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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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2
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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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3
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Michaud TL, Estabrooks PA, You W, Ern J, Scoggins D, Gonzales K, King KM, Dai H, Su D. Effectiveness of incentives to improve the reach of health promotion programs- a systematic review and meta-analysis. Prev Med 2022; 162:107141. [PMID: 35809822 DOI: 10.1016/j.ypmed.2022.107141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 05/31/2022] [Accepted: 07/02/2022] [Indexed: 10/17/2022]
Abstract
The reach (i.e., enrollment, engagement, and retention) of health promotion evidence-based programs (EBPs) at the participant level has been challenging. Incentives based on behavioral economics may be used to improve EBP reach. We aimed to systematically review and synthesize the evidence of the effectiveness of incentives as a dissemination strategy to increase EBP reach. We conducted a literature search in PubMed, SCOPUS, EMBASE, Cochrane Review and Cochrane CENTRAL for articles published between January 2000 and March 2020 to identify incentive strategies used to increase program reach among health promotion EBPs. Inclusion criteria included studies published in English, experimental or quasi-experimental designs, comparison of incentive to non-incentive or control strategies, and reported on reach (n = 35 health promotion studies). Monetary incentives using cash and a fixed schedule of reinforcement were the most used incentive schemes (71%). Incentives alone or combined with other strategies as a multicomponent approach were effective in improving program enrollment, engagement, and retention. Specifically, incentive strategies were associated with higher odds of program enrollment (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.82-4.24; n = 10) and retention (OR, 2.54, 95% CI, 1.34-4.85; n = 9) with considerable heterogeneity (I2 = 94% and 91%, respectively). Incentives are a promising individual-level dissemination strategy to improve the reach of health promotion EBPs. However, understanding the optimal amount, type, frequency, and target of incentives, and how incentives fit in a multicomponent approach in different contexts requires further research.
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Affiliation(s)
- Tzeyu L Michaud
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA; Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Paul A Estabrooks
- Department of Health and Kinesiology, College of Health, University of Utah, Salt Lake City, UT, USA
| | - Wen You
- Department of Public Health Sciences, University of Virginia, University of Virginia Cancer Center, Charlottesville, VA, USA
| | - Jessica Ern
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dylan Scoggins
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kelly Gonzales
- College of Nursing, Omaha Division, University of Nebraska Medical Center, Omaha, NE, USA
| | - Keyonna M King
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA; Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Hongying Dai
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dejun Su
- Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA; Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
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4
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Harte R, Norton L, Whitehouse C, Lorincz I, Jones D, Gerald N, Estrada I, Sabini C, Mitra N, Long JA, Cappella J, Glanz K, Volpp KG, Kangovi S. Design of a randomized controlled trial of digital health and community health worker support for diabetes management among low-income patients. Contemp Clin Trials Commun 2022; 25:100878. [PMID: 34977421 PMCID: PMC8688867 DOI: 10.1016/j.conctc.2021.100878] [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: 12/16/2020] [Revised: 09/14/2021] [Accepted: 12/04/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Insulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin. METHODS The study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin. CONCLUSION The design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.
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Affiliation(s)
- Rory Harte
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Community Health Workers, Penn Medicine, Philadelphia, PA, USA
| | - Lindsey Norton
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Community Health Workers, Penn Medicine, Philadelphia, PA, USA
| | - Christina Whitehouse
- Villanova University M. Louise Fitzpatrick College of Nursing, Villanova, PA, USA
| | - Ilona Lorincz
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Denerale Jones
- Penn Center for Community Health Workers, Penn Medicine, Philadelphia, PA, USA
| | - Norma Gerald
- Penn Center for Community Health Workers, Penn Medicine, Philadelphia, PA, USA
| | - Irene Estrada
- Penn Center for Community Health Workers, Penn Medicine, Philadelphia, PA, USA
| | - Carolyn Sabini
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Community Health Workers, Penn Medicine, Philadelphia, PA, USA
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Judith A. Long
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Joseph Cappella
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Glanz
- Perelman School of Medicine and School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin G. Volpp
- Penn Center for Health Incentives and Behavioral Economics, Departments of Medical Ethics and Health Policy and Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shreya Kangovi
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Community Health Workers, Penn Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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5
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Li R, Zhang Y, Cai X, Luo D, Zhou W, Long T, Zhang H, Jiang H, Li M. The nudge strategies for weight loss in adults with obesity and overweight: A systematic review and meta-analysis. Health Policy 2021; 125:1527-1535. [PMID: 34772518 DOI: 10.1016/j.healthpol.2021.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 12/28/2022]
Abstract
Obesity and overweight conditions have become major health challenges worldwide. The exploration of effective weight loss strategies is essential. Nudges are currently advancing approaches that represent a new and better method for changing the behaviors of people. However, the effectiveness of nudge interventions on weight loss in overweight people who may be obese has not been synthesized in a systematic manner. In this study, a systematic literature search was performed. Only randomized controlled trials (RCTs) were considered. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated as summary statistics. In total, 25 RCTs involving a population of 5,929 individuals were included. Significant effects of the nudge strategy on weight loss (WMD: -0.96 kg, 95% CI: -1.49 to -0.43), body mass index (WMD: -0.3 kg/m2, 95% CI: -0.41 to -0.19) and waist circumference (WMD: -0.75 cm, 95% CI: -1.23 to -0.27) were observed. The subgroup analysis showed that the reduction in body weight associated with nudge interventions was significant in younger and more obese people. Moreover, the effect of nudge intervention on weight loss weakened over time. Overall, the nudge strategy can promote changes in weight loss, body mass index and waist circumference of adults, albeit at a mild magnitude and in particular types of individuals. Nudge strategies can be recommended to clinical practitioners and policy-makers to promote obesity management.
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Affiliation(s)
- Ruxue Li
- School of Nursing, Peking University, Beijing, China
| | - Yating Zhang
- School of Nursing, Peking University, Beijing, China
| | - Xue Cai
- Zhongda Hospital Southeast University, Nanjing, China
| | - Dan Luo
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wuai Zhou
- Department of Automation, Tsinghua University, Beijing, China
| | - Tianxue Long
- School of Nursing, Peking University, Beijing, China
| | - Huijing Zhang
- School of Nursing, Peking University, Beijing, China
| | - Hua Jiang
- School of Nursing, Peking University, Beijing, China
| | - Mingzi Li
- School of Nursing, Peking University, Beijing, China.
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6
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Glanz K, Shaw PA, Kwong PL, Choi JR, Chung A, Zhu J, Huang QE, Hoffer K, Volpp KG. Effect of Financial Incentives and Environmental Strategies on Weight Loss in the Healthy Weigh Study: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2124132. [PMID: 34491350 PMCID: PMC8424479 DOI: 10.1001/jamanetworkopen.2021.24132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Modest weight loss can lead to meaningful risk reduction in adults with obesity. Although both behavioral economic incentives and environmental change strategies have shown promise for initial weight loss, to date they have not been combined, or compared, in a randomized clinical trial. OBJECTIVE To test the relative effectiveness of financial incentives and environmental strategies, alone and in combination, on initial weight loss and maintenance of weight loss in adults with obesity. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted from 2015 to 2019 at 3 large employers in Philadelphia, Pennsylvania. A 2-by-2 factorial design was used to compare the effects of lottery-based financial incentives, environmental strategies, and their combination vs usual care on weight loss and maintenance. Interventions were delivered via website, text messages, and social media. Participants included adult employees with a body mass index (BMI; weight in kilograms divided by height in meters squared) of 30 to 55 and at least 1 other cardiovascular risk factor. Data analysis was performed from June to July 2021. INTERVENTIONS Interventions included lottery-based financial incentives based on meeting weight loss goals, environmental change strategies tailored for individuals and delivered by text messages and social media, and combined incentives and environmental strategies. MAIN OUTCOME AND MEASURES The primary outcome was weight change from baseline to 18 months, measured in person. RESULTS A total of 344 participants were enrolled, with 86 participants each randomized to the financial incentives group, environmental strategies group, combined financial incentives and environmental strategies group, and usual care (control) group. Participants had a mean (SD) age of 45.6 (10.5) years and a mean (SD) BMI of 36.5 (7.1); 247 participants (71.8%) were women, 172 (50.0%) were Black, and 138 (40.1%) were White. At the primary end point of 18 months, participants in the incentives group lost a mean of 5.4 lb (95% CI, -11.3 to 0.5 lb [mean, 2.45 kg; 95% CI, -5.09 to 0.23 kg]), those in the environmental strategies group lost a mean of a 2.2 lb (95% CI, -7.7 to 3.3 lb [mean, 1.00 kg; 95% CI, -3.47 to 1.49 kg]), and the combination group lost a mean of 2.4 lb (95% CI, -8.2 to 3.3 lb [mean, 1.09 kg; 95% CI, -3.69 to 1.49 kg]) more than participants in the usual care group. Financial incentives, environmental change strategies, and their combination were not significantly more effective than usual care. At 24 months, after 6 months without an intervention, the difference in the change from baseline was similar to the 18-month results, with no significant differences among groups. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, across all study groups, participants lost a modest amount of weight but those who received financial incentives, environmental change, or the combined intervention did not lose significantly more weight than those in the usual care group. Employees with obesity may benefit from more intensive individualized weight loss strategies. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02878343.
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Affiliation(s)
- Karen Glanz
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- School of Nursing, University of Pennsylvania, Philadelphia
| | - Pamela A. Shaw
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Pui L. Kwong
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ji Rebekah Choi
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Annie Chung
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jingsan Zhu
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Qian Erin Huang
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Karen Hoffer
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kevin G. Volpp
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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7
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Voils CI, Pendergast J, Hale SL, Gierisch JM, Strawbridge EM, Levine E, McVay MA, Reed SD, Yancy WS, Shaw RJ. A randomized feasibility pilot trial of a financial incentives intervention for dietary self-monitoring and weight loss in adults with obesity. Transl Behav Med 2021; 11:954-969. [PMID: 33245118 DOI: 10.1093/tbm/ibaa102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Financial incentives could be used to improve adherence to behavioral weight loss interventions, increasing their effectiveness. This Phase IIb randomized pilot study evaluated the feasibility and acceptability of a study protocol for providing financial incentives for dietary self-monitoring and/or weight loss. Community-dwelling adults with obesity were enrolled in a 24 week, group-based weight loss program. Participants were randomized in a 2 × 2 factorial design to receive financial incentives for both dietary self-monitoring and weekly weight loss, just one, or neither. Participants could earn up to $300, evolving from fixed weekly payments to intermittent, variable payments. The notice of reward was provided by text message. The study was conducted in three successive cohorts to evaluate study procedure changes, including dietary approach, recruitment and retention strategies, text messaging, and incentives. Descriptive statistics calculated separately for each cohort described study performance relative to predefined targets for recruitment, including minority representation; retention; adherence; and weight loss. Acceptability was assessed via postintervention qualitative interviews. In Cohort 1 (n = 34), a low-carbohydrate diet was used. Recruitment, retention, adherence, and weight loss were adequate, but minority representation was not. For Cohort 2 (n = 31), employing an additional recruitment method and switching to a reduced-calorie diet yielded adequate recruitment, minority representation, retention, and adherence but less weight loss. Returning to a low-carbohydrate diet in Cohort 3 (n = 28) yielded recruitment, minority representation, retention, adherence, and weight loss similar to Cohort 2. Participant feedback informed changes to text message timing and content and incentive amount. Through successive cohorts, we optimized recruitment and retention strategies and text messaging. An adequately powered trial is warranted to evaluate the efficacy of these incentive structures for reducing weight. The trial registration number is NCT02691260.
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Affiliation(s)
- Corrine I Voils
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Research Service, William S Middleton Memorial Veterans Hospital, Madison, WI, USA
| | | | - Sarah L Hale
- School of Medicine, Duke University, Durham, NC, USA
| | - Jennifer M Gierisch
- School of Medicine, Duke University, Durham, NC, USA.,Health Services Research & Development, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | | | | | - Megan A McVay
- College of Health and Human Performance, University of Florida, Gainesville, FL, USA
| | - Shelby D Reed
- School of Medicine, Duke University, Durham, NC, USA
| | - William S Yancy
- School of Medicine, Duke University, Durham, NC, USA.,Health Services Research & Development, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Ryan J Shaw
- School of Nursing, Duke University, Durham, NC, USA
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8
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Becker J, Emmert-Fees KMF, Greiner GG, Rathmann W, Thorand B, Peters A, Karl FM, Laxy M, Schwettmann L. Associations between self-management behavior and sociodemographic and disease-related characteristics in elderly people with type 2 diabetes - New results from the population-based KORA studies in Germany. Prim Care Diabetes 2020; 14:508-514. [PMID: 32088161 DOI: 10.1016/j.pcd.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/18/2019] [Accepted: 01/17/2020] [Indexed: 12/14/2022]
Abstract
AIMS Self-management behavior (SMB) is an important aspect in the management of diabetes. This study aimed to identify sociodemographic and disease-related factors associated with good SMB in people with type 2 diabetes (T2D). METHODS We used data from 479 people with T2D aged 65 or older from the population-based KORA (Cooperative Health Research in the Area of Augsburg) Health Survey 2016 in Southern Germany. We estimated Poisson and logistic regression models testing the cross-sectional relationship between individual or disease-related characteristics and an established SMB sum index comprising six SMB dimensions stratified according to insulin treatment status. RESULTS Mean age in the sample was 75 and mean diabetes duration was 13 years. The overall level of SMB was low. Higher SMB index scores were associated with higher age, treatment with insulin, participation in a diabetes education program, and, for people with insulin treatment, with a BMI below 30 kg/m2. Single item analyses generally supported these findings. CONCLUSIONS SMB in people with T2D needs to be improved with efficient interventions. Targeting obese individuals and those at an early stage of the disease with low-barrier, regular education or self-management programs may be a preferred strategy.
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Affiliation(s)
- Jana Becker
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany; Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Karl M F Emmert-Fees
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - Gregory Gordon Greiner
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany; Institute for Health Services Research and Health Economics, German Diabetes Center, Auf'm Hennekamp 65, 40225 Duesseldorf, Germany; Institute for Health Services Research and Health Economics, Center for Health and Society, Medical Faculty, Heinrich Heine University, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Auf'm Hennekamp 65, 40225 Duesseldorf, Germany; German Centre for Diabetes Research (DZD), Ingolstädter Landstraße 1, 85764 München-Neuherberg, Germany
| | - Barbara Thorand
- German Centre for Diabetes Research (DZD), Ingolstädter Landstraße 1, 85764 München-Neuherberg, Germany; Institute of Epidemiology, Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - Annette Peters
- German Centre for Diabetes Research (DZD), Ingolstädter Landstraße 1, 85764 München-Neuherberg, Germany; Institute of Epidemiology, Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - Florian M Karl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany; German Centre for Diabetes Research (DZD), Ingolstädter Landstraße 1, 85764 München-Neuherberg, Germany
| | - Michael Laxy
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany; German Centre for Diabetes Research (DZD), Ingolstädter Landstraße 1, 85764 München-Neuherberg, Germany; Global Diabetes Research Center, Rollins School of Public Health, Emory University, 1518 Clifton Rd. NE Atlanta, GA 30322 USA
| | - Lars Schwettmann
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany; Department of Economics, Martin Luther University Halle-Wittenberg, 06099 Halle an der Saale, Germany.
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Stedman-Falls LM, Dallery J. Technology-based versus in-person deposit contract treatments for promoting physical activity. J Appl Behav Anal 2020; 53:1904-1921. [PMID: 32939749 DOI: 10.1002/jaba.776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/30/2020] [Accepted: 08/30/2020] [Indexed: 11/10/2022]
Abstract
Deposit contracts involve participants depositing their own money and earning it back contingent on behavior change. Deposit contracts are empirically supported treatments for promoting health behavior, but they have a history of poor uptake. We compared the effectiveness and acceptability of technology-based versus in-person deposit contracts for promoting physical activity with 12 individuals. Participants' daily step counts were monitored using Fitbits across 6 weeks, and treatment preferences were assessed at the end of the study. The 2 types of treatments were equally effective in increasing physical activity, but the technology-based deposit contracts were preferred by most participants. Most participants also reported that their preference was related to convenience. Technology-based implementation may be one way to improve deposit contract uptake, while maintaining similar effectiveness compared to in-person procedures.
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Heisler M, Kullgren J, Richardson C, Stoll S, Alvarado Nieves C, Wiley D, Sedgwick T, Adams A, Hedderson M, Kim E, Rao M, Schmittdiel JA. Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART). Contemp Clin Trials 2020; 95:106048. [PMID: 32497783 PMCID: PMC8059966 DOI: 10.1016/j.cct.2020.106048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM). METHODS In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed. RESULTS At least 296 participants and approximately 75 peer supporters will be enrolled. DISCUSSION Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes. TRIAL REGISTRATION The ClinicalTrials.gov registration number is NCT03689530.
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Affiliation(s)
- Michele Heisler
- 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.
| | - Jeffrey 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; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, United States of America; University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States of America.
| | - Caroline Richardson
- Department of Family 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.
| | - Cristina Alvarado Nieves
- University of Michigan, Department of Internal Medicine- Metabolism, Endocrinology and Diabetes, United States of America.
| | - Deanne Wiley
- Kaiser Permanente Northern California, United States of America.
| | - Tali Sedgwick
- Kaiser Permanente Northern California Division of Research, United States of America.
| | - Alyce Adams
- Kaiser Permanente Northern California, United States of America.
| | | | - Eileen Kim
- The Permanente Medical Group (Kaiser Permanente, Northern California), United States of America.
| | - Megan Rao
- The Permanente Medical Group (Kaiser Permanente, Northern California), United States of America.
| | - Julie A Schmittdiel
- Kaiser Permanente Northern California Division of Research, United States of America.
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Adding Financial Incentives to Online Group-Based Behavioral Weight Control: An RCT. Am J Prev Med 2020; 59:237-246. [PMID: 32446752 PMCID: PMC8510645 DOI: 10.1016/j.amepre.2020.03.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 02/24/2020] [Accepted: 03/29/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Internet-delivered behavioral weight control is promising for expanding the reach and availability of weight management, but online programs produce lower weight losses than typically achieved in person. Financial incentives have been shown to increase weight losses. This study examined whether adding financial incentives for self-monitoring and achieving target weight losses increases weight losses attained in a fully online, group-based behavioral weight management program compared with the same program alone. STUDY DESIGN This study was an RCT. SETTING/PARTICIPANTS Adults with overweight and obesity (n=418; 91% female; 28% minority) were recruited from 2 clinical centers. INTERVENTION The intervention was a 24-session online group-based behavioral weight control program with weekly synchronous chat sessions (Internet-only) or the same program with weekly financial incentives for self-monitoring body weight and dietary intake daily and for achieving target weight losses at 2 and 6 months (Internet + incentives). MAIN OUTCOME MEASURES This study measured weight loss at 6 months and treatment engagement (attendance, self-monitoring of body weight, dietary intake, and physical activity). Data were collected between February 2016 and August 2018, and analyses were completed in 2019. RESULTS Participants randomized to the Internet + incentives group lost more weight (-6.4 [SD=5.5] kg) than those in the Internet-only group (-4.7 [SD=6.6] kg; p<0.01). Further, a higher proportion of the Internet + incentives group achieved ≥5% weight loss (55%) than those in the Internet-only group (40%; p<0.05). Treatment engagement was higher in the Internet + incentives condition, with greater self-monitoring of behaviors targeted by incentives, as well as higher rates of behaviors not targeted and higher self-reported physical activity. Study retention was higher among those in the Internet + incentives condition (91%) than those in the Internet-only condition (81%; p=0.003). CONCLUSIONS Adding financial incentives to a program delivered fully online increases weight losses compared with the program alone and can achieve weight losses comparable to in-person programs, offering potential for substantial geographic reach. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02688621.
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Cleveland LP, Seward MW, Simon D, Rifas-Shiman SL, Lewis KH, Bennett-Rizzo C, Halperin F, McManus KD, Block JP. BWHealthy Weight Pilot Study: A randomized controlled trial to improve weight-loss maintenance using deposit contracts in the workplace. Prev Med Rep 2020; 17:101061. [PMID: 32071848 PMCID: PMC7011078 DOI: 10.1016/j.pmedr.2020.101061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/26/2019] [Accepted: 01/23/2020] [Indexed: 12/26/2022] Open
Abstract
Objective Deposit contracts, where participants “bet” on achieving a goal and get their money back only if successful, have been shown to be effective for short-term weight-loss. This pilot study examined their effect on weight-loss maintenance. Methods From 2016 to 2018, we conducted a pilot, 50-week randomized controlled trial among 42 hospital employees (19 intervention and 23 control), in Boston, Massachusetts, who lost ≥10 lb (4.5 kg) in the two years prior to enrollment. Participants were recruited primarily in-person. Both control and intervention participants were asked to attend a weigh in weekly and received weekly email communication. Intervention participants also entered into a deposit contract to maintain baseline weight within ≤2 lb (0.9 kg). We examined weight change from baseline to 50 weeks (primary outcome) and maintenance of baseline weight at 50 weeks (secondary outcome; binary – yes v. no). Participants completed baseline and follow-up surveys and received incentives for completion. Results At baseline, mean (SD) weight was 83.2 (15.5 kg) among intervention and 80.7 (14.5 kg) among control participants. After 50 weeks, intervention participants had slightly less but non-significant weight gain (adjusted β −1.12 kg; 95% CI −5.28, 3.05) than control participants; 73.7% of intervention v. 39.1% of control participants met their weight-loss maintenance goal by study end (adjusted OR 4.78; 95% CI 1.01, 22.71). Conclusions A deposit contract was not associated with differences in weight but led to more participants meeting their weight-loss maintenance goals; a deposit contract for weight-loss maintenance should be tested in a full-scale intervention. Most intervention participants viewed the deposit contract as acceptable.
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Affiliation(s)
- Lauren P Cleveland
- Division of Chronic Disease Research Across the Lifecourse (CoRAL), Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, MA, United States
| | - Michael W Seward
- Division of Chronic Disease Research Across the Lifecourse (CoRAL), Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, MA, United States
| | - Denise Simon
- Division of Chronic Disease Research Across the Lifecourse (CoRAL), Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, MA, United States
| | - Sheryl L Rifas-Shiman
- Division of Chronic Disease Research Across the Lifecourse (CoRAL), Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, MA, United States
| | - Kristina H Lewis
- Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Carin Bennett-Rizzo
- Occupational Health Department, Brigham and Women's Hospital, Boston, MA, United States
| | - Florencia Halperin
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Katherine D McManus
- Department of Nutrition, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jason P Block
- Division of Chronic Disease Research Across the Lifecourse (CoRAL), Department of Population Medicine, Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, MA, United States
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Bachireddy C, Joung A, John LK, Gino F, Tuckfield B, Foschini L, Milkman KL. Effect of Different Financial Incentive Structures on Promoting Physical Activity Among Adults: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e199863. [PMID: 31441936 PMCID: PMC6714021 DOI: 10.1001/jamanetworkopen.2019.9863] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Few adults engage in recommended levels of physical activity. Financial incentives can promote physical activity, but little is known about how the structure of these incentives influences their effectiveness (eg, how incentives are disbursed over time). OBJECTIVE To determine if it is more effective to disburse fixed total financial incentives at a constant, increasing, or decreasing rate to encourage physical activity. DESIGN, SETTING, AND PARTICIPANTS A 2-week randomized clinical trial was conducted from June 2 to 15, 2014, using an online platform that automatically records daily steps of pedometer-wearing users and awards points redeemable for cash. The study population comprised 3515 adult users of the online platform in the lower 70th percentile of steps taken among all users before treatment. Data analyses were performed from August 20, 2014, to February 1, 2018. Analysis was performed on an intent-to-treat basis. INTERVENTIONS Participants were randomized to either a control group or to 1 of 3 intervention groups during the 2 weeks of the study. Participants in the control group received a constant daily rate of $0.00001 per step. The 3 intervention groups received a 20-fold incentive increase ($0.00020 per step) distributed differently during the 2 weeks of the study: at a constant, increasing, or decreasing rate. Reminder emails explaining incentive schedules were sent the day before the intervention and halfway through the 2-week intervention. MAIN OUTCOMES AND MEASURES Change in mean daily steps during the 2-week intervention and 3 weeks after the intervention. The study had 80% power to detect a difference of 280 steps per day during the intervention at α = .05. RESULTS The study included 3515 participants (879 in the control condition, 879 in the constant incentive condition, 881 in the increasing incentive condition, and 876 in the decreasing incentive condition). During the intervention, compared with participants in the control group, participants receiving constant incentives logged 306.7 more steps per day (95% CI, 91.5-521.9 steps; P = .005), those receiving decreasing incentives logged 96.9 more steps per day (95% CI, 15.3-178.5 steps; P = .02), and those receiving increasing incentives logged no significant change in steps per day (1.5 steps per day; 95% CI, -81.6 to 84.7 steps; P = .97). One week after the intervention, compared with participants in the control group, only participants receiving constant incentives logged significantly more steps per day (329.5; 95% CI, 20.6-638.4; P = .04). Two and 3 weeks after the intervention, there were no significant differences compared with participants in the control group. Overall, for each $1 spent, participants in the constant incentives group logged 475.4 more steps than those in the increasing incentives group and 429.3 more steps than those in the decreasing incentives group. CONCLUSIONS AND RELEVANCE This study found that financial incentives for physical activity were more effective during a payment period when they were offered at a constant rate rather than an increasing or decreasing rate. However, this effectiveness dissipated shortly after the incentives were removed. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02154256.
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Affiliation(s)
- Chethan Bachireddy
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Andrew Joung
- Operations, Information and Decisions Department, The Wharton School of the University of Pennsylvania, Philadelphia
| | - Leslie K. John
- Negotiation, Organizations and Markets Unit, Harvard Business School, Boston, Massachusetts
| | - Francesca Gino
- Negotiation, Organizations and Markets Unit, Harvard Business School, Boston, Massachusetts
| | - Bradford Tuckfield
- Operations, Information and Decisions Department, The Wharton School of the University of Pennsylvania, Philadelphia
| | | | - Katherine L. Milkman
- Operations, Information and Decisions Department, The Wharton School of the University of Pennsylvania, Philadelphia
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Effectiveness and cost-effectiveness of incentives as a tool for prevention of non-communicable diseases: A systematic review. Soc Sci Med 2019; 232:340-350. [PMID: 31129504 DOI: 10.1016/j.socscimed.2019.05.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 01/27/2023]
Abstract
The rising epidemic of non-communicable diseases (NCDs) poses substantial health and economic challenges to both individuals and society. Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs. Yet, whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematically addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal. In this systematic review we aim to determine whether there is an evidence base for any of these strategies. Forty-eight published randomized controlled trials (70 contrasts) evaluating the effectiveness of incentive-based strategies for improvements in NCD risk-factors were reviewed. Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy. More evidence for long-term effectiveness and cost-effectiveness is needed to justify third party funding of any incentive based strategy.
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Delay discounting and its association with food purchasing considerations and food availability in the home in south-east Alabama, USA. Public Health Nutr 2018; 22:287-294. [DOI: 10.1017/s1368980018003142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveCertain factors, such as food quality, label content and grocery characteristics, may be considered when purchasing foods. Food availability in the home has been shown to influence dietary behaviours, also associated with delay discounting (DD). The present study sought to characterize the relationships between DD, food purchasing considerations and healthfulness of foods in the home.DesignA cross-sectional, online survey of adults (n 477) was conducted with the following measures: DD, consideration of food quality (nutrition, taste) and grocery characteristics (price, ease of preparation, shelf-life) while shopping, use of food labels and food availability in the home. DD was assessed by the area under the delay discounting curve (AUC) using a binary choice task. Greater AUC reflects lower DD. Structural equation modelling was used to allow AUC to simultaneously predict purchasing considerations and foods in the home.SettingOnline survey.ParticipantsAdult employees in south-east Alabama, USA.ResultsDD was negatively associated with food label use and emphasis on food quality when shopping (P<0·001). In the final model, DD was associated with availability of healthful foods in the home and emphasis on food quality and grocery characteristics. About 33 % of the variance in shopping behaviours, 5 % in food label use, 7 % in availability of healthful foods and 4 % in availability of unhealthful foods was explained by DD.ConclusionsIndividuals with lower DD appear to be more thoughtful in making food purchasing decisions and have healthful foods available in the home more frequently than individuals with higher DD.
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Gong Y, Trentadue TP, Shrestha S, Losina E, Collins JE. Financial incentives for objectively-measured physical activity or weight loss in adults with chronic health conditions: A meta-analysis. PLoS One 2018; 13:e0203939. [PMID: 30252864 PMCID: PMC6156024 DOI: 10.1371/journal.pone.0203939] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 08/30/2018] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE We conducted a meta-analysis and systematic review of published randomized controlled trials (RCTs) to evaluate the impact of financial incentives (FI) on objectively-measured physical activity (PA) and weight loss (WL) in adults with sedentary behavior or chronic health conditions. EVIDENCE REVIEW We performed a systematic search for RCTs published in English indexed in PubMed, Embase, or Web of Science through July 27, 2017. We limited our search to RCTs that involved an FI intervention with a monetary component, objectively-measured PA or WL outcomes, samples with either sedentary lifestyles or chronic health conditions, and a comparator group that did not receive performance-contingent FI. We calculated the mean difference and standardized mean difference (SMD) for each study and used a random effects model to summarize intervention efficacy. We used the Jadad scoring tool to assess the quality of the identified articles. RESULTS We abstracted data from 11 RCTs. Two of the 11 included studies focused on PA, totaling 126 intervention and 116 control subjects. Nine RCTs evaluated the effect of FI on WL, totaling 1,799 intervention and 1,483 control subjects. The combined estimate for change in daily steps was 940 (95%CI [306-1,574]) more in PA intervention groups than in control groups and 2.36 (95%CI [1.80-2.93]) more kilograms lost by WL intervention groups compared to control groups. The overall estimated SMD for both outcomes combined was 0.395 (95%CI [0.243-0.546; p<0.001]), favoring FI interventions. CONCLUSION FI interventions are efficacious in increasing PA and WL in adults with chronic conditions or sedentary adults. Public health programs to increase PA or prevent chronic disease should consider incorporating FI to improve outcomes.
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Affiliation(s)
- Yusi Gong
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and the Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Taylor P. Trentadue
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and the Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Swastina Shrestha
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and the Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and the Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Orthopedics, Harvard Medical School, Boston, Massachusetts, United States of America
- Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Jamie E. Collins
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and the Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Orthopedics, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Acharya Y, Alford J, Duffy R, Adler-Milstein J. Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial. BMJ Qual Saf 2017; 27:355-364. [DOI: 10.1136/bmjqs-2017-006699] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 09/08/2017] [Accepted: 10/07/2017] [Indexed: 11/04/2022]
Abstract
BackgroundLittle is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.MethodsWe conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.ResultsThe intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.ConclusionClinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.Trial registration numberNCT02247050; Pre-results.
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Kullgren JT, Hafez D, Fedewa A, Heisler M. A Scoping Review of Behavioral Economic Interventions for Prevention and Treatment of Type 2 Diabetes Mellitus. Curr Diab Rep 2017; 17:73. [PMID: 28755061 PMCID: PMC5619648 DOI: 10.1007/s11892-017-0894-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW The purpose of this paper was to review studies of behavioral economic interventions (financial incentives, choice architecture modifications, or commitment devices) to prevent type 2 diabetes mellitus (T2DM) among at-risk patients or improve self-management among patients with T2DM. RECENT FINDINGS We found 15 studies that used varied study designs and outcomes to test behavioral economic interventions in clinical, workplace, or health plan settings. Of four studies that focused on prevention of T2DM, two found that financial incentives increased weight loss and completion of a fasting blood glucose test, and two choice architecture modifications had mixed effects in encouraging completion of tests to screen for T2DM. Of 11 studies that focused on improving self-management of T2DM, four of six tests of financial incentives demonstrated increased engagement in recommended care processes or improved biometric measures, and three of five tests of choice architecture modifications found improvements in self-management behaviors. Though few studies have tested behavioral economic interventions for prevention or treatment of T2DM, those that have suggested such approaches have the potential to improve patient behaviors and such approaches should be tested more broadly.
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Affiliation(s)
- Jeffrey T Kullgren
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI, USA.
- Department of Internal Medicine, University of Michigan Medical School, 3101 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
- University of Michigan Institute for Healthcare Policy and Innovation, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.
| | - Dina Hafez
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, 3101 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, 2800 Plymouth Road, Building 10, Room G016, Ann Arbor, MI, 48109, USA
| | - Allison Fedewa
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, 2800 Plymouth Road, Building 10, Room G016, Ann Arbor, MI, 48109, USA
| | - Michele Heisler
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, 3101 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
- University of Michigan Institute for Healthcare Policy and Innovation, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
- Department of Health Behavior and Health Education, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA
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Ard JD, Emery M, Cook M, Hale E, Frain A, Lewis KH, Song E. Skin in the game: Does paying for obesity treatment out of pocket lead to better outcomes compared to insurance coverage? Obesity (Silver Spring) 2017; 25:993-996. [PMID: 28544796 DOI: 10.1002/oby.21837] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/07/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether insurance coverage for medical weight loss treatment was associated with different program engagement and weight loss outcomes compared to those who paid out of pocket. METHODS One-year outcomes from an academic medical weight management program were used to compare two groups: employees (n = 480) with insurance coverage ("covered") versus nonemployees (n = 463) who paid out of pocket ("self-pay"). Demographics and weight were abstracted from medical records. Socioeconomic status was estimated using neighborhood demographics. Group differences in weight were analyzed using generalized linear modeling adjusted for age, baseline BMI, sex, program type, and neighborhood socioeconomic status. RESULTS Covered patients were younger (46.5 ± 10.6 vs. 51.6 ± 12.5) with a lower BMI (38.5 ± 7.5 vs. 41.3 ± 9.9) compared to self-pay (P < 0.001). Self-pay patients resided in higher annual per capita income neighborhoods (+$4,545, P < 0.001). Program dropout was lower for covered patients (12.7% vs. 17.6%, P = 0.03). There was no significant difference in 12-month weight loss between groups in adjusted models; covered patients lost 13.4%, compared to 13.6% for self-pay. CONCLUSIONS Data from an academic medical weight management program suggest that individuals with access to insurance coverage for nonsurgical obesity treatment have lower levels of attrition and similar levels of participation and outcomes as those who pay out of pocket.
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Affiliation(s)
- Jamy D Ard
- Department of Surgery, Weight Management Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Matt Emery
- Department of Surgery, Weight Management Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Miranda Cook
- Department of Surgery, Weight Management Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Erica Hale
- Department of Surgery, Weight Management Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Annette Frain
- Department of Surgery, Weight Management Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kristina H Lewis
- Department of Surgery, Weight Management Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Eunyoung Song
- Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Finkelstein EA, Tham KW, Haaland BA, Sahasranaman A. Applying economic incentives to increase effectiveness of an outpatient weight loss program (TRIO) - A randomized controlled trial. Soc Sci Med 2017; 185:63-70. [PMID: 28554160 DOI: 10.1016/j.socscimed.2017.05.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 05/02/2017] [Accepted: 05/14/2017] [Indexed: 11/25/2022]
Abstract
The prevalence of overweight and obesity has more than doubled in the past three decades, leading to rising rates of non-communicable diseases. This study tests whether adding a payment/rewards (term reward) program to an existing evidence-based weight loss program can increase weight loss and weight loss maintenance. We conducted a parallel-group randomized controlled trial from October 2012 to October 2015 with 161 overweight or obese individuals randomized to either control or reward arm in a 1:2 ratio. Control and reward arm participants received a four month weight loss program at the LIFE (Lifestyle Improvement and Fitness Enhancement) Centre at Singapore General Hospital. Those in the reward arm paid a fee of S$165.00 (1US$ = 1.35S$) to access a program that provided rewards of up to S$660 for meeting weight loss and physical activity goals. Participants could choose to receive rewards as guaranteed cash payments or a lottery ticket with a 1 in 10 chance of winning but with the same expected value. The primary outcome was weight loss at months 4, 8, and 12. 161 participants were randomized to control (n = 54) or reward (n = 107) arms. Average weight loss was more than twice as great in the reward arm compared to the control arm at month 4 when the program concluded (3.4 kg vs 1.4 kg, p < 0.01), month 8 when rewards concluded (3.3 kg vs 1.8 kg, p < 0.05), and at month 12 (2.3 kg vs 0.8 kg, p < 0.05). These results reveal that a payment/rewards program can be used to improve weight loss and weight loss maintenance when combined with an evidence-based weight loss program. Future efforts should attempt to replicate this approach and identify how to cost effectively expand these programs to maximize their reach. This study is registered at www.clinicaltrials.gov (Identifier: NCT01533454).
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Affiliation(s)
- Eric A Finkelstein
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Level 4 169857, Singapore; Duke Global Health Institute, Duke University, 310 Trent Drive, Durham NC 27710, United States.
| | - Kwang-Wei Tham
- Department of Endocrinology, Obesity & Metabolic Unit, Singapore General Hospital, Outram Road 169608, Singapore
| | - Benjamin A Haaland
- H. Milton Stewart School of Industrial & Systems Engineering, Georgia Institute of Technology, 765 Ferst Drive NW, Atlanta GA 30332-0205, United States; Centre for Quantitative Medicine, Duke-NUS Medical School, 20 College Road, Level 6 169856, Singapore
| | - Aarti Sahasranaman
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Level 4 169857, Singapore
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