.1097/jom.0000000000002251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine if repeat annual health risk assessments (RAHRAs) with intervention reduce 10-year cardiovascular disease (CVD) risk in financial sector employees. METHODS Retrospective analysis from RAHRAs in 13,737 employees over 4 years. We report changes in 10-year FRS for CVD (%) and risk factors after 1 (GR1), 2 (GR2), and 3 (GR 3) RAHRAs. RESULTS Mean FRS increased with RAHRAs (GR1: +0.4%; GR2: +0.7%; GR3: +0.8%) (P < 0.001) and was higher for GR3 versus GR1 (P < 0.001) and GR2 (pairwise: P < 0.0355). RAHRAs were associated with increased inadequate fruit/vegetable intake (GR1: +5.4%; GR2: +9.8%; GR3: +15.8%) (all pairwise: P < 0.001) and overweight (GR1: +5.4% vs GR2: +9.8%) (P < 0.001) and only hypercholesterolemia decreased (GR1: -4.4% vs GR3: -9.6%) (P < 0.001). CONCLUSION RAHRAs did not reduce 10-year CVD risk in financial sector employees. Role of RAHRAs in chronic disease management requires further study.
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Affiliation(s)
- Nceba Hene
- Sport, Exercise Medicine and Lifestyle Institute (SEMLI) and Division of Biokinetics and Sports Science, Department of Physiology, Faculty of Health Sciences, University of Pretoria, South Africa (Mr Hene and Dr Wood); Sport, Exercise Medicine and Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, South Africa (Dr Schwellnus); International Olympic Committee (IOC) Research Centre, South Africa (Dr Schwellnus); Biostatistics Unit, South African Medical Research Council, South Africa (Ms Jordaan and Ms Laubscher); Statistics and Population Studies Department, University of the Western Cape, South Africa (Ms Jordaan)
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Abstract
Efforts to guide peoples' behavior toward environmental sustainability, good health, or new products have emphasized informational and attitude change strategies. There is evidence that changing attitudes leads to changes in behavior, yet this approach takes insufficient account of the nature and operation of habits, which form boundary conditions for attitude-directed interventions. Integration of research on attitudes and habits might enable investigators to identify when and how behavior change strategies will be most effective. How might attitudinally driven behavior change be consolidated into lasting habits? How do habits protect the individual against the vicissitudes of attitudes and temptations and promote goal achievement? How might attitudinal approaches aiming to change habits be improved by capitalizing on habit discontinuities and strategic planning? When and how might changing or creating habit architecture shape habits directly? A systematic approach to these questions might help move behavior change efforts from attitude change strategies to habit change strategies. Expected final online publication date for the Annual Review of Psychology, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Bas Verplanken
- Department of Psychology, University of Bath, Bath BA2 7AY, United Kingdom;
| | - Sheina Orbell
- Department of Psychology, University of Essex, Colchester CO4 3SQ, United Kingdom;
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Facente SN, Hunter LA, Packel LJ, Li Y, Harte A, Nicolette G, McDevitt S, Petersen M, Reingold AL. Feasibility and effectiveness of daily temperature screening to detect COVID-19 in a prospective cohort at a large public university. BMC Public Health 2021; 21:1693. [PMID: 34530802 PMCID: PMC8445011 DOI: 10.1186/s12889-021-11697-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/29/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Many persons with active SARS-CoV-2 infection experience mild or no symptoms, presenting barriers to COVID-19 prevention. Regular temperature screening is nonetheless used in some settings, including university campuses, to reduce transmission potential. We evaluated the potential impact of this strategy using a prospective university-affiliated cohort. METHODS Between June and August 2020, 2912 participants were enrolled and tested for SARS-CoV-2 by PCR at least once (median: 3, range: 1-9). Participants reported temperature and symptoms daily via electronic survey using a previously owned or study-provided thermometer. We assessed feasibility and acceptability of daily temperature monitoring, calculated sensitivity and specificity of various fever-based strategies for restricting campus access to reduce transmission, and estimated the association between measured temperature and SARS-CoV-2 test positivity using a longitudinal binomial mixed model. RESULTS Most participants (70.2%) did not initially have a thermometer for taking their temperature daily. Across 5481 total person months, the average daily completion rate of temperature values was 61.6% (median: 67.6%, IQR: 41.8-86.2%). Sensitivity for SARS-CoV-2 ranged from 0% (95% CI 0-9.7%) to 40.5% (95% CI 25.6-56.7%) across all strategies for self-report of possible COVID-19 symptoms on day of specimen collection, with corresponding specificity of 99.9% (95% CI 99.8-100%) to 95.3% (95% CI 94.7-95.9%). An increase of 0.1 °F in individual mean body temperature on the same day as specimen collection was associated with 1.11 increased odds of SARS-CoV-2 positivity (95% CI 1.06-1.17). CONCLUSIONS Our study is the first, to our knowledge, that examines the feasibility, acceptability, and effectiveness of daily temperature screening in a prospective cohort during an infectious disease outbreak, and the only study to assess these strategies in a university population. Daily temperature monitoring was feasible and acceptable; however, the majority of potentially infectious individuals were not detected by temperature monitoring, suggesting that temperature screening is insufficient as a primary means of detection to reduce transmission of SARS-CoV-2.
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Affiliation(s)
- Shelley N Facente
- School of Public Health, Division of Epidemiology and Biostatistics, University of California, Berkeley, 2121 Berkeley Way # 5302, Berkeley, CA, 94720, USA.
- Facente Consulting, Richmond, CA, USA.
| | - Lauren A Hunter
- School of Public Health, Division of Epidemiology and Biostatistics, University of California, Berkeley, 2121 Berkeley Way # 5302, Berkeley, CA, 94720, USA
| | - Laura J Packel
- School of Public Health, Division of Epidemiology and Biostatistics, University of California, Berkeley, 2121 Berkeley Way # 5302, Berkeley, CA, 94720, USA
| | - Yi Li
- School of Public Health, Division of Epidemiology and Biostatistics, University of California, Berkeley, 2121 Berkeley Way # 5302, Berkeley, CA, 94720, USA
| | - Anna Harte
- University Health Services, University of California Berkeley, Berkeley, CA, USA
| | - Guy Nicolette
- University Health Services, University of California Berkeley, Berkeley, CA, USA
| | - Shana McDevitt
- Innovative Genomics Institute, University of California Berkeley, Berkeley, CA, USA
| | - Maya Petersen
- School of Public Health, Division of Epidemiology and Biostatistics, University of California, Berkeley, 2121 Berkeley Way # 5302, Berkeley, CA, 94720, USA
| | - Arthur L Reingold
- School of Public Health, Division of Epidemiology and Biostatistics, University of California, Berkeley, 2121 Berkeley Way # 5302, Berkeley, CA, 94720, USA
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44
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Role of financial incentives in family planning services in India: a qualitative study. BMC Health Serv Res 2021; 21:905. [PMID: 34479545 PMCID: PMC8414850 DOI: 10.1186/s12913-021-06799-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 07/19/2021] [Indexed: 11/29/2022] Open
Abstract
Background In an effort to encourage Family Planning (FP) adoption, since 1952, the Government of India has been implementing various centrally sponsored schemes that offer financial incentives (FIs) to acceptors as well as service providers, for services related to certain FP methods. However, understanding of the role of FIs on uptake of FP services, and the quality of FP services provided, is limited and mixed. Methods A qualitative descriptive study was conducted in Chatra and Palamu districts of Jharkhand state. A total of 64 interviews involving multiple stakeholders were conducted. The stakeholders included recent FP acceptors or clients, FP service providers of public health facilities including Accredited Social Healthcare Activists (ASHAs), government health officials managing FP programs at the district and state level, and members of development partners supporting FP programs in Jharkhand. Data analysis included both inductive and deductive strategies. It was done using the software Atlas ti version 8. Results It has emerged that there is a strong felt need for FP among majority of the clients, and FIs may be a motivator for uptake of FP methods only among those belonging to the lower socio economic strata. For ASHAs, FI is the primary motivator for providing FP related services. There may be a tendency among them and the nurses to promote methods which have more financial incentives linked with them. There are mixed opinions on discontinuing FIs for clients or replacing them with non-financial incentives. Delays in payment of FIs to both clients and the ASHAs is a common issue and adversely effects the program. Conclusion FIs for clients have limited influence on their decision to take up a FP method while different amounts of FIs for ASHAs and nurses, linked with different FP methods, may be influencing their service provision. More research is needed to determine the effect of discontinuing FI for FP services. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06799-1.
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de Buisonjé D, Van der Geer J, Keesman M, Van der Vaart R, Reijnders T, Wentzel J, Kemps H, Kraaijenhagen R, Janssen V, Evers A. Financial Incentives for Healthy Living for Patients With Cardiac Disease From the Perspective of Health Care Professionals: Interview Study. JMIR Cardio 2021; 5:e27867. [PMID: 34459748 PMCID: PMC8438607 DOI: 10.2196/27867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/01/2021] [Accepted: 07/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background A promising new approach to support lifestyle changes in patients with cardiovascular disease (CVD) is the use of financial incentives. Although financial incentives have proven to be effective, their implementation remains controversial, and ethical objections have been raised. It is unknown whether health care professionals (HCPs) involved in CVD care find it acceptable to provide financial incentives to patients with CVD as support for lifestyle change. Objective This study aims to investigate HCPs’ perspectives on using financial incentives to support healthy living for patients with CVD. More specifically, we aim to provide insight into attitudes toward using financial incentives as well as obstacles and facilitators of implementing financial incentives in current CVD care. Methods A total of 16 semistructured, in-depth, face-to-face interviews were conducted with Dutch HCPs involved in supporting patients with CVD with lifestyle changes. The topics discussed were attitudes toward an incentive system, obstacles to using an incentive system, and possible solutions to facilitate the use of an incentive system. Results HCPs perceived an incentive system for healthy living for patients with CVD as possibly effective and showed generally high acceptance. However, there were concerns related to focusing too much on the extrinsic aspects of lifestyle change, disengagement when rewards are insignificant, paternalization and threatening autonomy, and low digital literacy in the target group. According to HCPs, solutions to mitigate these concerns included emphasizing intrinsic aspects of healthy living while giving extrinsic rewards, integrating social aspects to increase engagement, supporting autonomy by allowing freedom of choice in rewards, and aiming for a target group that can work with the necessary technology. Conclusions This study mapped perspectives of Dutch HCPs and showed that attitudes are predominantly positive, provided that contextual factors, design, and target groups are accurately considered. Concerns about digital literacy in the target group are novel findings that warrant further investigation. Follow-up research is needed to validate these insights among patients with CVD.
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Affiliation(s)
- David de Buisonjé
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
| | - Jessica Van der Geer
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
| | - Mike Keesman
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
| | - Roos Van der Vaart
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
| | - Thomas Reijnders
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands
| | - Jobke Wentzel
- Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands
| | - Hareld Kemps
- Department of Cardiology, Máxima Medical Center, Veldhoven, Netherlands
| | | | - Veronica Janssen
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands.,Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Andrea Evers
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, Netherlands.,Leiden University Medical Center, Leiden University, Leiden, Netherlands.,Medical Delta, Leiden-Delft-Erasmus Universities, Delft, Netherlands
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46
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Breen RJ, Ferguson SG, Palmer MA. Smokers' Perceptions of Incentivized Smoking Cessation Programs: Examining How Payment Thresholds Change With Income. Nicotine Tob Res 2021; 23:1567-1574. [PMID: 33621322 DOI: 10.1093/ntr/ntab031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 02/18/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Studies demonstrate that financial incentive programs increase smoking cessation. However, there is little guidance on which incentive magnitudes will ensure optimal enrollment and motivation levels. This study investigates current smokers' perceptions of varying incentive magnitudes to identify whether there is evidence for optimal amount(s) and whether perceptions differ by income group. METHODS Studies 1 (N = 56) and 2 (N = 147) were conducted online via Prolific.co. Current smokers were randomly shown multiple hypothetical incentive programs that differed only in the incentive amount offered. For each program, smokers rated its appeal and their likelihood of enrolling and predicted their motivation to quit if enrolled. Growth models were used to investigate the relationship between perspectives and the incentive amount. RESULTS An increasing quadratic trend in smokers' perceptions of programs as the incentive amount increased was identified. Incentive amounts beyond approximately £50-75 per week (£500-£750 total) did not significantly alter perceptions of programs. In Study 2, high-income smokers found programs significantly less appealing and motivating than low-income smokers, although no significant between-group differences were observed in the likelihood of enrollment. No significant differences were observed between low- and middle-income smokers. CONCLUSIONS Increasing the incentive amount increased smoker's perceptions of programs. This relationship was curvilinear, meaning there may be a point beyond which further increasing the amount will not improve enrollment or motivation levels. Incentives appear equally appealing to low- and middle-income smokers; the population among whom smoking is most prevalent. Future research could explore other elements of program design and whether findings hold under real-world conditions. IMPLICATIONS While acknowledging that they work, policymakers frequently request information about the monetary amount needed for incentive programs to be effective, and if this differs by income level. We investigated these questions using smokers' perceptions of hypothetical cessation programs that differed in the amount offered. An increasing quadratic trend in perceptions of programs by the amount and potential cut points was observed, suggesting a point may exist beyond which increasing the incentive will not improve perceptions of programs or enrollment levels. High-income smokers may not perceive incentives to be as appealing as other income groups, but appear equally willing to enroll.
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Affiliation(s)
- Rachel J Breen
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
| | - Stuart G Ferguson
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
| | - Matthew A Palmer
- College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
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47
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Hartmann-Boyce J, Theodoulou A, Oke JL, Butler AR, Scarborough P, Bastounis A, Dunnigan A, Byadya R, Hobbs FDR, Sniehotta FF, Jebb SA, Aveyard P. Association between characteristics of behavioural weight loss programmes and weight change after programme end: systematic review and meta-analysis. BMJ 2021; 374:n1840. [PMID: 34404631 PMCID: PMC8369384 DOI: 10.1136/bmj.n1840] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine if the characteristics of behavioural weight loss programmes influence the rate of change in weight after the end of the programme. DESIGN Systematic review and meta-analysis. DATA SOURCES Trial registries, 11 electronic databases, and forward citation searching (from database inception; latest search December 2019). Randomised trials of behavioural weight loss programmes in adults with overweight or obesity, reporting outcomes at ≥12 months, including at the end of the programme and after the end of the programme. REVIEW METHODS Studies were screened by two independent reviewers with discrepancies resolved by discussion. 5% of the studies identified in the searches met the inclusion criteria. One reviewer extracted the data and a second reviewer checked the data. Risk of bias was assessed with Cochrane's risk of bias tool (version 1). The rate of change in weight was calculated (kg/month; converted to kg/year for interpretability) after the end of the programme in the intervention versus control groups by a mixed model with a random intercept. Associations between the rate of change in weight and prespecified variables were tested. RESULTS Data were analysed from 249 trials (n=59 081) with a mean length of follow-up of two years (longest 30 years). 56% of studies (n=140) had an unclear risk of bias, 21% (n=52) a low risk, and 23% (n=57) a high risk of bias. Regain in weight was faster in the intervention versus the no intervention control groups (0.12-0.32 kg/year) but the difference between groups was maintained for at least five years. Each kilogram of weight lost at the end of the programme was associated with faster regain in weight at a rate of 0.13-0.19 kg/year. Financial incentives for weight loss were associated with faster regain in weight at a rate of 1-1.5 kg/year. Compared with programmes with no meal replacements, interventions involving partial meal replacements were associated with faster regain in weight but not after adjustment for weight loss during the programme. Access to the programme outside of the study was associated with slower regain in weight. Programmes where the intensity of the interaction reduced gradually were also associated with slower regain in weight in the multivariable analysis, although the point estimate suggested that the association was small. Other characteristics did not explain the heterogeneity in regain in weight. CONCLUSION Faster regain in weight after weight loss was associated with greater initial weight loss, but greater initial weight loss was still associated with reduced weight for at least five years after the end of the programme, after which data were limited. Continued availability of the programme to participants outside of the study predicted a slower regain in weight, and provision of financial incentives predicted faster regain in weight; no other clear associations were found. STUDY REGISTRATION PROSPERO CRD42018105744.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason L Oke
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ailsa R Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Peter Scarborough
- Oxford Biomedical Research Centre, Nuffield Department of Population Health, University of Oxford, Big Data Institute, Oxford, UK
| | - Anastasios Bastounis
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Anna Dunnigan
- Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Rimu Byadya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- United Nations World Food Programme, Cox's Bazar, Bangladesh
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Falko F Sniehotta
- Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Faculty of Behavioural, Management, and Social Sciences, University of Twente, Enschede, Netherlands
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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48
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Influence of Incentive Design and Organizational Characteristics on Wellness Participation and Health Outcomes. J Occup Environ Med 2021; 62:874-882. [PMID: 32826550 DOI: 10.1097/jom.0000000000002005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To explore how changing incentive designs influence wellness participation and health outcomes. METHODS Aggregated retrospective data were evaluated using cluster analysis to group 174 companies into incentive design types. Numerous statistical models assessed between-group differences in wellness participation, earning incentives, and over-time differences in health outcomes. RESULTS Four incentive design groups based on requirements for earning incentives were identified. The groups varied in support for and participation in wellness initiatives within each company. All four design types were associated with improved low density lipoprotein (LDL) (P < 0.01), three with improved blood pressure (P < 0.001), and two with improved fasting glucose (P < 0.03). No incentive plan types were associated with improved body mass index (BMI), but designs predominantly focused on health outcomes (eg, Outcomes-Focused) exhibited a significant increase over time in BMI risk. CONCLUSION Incentive design and organizational characteristics impact population-level participation and health outcomes.
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49
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Hoskins K, Schmidt H. Breastfeeding, Personal Responsibility and Financial Incentives. Public Health Ethics 2021. [DOI: 10.1093/phe/phab020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Should financial incentives be offered to mothers for breastfeeding? Given the significant socioeconomic and sociodemographic differences in breastfeeding in the USA, researchers and policymakers are exploring the role of financial incentives for breastfeeding promotion with the objective of increasing uptake and reducing disparities. Despite positive outcomes in other health domains, the acceptability of financial incentives is mixed. Financial incentives in the context of infant feeding are particularly controversial given the complex obligations that characterize decisions to breastfeed. After situating the specific ethical tensions related to personal responsibility, fairness, and intrusiveness, we argue that exploring carefully designed financial incentives can be ethically justified to support breastfeeding uptake particularly given (i) established medical guidelines that support breastfeeding benefits, (ii) wide socioeconomic and racial/ethnic disparities and (iii) notable influences in the broader choice architecture of infant feeding in the USA. Additional empirical research is warranted to better understand effectiveness, cost and specific ethical concerns related to free and informed choice.
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Affiliation(s)
- Katelin Hoskins
- Perelman School of Medicine, Leonard Davis Institute of Health Economics and Center for Health Incentives & Behavioral Economics, University of Pennsylvania, USA
| | - Harald Schmidt
- Perelman School of Medicine, Leonard Davis Institute of Health Economics and Center for Health Incentives & Behavioral Economics, University of Pennsylvania, USA
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50
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Pontin F, Lomax N, Clarke G, Morris MA. Socio-demographic determinants of physical activity and app usage from smartphone data. Soc Sci Med 2021; 284:114235. [PMID: 34311392 DOI: 10.1016/j.socscimed.2021.114235] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/19/2021] [Accepted: 07/14/2021] [Indexed: 11/19/2022]
Abstract
The increasing ubiquity of smartphones provides a potential new data source to capture physical activity behaviours. Though not designed as a research tool, these secondary data have the potential to capture a large population over a more extensive spatial area and with longer temporality than current methods afford. This paper uses one such secondary data source from a commercial app designed to incentivise activity. We explore the new insights these data provide, alongside the sociodemographic profile of those using physical activity apps, to gain insight into both physical activity behaviour and determinants of app usage in order to evaluate the suitability of the app in providing insights into the physical activity of the population. We find app usage to be higher in females, those aged 25-50, and users more likely to live in areas where a higher proportion of the population are of a lower socioeconomic status. We ascertain longer-term patterns of app usage with increasing age and more male users reaching physical activity guideline recommendations despite longer daily activity duration recorded by female users. Additionally, we identify key weekly and seasonal trends in physical activity. This is one of the first studies to utilise a large volume of secondary physical activity app data to co-investigate usage alongside activity behaviour captured.
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Affiliation(s)
- Francesca Pontin
- Leeds Institute for Data Analytics, University of Leeds, Level 11, Worsley Building, Clarendon Way, Leeds, LS2 9JT, United Kingdom; School of Geography, Garstang North, University of Leeds, LS2 9JT, United Kingdom.
| | - Nik Lomax
- Leeds Institute for Data Analytics, University of Leeds, Level 11, Worsley Building, Clarendon Way, Leeds, LS2 9JT, United Kingdom; School of Geography, Garstang North, University of Leeds, LS2 9JT, United Kingdom.
| | - Graham Clarke
- School of Geography, Garstang North, University of Leeds, LS2 9JT, United Kingdom.
| | - Michelle A Morris
- Leeds Institute for Data Analytics, University of Leeds, Level 11, Worsley Building, Clarendon Way, Leeds, LS2 9JT, United Kingdom; School of Medicine, Worsley Building, University of Leeds, Clarendon Way, Leeds, LS2 9JT, United Kingdom.
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