Financial motivation undermines potential enjoyment in an intensive diet and activity intervention

Are cash incentives always king? A randomized controlled trial evaluating hedonic versus cash incentives (TEH-C)

Introduction

Physical inactivity is a risk factor for obesity and non-communicable diseases. Despite myriad health and non-health benefits resulting from physical activity (PA), most individuals do not meet PA recommendations. Providing an incentive for meeting activity goals may increase activity levels. Classical economists argue that cash is the best incentive. Behavioral economists have posited that hedonic (pleasurable) incentives (e.g., massages, restaurant meals) may be superior to cash when incentives are offered over multiple time periods. To date, no studies have directly compared the effectiveness of cash versus hedonic incentives in promoting PA across multiple time periods.

Methods

We conducted a two-arm, parallel, 4-month randomized controlled trial with healthy adults in Singapore where participants were randomized to either cash or hedonic incentives. Participants could earn up to SGD50 (≈USD37) in cash or hedonic incentives each month they met the study's step target of 10,000 steps daily on at least 20/25 days out of the first 28 days of a month. The primary objective was to compare the mean proportion of months that participants met the step target between the two arms.

Results

By month 4, participants in the cash (N = 154) and hedonic incentive (N = 156) arms increased their mean daily steps by 870 (p < 0.001) and 1,000 steps (p < 0.001), respectively. The mean proportion of months the step target was achieved was 90.53 and 88.34 for participants in the cash and hedonic incentive arms respectively, but differences across arms were small and not statistically significant for this or any outcome assessed.

Conclusion

Our findings suggest that both cash and hedonic incentives are effective at promoting physical activity but that neither strategy is clearly superior.Clinical trial registration: ClinicalTrials.gov, NCT04618757 registered on November 6, 2020.

'Weighing' Losses and Gains: Evaluation of the Healthy Lifestyle Modification After Breast Cancer Pilot Program

Objectives

This pilot study sought to develop and evaluate a novel online group-based intervention (Healthy Lifestyle Modification after Breast Cancer; HLM-ABC) to help breast cancer survivors (BCSs) make healthy lifestyle changes intended to yield not only beneficial physical outcomes (i.e., weight loss, reduced body mass index) but also greater behavioral (e.g., increased physical activity, healthier eating), and psychosocial well-being (e.g., self-efficacy, motivation, body image).

Methods

An exploratory single-arm, mixed-method triangulation design was employed to evaluate the feasibility and preliminary effectiveness of the HLM-ABC intervention for overweight BCSs. Fourteen women participated in the 10-week intervention and completed quantitative measures of the above-mentioned outcomes at baseline, post-treatment, 6-month, and 12-month follow-up time points. Qualitative data were obtained post-treatment via semi-structured interviews and a treatment satisfaction questionnaire.

Results

Participants lost an average of 2.83% of their baseline weight (M = 196.65; SD = 38.59) by 1-year follow-up (M = 191.29; SD = 33.91), equal to a small effect size (d = -0.37). Despite achieving only modest weight loss, participants achieved meaningful gains in the form of increased physical activity (d = 0.2), discovery of gratifying movement, more intuitive eating habits (d = 1.12), greater bodily and emotional awareness, and positive shifts in beliefs about being able to make healthy choices regarding food (d = 0.63) and physical activity (d = 0.38). Furthermore, they demonstrated a slight improvement in body image (d = 0.36) and described feeling more self-compassionate, empowered, and acknowledging of variables beyond control (i.e., hormonal therapy, unsatisfactory surgery) that can present barriers to change.

Conclusion

After completing a 10-week online program, participants achieved meaningful and lasting changes on a number of healthful indicators, even when this did not correspond with a significant reduction in weight. Findings highlight the complex, multifaceted nature of "health" and lend support for promotion of healthier lifestyle following cancer treatment that encompasses not only physical weight, but also behavior, psychosocial well-being, and (often unmodifiable) circumstances such as life-preserving hormonal treatments.

Associations between previous sport and exercise experience and physical literacy elements among physically inactive Danes

Background

Physical inactivity is recognized as a leading global public health threat. Physical Literacy, a concept describing an individual’s prerequisites to participate in and adhere to physical activities, has been suggested to be a key concept in understanding physical activity in various populations. The aim of this study was to describe the prerequisites for physical activity among inactive adults in terms of their physical literacy and previous experience with sport and exercise and how these are interrelated.

Methods

Sample: 1033 physical inactive Danes. Measures: BREQ-3, ESES, the Levels of knowledge questionnaire and the physical self-confidence scale.

Results

Inactive Danish adult’s physical literacy scores are generally low compared to samples in other studies. Inactive adults with no or little previous experience with sport and exercise had lower levels of competences, self-efficacy and autonomous motivation for exercise and sport than the inactive with more experience. Previous sport and exercise experience was positively associated to the physical and affective domain of PL.

Conclusion

Previous experience with sport and exercise is very important to consider when developing sport and exercise activities for currently inactive adults as individuals with low previous experience have lower competences and autonomous motivation and therefore need lower challenges and other important attention to the motivational climate in order to ensure that the activities are motivating enough to secure continued engagement.

Randomized controlled trials of self-monitoring interventions with or without incentives for diet and exercise among individuals with overweight or obesity: Psychological and behavioural effects

OBJECTIVES

To test the effects of three behavioural interventions (daily monetary incentives + self-monitoring, delayed lump sum monetary incentives + self-monitoring, and self-monitoring only) on psychological constructs and fruit and vegetable consumption or physical activity behaviour change among a sample of adults with overweight or obesity.

DESIGN

A pair of 3-arm longitudinal randomized controlled trials compared daily monetary incentives + self-monitoring, delayed lump sum monetary incentives + self-monitoring, and self-monitoring only interventions for either fruit and vegetable consumption or physical activity.

METHODS

Individuals reporting elevated weight status and insufficient engagement in one of the target behaviours were randomly assigned to one of three 3-week interventions. All three interventions involved daily self-monitoring of the behaviour, and two provided monetary incentives contingent upon reported behaviour. Participants completed measures of psychological constructs and reported behaviour at baseline, the end of the intervention, and two and four weeks post-intervention.

RESULTS

Participants across all three intervention conditions demonstrated increased engagement in the target behaviour from pre- to post-intervention and reported behaviour remained above baseline levels at both follow-up time points. Increases in reported behaviour during the intervention were associated with increases in self-efficacy, and this enhanced self-efficacy prospectively predicted sustained reported behaviour at follow-up. However, contrary to hypotheses, the incentive interventions including self-monitoring were not more efficacious than self-monitoring alone, and increased reported behaviour was not associated with enhancements in attitudes.

CONCLUSIONS

Self-monitoring interventions can aid behaviour change efforts, and behavioural practice during these interventions can increase self-efficacy. However, among adults with overweight or obesity who are seeking behaviour change interventions, incentive-based self-monitoring approaches may not be superior to self-monitoring alone in driving behaviour change and maintenance.

Contemplation-action-maintenance model of behaviour change for persons with coronary heart disease: A qualitative study

AIMS AND OBJECTIVES

To explore factors of health behaviour maintenance from the perspective of coronary heart disease (CHD) patients.

BACKGROUND

The majority of CHD patients do not achieve appropriate theory-based intervention to maintain health behaviours. Previous health behaviour change theories give little importance to behaviour maintenance.

DESIGN

A qualitative descriptive study.

METHODS

Thirty CHD patients were recruited purposively and interviewed from four hospitals in Beijing, China, during January 2017-August 2019. Data were analysed using template analysis methods. The COREQ checklist was used.

RESULTS

Perceived enjoyment and perceived effectiveness from the newly adopted behaviours emerged as vital factors for maintaining health behaviour; contemplation-action-maintenance (CAM) model to explain the behaviour change and maintenance of CHD patients was constructed.

CONCLUSIONS

The CAM model provides insight into the factors of health behaviour action and maintenance among CHD patients. Professionals can develop interventions from the perspective of patients' experiences to promote maintenance of behaviour.

RELEVANCE TO CLINICAL PRACTICE

Professionals need to consider that the goal of behavioural intervention should initially and continuously target patients' perseverance. Interventions of health behaviour that bring enjoyment may aid long-term maintenance. Also, healthcare providers can enhance patients' perception of effectiveness to motivate their behaviour maintenance in lifestyle change programmes.

Association between response rates and monetary incentives in sample study: a systematic review and meta-analysis

OBJECTIVE

To investigate the effect of monetary incentive and the dose-response relationship of participants' response rates in surveys.

METHODS

Three databases were searched for randomised controlled trials (RCTs) that investigated the effect of monetary incentives on participants' first and final response rates. First response is defined as the responses after the participant was initially contacted and final response is defined as the responses after several reminders were sent. The potential dose-response relationship of the amount of monetary incentive on the relative response rate (RRR) was established by fitting a restricted cubic spline function based on the robust-error meta-regression model.

RESULTS

105 RCTs were identified. The first RRR increased by 49% (RRR=1.49; 95% CI 1.29 to 1.72) when monetary incentives were provided. Dose-response analysis revealed that an amount between US$6.25 and US$8 had the maximum effect on increasing the first response rate. On average, the final RRR increased almost by 20% (RRR=1.18; 95% CI 1.11 to 1.25) with monetary incentive compared to no-monetary incentive. An amount between US$10 and US$15 had the maximum effect on the final response rate, with an increase in the final RRR of 34% (RRR=1.34; 95% CI 1.19 to 1.51). There was a significant increase in the response rate when two or more reminders were sent.

CONCLUSION

Monetary incentives and reminders improve the response rates. Future studies need to consider providing monetary incentives and sending at least two reminders to increase the response rate and reduce the chances of non-response bias.

Active Children Through Individual Vouchers Evaluation: A Mixed-Method RCT

INTRODUCTION

Physical activity declines in adolescence, especially among those in deprived areas. Research suggests this may result from accessibility barriers (e.g., cost and locality). The Active Children Through Individual Vouchers Evaluation RCT aimed to improve the fitness and heart health of teenagers in Wales with the help of teenagers who co-produced the study.

STUDY DESIGN

This study was a mixed-method RCT.

SETTING/PARTICIPANTS

Before data collection, which took place at baseline, 6 months, and 12 months for both arms, 7 schools were randomized by an external statistician (4 intervention schools, n=524; 3 control schools, n=385).

INTERVENTION

The Active Children Through Individual Vouchers Evaluation intervention included provision of activity vouchers (£20 per month), a peer mentoring scheme, and support worker engagement for 12 months between January and December 2017. Data analysis occurred February-April 2018.

MAIN OUTCOME MEASURES

Data included measures of cardiovascular fitness, cardiovascular health (blood pressure and pulse wave analysis), motivation, and focus groups.

RESULTS

The intervention showed a trend to improve the distance ran (primary outcome) and was significant in improving the likelihood of intervention teenagers being fit (OR=1.21, 95% CI=1.07, 1.38, p=0.002). There was a reduction in teenagers classified as having high blood pressure (secondary outcome) in the intervention group (baseline, 5.3% [28/524]; 12 months, 2.7% [14/524]). Data on where teenagers used vouchers and evidence from focus groups showed that teenagers wanted to access more unstructured, informal, and social activities in their local areas.

CONCLUSIONS

Active Children Through Individual Vouchers Evaluation identified methods that may have a positive impact on cardiovascular fitness, cardiovascular health, and perspectives of activity. Consulting with teenagers, empowering them, and providing more local opportunities for them to take part in activities that are fun, unstructured, and social could positively impact teenage physical activity.

TRIAL REGISTRATION

ISRCTN, ISRCTN75594310.

Financial Incentives May Influence Health Behaviors, But Do We End Up With Less Than We Paid For? A Self-determination Theory Perspective

Paying people to make healthier choices produces inconsistent and sometimes harmful results. Considering how payments can feel coercive is important for promoting long-term, holistic well-being.

A loyalty scheme to encourage physical activity in office workers: a cluster RCT

Background

Increasing physical activity in the workplace can provide physical and mental health benefits for employees and economic benefits for the employer through reduced absenteeism and increased productivity. However, there is limited evidence on effective behaviour change interventions in workplace settings that led to maintained physical activity. This study aimed to address this gap and contribute to the evidence base for effective and cost-effective workplace interventions.

Objectives

To determine the effectiveness and cost-effectiveness of the Physical Activity Loyalty scheme, a multicomponent intervention based on concepts similar to those that underpin a high-street loyalty card, which was aimed at encouraging habitual physical activity behaviour and maintaining increases in mean number of steps per day.

Design

A cluster randomised controlled trial with an embedded economic evaluation, behavioural economic experiments, mediation analyses and process evaluation.

Setting

Office-based employees from public sector organisations in Belfast and Lisburn city centres in Northern Ireland.

Participants

A total of 853 participants [mean age 43.6 years (standard deviation 9.6 years); 71% of participants were female] were randomly allocated by cluster to either the intervention group or the (waiting list) control group.

Intervention

The 6-month intervention consisted of financial incentives (retail vouchers), feedback and other evidence-based behaviour change techniques. Sensors situated in the vicinity of the workplaces allowed participants to monitor their accumulated minutes of physical activity.

Main outcome measures

The primary outcome was mean number of steps per day recorded using a sealed pedometer (Yamax Digiwalker CW-701; Yamax, Tasley, UK) worn on the waist for 7 consecutive days and at 6 and 12 months post intervention. Secondary outcomes included health, mental well-being, quality of life, work absenteeism and presenteeism, and the use of health-care resources.

Results

The mean number of steps per day were significantly lower for the intervention group than the control group [6990 mean number of steps per day (standard deviation 3078) vs. 7576 mean number of steps per day (standard deviation 3345), respectively], with an adjusted mean difference of –336 steps (95% confidence interval –612 to –60 steps; p = 0.02) at 6 months post baseline, but not significantly lower at 12 months post baseline. There was a small but significant enhancement of mental well-being in the intervention group (difference between groups for the Warwick–Edinburgh Mental Wellbeing Scale of 1.34 points, 95% confidence interval 0.48 to 2.20 points), but not for the other secondary outcomes. An economic evaluation suggested that, overall, the scheme was not cost-effective compared with no intervention. The intervention was £25.85 (95% confidence interval –£29.89 to £81.60) more costly per participant than no intervention and had no effect on quality-adjusted life-years (incremental quality-adjusted life-years –0.0000891, 95% confidence interval –0.008 to 0.008).

Limitations

Significant restructuring of participating organisations during the study resulted in lower than anticipated recruitment and retention rates. Technical issues affected intervention fidelity.

Conclusions

Overall, assignment to the intervention group resulted in a small but significant decline in the mean pedometer-measured steps per day at 6 months relative to baseline, compared with the waiting list control group. The Physical Activity Loyalty scheme was deemed not to be cost-effective compared with no intervention, primarily because no additional quality-adjusted life-years were gained through the intervention. Research to better understand the mechanisms of physical activity behaviour change maintenance will help the design of future interventions.

Trial registration

Current Controlled Trials ISRCTN17975376.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 7, No. 15. See the NIHR Journals Library website for further project information.

Financial incentives for physical activity in adults: systematic review and meta-analysis

Objective

The use of financial incentives to promote physical activity (PA) has grown in popularity due in part to technological advances that make it easier to track and reward PA. The purpose of this study was to update the evidence on the effects of incentives on PA in adults.

Data sources

Medline, PubMed, Embase, PsychINFO, CCTR, CINAHL and COCH.

Eligibility criteria

Randomised controlled trials (RCT) published between 2012 and May 2018 examining the impact of incentives on PA.

Design

A simple count of studies with positive and null effects (‘vote counting’) was conducted. Random-effects meta-analyses were also undertaken for studies reporting steps per day for intervention and post-intervention periods.

Results

23 studies involving 6074 participants were included (64.42% female, mean age = 41.20 years). 20 out of 22 studies reported positive intervention effects and four out of 18 reported post-intervention (after incentives withdrawn) benefits. Among the 12 of 23 studies included in the meta-analysis, incentives were associated with increased mean daily step counts during the intervention period (pooled mean difference (MD), 607.1; 95% CI: 422.1 to 792.1). Among the nine of 12 studies with post-intervention daily step count data incentives were associated with increased mean daily step counts (pooled MD, 513.8; 95% CI:312.7 to 714.9).

Conclusion

Demonstrating rising interest in financial incentives, 23 RCTs were identified. Modest incentives ($1.40 US/day) increased PA for interventions of short and long durations and after incentives were removed, though post-intervention ‘vote counting’ and pooled results did not align. Nonetheless, and contrary to what has been previously reported, these findings suggest a short-term incentive ‘dose’ may promote sustained PA.

What works best when implementing a physical activity intervention for teenagers? Reflections from the ACTIVE Project: a qualitative study

OBJECTIVE

This paper explores what aspects of a multicomponent intervention were deemed strengths and weaknesses by teenagers and the local council when promoting physical activity to young people.

DESIGN

Qualitative findings at 12 months from a mixed method randomised control trial.

METHODS

Active Children Through Incentive Vouchers-Evaluation (ACTIVE) gave teenagers £20 of activity enabling vouchers every month for a year. Peer mentors were also trained and a support worker worked with teenagers to improve knowledge of what was available. Semistructured focus groups took place at 12 months to assess strengths and weaknesses of the intervention. Eight focus groups (n=64 participants) took place with teenagers and one additional focus group was dedicated to the local council's sport development team (n=8 participants). Thematic analysis was used to analyse the data.

RESULTS

Teenagers used the vouchers on three main activities: trampolining, laser tag or the water park. These appeal to both genders, are social, fun and require no prior skill or training. Choice and financial support for teenagers in deprived areas was considered a strength by teenagers and the local council. Teenagers did not engage with a trained peer mentor but the support worker was considered helpful.

CONCLUSIONS

The ACTIVE Project's delivery had both strengths and weakness that could be used to underpin future physical activity promotion. Future interventions should focus on improving access to low cost, fun, unstructured and social activities rather than structured organised exercise/sport. The lessons learnt from this project can help bridge the gap between what is promoted to teenagers and what they actually want from activity provision.

TRIAL REGISTRATION NUMBER

ISRCTN75594310.

Using financial incentives to promote physical activity in American Indian adolescents: A randomized controlled trial

American Indians (AI) have high prevalence of diabetes in youth and may benefit from increasing physical activity as a strategy to improve metabolic health. We tested whether financial incentives would elicit greater frequency and/or duration of exercise in AI youth at high risk for developing diabetes. Overweight/obese AI boys and girls, 11-20 years old, were instructed to exercise on 3 days/week for 48 weeks at a tribal wellness center. The program was divided into three, 16-week-long phases to test different financial incentive strategies. Within each phase participants were randomly assigned to one of two groups that received different payments for exercise. Phase 1 was designed to test whether the size of the incentive would affect exercise frequency. In Phase 1, the number of exercise sessions did not differ between the group receiving a modest fixed-value payment per exercise session and the group receiving enhanced incentives to exercise more frequently (26 ± 3 versus 28 ± 2 sessions, respectively, p = 0.568). In Phase 2, the provision of an enhanced financial incentive to increase exercise duration resulted longer sessions, as the incentivized and standard payment groups exercised 38 ± 2 versus 29 ± 1 minutes per session (p = 0.002), respectively. In Phase 3, the effect of reducing the incentives on maintenance of exercise behaviors was inconclusive due to high participant withdrawal. Aerobic fitness increased 10% during Phase 1 but was unchanged thereafter. Insulin sensitivity and body composition were unchanged during the study. In conclusion, enhanced financial incentives increased the duration of exercise sessions, but had minimal effects on exercise participation. These results indicate that financial incentives hold promise in motivating previously sedentary, overweight/obese adolescents to exercise longer, but motivating them to sustain an exercise program remains the major challenge.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01848353.

The effect of financial incentives on patients' motivation for treatment: results of "Money for Medication," a randomised controlled trial

BACKGROUND

Offering financial incentives is an effective intervention for improving adherence in patients taking antipsychotic depot medication. We assessed whether patients' motivation for treatment might be reduced after receiving financial rewards.

METHODS

This study was part of Money for Medication, a multicentre, open-label, randomised controlled trial, which demonstrated the positive effects of financial incentives on antipsychotic depot compliance. Three mental healthcare institutions in Dutch secondary psychiatric care services participated. Eligible patients were aged 18-65 years, had been diagnosed with schizophrenia or another psychotic disorder, had been prescribed antipsychotic depot medication or had an indication to start using depot medication, and were participating in outpatient treatment. For 12 months, patients were randomly assigned either to treatment as usual (control group) or to treatment as usual plus a financial reward for each depot of medication received (€30 per month if fully compliant; intervention group). They were followed up for 6 months, during which time no monetary rewards were offered for taking antipsychotic medication. To assess treatment motivation after 0, 12 and 18 months, interviews were conducted using a supplement to the Health of the Nation Outcome Scales (HoNOS) and the Treatment Entry Questionnaire (TEQ).

RESULTS

Patients were randomly assigned to the intervention (n = 84) or the control group (n = 85). After 12 months, HoNOS motivation scores were available for 131 patients (78%). Ninety-one percent of the patients had no or mild motivational problems for overall treatment; over time, there were no significant differences between the intervention and control groups. TEQ data was available for a subgroup of patients (n = 61), and showed no significant differences over time between the intervention and control groups for external motivation (β = 0.37 95% CI: -2.49 - 3.23, p = 0.799); introjected motivation (β = - 2.39 95% CI: -6.22 - 1.44, p = 0.222); and identified motivation (β = - 0.91 95% CI: -4.42 - 2.61, p = 0.613). After the 6-month follow-up period, results for the HoNOS and TEQ scores remained comparable.

CONCLUSIONS

Offering financial incentives for taking antipsychotic depot medication does not reduce patients' motivation for treatment.

TRIAL REGISTRATION

Netherlands Trial registration, number NTR2350 .

Formative Assessment: Design of a Web-Connected Sedentary Behavior Intervention for Females

Background

Sedentary behavior (SB) is a significant risk factor for heart disease, diabetes, obesity, and early mortality, particularly among women, and the health consequences associated with SB are independent of physical activity status. Interventions utilizing wearable technologies can improve SB, but their effectiveness is influenced by individual preferences, device engagement strategies, and technological features, which may affect user compliance. Gathering a priori insight from target populations on their preferences for program tools and strategies may assist researchers in identifying effective methods to improve the efficacy of SB interventions.

Objective

The objective of this study was to (1) explore the likeability (likes and dislikes) and usability (engagement intentions and navigation) of a wearable device (Movband) and its accompanying website (dashboard), (2) examine social incentive preferences (teammates), and (3) assess the feasibility (participants’ experiences during an activity-monitoring period) of these tools for use in an intervention to reduce SB in girls and women.

Methods

A total of 9 girls (mean age: 8.9 years, standard deviation [SD] 1.1 years) and 11 college-aged women (mean age: 22.6 years, SD 3.2 years) participated in this study. Separate focus groups were held for girls and women, and all participants attended one before and the other following a 7-day activity-monitoring period. During the focus groups, participants were prompted with questions to address the study aims, and the nominal group technique was used to compile lists of group-specific preferences for the activity-monitoring system. The top three ranking likes and dislikes were reverse coded to determine likeability.

Results

The top-ranking responses for the girls and women were the following: visual display of movements and ease of navigation (dashboard like), boring to look at and no calorie-tracking function (dashboard dislike), backlight and long battery life (Movband like), and color and not waterproof (tied for girls) and vertical time display (Movband dislike). Additionally, participants identified several aesthetic preferences and functional limitations. At the second focus group visit, the majority of the participants self-reported less SB during the previous week. Objective data from the activity-monitoring period revealed that the average steps per day for girls and women were 12,373.4 (SD 2617.6) and 8515.8 (SD 3076.7), respectively.

Conclusions

These results suggest that the girls and women liked many features of the Movband and dashboard. However, several dislikes were mentioned, which may negatively influence compliance and the effectiveness of the activity-monitoring system and require improvements before using in an SB intervention.

Active children through individual vouchers - evaluation (ACTIVE): protocol for a mixed method randomised control trial to increase physical activity levels in teenagers

Background

Many teenagers are insufficiently active despite the health benefits of physical activity (PA). There is strong evidence to show that inactivity and low fitness levels increase the risk of non-communicable diseases such as coronary heart disease (CHD), type 2 diabetes and breast and colon cancers (Lee et al. Lancet 380:219–29, 2012). A major barrier facing adolescents is accessibility (e.g. cost and lack of local facilities). The ACTIVE project aims to tackle this barrier through a multi-faceted intervention, giving teenagers vouchers to spend on activities of their choice and empowering young people to improve their fitness and PA levels.

Design

ACTIVE is a mixed methods randomised control trial in 7 secondary schools in Swansea, South Wales. Quantitative and qualitative measures including PA (cooper run test (CRT), accelerometery over 7 days), cardiovascular (CV) measures (blood pressure, pulse wave analysis) and focus groups will be undertaken at 4 separate time points (baseline, 6 months,12 months and follow-up at 18 months). Intervention schools will receive a multi-component intervention involving 12 months of £20 vouchers to spend on physical activities of their choice, a peer mentor scheme and opportunities to attend advocacy meetings. Control schools are encouraged to continue usual practice. The primary aim is to examine the effect of the intervention in improving cardiovascular fitness.

Discussion

This paper describes the protocol for the ACTIVE randomised control trial, which aims to increase fitness, physical activity and socialisation of teenagers in Swansea, UK via a voucher scheme combined with peer mentoring. Results can contribute to the evidence base on teenage physical activity and, if effective, the intervention has the potential to inform future physical activity interventions and policy.

Trial registration

ISRCTN75594310 (Assigned 06/03/2017).

Paying for antiretroviral adherence: is it unethical when the patient is an adolescent?

With the expansion of antiretroviral treatment programmes, many children and adolescents with HIV in sub-Saharan Africa could expect to live healthy lives. Yet adolescents have the highest levels of poor antiretroviral adherence and of loss to follow-up compared with other age groups. This can lead to increased morbidity and mortality, to the development of drug-resistant strains, and to high societal costs. While financial incentives have been extensively used to promote medication adherence among adults, their use among adolescents remains rare. And while there is a large body of ethical literature exploring financial incentives among adults, little philosophical thought has gone into their use among adolescents. This paper explores three oft-mentioned ethical worries about financial incentives for health behaviours and it asks whether these concerns are more serious in the context of incentives for improving adolescent adherence. The three worries are that such incentives would unduly coerce adolescents' decision-making, would compromise distributive justice and would crowd out intrinsic motivations and non-monetary values. Our tentative conclusion is that more empirical investigation of these concerns is necessary, and that at this point they are not compelling enough to rule out trials in which adolescents are incentivised for antiretroviral adherence.

Effect of team sports and resistance training on physical function, quality of life, and motivation in older adults

The aim of this study was to investigate the effect of team sports and resistance training on physical function, psychological health, quality of life, and motivation in older untrained adults. Twenty-five untrained men and forty-seven untrained women aged 80 (range: 67-93) years were recruited. Fifty-one were assigned to a training group (TRG) of which twenty-five performed team training (TG) and twenty-six resistance training (RG). The remaining twenty-one were allocated to a control group (CG). TRG trained for 1 hour twice a week for 12 weeks. Compared with CG, TRG improved the number of arm curls within 30 seconds (P<.05) and 30-seconds chair stand (P<.05) during the intervention. In TRG, participation in training led to higher (P<.05) scores in the subscales psychological well-being, general quality of life, and health-related quality of life, as well as decreased anxiety and depression levels. No differences between changes in TG and RG were found over the intervention period, neither in physical function tests nor psychological questionnaires. Both TG and RG were highly motivated for training, but TG expressed a higher degree of enjoyment and intrinsic motivation mainly due to social interaction during the activity, whereas RG was more motivated by extrinsic factors like health and fitness benefits. In conclusion, both team training and resistance training improved physical function, psychological well-being, and quality of life. However, team sport training motivated the participants more by intrinsic factors than resistance training.

Secondary data analysis from a randomized trial examining the effects of small financial incentives on intrinsic and extrinsic motivation for weight loss

Objectives

To examine whether (a) an obesity treatment involving financial incentives yields higher levels of extrinsic motivation for weight management compared to an identical intervention without incentives, (b) extrinsic motivation for weight management mediates, or accounts for, the difference in weight loss outcomes between the two interventions, and (c) there is any evidence that financial incentives and associated extrinsic motivation "crowd out" intrinsic motivation for weight control.

Methods

Participants (N=153, 80.4% Female; BMI = 33.2 ± 5.9) were randomly assigned to a 3-month Web-based behavioral weight loss program (WBWL) or the same program plus small financial incentives delivered consistent with behavioral economics and behavior change theories (WBWL+$). Weight was objectively assessed at baseline, post-treatment (month 3), and after a 9-month no-treatment follow-up phase (month 12). Intrinsic and extrinsic motivation for weight management were assessed at months 3 and 12 using a modified version of the Treatment Self-Regulation Questionnaire, with questions added to specifically target extrinsic motivation related to incentives.

Results

Compared to WBWL alone, WBWL+$ had better weight loss and higher levels of both extrinsic and intrinsic motivation for weight management (p's≤.02). Moreover, during the no-treatment follow-up phase, the trajectories of weight regain did not significantly differ between WBWL and WBWL+$ (p=.58). Extrinsic motivation was not a significant mediator of treatment outcomes.

Conclusions

Modest financial incentives delivered consistent with behavioral economics and behavior change theories do not undermine intrinsic motivation for weight management during obesity treatment; in fact, they yield higher levels of both extrinsic and intrinsic motivation. Additional research is needed to better understand the mechanisms by which incentives improve outcomes in health behavior change interventions.

Addressing sleep disturbances: an opportunity to prevent cardiometabolic disease?

There is increasing awareness of the role of sleep disturbance as an important factor in health and disease. Although sub-clinical sleep disturbances (insufficient sleep duration or inadequate sleep quality) may be difficult to assess with conceptual and/or methodological clarity, this review attempts to summarize and synthesize these findings. First, the concept of sleep disturbance in a public health context is introduced, to provide context and rationale. Second, operational definitions of 'cardiometabolic disease' and 'sleep disturbance' are offered, to address many unclear operationalizations. Third, the extant literature is summarized regarding short or long sleep duration and/or insufficient sleep, insomnia and insomnia symptoms, general (non-specific sleep disturbances), circadian rhythm abnormalities that result in sleep disturbances, and, briefly, sleep-disordered breathing. Fourth, the review highlights the social/behavioural context of sleep, including discussions of sleep and race/ethnicity, socio-economic position, and other social/environmental factors, in order to place these findings in a social-environmental context relevant to public health. Fifth, the review highlights the issue of sleep as a domain of health behaviour and addresses issues regarding development of healthy sleep interventions. Finally, a research agenda of future directions is proposed.

A cluster randomised controlled trial of an intervention to promote healthy lifestyle habits to school leavers: study rationale, design, and methods

BACKGROUND

Physical inactivity and a poor diet predict lifestyle diseases such as diabetes, cardiovascular disease, and certain types of cancer. Marked declines in physical activity occur during late adolescence, coinciding with the point at which many young people leave school and enter the workforce and begin to take greater control over their lifestyle behaviours. The work outlined within this paper sought to test a theoretically-informed intervention aimed at supporting increased engagement in physical activity and healthy eating habits in young people at the point of transition from school to work or work-based learning. As actively engaging young people in initiatives based on health messages is challenging, we also tested the efficacy of financial incentives in promoting initial engagement with the programme.

METHODS/DESIGN

A three-arm cluster-randomised design was used. Participants were school pupils from Year 11 and 13 (i.e., in their final year of study), aged 16-18 years. To reduce contamination effects, the unit of randomisation was school. Participants were randomly allocated to receive (i) a 12-week behavioural support intervention consisting of six appointments, (ii) a behavioural support intervention plus incentives (totalling £40), or (iii) an information-only control group. Behavioural support was provided by fitness advisors at local leisure centres following an initial consultation with a dietician. Sessions focused on promoting habit formation through setting implementation intentions as part of an incremental goal setting process. Consistent with self-determination theory, all advisors were trained to provide guidance in an autonomy-supportive manner so that they were equipped to create a social context supportive of autonomous forms of participant motivation. The primary outcome was objectively assessed physical activity (via GT1M accelerometers). Secondary outcome measures were diet, motivation and habit strength. Data were collected at baseline, post-intervention (12 weeks) and 12 months.

DISCUSSION

Findings of this trial will provide valuable insight into the feasibility of promoting autonomous engagement in healthy physical activity and dietary habits among school leavers. The research also provides much needed data and detailed information related to the use of incentives for the initial promotion of young peoples' behaviour change during this important transition.

TRIAL REGISTRATION

The trial is registered as Current Controlled Trials ISRCTN55839517.