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Tzikas A, Koulierakis G, Athanasakis K, Merakou K. Nudging Interventions on Stair Use: A Scoping Review. JOURNAL OF PREVENTION (2022) 2024; 45:685-722. [PMID: 38877174 DOI: 10.1007/s10935-024-00790-2] [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] [Accepted: 06/01/2024] [Indexed: 06/16/2024]
Abstract
Stair use is a physical activity that can be incorporated into the daily lifestyle of a majority of the population, resulting in several health benefits. Nudges are increasingly used in public health interventions to encourage healthy behaviours such as physical activity in a cost-effective manner. This scoping review aimed to investigate the effect and the characteristics of nudges used on interventions to promote stair use. We reviewed the relevant literature published in PubMed, Cochrane Library, Mendeley and Google Scholar, from January 2009 to May 2022. Eligibility criteria included original studies of any type of design, written in English, targeting healthy adults, reporting nudging interventions, using elevator or escalator as comparators and defining a baseline for comparisons. Initially, 118 publications were identified, and after applying exclusion criteria, 27 articles were included in the analysis. Results showed that most of the nudging interventions had significant positive effect on stair use in several settings. The evidence from this review suggests that incorporating nudges into public health interventions can effectively promote physical activity through increased stair usage. Emphasizing prevention measures in public health interventions may contribute to better health outcomes.
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Affiliation(s)
- Alexandros Tzikas
- Department of Public Health Policy, School of Public Health, University of West Attica, Athens, Greece.
| | - George Koulierakis
- Laboratory of Epidemiology, Health Determinants and Well-Being, Division of Epidemiology, Prevention and Quality of Life, Department of Public Health Policy, School of Public Health, University of West Attica, Athens, Greece
| | - Konstantinos Athanasakis
- Laboratory for Health Technology Assessment, Division of Health Systems and Policy, Department of Public Health Policy, School of Public Health, University of West Attica, Athens, Greece
| | - Kyriakoula Merakou
- Laboratory of Epidemiology, Health Determinants and Well-Being, Division of Epidemiology, Prevention and Quality of Life, Department of Public Health Policy, School of Public Health, University of West Attica, Athens, Greece
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Forberger S, Reisch LA, van Gorp P, Stahl C, Christianson L, Halimi J, De Santis KK, Malisoux L, de-Magistris T, Bohn T. 'Let me recommend… ': use of digital nudges or recommender systems for overweight and obesity prevention-a scoping review protocol. BMJ Open 2024; 14:e080644. [PMID: 39089719 PMCID: PMC11293388 DOI: 10.1136/bmjopen-2023-080644] [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: 10/09/2023] [Accepted: 06/24/2024] [Indexed: 08/04/2024] Open
Abstract
INTRODUCTION Recommender systems, digital tools providing recommendations, and digital nudges increasingly affect our lives. The combination of digital nudges and recommender systems is very attractive for its application in preventing overweight and obesity. However, linking recommender systems with personalised digital nudges has a potential yet to be fully exploited. Therefore, this study aims to conduct a scoping review to identify which digital nudges or recommender systems or their combinations have been used in obesity prevention and to map these systems according to the target population, health behaviour, system classification (eg, mechanisms for developing recommendations, delivery channels, personalisation, interconnection, used combination), and system implementation. METHODS AND ANALYSIS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guideline was used to inform protocol development. The eligibility criteria are based on the PCC framework (Population: any human; Concept: recommender systems or digital nudges; Context: obesity prevention). MEDLINE, PsycINFO, Web of Science, CINHAL, Scopus, ACM Digital Library and IEEE Xplore were searched until September 2023. Primary studies with any design published in peer-reviewed academic journals and peer-reviewed conference papers will be included. Data will be extracted into a pre-developed extraction sheet. Results will be synthesised descriptively and narratively. ETHICS AND DISSEMINATION No ethical approval is required for the scoping review, as data will be obtained from publicly available sources. The results of this scoping review will be published in a peer-reviewed journal, presented at conferences and used to inform the co-creation process and intervention adaptation in the context of a HealthyW8 project (www.healthyw8.eu).
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Affiliation(s)
- Sarah Forberger
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
- Department of Health Science, University of York, York, UK
| | - Lucia A Reisch
- Cambridge Judge Business School, University of Cambridge, Cambridge, UK
| | - Pieter van Gorp
- Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Christoph Stahl
- Luxembourg Institute of Science and Technology, Esch-sur-Alzette, Luxembourg
| | - Lara Christianson
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Jihan Halimi
- Instituto Agroalimentario de Aragón, IA2 (CITA-Universidad de Zaragoza), Zaragoza, Spain
| | | | | | - Tiziana de-Magistris
- Instituto Agroalimentario de Aragón, IA2 (CITA-Universidad de Zaragoza), Zaragoza, Spain
| | - Torsten Bohn
- Luxembourg Institute of Health, Strassen, Luxembourg
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Nicholls N, Watson ED. Get active now or later? The association between physical activity and risk and time preferences. PSYCHOLOGY OF SPORT AND EXERCISE 2024; 73:102650. [PMID: 38648871 DOI: 10.1016/j.psychsport.2024.102650] [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: 05/11/2023] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
Despite the well-established link between physical activity and positive health outcomes, much of the world's population remains inactive. Many people don't invest in health behaviours, such as physical activity, in the present, despite the long-term benefits of this. The aim of this study was to assess the relationship between physical activity levels and risk and time preferences in university students. A maximum likelihood model was used to jointly estimate risk and time preferences (elicited in an incentivised choice experiment), and to examine the relationship between these preferences and self-reported physical activity. Physically inactive people discounted the future significantly more than physically active people did. Physically active people made slightly more risky choices in our risk attitude task, although this directional relationship was not statistically significant. The link between time preferences and physical activity suggests that further research on behavioural strategies such as commitment devices, nudging or temptation bundling may be helpful in increasing physical activity for individuals who discount the future in favour of more immediate benefits.
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Affiliation(s)
- Nicky Nicholls
- Department of Economics, University of Pretoria, Lynnwood Road, Pretoria, South Africa.
| | - Estelle D Watson
- Department of Exercise Sciences, Faculty of Science, The University of Auckland, Auckland, New Zealand; Centre for Exercise Science and Sports Medicine, School of Therapeutic Sciences, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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van Mierlo T, Rondina R, Fournier R. Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial. JMIR Form Res 2024; 8:e52558. [PMID: 38592752 DOI: 10.2196/52558] [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: 09/07/2023] [Revised: 01/04/2024] [Accepted: 02/13/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. The effectiveness of self-guided treatment is well established, and its use has intensified because of the COVID-19 pandemic. Engagement remains important as dose-response relationships have been observed. Platforms such as Facebook (Meta Platform, Inc), LinkedIn (Microsoft Corp), and X Corp (formerly known as Twitter, Inc) use principles of behavioral economics to increase engagement. We hypothesized that similar concepts would increase engagement in self-guided digital health. OBJECTIVE This 3-arm randomized controlled trial aimed to test whether members of 2 digital self-health courses for anxiety and depression would engage with behavioral nudges and prompts. Our primary hypothesis was that members would click on 2 features: tips and a to-do checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in arm 2 versus social proof and present bias tips in arm 3. Our tertiary hypothesis was that rotating tips and a to-do checklist would increase completion rates. The results of this study will form a baseline for future artificial intelligence-directed research. METHODS Overall, 13,224 new members registered between November 2021 and May 2022 for Evolution Health's self-guided treatment courses for anxiety and depression. The control arm featured a member home page without nudges or prompts. Arm 2 featured a home page with a tip-of-the-day section. Arm 3 featured a home page with a tip-of-the-day section and a to-do checklist. The research protocol for this study was published in JMIR Research Protocols on August 15, 2022. RESULTS Arm 3 had significantly younger members (F2,4564=40.97; P<.001) and significantly more female members (χ24=92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001). CONCLUSIONS Members engaged with behavioral nudges and prompts. The results of this study may be important because efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/37231.
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Affiliation(s)
| | - Renante Rondina
- Rotman School of Managment, University of Toronto, Toronto, ON, Canada
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Moraitis AM, Iacob E, Wong B, Beck SL, Echeverria C, Donaldson G, Mooney K. Pairing automated exercise coaching with patient-reported symptom monitoring: A way to nudge exercise uptake during cancer treatment? Support Care Cancer 2024; 32:258. [PMID: 38558321 DOI: 10.1007/s00520-024-08450-1] [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: 11/22/2023] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Symptoms during cancer treatment cause burden, diminished physical functioning, and poor quality of life. Exercise is recommended during treatment to mitigate symptoms; however, interventions are difficult to translate into clinical care due to the lack of patient uptake and clinical implementation barriers. We evaluated the uptake, acceptability, and impact of an automated ePRO exercise module triggered by three patient-reported symptoms: nausea/vomiting, fatigue, and anxiety, during chemotherapy. METHODS We conducted a secondary analysis of an exercise module intervention imbedded in the cancer symptom monitoring and management platform, Symptom Care at Home (SCH). Utilizing behavioral economics principles, the exercise module was triggered when any of the three symptoms were reported. Once triggered, participants were coached on exercise benefits for symptom reduction and then offered the opportunity to set weekly exercise goals plus tracking of the goal outcomes and receive further encouragement. We examined uptake, exercise goal setting and attainment, and symptom impact. RESULTS Of 180 SCH participants receiving the SCH intervention, 170 (94.4%) triggered the exercise module and 102 of the 170 (60%) accepted the module, setting goals on average for 6.3 weeks. Of 102 participants, 82 (80.4%) achieved one or more exercise goals, exercising on average 79.8 min/week. Participants who achieved a higher proportion of goals had statistically significant lower overall symptom severity and lower severity of the triggered symptom. CONCLUSION An automated mHealth exercise coaching intervention, aimed to nudge those receiving chemotherapy to initiate an exercise routine had significant uptake, is acceptable and may reduce symptom severity. TRIAL REGISTRATION NCT01973946.
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Affiliation(s)
- Ann Marie Moraitis
- Dana Farber Cancer Institute, Department of Pediatric Oncology, Boston, MA, USA.
| | - Eli Iacob
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Bob Wong
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | - Susan L Beck
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | | | - Gary Donaldson
- Pain Research Center, Department of Anesthesiology, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kathi Mooney
- College of Nursing, University of Utah, Salt Lake City, Utah, USA
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Byrne AL, Harvey C, Baldwin A. The discourse of delivering person-centred nursing care before, and during, the COVID-19 pandemic: Care as collateral damage. Nurs Inq 2024; 31:e12593. [PMID: 37583275 DOI: 10.1111/nin.12593] [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: 12/12/2022] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/17/2023]
Abstract
The global COVID-19 pandemic challenged the world-how it functions, how people move in the social worlds and how government/government services and people interact. Health services, operating under the principles of new public management, have undertaken rapid changes to service delivery and models of care. What has become apparent is the mechanisms within which contemporary health services operate and how services are not prioritising the person at the centre of care. Person-centred care (PCC) is the philosophical premise upon which models of health care are developed and implemented. Given the strain that COVID-19 has placed on the health services and the people who deliver the care, it is essential to explore the tensions that exist in this space. This article suggests that before the pandemic, PCC was largely rhetoric, and rendered invisible during the pandemic. The paper presents an investigation into the role of PCC in these challenging times, adopting a Foucauldian lens, specifically governmentality and biopolitics, to examine the policies, priorities and practical implications as health services pivoted and adapted to changing and acute demands. Specifically, this paper draws on the Australian experience, including shifting nursing workforce priorities and additional challenges resulting from public health directives such as lockdowns and limitations. The findings from this exploration open a space for discussion around the rhetoric of PCC, the status of nurses and that which has been lost to the pandemic.
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Affiliation(s)
- Amy-Louise Byrne
- School of Nursing Midwifery and Social Sciences, Central Queensland University, Townsville, Queensland, Australia
| | - Clare Harvey
- School of Nursing, Massey University, Wellington, New Zealand
| | - Adele Baldwin
- School of Nursing Midwifery and Social Sciences, Central Queensland University, Townsville, Queensland, Australia
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Lee CS, Lim KK, Kim HK. Nudging Public Health Behaviors to Prevent COVID-19: A Systematic Review. HEALTH COMMUNICATION 2024:1-12. [PMID: 38425006 DOI: 10.1080/10410236.2024.2317567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Many countries have implemented strict preventive measures and mandatory policies to curb virus transmission during the COVID-19 pandemic. Some have adopted softer approaches, such as nudge-based intervention, to influence public health behavior. This systematic review, conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines, aims to determine if the nudge-based intervention can effectively influence people's preventive behavior during the early period of the COVID-19 pandemic. The review indicated an overall positive outcome, but results were mixed as nudge-based interventions substantially depended on the situational context. While the review found that the nudging technique that presents and conveys decision-related information was essential to nudging people, a secondary nudge would often applied to deliver the interventions. In addition, there was no indication of an ideal nudge technique that would be effective in most situations. Conversely, our findings indicate that the nudge would likely suffer from habituation after repeated intervention or backfire due to inappropriate use of nudges. Also, the ceiling effect would inhibit any nudge influences regardless of the technique(s) used. In sum, the results and the applicability of nudge-based interventions were mixed, highlighting the need for further research to advance the theory and practical developments.
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Affiliation(s)
- Chei Sian Lee
- Wee Kim Wee School of Communication and Information, Nanyang Technological University
| | - Kok Khiang Lim
- Wee Kim Wee School of Communication and Information, Nanyang Technological University
| | - Hye Kyung Kim
- Wee Kim Wee School of Communication and Information, Nanyang Technological University
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Durão S, Wilkinson M, Davids EL, Gerritsen A, Kredo T. Effects of policies or interventions that influence the school food environment on children's health and nonhealth outcomes: a systematic review. Nutr Rev 2024; 82:332-360. [PMID: 37253393 PMCID: PMC10859694 DOI: 10.1093/nutrit/nuad059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
CONTEXT Globally, 1 in 3 children under 5 years is undernourished or overweight, and 1 in 2 suffers from hidden hunger due to nutrient deficiencies. As children spend a considerable time at school, school-based policies that aim to improve children's dietary intake may help address this double burden of malnutrition. OBJECTIVE This systematic review aimed to assess the effects of implementing policies or interventions that influence the school food environment on children's health and nonhealth outcomes. DATA SOURCES, EXTRACTION, AND ANALYSIS Eleven databases were searched up to April 2020 and the World Health Organization (WHO) released a call for data due in June 2020. Records were screened against the eligibility criteria, and data extraction and risk-of-bias assessment were conducted by 1 reviewer and checked by another. The synthesis was based on effect direction, and certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. CONCLUSIONS Seventy-four studies reporting 10 different comparisons were included. The body of evidence indicates that interventions addressing the school food environment may have modest beneficial effects on certain key outcomes. Nutrition standards for healthy foods and beverages at schools, interventions that change how food is presented and positioned, and fruit and vegetable provision may have a beneficial effect on the consumption of healthy foods and beverages. Regarding effects on the consumption of discretionary foods and beverages, nutrition standards may have beneficial effects. Nutrition standards for foods and beverages, changes to portion size served, and the implementation of multiple nudging strategies may have beneficial effects on energy intake. Regarding effects of purchasing or selecting healthier foods, changes to how food is presented and positioned may be beneficial. This review was commissioned and supported by the WHO (registration 2020/1001698-0). WHO reviewed and approved the protocol for the systematic review and reviewed the initial report of the completed systematic review. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no: CRD42020186265.
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Affiliation(s)
- Solange Durão
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Maryke Wilkinson
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Better Health Programme South Africa, Mott MacDonald, Cape Town, South Africa
| | - Eugene L Davids
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Child and Adolescent Psychiatry, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Annette Gerritsen
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Clinical Pharmacology, Department of Medicine and Division of Epidemiology and Biostatistics, and Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Zucchelli MM, Gambetti E, Giusberti F, Nori R. Use of default option nudge and individual differences in everyday life decisions. Cogn Process 2024; 25:75-88. [PMID: 37740853 DOI: 10.1007/s10339-023-01161-1] [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: 04/11/2023] [Accepted: 08/31/2023] [Indexed: 09/25/2023]
Abstract
People often make inefficient decisions for themselves and the community (e.g. they underuse medical screenings or vaccines and they do not vote) also because of their individual characteristics, such as their level of avoidance or anxiety. In recent years, governments have successfully applied strategies, called "nudges", to help people maximizing their decisions in several fields; however, the role of individual characteristics has been poorly explored. The present study investigated whether one kind of nudge, the default option (automatic enrolment in a specific plan), can modulate the influence of such individual differences, promoting favourable decisions in different field, such as the medical and civic ones. One hundred and eighty-three participants completed the Trait Anxiety Inventory, the General Decision-Making Styles Inventory and scenarios about health and civic decisions. Participants have hypothetically been enrolled by default or not enrolled in specific plans and had to decide whether adhere or not to the plan proposed. Result showed that the default option drives anxious and avoidant individuals, who usually refuse to make a choice due to their overestimation of negative events' occurrence, to undergo medical screenings and vaccine and to vote more. Nudge confirmed its effectiveness in favouring better decisions among people according to their individual differences.
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Affiliation(s)
- Micaela Maria Zucchelli
- Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy.
| | - Elisa Gambetti
- Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy
| | - Fiorella Giusberti
- Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy
| | - Raffaella Nori
- Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127, Bologna, Italy
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Johansen ND, Vaduganathan M, Bhatt AS, Biering-Sørensen T. Nudging a Nation - The Danish NUDGE Trial Concept. NEJM EVIDENCE 2024; 3:EVIDctw2300024. [PMID: 38320517 DOI: 10.1056/evidctw2300024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Danish NUDGE Trial ConceptRandomized encouragement trials randomize to an opportunity to receive treatment instead of to the treatment. Here, Johansen and colleagues combine randomized encouragement trials with several advantages inherent in the Danish health system.
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Affiliation(s)
- Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
- Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital, Boston
| | - Ankeet S Bhatt
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
- Center for Cardiometabolic Implementation Science, Brigham and Women's Hospital, Boston
- Division of Research, Kaiser Permanente San Francisco Medical Center, San Francisco
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen
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Sumner J, Bundele A, Lim HW, Phan P, Motani M, Mukhopadhyay A. Developing an Artificial Intelligence-Driven Nudge Intervention to Improve Medication Adherence: A Human-Centred Design Approach. J Med Syst 2023; 48:3. [PMID: 38063940 PMCID: PMC10709244 DOI: 10.1007/s10916-023-02024-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023]
Abstract
To improve medication adherence, we co-developed a digital, artificial intelligence (AI)-driven nudge intervention with stakeholders (patients, providers, and technologists). We used a human-centred design approach to incorporate user needs in creating an AI-driven nudge tool. We report the findings of the first stage of a multi-phase project: understanding user needs and ideating solutions. We interviewed healthcare providers (n = 10) and patients (n = 10). Providers also rated example nudge interventions in a survey. Stakeholders felt the intervention could address existing deficits in medication adherence tracking and were optimistic about the solution. Participants identified flexibility of the intervention, including mode of delivery, intervention intensity, and the ability to stratify to user ability and needs, as critical success factors. Reminder nudges and provision of healthcare worker contact were rated highly by all. Conversely, patients perceived incentive-based nudges poorly. Finally, participants suggested that user burden could be minimised by leveraging existing software (rather than creating a new App) and simplifying or automating the data entry requirements where feasible. Stakeholder interviews generated in-depth data on the perspectives and requirements for the proposed solution. The participatory approach will enable us to incorporate user needs into the design and improve the utility of the intervention. Our findings show that an AI-driven nudge tool is an acceptable and appropriate solution, assuming it is flexible to user requirements.
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Affiliation(s)
- Jennifer Sumner
- Medical Affairs - Research Innovation & Enterprise, Alexandra Hospital, National University Health System, Singapore, Singapore.
| | - Anjali Bundele
- Medical Affairs - Research Innovation & Enterprise, Alexandra Hospital, National University Health System, Singapore, Singapore
| | - Hui Wen Lim
- Medical Affairs - Research Innovation & Enterprise, Alexandra Hospital, National University Health System, Singapore, Singapore
| | - Phillip Phan
- Johns Hopkins Carey Business School and the Department of Medicine, Baltimore, USA
| | - Mehul Motani
- Department of Electrical & Computer Engineering, National University of Singapore, Singapore, Singapore
| | - Amartya Mukhopadhyay
- Medical Affairs - Research Innovation & Enterprise, Alexandra Hospital, National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Kazemian A, Hoseinzadeh M, Banihashem Rad SA, Jouya A, Tahani B. Nudging oral habits; application of behavioral economics in oral health promotion: a critical review. Front Public Health 2023; 11:1243246. [PMID: 38145077 PMCID: PMC10739307 DOI: 10.3389/fpubh.2023.1243246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/24/2023] [Indexed: 12/26/2023] Open
Abstract
Background Oral health disorders significantly contribute to the global incidence of chronic diseases. Nudge interventions have demonstrated effectiveness in enhancing people's decision-making and self-management capacities in a cost-efficient manner. As a result, these interventions could be valuable tools for fostering improved oral care habits. This critical review explores potential behavioral nudges applicable to promoting oral health. Methods A thorough electronic literature search was conducted on Scopus, Embase, and PubMed databases for papers published post-2008. The search focused on empirical evidence concerning the direct and indirect application of Nudge theory in oral health enhancement. In addition, the investigation included the nudge intervention's role in managing common non-communicable disease risk factors (tobacco, alcohol, and sugar) and their use in other health sectors. Results and conclusion There is a dearth of studies on behavioral economics, particularly those involving reward and reminder techniques. However, various successful nudge interventions have been identified in other sectors that aim to improve health decisions. These include strategies encouraging healthier nutritional choices, tobacco and alcohol cessation, medication compliance, routine physical activity, and regular health check-ups. Such interventions can also have direct or indirect positive impacts on oral health. Implementing these interventions within an oral care framework could promote oral health due to similar underlying cognitive mechanisms. However, different types of nudge interventions have varying degrees of effectiveness. Furthermore, factors such as the method of delivery and the characteristics of the targeted population significantly influence the outcome of the intervention. Hence, it is imperative to conduct extensive studies in diverse socioeconomic settings to fully understand the potentials, limitations, and impacts of nudge interventions in promoting oral health.
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Affiliation(s)
- Ali Kazemian
- Department of Community Oral Health, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Melika Hoseinzadeh
- Dental Research Center, Mashhad Dental School, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Ahmad Banihashem Rad
- Department of Restorative, Preventive and Pediatric Dentistry, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Anahid Jouya
- Department of Community Oral Health, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bahareh Tahani
- Department of Oral Public Health, Dental Research Center, School of Dentistry, Dental Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Strobl H, Herrmann-Johns A, Loss J, Hable R, Tittlbach S. A Person-Centered Perspective on Physical Activity-Related Barriers Perceived by Male Fluctuators 50 Plus: A Cross-Sectional Study. Am J Mens Health 2023; 17:15579883231193915. [PMID: 37688411 PMCID: PMC10493066 DOI: 10.1177/15579883231193915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/02/2023] [Accepted: 07/06/2023] [Indexed: 09/10/2023] Open
Abstract
Men aged 50 or older (50 plus) represent a hard-to-reach target group for health-enhancing physical activity (PA) interventions. However, a considerable percentage of men 50 plus do not entirely fail to achieve the PA milestones set by the World Health Organization (WHO) guidelines. They show fluctuating PA behavior, influenced by various barriers hindering or preventing regular PA participation. As "one-size-fits-all" behavioral change interventions are only partially effective in specific subgroups, it is essential to tailor PA promotion measures to the particular needs of male fluctuators 50 plus. The standardized questionnaire included validated instruments measuring participants' current stage of behavioral change, their perceived barriers to PA, questions on selected psychosocial correlates of PA, and sociodemographic variables. Out of 1,013 participants, 133 men (13.1%) classified themselves as fluctuators. Using a person-centered approach, we formed groups with similar intra-individual relevant barrier profiles using hierarchical cluster analysis (Ward method) followed by k-means clustering. We identified four clusters. Cluster 1 (n = 31) involves men predominantly perceiving physical constraints. Cluster 2 (n = 33) represents men lacking self-motivation and struggling with their weaker selves. Men in Cluster 3 (n = 51) primarily indicate professional and private obligations that prevent them from being physically active. Finally, men in Cluster 4 (n = 18) miss appropriate sports courses that meet their individual needs. Our findings support identifying individually tailored strategies designed to promote regular PA in male fluctuators 50 plus. Further research is required to determine the effectiveness of this approach in improving adherence to PA guidelines and corresponding health-enhancing effects for men 50 plus.
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Affiliation(s)
- Helmut Strobl
- Bayreuth Center of Sport Science, University of Bayreuth, Bayreuth, Germany
| | | | | | - Robert Hable
- Deggendorf Institute of Technology, Deggendorf, Germany
| | - Susanne Tittlbach
- Bayreuth Center of Sport Science, University of Bayreuth, Bayreuth, Germany
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Vandelanotte C, Trost S, Hodgetts D, Imam T, Rashid M, To QG, Maher C. Increasing physical activity using an just-in-time adaptive digital assistant supported by machine learning: A novel approach for hyper-personalised mHealth interventions. J Biomed Inform 2023; 144:104435. [PMID: 37394024 DOI: 10.1016/j.jbi.2023.104435] [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: 01/19/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVE Physical inactivity is a leading modifiable cause of death and disease worldwide. Population-based interventions to increase physical activity are needed. Existing automated expert systems (e.g., computer-tailored interventions) have significant limitations that result in low long-term effectiveness. Therefore, innovative approaches are needed. This special communication aims to describe and discuss a novel mHealth intervention approach that proactively offers participants with hyper-personalised intervention content adjusted in real-time. METHODS Using machine learning approaches, we propose a novel physical activity intervention approach that can learn and adapt in real-time to achieve high levels of personalisation and user engagement, underpinned by a likeable digital assistant. It will consist of three major components: (1) conversations: to increase user's knowledge on a wide range of activity-related topics underpinned by Natural Language Processing; (2) nudge engine: to provide users with hyper-personalised cues to action underpinned by reinforcement learning (i.e., contextual bandit) and integrating real-time data from activity tracking, GPS, GIS, weather, and user provided data; (3) Q&A: to facilitate users asking any physical activity related questions underpinned by generative AI (e.g., ChatGPT, Bard) for content generation. RESULTS The detailed concept of the proposed physical activity intervention platform demonstrates the practical application of a just-in-time adaptive intervention applying various machine learning techniques to deliver a hyper-personalised physical activity intervention in an engaging way. Compared to traditional interventions, the novel platform is expected to show potential for increased user engagement and long-term effectiveness due to: (1) using new variables to personalise content (e.g., GPS, weather), (2) providing behavioural support at the right time in real-time, (3) implementing an engaging digital assistant and (4) improving the relevance of content through applying machine learning algorithms. CONCLUSION The use of machine learning is on the rise in every aspect of today's society, however few attempts have been undertaken to harness its potential to achieve health behaviour change. By sharing our intervention concept, we contribute to the ongoing dialogue on creating effective methods for promoting health and well-being in the informatics research community. Future research should focus on refining these techniques and evaluating their effectiveness in controlled and real-world circumstances.
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Affiliation(s)
- Corneel Vandelanotte
- Appleton Institute, Central Queensland University, Bruce Highway, Rockhampton, Queensland 4702, Australia.
| | - Stewart Trost
- School of Human Movement and Nutrition Science, The University of Queensland, St Lucia, Queensland 4072, Australia.
| | - Danya Hodgetts
- Appleton Institute, Central Queensland University, Bruce Highway, Rockhampton, Queensland 4702, Australia.
| | - Tasadduq Imam
- School of Business and Law, Central Queensland University, 120 Spencer Street, Melbourne, Victoria 3000, Australia.
| | - Mamunur Rashid
- School of Engineering and Technology, Central Queensland University, 120 Spencer Street, Melbourne, Victoria 3000, Australia.
| | - Quyen G To
- Appleton Institute, Central Queensland University, Bruce Highway, Rockhampton, Queensland 4702, Australia.
| | - Carol Maher
- Allied Health and Human Performance, University of South Australia, City East Campus, Adelaide, South Australia 5001, Australia.
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15
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Appleton KM, Adams C. A role for enjoyment for encouraging fruit consumption. Appetite 2023; 187:106609. [PMID: 37247726 DOI: 10.1016/j.appet.2023.106609] [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: 11/27/2022] [Revised: 03/21/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
This work investigated the value of highlighting the enjoyment conferred by fruit for encouraging fruit consumption. Study 1 investigated the effects on fruit consumption of visualizing eating fruit that was either enjoyable, not enjoyable, or was unassociated with enjoyment. Study 2 investigated the effects on fruit consumption of health promotion posters that featured either enjoyable or less enjoyable fruit. Both studies used an independent-groups design, where young adults (Study 1, N = 142; Study 2, N = 221) were randomized to conditions, and outcomes: intentions to consume fruit, attitudes towards fruit, immediate fruit selection, subsequent fruit consumption; and a range of characteristics likely to be associated with fruit and vegetable consumption were assessed. In Study 1, higher intentions to consume fruit and more positive attitudes towards fruit were associated with higher likely enjoyment of the fruit visualized, higher fruit liking in general and higher fruit-related self-efficacy (smallest Beta = 0.270, p = 0.02). In Study 2, similar effects were found for likely enjoyment of the fruit featured on a poster; higher likely enjoyment also predicted greater immediate fruit selection (smallest Beta = 0.122, p = 0.03). These outcomes were also associated with variables often associated with fruit and vegetable consumption. Subsequent fruit consumption was only associated with past fruit consumption (smallest Beta = 0.340, p = 0.05). These two studies (Study 1 using visualisation, Study 2 using health promotion posters) highlight a role for enjoyment for encouraging fruit consumption. The value of enjoyment and the simplicity of the poster intervention particularly should be noted.
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Affiliation(s)
- Katherine M Appleton
- Department of Psychology, Bournemouth University, UK; School of Psychology, Queen's University, Belfast, UK.
| | - Catherine Adams
- School of Psychology, Queen's University, Belfast, UK; NICTU, Belfast, UK
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16
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Liaset IF, Fimland MS, Holtermann A, Mathiassen SE, Redzovic S. Can home care work be organized to promote health among the workers while maintaining productivity? An investigation into stakeholders' perspectives on organizational work redesign concepts based on the Goldilocks Work principles. BMC Health Serv Res 2023; 23:667. [PMID: 37340464 DOI: 10.1186/s12913-023-09691-2] [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: 02/08/2023] [Accepted: 06/13/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Due to the aging population, the need for home care services is increasing in most Western countries, including Norway. However, the highly physical nature of this job could contribute to make recruiting and retaining qualified home care workers (HCWs) challenging. This issue may be overcome by adopting the Goldilocks Work principles, aiming at promoting workers' physical health by determining a "just right" balance between work demands and recovery periods while maintaining productivity. The aim of this study was to 1) gather suggestions from home care employees on suitable organizational (re)design concepts for promoting HCWs' physical health and 2) have researchers and managers define actionable behavioral aims for the HCWs for each proposed (re)design concept and evaluate them in the context of the Goldilocks Work principles. METHODS HCWs, safety representatives, and operation coordinators (n = 14) from three Norwegian home care units participated in digital workshops led by a researcher. They suggested, ranked, and discussed redesign concepts aimed at promoting HCWs' health. The redesign concepts were subsequently operationalized and evaluated by three researchers and three home care managers. RESULTS Workshop participants suggested five redesign concepts, namely "operation coordinators should distribute work lists with different occupational physical activity demands more evenly between HCWs", "operation coordinators should distribute transportation modes more evenly between HCWs", "Managers should facilitate correct use of ergonomic aids and techniques", "HCWs should use the stairs instead of the elevator", and "HCWs should participate in home-based exercise training with clients". Only the first two redesign concepts were considered to be aligned with the Goldilocks Work principles. A corresponding behavioral aim for a "just right" workload was defined: reduce inter-individual differences in occupational physical activity throughout a work week. CONCLUSIONS Operation coordinators could have a key role in health-promoting organizational work redesign based on the Goldilocks Work principles in home care. By reducing the inter-individual differences in occupational physical activity throughout a work week, HCWs' health may be improved, thus reducing absenteeism and increasing the sustainability of home care services. The two suggested redesign concepts should be considered areas for evaluation and adoption in practice by researchers and home care services in similar settings.
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Affiliation(s)
- Ingeborg Frostad Liaset
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway.
| | - Marius Steiro Fimland
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- Unicare Helsefort Rehabilitation Centre, Rissa, Norway
| | - Andreas Holtermann
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Svend Erik Mathiassen
- Department of Occupational Health Science and Psychology, Centre for Musculoskeletal Research, University of Gävle, Gävle, Sweden
| | - Skender Redzovic
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU Norwegian University of Science and Technology, Trondheim, Norway
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Zeuge A, Lemmer K, Klesel M, Kordyaka B, Jahn K, Niehaves B. To be or not to be stressed: Designing autonomy to reduce stress at work. Work 2023; 75:1199-1213. [PMID: 36744355 PMCID: PMC10473107 DOI: 10.3233/wor-220177] [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: 03/25/2022] [Accepted: 09/23/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Many organizations are undertaking efforts to reduce the stress of (oftentimes overworked) employees. Information Technology (IT) (e.g., smartphones) has the potential to be a key instrument for reducing stress. One design-relevant factor considered to reduce stress is the concept of autonomy. Unfortunately, little research exists using autonomy as a characteristic of technology design. OBJECTIVE Against this background, this study aimed to investigate specific autonomy-related design options with the potential to prevent stress. METHODS In a factorial survey, this experimental study tested three design options in an overwork scenario: 1) autonomy (no intervention by design), 2) nudge ("nudging" by design), and 3) enforcement (hard stop by design). 51 participants (mean age 38 years, 50% women, mean work experience 18 years) from the Netherlands, United Kingdom, United States of America, and Germany participated in the experiment for 330 seconds on average. To test our hypothesis, we used a two-step approach. First, a multiple linear regression was applied. Second, we carried out a one-way ANCOVA comparing the effects of our design options. RESULTS Our results indicate that autonomy can be manipulated through technology design and is negatively correlated with stress. Additionally, the design options autonomy and nudge were associated with lower levels of perceived stress than was enforcement. CONCLUSION The study proposes a careful use of IT and policies that limit the perceived autonomy of employees. Overall, this study offers a set of design recommendations arguing that organizations should implement technology that helps employees prevent overwork and maintain their autonomy.
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Wolf A, Sant'Anna A, Vilhelmsson A. Using nudges to promote clinical decision making of healthcare professionals: A scoping review. Prev Med 2022; 164:107320. [PMID: 36283484 DOI: 10.1016/j.ypmed.2022.107320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/25/2022] [Accepted: 10/18/2022] [Indexed: 10/31/2022]
Abstract
Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.
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Affiliation(s)
- Axel Wolf
- University of Gothenburg, Centre for Person-Centred Care (GPCC), Sweden; University of Gothenburg, Institute of Health and Care Sciences, Sahlgrenska Academy, Sweden
| | | | - Andreas Vilhelmsson
- Lund University, Department of Laboratory Medicine, Division of Occupational and Environmental Medicine, Sweden.
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19
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Measuring “Nudgeability”: Development of a Scale on Susceptibility to Physical Activity Nudges among College Students. Behav Sci (Basel) 2022; 12:bs12090318. [PMID: 36135122 PMCID: PMC9495621 DOI: 10.3390/bs12090318] [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] [Received: 06/30/2022] [Revised: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 12/03/2022] Open
Abstract
Background: The current college lifestyle create more opportunities for students to develop unhealthy behaviors, especially physical inactivity. Nudging could be an effective tool to improve physical activity behaviors by changing college settings. One-nudge-fits-all leads to ineffective nudges, so it is necessary to develop a reliable and valid instrument capable of measuring the “nudgeability” of physical activity nudges for college students, which is for a higher level of nudge efficacy. Method: Developing the College Physical Activity Nudges Susceptibility Scale (CPANSS) that integrated the nudge method with the Likert scale, which is the first attempt to measure the susceptibility to nudges directly by a scale. There are four steps for developing CPANSS, including Scale Dimensions, Item Generation, Exploratory Factor Analysis (n = 294), and Confirmatory Factor Analysis (n = 293) with appropriate procedures. Results: The five-factor 21-item CPANSS with good reliability and validity fitted the data reasonably well. Conclusion: The CPANSS was to provide a new tool for policymakers to design effective nudges in changing and promoting physical activity in college settings, and to provide a method for scholars to promote other healthy behaviors for different target groups.
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20
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Rondina R, van Mierlo T, Fournier R. Testing Behavioral Nudges and Prompts in Digital Courses for the Self-guided Treatment of Depression and Anxiety: Protocol for a 3-Arm Randomized Controlled Trial. JMIR Res Protoc 2022; 11:e37231. [PMID: 35969446 PMCID: PMC9425166 DOI: 10.2196/37231] [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: 02/11/2022] [Revised: 05/26/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite showing strong evidence of positive outcomes, a common problem in the field of digital health is poor engagement and adherence. Non-health care, for-profit digital ventures, such as Facebook, LinkedIn, and Twitter, conduct behavioral experiments to increase user engagement. To our knowledge, digital health organizations have not published similar types of experiments in ad libitum environments, and there are limited published data indicating whether nudges and prompts can be leveraged to increase engagement with digital health interventions. OBJECTIVE The main objective of our 3-arm randomized controlled trial is to test whether registered members in two well-established digital health courses for anxiety and depression will engage with four different types of nudges and prompts, and whether engaging with nudges and prompts increases engagement within the courses. METHODS New members who register for the self-guided anxiety and depression courses on the Evolution Health platform will be randomized into 1 of 3 arms. The first control arm will feature a member home page without any behavioral nudges or prompts. The second arm will feature a member home page with a Tip-of-the-Day section containing directive content. Arm 3 will feature a member home page with a Tip-of-the-Day section containing social proof and present bias content. The third arm will also feature a to-do item checklist. RESULTS The experiment was designed in August 2021 and was launched in November 2021. Initially, we will measure engagement with the tips and the to-do checklist by calculating the frequency of use by age and gender. If members do engage, we will then, according to age and gender, examine whether nudges and prompts result in higher course completion rates and whether specific types of prompts and nudges are more popular than others. CONCLUSIONS Our 3-arm randomized controlled trial will be the first to compare four distinct types of behavioral prompts and nudges in two self-guided digital health courses that were designed to treat mental health issues. We expect the results to generate insights into which types of behavioral prompts and nudges work best in the population. If they are shown to increase engagement, the insights will then be used to apply prompts and nudges to the platform's addiction-focused courses. Based on the results of the experiment, the insights will be applied to using artificial intelligence to train the platform to recognize different usage patterns and provide specific engagement recommendations to stratified users. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/37231.
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Affiliation(s)
- Renante Rondina
- Rotman School of Mangement, University of Toronto, Toronto, ON, Canada
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21
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Stawarz K, Liang IJ, Alexander L, Carlin A, Wijekoon A, Western M. Exploring the potential of technology to promote “exercise snacking” for pre-frail older adults in the home setting: User-Centered Design Study (Preprint). JMIR Aging 2022; 6:e41810. [DOI: 10.2196/41810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/01/2023] [Accepted: 02/26/2023] [Indexed: 02/27/2023] Open
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22
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Marsh ATM, Jahja NA, Gleed F, Peacock O, Coley D, Codinhoto R. Developing non-exercise activity thermogenesis (NEAT) through building design. FACILITIES 2022. [DOI: 10.1108/f-01-2022-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Physical inactivity has a considerable negative impact on health. Physical activity has reduced partly due to workplace and lifestyle changes, causing people to spend more time in buildings and increasing sedentary behaviour. The purpose of this paper is to address a largely untapped opportunity for designers and managers to improve building users’ health by designing buildings that raise users’ Non-Exercise Activity Thermogenesis (NEAT) levels. In this research a conceptual model was developed to assess buildings’ performance in providing NEAT-promoting opportunities through building design features and management, in relation to building users’ propensity for NEAT behaviours.
Design/methodology/approach
The conceptual model was developed by a multi-disciplinary team of researchers and data to populate the model was obtained through a survey of 75 buildings in Jakarta (Indonesia).
Findings
The presented proof-of-concept shows that the model’s “meso-scale” approach to study physical activity and building design can lead to potential improvements of NEAT levels and physical activity in buildings.
Originality/value
The review of precedent models shows that this subject has been researched at micro-scale (i.e. detailed monitoring of individuals’ movement) and macro-scale (i.e. epidemiological studies of populations’ health). The presented model is original, as it explores a “meso-scale”(i.e. building scale) that is unique.
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23
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Tentori K, Pighin S, Giovanazzi G, Grignolio A, Timberlake B, Ferro A. Nudging COVID-19 Vaccine Uptake by Changing the Default: A Randomized Controlled Trial. Med Decis Making 2022; 42:837-841. [PMID: 35658775 DOI: 10.1177/0272989x221101536] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although vaccination against SARS-CoV-2 is considered the central strategy against the pandemic, uptake lags behind target rates. METHOD To explore whether this rate could be enhanced by a nudging strategy that exploits the status quo bias, we conducted a randomized controlled trial in northern Italy comparing vaccination acceptance among 2000 adults, ages 50 to 59 years, who were either invited to set an appointment (opt-in group) or assigned an individual appointment (opt-out group). RESULTS Results indicate a difference of 3.2 percentage points, which represents a 32% relative increase in the vaccination rate for the opt-out group compared with the opt-in group. CONCLUSIONS A significant portion of those who remain unvaccinated may not hold strong beliefs against vaccination but rather tend to inaction and may therefore be nudged toward vaccination with a reduction of action required. HIGHLIGHTS Reluctant adults (50-59 years), who had not yet received vaccines against COVID-19, were sent letters announcing appointment availabilityIn an RCT, the status quo option in the notices influenced the rate of vaccine acceptanceNudging via pre-scheduled appointments encouraged vaccine uptake more than invitations to schedule didSwitching the default option yielded a 32% relative increase (13.1% vs. 9.9%) in vaccination.
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Affiliation(s)
- Katya Tentori
- Center for Mind/Brain Sciences (CIMeC), University of Trento, Rovereto, Italy.,Centre for Medical Sciences (CISMed), University of Trento, Trento, Italy
| | - Stefania Pighin
- Center for Mind/Brain Sciences (CIMeC), University of Trento, Rovereto, Italy
| | - Giulia Giovanazzi
- Provincial Authority for Health Services (APSS), Autonomous Province of Trento, Italy
| | - Andrea Grignolio
- International MD Program, Vita-Salute San Raffaele University, Milan, Italy.,Interdepartmental Center for Research Ethics and Integrity, National Research Council (CNR)
| | - Benjamin Timberlake
- Center for Mind/Brain Sciences (CIMeC), University of Trento, Rovereto, Italy
| | - Antonio Ferro
- Provincial Authority for Health Services (APSS), Autonomous Province of Trento, Italy
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Yi S, Kanetkar V, Brauer P. Customer support for nudge strategies to promote fruit and vegetable intake in a university food service. BMC Public Health 2022; 22:706. [PMID: 35399080 PMCID: PMC8994925 DOI: 10.1186/s12889-022-13054-7] [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] [Received: 06/21/2021] [Accepted: 03/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background Diverse nudges, also known as choice architectural techniques, have been found to increase fruit and vegetable (FV) selection in both lab and field studies. Such strategies are unlikely to be adopted in mass eating settings without clear evidence of customer support; confirmation in specific contexts is needed. Inspired by the Taxonomy of Choice Architecture, we assessed support for eight types of nudging to increase the choice of FV-rich foods in a university food service. We also explored whether and to what extent nudge support was associated with perceived effectiveness and intrusiveness. Methods An online survey was conducted with students who used on-campus cafeterias. Multiple recruitment methods were used. Participants were given 20 specific scenarios for increasing FV selection and asked about their personal support for each nudge, as well as perceived intrusiveness and effectiveness. General beliefs about healthy eating and nudging were also measured. Results were assessed by repeated measures ANOVA for the 8 nudge types. Results All nudge scenarios achieved overall favourable ratings, with significant differences among different types of nudging by the 298 respondents. Changing range of options (type B3) and changing option-related consequences (type B4) received the highest support, followed by changing option-related effort (type B2) and making information visible (type A2). Translating information (type A1), changing defaults (type B1) and providing reminders or facilitating commitment (type C) were less popular types of nudging. Providing social reference points (type A3) was least supported. Support for nudge types was positively associated with the belief that food services have a role in promoting healthy eating, perceived importance of FV intake, trustworthiness of the choice architect and female gender. Lastly, support for all types of nudges was positively predicted by perceived effectiveness of each nudge and negatively predicted by perceived intrusiveness above and beyond the contribution of general beliefs about healthy eating and nudging. Conclusions Findings from the current study indicate significant differences in support for nudge techniques intended to increase FV selection among university cafeteria users. These findings offer practical implications for food service operators as well as public health researchers. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13054-7.
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Forberger S, Wichmann F, Comito CN. Nudges used to promote physical activity and to reduce sedentary behaviour in the workplace: Results of a scoping review. Prev Med 2022; 155:106922. [PMID: 34933021 DOI: 10.1016/j.ypmed.2021.106922] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 12/01/2021] [Accepted: 12/13/2021] [Indexed: 12/17/2022]
Abstract
Physical inactivity is one of the most important risk factors for non-communicable diseases. Workplace health promotion is therefore of growing interest to support an active day using nudges. The scoping review aims to (a) analyse how frequently nudges are applied in workplace health promotion to increase physical activity and/or reduce sedentary behaviour, and (b) characterise the nudges used. A systematic database search was conducted for the period 2009 to June 2020. According to predefined inclusion and exclusion criteria, studies promoting physical activity and/or reducing sedentary behaviour using nudges were included. Nudges were classified according to MINDSPACE and TIPPME. A study protocol was previously published. Of the 256 studies identified, 26 used nudges. Most studies were conducted in Europe (n = 12) and the USA (n = 8). N = 18 studies targeted physical activity and n = 8 studies targeted sedentary behaviour. In most studies promoting physical activity, prompts were given to climb stairs (n = 11). Interventions targeting sedentary behaviour were more diverse, using digital interventions or mixed approaches (n = 8). Although nudges can help increase physical activity and reduce sedentary behaviour, there are still gaps in terms of their effective and efficient use. There is a lack of long-term studies that analyse habituation and behavioural changes beyond the intervention period. In addition, the potential of digital and mixed approaches is not yet fully exploited. Further studies from low- and middle-income countries with different climates and working conditions are needed to investigate the feasibility of approaches and advance the fight against physical inactivity.
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Affiliation(s)
- Sarah Forberger
- Department Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.
| | - Frauke Wichmann
- Department Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany.
| | - Chiara Nicoletta Comito
- Department Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
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KAMADA MASAMITSU, HAYASHI HANA, SHIBA KOICHIRO, TAGURI MASATAKA, KONDO NAOKI, LEE IMIN, KAWACHI ICHIRO. Large-Scale Fandom-based Gamification Intervention to Increase Physical Activity: A Quasi-experimental Study. Med Sci Sports Exerc 2022; 54:181-188. [PMID: 34366420 PMCID: PMC8677610 DOI: 10.1249/mss.0000000000002770] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Gamification, the use of game design elements in nongame contexts, in combination with insights from behavioral economics, has been applied increasingly to behavior change interventions. However, little is known about the effectiveness or scalability of this approach, especially in the long term. We tested a large-scale smartphone-based intervention to encourage physical activity among Japanese baseball fans using gamification techniques that leveraged fandom and interteam competition inherent in sports. METHODS A quasi-experimental study was conducted among fans of the Japanese Pacific League. The app, Pa-League Walk, included gamification elements, such as competition between opposing teams' fans based on total daily step counts on game days (>60,000 free downloads since March 2016). We analyzed daily steps of 20,052 app users, supplemented by online survey data of 274 users and 613 matched controls. Difference-in-differences estimators evaluated change in daily steps before and after app installation in users versus matched controls. RESULTS Users' daily steps increased by 574 (95% confidence interval, 83-1064) steps 3 months after installation, compared with controls. The increase was maintained for up to 9 months (559 (99-1018) more steps per day vs baseline), attenuating over a longer follow-up. Positive effect modification was found by high-frequency of the app use (P < 0.001) but not by other covariables (P ≥ 0.14) such as education or income. Days with 10,000-step achievement increased from 24.4% to 27.5% after the additional introduction of incentives (digital player photographs; P < 0.001). CONCLUSIONS Using existing fandom and solidarity, the gamification app increased physical activity at scale among baseball fans, including people with lower socioeconomic status underrepresented in traditional health programs.
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Affiliation(s)
- MASAMITSU KAMADA
- Department of Health Education and Health Sociology, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, JAPAN
| | - HANA HAYASHI
- Department of Health Education and Health Sociology, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, JAPAN
- Down to Earth, Inc., Katori City, Chiba, JAPAN
| | - KOICHIRO SHIBA
- Department of Health Education and Health Sociology, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, JAPAN
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - MASATAKA TAGURI
- Department of Data Science, Yokohama City University School of Data Science, Yokohama City, Kanagawa, JAPAN
| | - NAOKI KONDO
- Department of Social Epidemiology and Global Health, Graduate School of Medicine and School of Public Health, Kyoto University, Kyoto City, Kyoto, JAPAN
| | - I-MIN LEE
- Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - ICHIRO KAWACHI
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
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Vilhelmsson A, Sant'Anna A, Wolf A. Nudging healthcare professionals to improve treatment of COVID-19: a narrative review. BMJ Open Qual 2021; 10:e001522. [PMID: 34887299 PMCID: PMC8662583 DOI: 10.1136/bmjoq-2021-001522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 11/25/2021] [Indexed: 01/08/2023] Open
Affiliation(s)
- Andreas Vilhelmsson
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
- Occupational and Environmental Medicine, Lund University Faculty of Medicine, Lund, Sweden
| | | | - Axel Wolf
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Vande Velde F, Overgaard HJ, Bastien S. Nudge strategies for behavior-based prevention and control of neglected tropical diseases: A scoping review and ethical assessment. PLoS Negl Trop Dis 2021; 15:e0009239. [PMID: 34723983 PMCID: PMC8584752 DOI: 10.1371/journal.pntd.0009239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 11/11/2021] [Accepted: 10/13/2021] [Indexed: 12/19/2022] Open
Abstract
Background Nudging, a strategy that uses subtle stimuli to direct people’s behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The present scoping review aims to provide a timely overview of how nudge interventions have been applied within this field. In addition, the review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion. Methods A comprehensive search was performed in several databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC and Econ.Lit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Additionally, studies were included through a handpicked search on websites of governmental nudge units and global health or development organizations. Results This scoping review identified 33 relevant studies, with only two studies targeting NTDs in particular, resulting in a total of 67 nudge strategies. Most nudges targeted handwashing behavior and were focused on general health practices rather than targeting a specific disease. The most common nudge strategies were those targeting decision assistance, such as facilitating commitment and reminder actions. The majority of nudges were of moderate to high ethical standards, with the highest standards being those that had the most immediate and significant health benefits, and those implemented by agents in a trust relationship with the target audience. Conclusion Three key recommendations should inform research investigating nudge strategies in global health promotion in general. Firstly, future efforts should investigate the different opportunities that nudges present for targeting NTDs in particular, rather than relying solely on integrated health promotion approaches. Secondly, to apply robust study designs including rigorous process and impact evaluation which allow for a better understanding of ‘what works’ and ‘how it works’. Finally, to consider the ethical implications of implementing nudge strategies, specifically in LMIC. Behavior is at the core of neglected tropical disease (NTD) prevention and control, certainly within low-, and middle- income countries (LMIC) where resources are often limited. Therefore, strategies to promote behavior change should be included and investigated in future efforts. Nudging, a low-cost strategy that subtly directs people towards positive behavioral choices, has recently gained attention in global health promotion. Nudge strategies have been applied to a wide range of health-promoting behaviors such as handwashing. To understand which strategies were used, where and how these were applied, and whether these were ethically informed and implemented, we undertook a comprehensive review of the available sources. This resulted in 33 included studies, with a total of 67 nudge strategies for behavior-based prevention and control of NTDs in LMIC. Only two studies targeted NTDs in particular, the other 31 included studies were focused on more general health promoting behaviors, with the majority targeting handwashing with soap. The most common nudge strategies were those targeting decision assistance, such as fostering commitment and reminder actions. In general, the ethical assessment presented favorable results. We identified the need for robust study designs to better understand how nudges can be implemented in the future.
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Affiliation(s)
- Fiona Vande Velde
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, Ås, Norway
- * E-mail:
| | - Hans J. Overgaard
- Faculty of Science and Technology, Norwegian University of Life Sciences, Ås, Norway
- Department of Microbiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sheri Bastien
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, Ås, Norway
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- The Centre for Evidence-Based Public Health: A JBI Affiliated Group, Department of Public Health Science, NMBU, Ås, Norway
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Nudge theory in anesthesiology clinical practice. Int Anesthesiol Clin 2021; 59:22-26. [PMID: 34387251 DOI: 10.1097/aia.0000000000000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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A model of integrated remote monitoring and behaviour change for osteoarthritis. BMC Musculoskelet Disord 2021; 22:669. [PMID: 34372822 PMCID: PMC8350550 DOI: 10.1186/s12891-021-04555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background The National Institute for Health and Care Excellence recommends the use of digital and mobile health technologies to facilitate behaviour change interventions. Due to its high prevalence and dependence upon patient self-management strategies, osteoarthritis is one musculoskeletal condition which may benefit from such approaches. This is particularly pertinent due to the increasing use of remote monitoring technologies to collect patient data and facilitate self-management in individuals outside of hospital clinics. In practice however, application of digital behaviour change interventions is difficult due to insufficient reporting of behaviour change theories in the current literature. When digital technologies are employed to alter behaviour change in osteoarthritis, they often focus on physical activity. Currently, such interventions focus of self-efficacy but do not often explicitly report the behaviour change techniques they use to facilitate these changes. Methods This paper proposes a new model of integrating specific behaviour change principles (persuasive design) in an integrated model of remote monitoring and digital behaviour change interventions for osteoarthritis. Results There is potential to combine remote monitoring systems of patient data through digital and mobile technologies with behaviour change principles to improve physical activity behaviours in individuals with osteoarthritis. The use of persuasive design principles (e.g. prompts or nudges) through mobile notifications and strategic system design can be directed to enhance behaviour change. A validated measure of behaviour change, such as the patient activation measure, will allow effective evaluation of such systems. Conclusions Digital behaviour change interventions should be directed towards the underlying principles of behaviour change they employ, although this is not commonly reported in practice. Such interventions can be integrated within remote monitoring pathways using persuasive design techniques to enhance patient activation. This approach can enhance self-management in individuals with musculoskeletal conditions, such as osteoarthritis.
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Wrist actigraphic approach in primary, secondary and tertiary care based on the principles of predictive, preventive and personalised (3P) medicine. EPMA J 2021; 12:349-363. [PMID: 34377218 PMCID: PMC8342270 DOI: 10.1007/s13167-021-00250-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
Abstract Sleep quality and duration as well as activity-rest-cycles at individual level are crucial for maintaining physical and mental health. Although several methods do exist to monitor these parameters, optimal approaches are still under consideration and technological development. Wrist actigraphy is a non-invasive electro-physical method validated in the field of chronobiology to record movements and to allow for monitoring human activity-rest-cycles. Based on the continuous recording of motor activity and light exposure, actigraphy provides valuable information about the quality and quantity of the sleep–wake rhythm and about the amount of motor activity at day and night that is highly relevant for predicting a potential disease and its targeted prevention as well as personalisation of medical services provided to individuals in suboptimal health conditions and patients. Being generally used in the field of sleep medicine, actigraphy demonstrates a great potential to be successfully implemented in primary, secondary and tertiary care, psychiatry, oncology, and intensive care, military and sports medicines as well as epidemiological monitoring of behavioural habits as well as well-being medical support, amongst others. Prediction of disease development and individual outcomes Activity-rest-cycles have been demonstrated to be an important predictor for many diseases including but not restricted to the development of metabolic, psychiatric and malignant pathologies. Moreover, activity-rest-cycles directly impact individual outcomes in corresponding patient cohorts. Targeted prevention Data acquired by actigraphy are instrumental for the evidence-based targeted prevention by analysing individualised patient profiles including light exposure, sleep duration and quality, activity-rest-cycles, intensity and structure of motion pattern. Personalised therapy Wrist actigraphic approach is increasingly used in clinical care. Personalised measurements of sedation/agitation rhythms are useful for ICU patients, for evaluation of motor fatigue in oncologic patients, for an individual enhancement of performance in military and sport medicine. In the framework of personalised therapy intervention, patients can be encouraged to optimise their behavioural habits improving recovery and activity patterns. This opens excellent perspectives for the sleep-inducing medication and stimulants replacement as well as for increasing the role of participatory medicine by visualising and encouraging optimal behavioural patterns of the individual.
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Schüz B, Meyerhof H, Hilz LK, Mata J. Equity Effects of Dietary Nudging Field Experiments: Systematic Review. Front Public Health 2021; 9:668998. [PMID: 34368049 PMCID: PMC8342848 DOI: 10.3389/fpubh.2021.668998] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Dietary behaviours are among the key modifiable risk factors for non-communicable diseases. Importantly, dietary behaviours vary substantially between groups and individuals with different socioeconomic positions, with more disadvantaged groups and individuals being exposed to more dietary risk factors. The goal of this review is to summarise the existing research on equity effects of dietary nudging interventions. Methods: Systematic review of nudging interventions conducted in a field setting that report an observable indicator of dietary behaviour, include a control group, and report effect sizes stratified by indicators of socioeconomic status as outlined in the PROGRESS-Plus framework. Two databases (scopus, Pubmed) were searched (last search June 2021), and 18 articles with 19 studies (k = 46 equity comparisons) were included. Risk of bias was assessed using the ROBINS-I tool. Due to heterogeneity in equity dimensions and study outcomes, a harvest plot was used to summarise data. Results: The majority of equity comparisons (38 out of 46) were available for cognitive nudges. Most of these (22 out of 38 comparisons) found that cognitive nudges worked equally well in more and less disadvantaged populations; however, in 12 out of the 38 comparisons, they favoured those who were less disadvantaged. Two out of four comparisons on behavioural nudges favoured more disadvantaged persons. Conclusions: The differential effects of dietary nudging interventions in this review can contribute to increases in health inequalities. At the same time, a substantial number of interventions showed no equity effects. Importantly, this review suggests that more research on nudging interventions and health equity is needed. Future interventions should report effect sizes stratified by indicators of social inequality. Systematic Review Registration: PROSPERO (CRD42019137469).
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Affiliation(s)
- Benjamin Schüz
- Faculty 11, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
| | - Hannah Meyerhof
- Faculty 11, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
| | - Lisa Karla Hilz
- Faculty 11, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
| | - Jutta Mata
- Department of Psychology, University of Mannheim, Mannheim, Germany
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Testing the Youth Physical Activity Promotion Model during the COVID-19 Pandemic, with Partial Least Squares Second-Order Latent Constructs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126398. [PMID: 34199185 PMCID: PMC8296221 DOI: 10.3390/ijerph18126398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022]
Abstract
We tested the Youth Physical Activity Promotion (YPAP) framework on Romanian students in order to identify actionable determinants to support participation in physical activity. Our sample consisted of 665 responses to an online survey, with participants aged 18-23 (mean = 19 years); 70% were women. We used the partial least squares algorithm to estimate the relationships between students' behavior and possible predictors during the COVID-19 pandemic. Our results indicate that all the theoretical dimensions of YPAP (predisposing, enabling and reinforcing) have a positive and significant impact on physical activity, with two mediating mechanisms expressed as predisposing factors: able and worth. Unlike previous research, we used second-order latent constructs, unveiling a particular structure for the enabling dimension that only includes sport competence, fitness and skills, but not the environmental factors.
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Mourits K, van der Velden K, Molleman G. The perceptions and priorities of professionals in health and social welfare and city planning for creating a healthy living environment: a concept mapping study. BMC Public Health 2021; 21:1085. [PMID: 34090403 PMCID: PMC8180117 DOI: 10.1186/s12889-021-11151-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 05/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is helpful for collaboration if professionals from the field of health and social welfare and the field of city planning are aware of each other's concepts of what a healthy living environment entails and what its components are. This study examined perceptions about creating a healthy living environment of professionals from these two fields, as well as the differences between them. METHODS We recruited 95 professionals from Nijmegen, the Netherlands who worked in the fields of health, social welfare and city planning in governmental and non-governmental capacities. We used the concept mapping method to collect and analyse their thoughts on healthy living environments. Participants first submitted statements on this subject in a brainstorming session, using an online mapping tool. Then they sorted these statements and rated them on priorities and opportunities within urban planning processes. RESULTS During the brainstorm, 43 professionals generated 136 statements. After the elimination of duplicates, 92 statements were individually sorted by 32 professionals. Concept mapping software was used to create an overall map, in which the statements were sorted into ten clusters. Each of these clusters represented one of the main features of a healthy living environments. After 36 participants rated these statements, it emerged that professionals from both fields agreed on priorities and opportunities for the clusters 'Spatial quality' and 'Conducive to exercise'. Professionals also agreed on which three clusters had the fewest priorities and possibilities ('Promotes personal wellbeing', 'Encourages healthy choices', 'Conducive to social connections'). CONCLUSION We found that professionals in health and social welfare and city planning have similar views concerning the most and least important features of a healthy living environment in urban planning process. This could indicate that the differences between the two fields may be more nuanced and specific than previously thought. This knowledge offers perspectives for professionals to strengthen their collaboration and to come to a joint result in urban planning projects.
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Affiliation(s)
- Kristine Mourits
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Koos van der Velden
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Gerard Molleman
- Department of Primary and Community Care, Radboud University Medical Center, Radboud Institute for Health Sciences, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Sant'Anna A, Vilhelmsson A, Wolf A. Nudging healthcare professionals in clinical settings: a scoping review of the literature. BMC Health Serv Res 2021; 21:543. [PMID: 34078358 PMCID: PMC8170624 DOI: 10.1186/s12913-021-06496-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 05/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Healthcare organisations are in constant need of improvement and change. Nudging has been proposed as a strategy to affect people's choices and has been used to affect patients' behaviour in healthcare settings. However, little is known about how nudging is being interpreted and applied to change the behaviour of healthcare professionals (HCPs). The objective of this review is to identify interventions using nudge theory to affect the behaviour of HCPs in clinical settings. METHODS A scoping review. We searched PubMed and PsycINFO for articles published from 2010 to September 2019, including terms related to "nudging" in the title or abstract. Two reviewers screened articles for inclusion based on whether the articles described an intervention to change the behaviour of HCPs. Two reviewers extracted key information and categorized included articles. Descriptive analyses were performed on the data. RESULTS Search results yielded 997 unique articles, of which 25 articles satisfied the inclusion criteria. Five additional articles were selected from the reference lists of the included articles. We identified 11 nudging strategies: accountable justification, goal setting, suggested alternatives, feedback, information transparency, peer comparison, active choice, alerts and reminders, environmental cueing/priming, defaults/pre-orders, and education. These strategies were employed to affect the following 4 target behaviours: vaccination of staff, hand hygiene, clinical procedures, prescriptions and orders. To compare approaches across so many areas, we introduced two independent dimensions to describe nudging strategies: synchronous/asynchronous, and active/passive. CONCLUSION There are relatively few studies published referring to nudge theory aimed at changing HCP behaviour in clinical settings. These studies reflect a diverse set of objectives and implement nudging strategies in a variety of ways. We suggest distinguishing active from passive nudging strategies. Passive nudging strategies may achieve the desired outcome but go unnoticed by the clinician thereby not really changing a behaviour and raising ethical concerns. Our review indicates that there are successful active strategies that engage with clinicians in a more deliberate way. However, more research is needed on how different nudging strategies impact HCP behaviour in the short and long term to improve clinical decision making.
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Affiliation(s)
| | - Andreas Vilhelmsson
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Box 100, 40530, Gothenburg, SE, Sweden
| | - Axel Wolf
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Box 100, 40530, Gothenburg, SE, Sweden.
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Machado CLR, Crespo-Lopez ME, Augusto-Oliveira M, Arrifano GDP, Macchi BDM, Lopes-Araújo A, Santos-Sacramento L, Souza-Monteiro JR, Alvarez-Leite JI, de Souza CBA. Eating in the Amazon: Nutritional Status of the Riverine Populations and Possible Nudge Interventions. Foods 2021; 10:1015. [PMID: 34066557 PMCID: PMC8148567 DOI: 10.3390/foods10051015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 12/11/2022] Open
Abstract
The Amazon is the largest tropical forest in the world and a source of healthy food, such as fruits and fish. Surprisingly, the Amazonian riverine population present an increased prevalence (as high as 58%) of non-communicable diseases, such as hypertension and insulin resistance, even higher than that described for the urban population of the Amazon. Therefore, this work aimed to analyze the nutritional status and associated risk of the riverine population. Body mass index, waist circumference (WC), waist-to-hip ratio, and neck circumference (NC) were evaluated, and risk analysis was assayed. Furthermore, data about occupation and the prevalence of consumers of the different groups of food were analyzed. All anthropometric parameters revealed high proportions of individuals at risk, WC and NC being the factors that had more high-risk women and men, respectively. Our data confirmed the characteristic profile of the riverine communities with a high number of fish consumers, but also observed different patterns probably associated to a phenomenon of nutrition transition. Based on our data, some nudge interventions that take into account the principles of behavior analysis are discussed and proposed for these populations, aiming to improve the nutritional status and avoid the long-term consequences of the results showed by this work.
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Affiliation(s)
- Camila Lorena Rodrigues Machado
- Laboratório de Farmacologia Molecular, Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-110 Belém, PA, Brazil; (C.L.R.M.); (M.A.-O.); (G.d.P.A.); (A.L.-A.); (L.S.-S.)
| | - Maria Elena Crespo-Lopez
- Laboratório de Farmacologia Molecular, Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-110 Belém, PA, Brazil; (C.L.R.M.); (M.A.-O.); (G.d.P.A.); (A.L.-A.); (L.S.-S.)
| | - Marcus Augusto-Oliveira
- Laboratório de Farmacologia Molecular, Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-110 Belém, PA, Brazil; (C.L.R.M.); (M.A.-O.); (G.d.P.A.); (A.L.-A.); (L.S.-S.)
| | - Gabriela de Paula Arrifano
- Laboratório de Farmacologia Molecular, Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-110 Belém, PA, Brazil; (C.L.R.M.); (M.A.-O.); (G.d.P.A.); (A.L.-A.); (L.S.-S.)
| | - Barbarella de Matos Macchi
- Laboratório de Neuroquímica Molecular e Celular, Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-110 Belém, PA, Brazil;
| | - Amanda Lopes-Araújo
- Laboratório de Farmacologia Molecular, Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-110 Belém, PA, Brazil; (C.L.R.M.); (M.A.-O.); (G.d.P.A.); (A.L.-A.); (L.S.-S.)
| | - Letícia Santos-Sacramento
- Laboratório de Farmacologia Molecular, Instituto de Ciências Biológicas, Universidade Federal do Pará, 66075-110 Belém, PA, Brazil; (C.L.R.M.); (M.A.-O.); (G.d.P.A.); (A.L.-A.); (L.S.-S.)
| | | | | | - Carlos Barbosa Alves de Souza
- Núcleo de Teoria e Pesquisa do Comportamento, Instituto Nacional de Ciência e Tecnologia Sobre Comportamento, Cognição e Ensino, Universidade Federal do Pará, 66075-110 Belém, PA, Brazil
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Vande Velde F, Longva J, Overgaard HJ, Bastien S. Identifying nudge strategies for behavior-based prevention and control of neglected tropical diseases: a scoping review protocol. JBI Evid Synth 2021; 18:2704-2713. [PMID: 32740033 DOI: 10.11124/jbies-20-00042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The aim of this scoping review is to synthesize the existing body of studies that use nudge strategy and focus on behavioral practices suitable for prevention and control of neglected tropical diseases. The review will map the existing literature, identify gaps in knowledge, and provide a series of recommendations for future research. INTRODUCTION There is a well-established body of knowledge related to "nudging," a strategy that uses subtle stimuli to direct people's behavior within public health interventions, with the aim of changing behaviors to reduce the prevalence of non-communicable diseases. Recently, interventions to promote prevention and control of neglected tropical diseases have included nudging as a strategy for altering behavior. However, these interventions not been synthesized and present the opportunity for a scoping review. INCLUSION CRITERIA Eligible studies are those that include nudge strategies aimed at changing behavior to prevent and control neglected tropical diseases. All types of behavioral practices suitable for targeting neglected tropical diseases (e.g. handwashing behaviors) will be considered, not exclusively focusing on a specific type or group of neglected tropical diseases. The nudge strategy must be described in full, without restrictions to the study design. The context or population will be limited to low- and middle-income countries. METHODS A comprehensive search will be performed in the following databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC, and EconLit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Titles will be screened by one reviewer, and non-eligible studies excluded. Two reviewers (SB and FVV) will screen abstracts independently. Eligible studies will be selected through a questionnaire that specifies the inclusion criteria. Papers selected for inclusion will be subject to data extraction using a tool designed by one review author and agreed upon by the other review authors. Data will be presented in a table and other conceptual styles.
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Affiliation(s)
- Fiona Vande Velde
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, Ås, Norway
| | - Johanne Longva
- University Library, Norwegian University of Life Sciences, Ås, Norway.,The Centre for Evidence-Based Public Health: A JBI Affiliated Group, Norwegian University of Life Sciences, Ås, Norway
| | - Hans J Overgaard
- Faculty of Science and Technology, Norwegian University of Life Sciences, Ås, Norway.,Department of Microbiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Sheri Bastien
- Department of Public Health Science, Faculty of Landscape and Society, Norwegian University of Life Sciences, Ås, Norway.,The Centre for Evidence-Based Public Health: A JBI Affiliated Group, Norwegian University of Life Sciences, Ås, Norway.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Mamede A, Noordzij G, Jongerling J, Snijders M, Schop-Etman A, Denktas S. Combining Web-Based Gamification and Physical Nudges With an App (MoveMore) to Promote Walking Breaks and Reduce Sedentary Behavior of Office Workers: Field Study. J Med Internet Res 2021; 23:e19875. [PMID: 33843593 PMCID: PMC8076996 DOI: 10.2196/19875] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/22/2020] [Accepted: 01/17/2021] [Indexed: 01/16/2023] Open
Abstract
Background Sedentary behavior (SB) and lack of physical activity (PA) have been associated with poorer health outcomes and are increasingly prevalent in individuals working in sedentary occupations such as office jobs. Gamification and nudges have attracted attention as promising strategies to promote changes in health behavior. However, most effectiveness studies thus far lacked active controls, and few studies have tested interventions combining these strategies. Objective This study investigates the effectiveness of combining a gamified digital app with physical nudges to increase PA and reduce SB in Dutch office workers. Methods Employees in the municipality of Rotterdam (N=298) from two office locations were randomized at the location level to either a 10-week intervention, combining a 5-week gamification phase encompassing a gamified digital app with social support features and a 5-week physical nudges phase, or to an active control (ie, basic digital app with self-monitoring and goal setting). The primary outcome was the daily step count, objectively measured via accelerometers. Secondary outcomes were self-reported PA and SB measured at baseline and at 5, 10, and 14 weeks. Mixed effects models were used to analyze the effects of the intervention on the outcome measures. Results A total of 78.5% (234/298) of participants completed the study and provided accelerometer data, whereas 36.9% (110/298) participants completed the self-report measures at 14 weeks. In the gamification phase, step count data were missing for 13.5% (473/3492) of observations in the control and 11.4% (445/3888) in the intervention condition; however, these percentages increased to 39.6% (1154/2910) and 59.6% (1932/3492) at follow-up, respectively. During the gamification phase, intervention participants increased their number of daily steps by 634 (95% CI 154.2-1113.8; P=.01) more than participants in the control group, after controlling for relevant factors. Improvements were not sustained during the physical nudges phase (P=.76) or follow-up (P=.88). Conclusions A digital intervention with gamification and social support features significantly increased the step count of office workers compared with an active control. Physical nudges in the workplace were insufficient to promote the maintenance of behavioral changes achieved in the gamification phase. Future research should explore the long-term effectiveness of similar gamified digital interventions. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN) 49129401; https://www.isrctn.com/ISRCTN14881571
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Affiliation(s)
- André Mamede
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Gera Noordzij
- Erasmus University College, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Joran Jongerling
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Merlijn Snijders
- Department of Public Health, Welfare and Care, Municipality of Rotterdam, Rotterdam, Netherlands
| | - Astrid Schop-Etman
- Erasmus University College, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Semiha Denktas
- Department of Psychology, Education and Child Studies, Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, Netherlands
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Trafford EP, de la Hunty A. A gentle nudge: Can choice architecture play a role in retailers’ efforts to promote healthier choices? NUTR BULL 2021. [DOI: 10.1111/nbu.12484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Fuster M, Handley MA, Alam T, Fullington LA, Elbel B, Ray K, Huang TTK. Facilitating Healthier Eating at Restaurants: A Multidisciplinary Scoping Review Comparing Strategies, Barriers, Motivators, and Outcomes by Restaurant Type and Initiator. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041479. [PMID: 33557280 PMCID: PMC7915132 DOI: 10.3390/ijerph18041479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 12/15/2022]
Abstract
Restaurants are understudied yet increasingly important food environment institutions for tackling diet-related diseases. This scoping review analyzes research and gray literature (n = 171 records) to assess which healthy eating promotion strategies have been implemented in restaurants and the associated motivations, barriers, and outcomes, compared by restaurant type (corporate/chain vs. independently owned restaurants) and initiator (restaurant-initiated vs. investigator-initiated). We found that the most commonly reported strategy was the increase of generally healthy offerings and the promotion of such offerings. Changes in food availability were more common among corporate restaurants and initiated by restaurants, while environmental facilitators were more commonly initiated by investigators and associated with independently owned restaurants. Aside from those associated with revenue, motivations and barriers for healthy eating promoting strategies varied by restaurant type. While corporate restaurants were also motivated by public health criticism, independently owned restaurants were motivated by interests to improve community health. Revenue concerns were followed by food sourcing issues in corporate restaurants and lack of interest among independently owned restaurants. Among reporting sources, most outcomes were revenue positive. This study shows the need for practice-based evidence and accounting for restaurant business models to tailor interventions and policies for sustained positive changes in these establishments.
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Affiliation(s)
- Melissa Fuster
- Department of Health and Nutrition Science, Brooklyn College, City University of New York, Brooklyn, New York, NY 11210, USA;
- Correspondence:
| | - Margaret A. Handley
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA 94158, USA;
| | - Tamara Alam
- Department of Health and Nutrition Science, Brooklyn College, City University of New York, Brooklyn, New York, NY 11210, USA;
| | - Lee Ann Fullington
- Library, Brooklyn College, City University of New York, Brooklyn, New York, NY 11210, USA;
| | - Brian Elbel
- Department of Population Health, New York University Grossman School of Medicine, and Wagner Graduate School of Public Service, New York University, New York, NY 10016, USA;
| | - Krishnendu Ray
- Department of Nutrition and Food Studies, Steinhardt School of Culture, Education, and Human Development, New York University, New York, NY 10003, USA;
| | - Terry T-K Huang
- Department of Community Health and Social Sciences and Center for Systems and Community Design, City University of New York Graduate School of Public Health and Health Policy, New York, NY 10027, USA;
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Forberger S, Wichmann F, Comito CNN. Using nudges to promote physical activity and to reduce sedentary behaviour in the workplace: a scoping review protocol. BMJ Open 2020; 10:e038205. [PMID: 33444182 PMCID: PMC7678358 DOI: 10.1136/bmjopen-2020-038205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Physical inactivity and sedentary behaviour are associated with numerous health problems and increasing risks of premature morbidity and mortality. Workplace health promotion with a focus on increasing physical activity (PA) and reducing sedentary behaviour is of growing interest. The concept of choice architecture with the use of nudges is a promising approach to influence decision making regarding health behaviours. It can help to understand why people often fail to act in their best interest, to follow well-informed preferences or to achieve their set goals. Nudges, the way the choice is presented, can help to overcome these challenges by using the same habits, biases or boundaries to alter our decision-making in favour of the more preferred behaviour. Aims of the scoping review will be to analyse (a) to what extent the concept of choice architecture is used in workplace health promotion to promote PA and/or to reduce sedentary behaviour and (b) which instruments (nudges) are used to archive that. METHODS AND ANALYSES Medline, PsychInfo, Web of Science and CINHAL will be searched from 2009 until June 2020. Applying a two-level screening process, title and abstracts will be screened according to a set of predetermined inclusion and exclusion criteria. Included articles will be screened a second time to determine the extent to which choice architecture has been used. Analyses for publication year, location, setting and target group will be provided. Interventions will be analysed presenting the instruments used, number of studies per instrument, combinations of instruments and alteration of the environment. Outcome measures and results will be reported as they occur. ETHICS AND DISSEMINATION Due to the nature of the scoping review, ethical concerns are minimal. No patient data will be included. Results are published in peer-review journals.
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Affiliation(s)
- Sarah Forberger
- Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
| | - Frauke Wichmann
- Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
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Wang S, Richardson MB, Wu CY, Zaitchik BF, Gohlke JM. Effect of an Additional 30 Minutes Spent Outdoors during Summer on Daily Steps and Individually Experienced Heat Index. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7558. [PMID: 33080822 PMCID: PMC7589302 DOI: 10.3390/ijerph17207558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 12/24/2022]
Abstract
Spending time outdoors is associated with increased physical activity; however, high ambient temperature/humidity, together with built environment features in urban versus rural environments, may influence physical activity. We conducted an intervention trial with 89 urban and 88 rural participants performing normal activities on Days 1-2 (baseline) and spending an additional 30 min outdoors on Days 3-7 (intervention) in the summer. Participants wore a pedometer with real-time visual feedback to track daily steps taken and a thermometer clipped to their shoe to track temperatures experienced individually. Hygrometer-thermometers were deployed in participants' neighborhoods to collect finer resolution ambient heat indexes in addition to regional weather station measurements. Using linear mixed effects models and adjusting for ambient conditions and individual-level factors, participants on average walked 637 (95%CI (83, 1192)) more steps and had a 0.59 °C (95%CI (0.30, 0.88)) lower daily mean individually experienced heat index during intervention days compared to baseline days. The intervention benefit of increased physical activity was greater in rural residents who were less active at baseline, compared to urban residents. Our results suggest adding a small amount of additional time outdoors may improve physical activity without increasing participants' heat exposure, even during summer in a humid subtropical climate.
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Affiliation(s)
- Suwei Wang
- Translational Biology, Medicine, and Health (TBMH), Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA;
- Department of Population Health Sciences, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA
| | - Molly B. Richardson
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL 35205, USA;
| | - Connor Y.H. Wu
- Department of Geospatial Informatics, Troy University, Troy, AL 36082, USA;
| | - Benjamin F. Zaitchik
- Department of Earth and Planetary Sciences, Johns Hopkins University, Baltimore, MD 21218, USA;
| | - Julia M. Gohlke
- Department of Population Health Sciences, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA
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Buttriss JL. Why food reformulation and innovation are key to a healthier and more sustainable diet. NUTR BULL 2020. [DOI: 10.1111/nbu.12455] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Piggin J. What Is Physical Activity? A Holistic Definition for Teachers, Researchers and Policy Makers. Front Sports Act Living 2020; 2:72. [PMID: 33345063 PMCID: PMC7739796 DOI: 10.3389/fspor.2020.00072] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/19/2020] [Indexed: 11/13/2022] Open
Abstract
This conceptual analysis presents an argument that a new and broader definition of physical activity is needed for educators, researchers, and policy makers. To build a case for change, this paper has four parts. First, it outlines why definitions are important. Second, the current dominant definition of physical activity is examined and critiqued. Third, the case for change to the dominant definition is made. Fourth, a new, broader definition for physical activity is offered and justified. The new, broader definition of physical activity is proposed as involving "people moving, acting and performing within culturally specific spaces and contexts, and influenced by a unique array of interests, emotions, ideas, instructions and relationships."
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Affiliation(s)
- Joe Piggin
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
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Liu J, Gutierrez E, Tiwari A, Padam S, Li D, Dale W, Pal SK, Stewart D, Subbiah S, Bosserman LD, Presant C, Phillips T, Yap K, Hill A, Bhatt G, Yeon C, Cianfrocca M, Yuan Y, Mortimer J, Sedrak MS. Strategies to Improve Participation of Older Adults in Cancer Research. J Clin Med 2020; 9:jcm9051571. [PMID: 32455877 PMCID: PMC7291007 DOI: 10.3390/jcm9051571] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 02/02/2023] Open
Abstract
Cancer is a disease associated with aging. As the US population ages, the number of older adults with cancer is projected to dramatically increase. Despite this, older adults remain vastly underrepresented in research that sets the standards for cancer treatments and, consequently, clinicians struggle with how to interpret data from clinical trials and apply them to older adults in practice. A combination of system, clinician, and patient barriers bar opportunities for trial participation for many older patients, and strategies are needed to address these barriers at multiple fronts, five of which are offered here. This review highlights the need to (1) broaden eligibility criteria, (2) measure relevant end points, (3) expand standard trial designs, (4) increase resources (e.g., institutional support, interdisciplinary care, and telehealth), and (5) develop targeted interventions (e.g., behavioral interventions to promote patient enrollment). Implementing these solutions requires a substantial investment in engaging and collaborating with community-based practices, where the majority of older patients with cancer receive their care. Multifaceted strategies are needed to ensure that older patients with cancer, across diverse healthcare settings, receive the highest-quality, evidence-based care.
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Affiliation(s)
- Jennifer Liu
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Eutiquio Gutierrez
- Department of Internal Medicine, Harbor-UCLA Medical Center, Los Angeles, CA 90502, USA;
| | - Abhay Tiwari
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Simran Padam
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Daneng Li
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - William Dale
- Department of Supportive Care Medicine, City of Hope, Duarte, CA 91010, USA;
| | - Sumanta K. Pal
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Daphne Stewart
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Shanmugga Subbiah
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Linda D. Bosserman
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Cary Presant
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Tanyanika Phillips
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Kelly Yap
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Addie Hill
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Geetika Bhatt
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Christina Yeon
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Mary Cianfrocca
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Yuan Yuan
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Joanne Mortimer
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
| | - Mina S. Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA; (J.L.); (A.T.); (S.P.); (D.L.); (S.K.P.); (D.S.); (S.S.); (L.D.B.); (C.P.); (T.P.); (K.Y.); (A.H.); (G.B.); (C.Y.); (M.C.); (Y.Y.); (J.M.)
- Correspondence:
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Stuber JM, Mackenbach JD, de Boer FE, de Bruijn GJ, Gillebaart M, Harbers MC, Hoenink JC, Klein MCA, Middel CNH, van der Schouw YT, Schuitmaker-Warnaar TJ, Velema E, Vos AL, Waterlander WE, Lakerveld J, Beulens JWJ. Reducing cardiometabolic risk in adults with a low socioeconomic position: protocol of the Supreme Nudge parallel cluster-randomised controlled supermarket trial. Nutr J 2020; 19:46. [PMID: 32429917 PMCID: PMC7236937 DOI: 10.1186/s12937-020-00562-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 05/05/2020] [Indexed: 12/17/2022] Open
Abstract
Background Unhealthy lifestyle behaviours such as unhealthy dietary intake and insufficient physical activity (PA) tend to cluster in adults with a low socioeconomic position (SEP), putting them at high cardiometabolic disease risk. Educational approaches aiming to improve lifestyle behaviours show limited effect in this population. Using environmental and context-specific interventions may create opportunities for sustainable behaviour change. In this study protocol, we describe the design of a real-life supermarket trial combining nudging, pricing and a mobile PA app with the aim to improve lifestyle behaviours and lower cardiometabolic disease risk in adults with a low SEP. Methods The Supreme Nudge trial includes nudging and pricing strategies cluster-randomised on the supermarket level, with: i) control group receiving no intervention; ii) group 1 receiving healthy food nudges (e.g., product placement or promotion); iii) group 2 receiving nudges and pricing strategies (taxing of unhealthy foods and subsidizing healthy foods). In collaboration with a Dutch supermarket chain we will select nine stores located in low SEP neighbourhoods, with the nearest competitor store at > 1 km distance and managed by a committed store manager. Across the clusters, a personalized mobile coaching app targeting walking behaviour will be randomised at the individual level, with: i) control group; ii) a group receiving the mobile PA app. All participants (target n = 1485) should be Dutch-speaking, aged 45–75 years with a low SEP and purchase more than half of their household grocery shopping at the selected supermarkets. Participants will be recruited via advertisements and mail-invitations followed by community-outreach methods. Primary outcomes are changes in systolic blood pressure, LDL-cholesterol, HbA1c and dietary intake after 12 months follow-up. Secondary outcomes are changes in diastolic blood pressure, blood lipid markers, waist circumference, steps per day, and behavioural factors including healthy food purchasing, food decision style, social cognitive factors related to nudges and to walking behaviours and customer satisfaction after 12 months follow-up. The trial will be reflexively monitored to support current and future implementation. Discussion The findings can guide future research and public health policies on reducing lifestyle-related health inequalities, and contribute to a supermarket-based health promotion intervention implementation roadmap. Trial registration Dutch Trial Register ID NL7064, 30th of May, 2018
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Affiliation(s)
- Josine M Stuber
- Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands. .,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands.
| | - Joreintje D Mackenbach
- Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands.,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands
| | - Femke E de Boer
- Department of Social, Health and Organizational Psychology, Utrecht University, Utrecht, the Netherlands
| | - Gert-Jan de Bruijn
- Amsterdam School of Communication Research ASCoR, University of Amsterdam, Amsterdam, the Netherlands
| | - Marleen Gillebaart
- Department of Social, Health and Organizational Psychology, Utrecht University, Utrecht, the Netherlands
| | - Marjolein C Harbers
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jody C Hoenink
- Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands.,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands
| | - Michel C A Klein
- Social AI group, department of Computer Science, VU University Amsterdam, Amsterdam, the Netherlands
| | - Cédric N H Middel
- Athena Institute, Faculty of Science, VU University, Amsterdam, The Netherlands
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Elizabeth Velema
- Netherlands Nutrition Centre (Voedingscentrum), The Hague, The Netherlands
| | - Anne L Vos
- Amsterdam School of Communication Research ASCoR, University of Amsterdam, Amsterdam, the Netherlands
| | - Wilma E Waterlander
- Department of Public Health, Amsterdam Public Health research institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeroen Lakerveld
- Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands.,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joline W J Beulens
- Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands.,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Landais LL, Damman OC, Schoonmade LJ, Timmermans DRM, Verhagen EALM, Jelsma JGM. Choice architecture interventions to change physical activity and sedentary behavior: a systematic review of effects on intention, behavior and health outcomes during and after intervention. Int J Behav Nutr Phys Act 2020; 17:47. [PMID: 32264899 PMCID: PMC7140383 DOI: 10.1186/s12966-020-00942-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/26/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Choice architecture interventions, which subtly change the environment in which individuals make decisions, can be used to promote behavior change. This systematic review aimed to summarize studies on micro-environmental choice architecture interventions that encouraged physical activity or discouraged sedentary behavior in adults, and to describe the effectiveness of those interventions on these behaviors - and on related intentions or health outcomes - in presence of the intervention and after removal of the intervention (i.e. post-intervention, regardless of the time elapsed). METHODS We systematically searched PubMed, Embase, PsycINFO and the Cochrane Library for (quasi) experimental studies published up to December 2019 that evaluated the effect of choice architecture interventions on physical activity and sedentary behavior, as well as on intentions and health outcomes related to physical activity/sedentary behavior. Studies that combined choice architecture techniques with other behavior change techniques were excluded. All studies were screened for eligibility, relevant data was extracted and two independent reviewers assessed the methodological quality using the QualSyst tool. RESULTS Of the 9609 records initially identified, 88 studies met our eligibility criteria. Most studies (n = 70) were of high methodologic quality. Eighty-six studies targeted physical activity, predominantly stair use, whereas two studies targeted sedentary behavior, and one targeted both behaviors. Intervention techniques identified were prompting (n = 53), message framing (n = 24), social comparison (n = 12), feedback (n = 8), default change (n = 1) and anchoring (n = 1). In presence of the intervention, 68% of the studies reported an effect of choice architecture on behavior, whereas after removal of the intervention only 47% of the studies reported a significant effect. For all choice architecture techniques identified, except for message framing, the majority of studies reported a significant effect on behavioral intentions or behavior in presence of the intervention. CONCLUSIONS The results suggest that prompting can effectively encourage stair use in adults, especially in presence of a prompt. The effectiveness of the choice architecture techniques social influence, feedback, default change and anchoring cannot be assessed based on this review. More (controlled) studies are needed to assess the (sustained) effectiveness of choice architecture interventions on sedentary behavior and other types of physical activity than stair use.
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Affiliation(s)
- Lorraine L Landais
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands.
| | - Olga C Damman
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
| | | | - Danielle R M Timmermans
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
| | - Evert A L M Verhagen
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
- Department of Public and Occupational Health, Amsterdam Collaboration on Health & Safety in Sports, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Judith G M Jelsma
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health research institute, Van der Boechorststraat 7, NL-1081 BT, Amsterdam, The Netherlands
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