Large-Scale Fandom-based Gamification Intervention to Increase Physical Activity: A Quasi-experimental Study

A Nationwide Physical Activity Intervention for 654,500 Adults in Singapore: Cost-Utility Analysis

Background

Increasing physical inactivity is a primary risk factor for diabetes and hypertension, contributing to rising health care expenditure and productivity losses. As Singapore's aging population grows, there is an increased disease burden on Singapore's health systems. Large-scale physical activity interventions could potentially reduce the disease burden but face challenges with the uncertainty of long-term health impact and high implementation costs, hindering their adoption.

Objective

We examined the cost-effectiveness of the Singapore National Steps Challenge (NSC), an annual nationwide mobile health (mHealth) intervention to increase physical activity, from both the health care provider perspective, which only considers the direct costs, and the societal perspective, which considers both the direct and indirect costs.

Methods

We used a Markov model to assess the long-term impact of increased physical activity from the NSC on adults aged 17 years and older. A Monte Carlo simulation with 1000 samples was conducted to compare two situations: the NSC conducted yearly for 10 years against a no-intervention situation with no NSC. The model projected inpatient and outpatient costs and mortality arising from diabetes and hypertension, as well as their complications. Health outcomes were expressed in terms of the quality-adjusted life-years (QALYs) gained. All future costs and QALYs were discounted at 3% per annum. Sensitivity analyses were done to test the robustness of our model results.

Results

We estimated that conducting the NSC yearly for 10 years with a mean cohort size of 654,500 participants was projected to prevent 6200 diabetes cases (95% credible interval 3700 to 9100), 10,500 hypertension cases (95% credible interval 6550 to 15,200), and 4930 deaths (95% credible interval 3260 to 6930). This led to a reduction in health care costs of SGD (Singapore dollar) 448 million (95% credible interval SGD 132 million to SGD 1.09 billion; SGD 1=US $0.73 for the year 2019). There would be 78,800 (95% credible interval 55,700 to 102,000) QALYs gained. Using a willingness-to-pay threshold of SGD 10,000 per QALY gained, the NSC would be cost-saving. When indirect costs were included, the NSC was estimated to reduce societal costs by SGD 1.41 billion (95% credible interval SGD 353 million to SGD 3.80 billion). The model was most sensitive to changes in the inpatient cost of treatment for diabetes complications, time horizon, and program compliance.

Conclusions

In this modeling study, increasing physical activity by conducting a yearly nationwide physical activity intervention was cost-saving, preventing diabetes and hypertension and reducing mortality from these diseases. Our results provide important information for decision-making in countries that may consider introducing similar large-scale physical activity programs.

A Smartphone-Based Shopping Mall Walking Program and Daily Walking Steps

Importance

Because shopping malls are considered safe places for walking, several mall walking programs have been developed. Research on the association between the use of walking programs and the number of daily steps taken is limited.

Objective

To evaluate the association between use of a smartphone-based shopping mall walking program and daily steps taken after the COVID-19 pandemic.

Design, Setting, and Participants

This cohort study evaluated a nationwide longitudinal data set of 217 344 registered smartphone app users at least 18 years of age residing in Japan. Daily step counts were collected from January 1 to December 31, 2021.

Exposures

The mall walking program Mall Challenge integrated a global positioning system with a smartphone app's incentive system to reward achieving a goal of 1000 daily steps with lottery-based coupons to win from 0 to 500 shopping points (1 point equaled 1 yen or approximately US $0.01).

Main Outcomes and Measures

Daily step records were collected from the smartphone app's walking program and adjusted for gender and age. Multilevel analyses using mixed-effect linear regression models were used to estimate the coefficients for the association between daily participation in the walking program and daily step counts. Cross-level interaction terms of age and gender by walking program participation were included in one model.

Results

Among the 217 344 registered mall app users (23 638 110 daily step records; 154 616 [71.1%] women; 18 014 [8.3%] participants 65 years or older, and 199 330 [91.7%] adults younger than 65 years), the mean (SD) daily steps were 7415 (4686) on walking program participation days and 5281 (4339) on days without participation in the program. Walking program participation days were associated with 1219 additional daily steps (95% CI, 1205-1232) compared with nonparticipation days after adjusting for gender and age. By geographic region, participation in the walking program was associated with 1130 (95% CI, 1113-1146) more steps in rural malls, 1403 (95% CI, 1379-1428) more steps in suburban malls, and 1433 (95% CI, 1408-1457) more steps in urban malls than nonparticipation. Moreover, participation in the walking program was associated with 1422 (95% CI, 1405-1439) more steps in large malls and 1059 (95% CI, 1041-1077) more steps in small malls compared with nonparticipation. Regarding cross-level interactions, women were associated with walking 728 (95% CI, 698-758) more steps than men, and older adults were associated with walking 228 (95% CI, 183-273) more steps than younger adults on walking program participation days.

Conclusions and Relevance

This cohort study found that the use of a smartphone-based mall walking program combined with physical shopping mall facilities and lottery-based digital incentive coupons may motivate people to increase their daily number of walking steps.