A Systematic Review of Financial Incentives for Physical Activity: The Effects on Physical Activity and Related Outcomes

Cost-effectiveness of incentives for physical activity in coronary heart disease in Germany: pre-trial health economic model of a complex intervention following the new MRC framework

Objectives

The German Incentives for Physical Activity in Cardiac Patients trial is a three-arm, randomised controlled trial for secondary prevention of coronary heart disease (CHD). Guidance for developing complex interventions recommends pre-trial health economic modelling. The aim of this study is to model the long-term cost-effectiveness of the incentive-based physical activity interventions in a population with CHD.

Methods

A decision-analytical Markov model was developed from a health services provider perspective, following a cohort aged 65 years with a previous myocardial infarction for 25 years. Monetary and social incentives were compared relative to no incentive. Intervention effects associated with physical activity were used to determine the costs, quality-adjusted life-years (QALYs) gained, incremental cost-effectiveness and cost-utility ratios. The probability of cost-effectiveness was calculated through sensitivity analyses.

Results

The incremental QALYs gained from the monetary and social incentives, relative to control, were respectively estimated at 0.01 (95% CI 0.00 to 0.01) and 0.04 (95% CI 0.02 to 0.05). Implementation of the monetary and social incentive interventions increased the costs by €874 (95% CI €744 to €1047) and €909 (95% CI €537 to €1625). Incremental cost-utility ratios were €25 912 (95% CI €15 056 to €50 210) and €118 958 (95% CI €82 930 to €196 121) per QALY gained for the social and monetary incentive intervention, respectively. With a willingness-to-pay threshold set at €43 000/QALY, equivalent to the per-capita gross domestic product in Germany, the probability that the social and monetary incentive intervention would be seen as cost-effective was 95% and 0%, respectively.

Conclusions

Exercise-based secondary prevention using inventive schemes may offer a cost-effective strategy to reduce the burden of CHD.

Combining anchoring with financial incentives to increase physical activity: a randomized controlled trial among college students

The purpose of this study was to: (1) compare the relative efficacy of different combinations of three behavioral intervention strategies (i.e., personalized reminders, financial incentives, and anchoring) for establishing physical activity habits using an mHealth app and (2) to examine the effects of these different combined interventions on intrinsic motivation for physical activity and daily walking habit strength. A four-arm randomized controlled trial was conducted in a sample of college students (N = 161) who had a self-reported personal wellness goal of increasing their physical activity. Receiving cue-contingent financial incentives (i.e., incentives conditional on performing physical activity within ± one hour of a prespecified physical activity cue) combined with anchoring resulted in the highest daily step counts and greatest odds of temporally consistent walking during both the four-week intervention and the full eight-week study period. Cue-contingent financial incentives were also more successful at increasing physical activity and maintaining these effects post-intervention than traditional non-cue-contingent incentives. There were no differences in intrinsic motivation or habit strength between study groups at any time point. Financial incentives, particularly cue-contingent incentives, can be effectively used to support the anchoring intervention strategy for establishing physical activity habits. Moreover, mHealth apps are a feasible method for delivering the combined intervention technique of financial incentives with anchoring.

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.

Incentivised physical activity intervention promoting daily steps among university employees in the workplace through a team-based competition

Introduction

The benefits of walking on health and well-being is well established and regarded as the most accessible form of physical activity (PA) that most individuals can incorporate into their lives. Despite the benefits, the impact of a competitive walking intervention combined with a prize incentive in the workplace is yet to be established. The aim of this intervention was to promote PA among university employees through teams-based competition with a prize incentive targeted towards the recommended 10,000 steps per day.

Methods

A total of 49 employees participated and formed eight departmental teams ranging from Senior Admin management, Educational & Social work, Nursing & Midwifery, Sport & Exercise, Health Sciences, Admin Assistant, Library, and IT to compete in a walking intervention. Each team was handed an ActiGraph wGT3X-BT from Monday to Friday to record their walking steps. Steps. Post intervention participants completed an open-ended survey to provide their views about the intervention.

Results

The ActiGraph findings determined that steps increased by 4,799 per day from daily baseline of 5,959 to 10,758 throughout this intervention. The themes from qualitative data showed that the prize incentive and competitive nature of this intervention has motivated staff to walk more, changed their behaviour, enjoyed the team-based competition, and improved perceived productivity in the workplace.

Discussion and conclusion

This intervention increased employees' daily steps by 4,799 and met the 10,000 steps guideline. The 'Health Sciences' team recorded the highest steps 531,342 followed by the 'Education and Social Work' accumulating 498,045 steps throughout this intervention. This intervention with prize incentive demonstrated a positive impact on employees personal and work-based outcomes as well as contributed to the workplace PA, health, and wellbeing literature, and more specifically, to the scarce research focused on university settings.

Who needs what (features) when? Personalizing engagement with data-driven self-management to improve health equity

OBJECTIVES

To examine the feasibility of promoting engagement with data-driven self-management of health among individuals from minoritized medically underserved communities by tailoring the design of self-management interventions to individuals' type of motivation and regulation in accordance with the Self-Determination Theory.

METHODS

Fifty-three individuals with type 2 diabetes from an impoverished minority community were randomly assigned to four different versions of an mHealth app for data-driven self-management with the focus on nutrition, Platano; each version was tailored to a specific type of motivation and regulation within the SDT self-determination continuum. These versions included financial rewards (external regulation), feedback from expert registered dietitians (RDF, introjected regulation), self-assessment of attainment of one's nutritional goals (SA, identified regulation), and personalized meal-time nutrition decision support with post-meal blood glucose forecasts (FORC, integrated regulation). We used qualitative interviews to examine interaction between participants' experiences with the app and their motivation type (internal-external).

RESULTS

As hypothesized, we found a clear interaction between the type of motivation and Platano features that users responded to and benefited from. For example, those with more internal motivation reported more positive experience with SA and FORC than those with more external motivation. However, we also found that Platano features that aimed to specifically address the needs of individuals with external regulation did not create the desired experience. We attribute this to a mismatch in emphasis on informational versus emotional support, particularly evident in RDF. In addition, we found that for participants recruited from an economically disadvantaged community, internal factors, such as motivation and regulation, interacted with external factors, most notably with limited health literacy and limited access to resources.

CONCLUSIONS

The study suggests feasibility of using SDT to tailor design of mHealth interventions for promoting data-driven self-management to individuals' motivation and regulation. However, further research is needed to better align design solutions with different levels of self-determination continuum, to incorporate stronger emphasis on emotional support for individuals with external regulation, and to address unique needs and challenges of underserved communities, with particular attention to limited health literacy and access to resources.

The Influence of a Wearable-Based Reward Program on Health Care Costs: Retrospective, Propensity Score-Matched Cohort Study

BACKGROUND

Mobile health (mHealth) technology holds great promise as an easily accessible and effective solution to improve population health at scale. Despite the abundance of mHealth offerings, only a minority are grounded in evidence-based practice, whereas even fewer have line of sight into population-level health care spending, limiting the clinical utility of such tools.

OBJECTIVE

This study aimed to explore the influence of a health plan-sponsored, wearable-based, and reward-driven digital health intervention (DHI) on health care spending over 1 year. The DHI was delivered through a smartphone-based mHealth app available only to members of a large commercial health plan and leveraged a combination of behavioral economics, user-generated sensor data from the connected wearable device, and claims history to create personalized, evidence-based recommendations for each user.

METHODS

This study deployed a propensity score-matched, 2-group, and pre-post observational design. Adults (≥18 years of age) enrolled in a large, national commercial health plan and self-enlisted in the DHI for ≥7 months were allocated to the intervention group (n=56,816). Members who were eligible for the DHI but did not enlist were propensity score-matched to the comparison group (n=56,816). Average (and relative change from baseline) medical and pharmacy spending per user per month was computed for each member of the intervention and comparison groups during the pre- (ie, 12 months) and postenlistment (ie, 7-12 months) periods using claims data.

RESULTS

Baseline characteristics and medical spending were similar between groups (P=.89). On average, the total included sample population (N=113,632) consisted of young to middle-age (mean age 38.81 years), mostly White (n=55,562, 48.90%), male (n=46,731, 41.12%) and female (n=66,482, 58.51%) participants. Compared to a propensity score-matched cohort, DHI users demonstrated approximately US $10 per user per month lower average medical spending (P=.02) with a concomitant increase in preventive care activities and decrease in nonemergent emergency department admissions. These savings translated to approximately US $6.8 million in avoidable health care costs over the course of 1 year.

CONCLUSIONS

This employer-sponsored, digital health engagement program has a high likelihood for return on investment within 1 year owing to clinically meaningful changes in health-seeking behaviors and downstream medical cost savings. Future research should aim to elucidate health behavior-related mechanisms in support of these findings and continue to explore novel strategies to ensure equitable access of DHIs to underserved populations that stand to benefit the most.

Loss-Framed Adaptive Microcontingency Management for Preventing Prolonged Sedentariness: Development and Feasibility Study

BACKGROUND

A growing body of evidence shows that financial incentives can effectively reinforce individuals' positive behavior change and improve compliance with health intervention programs. A critical factor in the design of incentive-based interventions is to set a proper incentive magnitude. However, it is highly challenging to determine such magnitudes as the effects of incentive magnitude depend on personal attitudes and contexts.

OBJECTIVE

This study aimed to illustrate loss-framed adaptive microcontingency management (L-AMCM) and the lessons learned from a feasibility study. L-AMCM discourages an individual's adverse health behaviors by deducting particular expenses from a regularly assigned budget, where expenses are adaptively estimated based on the individual's previous responses to varying expenses and contexts.

METHODS

We developed a mobile health intervention app for preventing prolonged sedentary lifestyles. This app delivered a behavioral mission (ie, suggesting taking an active break for a while) with an incentive bid when 50 minutes of uninterrupted sedentary behavior happened. Participants were assigned to either the fixed (ie, deducting the monotonous expense for each mission failure) or adaptive (ie, deducting varying expenses estimated by the L-AMCM for each mission failure) incentive group. The intervention lasted 3 weeks.

RESULTS

We recruited 41 participants (n=15, 37% women; fixed incentive group: n=20, 49% of participants; adaptive incentive group: n=21, 51% of participants) whose mean age was 24.0 (SD 3.8; range 19-34) years. Mission success rates did not show statistically significant differences by group (P=.54; fixed incentive group mean 0.66, SD 0.24; adaptive incentive group mean 0.61, SD 0.22). The follow-up analysis of the adaptive incentive group revealed that the influence of incentive magnitudes on mission success was not statistically significant (P=.18; odds ratio 0.98, 95% CI 0.95-1.01). On the basis of the qualitative interviews, such results were possibly because the participants had sufficient intrinsic motivation and less sensitivity to incentive magnitudes.

CONCLUSIONS

Although our L-AMCM did not significantly affect users' mission success rate, this study configures a pioneering work toward adaptively estimating incentives by considering user behaviors and contexts through leveraging mobile sensing and machine learning. We hope that this study inspires researchers to develop incentive-based interventions.

Incentivising public transport use for physical activity gain: process evaluation of the COVID-19 disrupted trips4health randomised controlled trial

BACKGROUND

Partnering with a public transport (PT) provider, state government, and local government, the single-blinded randomised controlled trial, trips4health, investigated the impact of PT use incentives on transport-related physical activity (PA) in Tasmania, Australia. The intervention involved 16-weeks of incentives (bus trip credits) for achieving weekly PT use targets, supported by weekly text messages. This study objective was to conduct a process evaluation of the COVID-19 disrupted trips4health study.

METHODS

The Medical Research Council UK's framework for complex public health interventions guided the process evaluation. Participant reach, acceptability, fidelity and feasibility were evaluated. Administrative and post-intervention survey data were analysed descriptively. Semi-structured interviews with intervention participants (n = 7) and PT provider staff (n = 4) were analysed thematically.

RESULTS

Due to COVID-19, trips4health was placed on hold (March 2020) then stopped (May 2020) as social restrictions impacted PT use. At study cessation, 116 participants (approximately one third of target sample) had completed baseline measures, 110 were randomised, and 64 (n = 29 in the intervention group; n = 35 in the control group) completed post-intervention measures. Participants were 18 - 80 years (average 44.5 years) with females (69%) and those with tertiary education (55%) over-represented. The intervention was delivered with high fidelity with 96% of bus trip credits and 99% of behavioural text messages sent as intended. Interviewed PT staff said implementation was highly feasible. Intervention participant acceptability was high with 90% reporting bus trip incentives were helpful and 59% reporting the incentives motivated them to use PT more. From a total of 666 possible bus trip targets, 56% were met with 38% of intervention participants agreeing and 41% disagreeing that 'Meeting the bus trip targets was easy'. Interviews and open-ended survey responses from intervention participants revealed incentives motivated bus use but social (e.g., household member commitments) and systemic (e.g., bus availability) factors made meeting bus trip targets challenging.

CONCLUSIONS

trips4health demonstrated good acceptability and strong fidelity and feasibility. Future intervention studies incentivising PT use will need to ensure a broader demographic is reached and include more supports to meet PT targets.

TRIAL REGISTRATION

ACTRN12619001136190 .

Effectiveness of Incentives for Improving Diabetes-Related Health Indicators in Chronic Disease Lifestyle Modification Programs: a Systematic Review and Meta-Analysis

Introduction

We examined the effectiveness of providing incentives to participants in lifestyle modification programs to improve diabetes-related health indicators: body weight, body mass index (BMI), blood pressure, cholesterol, and hemoglobin A_1C (HbA_1C). We also examined the potential effect of 4 different incentive domains (ie, type, monetary value, attainment certainty, and schedule) on those indicators.

Methods

We searched Medline, Embase, PsycINFO, and Cochrane Library to identify relevant studies published from January 2008 through August 2021. We used a random-effects model to pool study results and examine between-study heterogeneity by using the I² statistic and the Cochran Q test. We also conducted moderator analyses by using a mixed-effects model to examine differences between subgroups of incentive domains (eg, incentive type [cash vs other types]).

Results

Our search yielded 10,965 articles, of which 19 randomized controlled trials met our selection criteria. The random-effects model revealed that, relative to the control group, the incentive group had significant reductions in weight (−1.85kg; 95% CI, −2.40 to −1.29; P < .001), BMI (−0.47kg/m²; 95% CI, −0.71 to −0.22; P < .001), and both systolic blood pressure (−2.59 mm HG; 95% CI, −4.98 to −0.20; P = .03) and diastolic blood pressure (−2.62 mm Hg; 95% CI, −4.61 to −0.64; P = .01). A reduction in cholesterol level was noted but was not significant (−2.81 mg/dL; 95% CI, −8.89 to −3.28; P = .37). One study found a significant reduction in hemoglobin A_1c (−0.17%; 95% CI, −0.30% to −0.05%; P < .05). The moderator analyses showed that the incentive effect did not vary significantly between the subgroups of the incentive domains, except on weight loss for the attainment certainty domain, suggesting that a variety of incentive subgroups could be equally useful.

Conclusion

Providing incentives in lifestyle modification programs is a promising strategy to decrease weight, BMI, and blood pressure.

Identifying Strategies for Facilitating Physical Activity Among Older Adults: A Behaviour Change Wheel 'Retrofit' Driven Analysis of Victorian Local Government Policy

ISSUE ADDRESSED

The significance of physical activity (PA) for the health and wellbeing of older adults is well documented. Local government (LG) publish PA policy and interventions to encourage and improve older adult PA participation. However, LG documents have rarely been studied to examine the extent to which LG incorporates evidence-based strategies into the development of older adult PA policy.

METHODS

The Behaviour Change Wheel (BCW) 'retrofitting' approach was used to identify and explain available evidence-based PA policies and interventions across 10 Victorian LGs. A document analysis was completed using LG policy and involved elements of content analysis and thematic analysis.

RESULTS

The analysis found 41 documents that included policy and interventions to encourage and improve PA among older adults. Some of the more popular BCW combinations included service provision and enablement and environmental/ social planning, and environmental restructuring. In addition, LGs embrace modifying the built environment and creating partnerships. However, our results suggest that some are not considering modelling or incentives to increase PA.

CONCLUSIONS

According to the BCWs, Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity (APEASE) criteria, it is not feasible for Victorian LGs to be including all intervention functions and supporting policy functions. However, contemporary older adult PA intervention literature suggests LGs could benefit from including incentives and modelling into current PA policy. SO WHAT?: This research is one of the first to identify and explain how Victorian LGs facilitate PA participation among older adults. This research will guide Victorian LGs when drafting and implementing PA policy in the future.

Active Use and Engagement in an mHealth Initiative Among Young Men With Obesity: Mixed Methods Study

Background

The effectiveness of mobile health (mHealth) approaches that employ wearable technology to promote physical activity have been the subject of concern due to the declining active use observed in trial settings.

Objective

To better contextualize active use, this study aimed to identify the barriers and enablers to engagement in a tracker-based mHealth initiative among young men who had recently completed a 19-week residential weight loss program.

Methods

A mixed methods study was conducted among 167 young men who had voluntarily enrolled in the national steps challenge (NSC), an mHealth physical activity promotion initiative, following a residential weight loss intervention. A subsample of 29 enrollees with a body mass index of 29.6 (SD 3.1) participated in semistructured interviews and additional follow-up assessments. Quantitative systems data on daily step count rates were used to describe active use. Qualitative data were coded and analyzed to elicit barriers and enablers to microlevel engagement in relation to the NSC, focusing on tracker and smartphone use. We further elicited barriers and enablers to macrolevel engagement by exploring attitudes and behaviors toward the NSC. Using triangulation, we examined how qualitative engagement in the NSC could account for quantitative findings on active use. Using integration of findings, we discussed how the mHealth intervention might have changed physical activity behavior.

Results

Among the 167 original enrollees, active use declined from 72 (47%) in week 1 to 27 (17%) in week 21. Mean daily step counts peaked in week 1 at 10,576 steps per day and were variable throughout the NSC. Barriers to engagement had occurred in the form of technical issues leading to abandonment, device switching, and offline tracking. Passive attitudes toward step counting and disinterest in the rewards had also prevented deeper engagement. Enablers of engagement included self-monitoring and coaching features, while system targets and the implicit prospect of reward had fostered new physical activity behaviors.

Conclusions

Our study showed that as the NSC is implemented in this population, more emphasis should be placed on technical support and personalized activity targets to promote lasting behavior change.

Effectiveness of financial incentives and message framing to improve clinic visits of people with moderate-high cardiovascular risk in a vulnerable population in Argentina: A cluster randomized trial

In Argentina, cardiovascular disease (CVD) represents the first cause of mortality, but effective coverage for CVD prevention is low. Strategies based on behavioral economics are emerging worldwide as key pieces to increase the effectiveness of CVD prevention approaches. The aim of this study was to evaluate whether the implementation of two strategies based on financial incentives and framing increased attendance to clinical visits as proposed by the national program for CVD risk factors management among the uninsured and poor population with moderate or high CVD risk in Argentina. We conducted a cluster randomized trial in nine primary care clinics (PCCs) in Argentina. Three PCCs were assigned to financial incentives, 3 to framing-text messages (SMS) and 3 to usual care. The incentive scheme included a direct incentive for attending the first clinical visit and the opportunity to participate in a lottery when attending a second clinical visit. The framing-text messages group received messages with a gain-frame format. The main outcome was the proportion of participants who attended the clinical visits. A total of 918 individuals with a risk ≥10% of suffering a CVD event within the next 10 years were recruited to participate in the study. The financial incentive group had a significantly higher percentage of participants who attended the first (59.0% vs 33.9%, p˂ 0.001) and the follow up visit (34.4% and 16.6%, p˂ 0.001) compared to control group. However, the framing-SMS group did not show significant differences compared to the control group. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.govNCT03300154.

Aiming at Optimal Physical Activity for Longevity (OPAL)

Although even small volumes (15–20 min) of daily physical activity (PA) are associated with health benefits, the optimal volume for healthy aging and longevity is substantially larger, amounting to about 100 min of daily moderate PA. The accomplishment of this objective likely requires the development of an appropriate PA lifestyle at an early age. Research initiatives are necessary addressing the motivational contribution of families, school surroundings and sport clubs, perhaps combined with role model effects and instructions for the specific implementation. Such approaches would need an enlarged agreement in readdressing this new aim followed by the launch of a new research strategy in order to develop specific offers for the respective age cohorts.

What are the ethical implications of using prize-based contingency management in substance use? A scoping review

BACKGROUND

The area of substance use is notable for its early uptake of incentives and wealth of research on the topic. This is particularly true for prize-based contingency management (PB-CM), a particular type of incentive that uses a fishbowl prize-draw design. Given that PB-CM interventions are gaining momentum to address the dual public health crises of opiate and stimulant use in North America and beyond, it is imperative that we better understand and critically analyze their implications.

PURPOSE

The purpose of this scoping review paper is to identify the characteristics of PB-CM interventions for people who use substances and explore ethical implications documented in the literature as well as emerging ethical implications that merit further consideration.

METHODS

The PRISMA-ScR checklist was used in conjunction with Arksey and O'Malley's methodological framework to guide this scoping review. We completed a two-pronged analysis of 52 research articles retrieved through a comprehensive search across three key scholarly databases. After extracting descriptive data from each article, we used 9 key domains to identify characteristics of the interventions followed by an analysis of ethical implications.

RESULTS

We analyzed the characteristics of PB-CM interventions which were predominantly quantitative studies aimed at studying the efficacy of PB-CM interventions. All of the interventions used a prize-draw format with a classic magnitude of 50%. Most of the interventions combined both negative and positive direction to reward processes, behaviors, and/or outcomes. One ethical implication was identified in the literature: the risk of gambling relapse. We also found three emerging ethical implications by further analyzing participant characteristics, intervention designs, and potential impact on the patient-provider relationship. These implications include the potential deceptive nature of PB-CM, the emphasis placed on the individual behaviors to the detriment of social and structural determinants of health, and failures to address vulnerability and power dynamics.

CONCLUSIONS

This scoping review offers important insights into the ethics on PB-CM and its implications for research ethics, clinical ethics, and public health ethics. Additionally, it raises important questions that can inform future research and dialogues to further tease out the ethical issues associated with PB-CM.

A socially responsible financial institution - The bumpy road to improving consumer well-being

There is a strong belief that in addition to making a profit, companies should act for the benefit of the society. This research has evaluated a novel cooperation model between a non-profit financial institution and a community service provider (a local YMCA) with the overarching aim of advancing customers' well-being. By offering a financial incentive (a savings account with higher interest payouts, contingent on account holders' increased participation in YMCA activities), the financial institution and the YMCA partnered to improve consumers' financial standing, positive health behaviors, and overall well-being. The collaboration exemplified a business engagement in the community that goes beyond philanthropy. Participation in YMCA activities was found not to be influenced by the financial incentive. However, households participating in the program swiftly transferred their financial resources to the incentivized account and along with that increased their activity in YMCA to boost the interest rate. Sport-related YMCA visits had some positive effects on momentary well-being, but none were observed for non-sport-related activities. Furthermore, the incentivized activities did not translate into improved well-being outcomes but had a potential to positively contribute to emergency savings. The evidence from qualitative feedback from in-depth participant interviews pointed to a reverse effect of the incentive, where YMCA engagement was a trigger for setting up the savings account. The findings have corroborated the understanding that designing interventions that target customers' well-being is not a straightforward task.

Can a 'rewards-for-exercise app' increase physical activity, subjective well-being and sleep quality? An open-label single-arm trial among university staff with low to moderate physical activity levels

BACKGROUND

This study examined the impact of a 'rewards-for-exercise' mobile application on physical activity, subjective well-being and sleep quality among 148 employees in a UK university with low to moderate physical activity levels.

METHODS

A three-month open-label single-arm trial with a one-year follow-up after the end of the trial. Participants used the Sweatcoin application which converted their outdoor steps into a virtual currency used for the purchase of products available at the university campus' outlets, using an in-app marketplace. The primary outcome measure was self-reported physical activity. Secondary measures included device-measured physical activity, subjective well-being (i.e., life satisfaction, positive affect, negative affect), and self-reported sleep quality.

RESULTS

The findings show an increase in self-reported physical activity (d = 0.34), life satisfaction (d = 0.31), positive affect (d = 0.29), and sleep quality (d = 0.22) during the three-month trial period.

CONCLUSION

The study suggests that mobile incentives-for-exercise applications might increase physical activity levels, positive affect, and sleep quality, at least in the short term. The observed changes were not sustained 12 months after the end of the trial.

An investigation of health insurance policy and behavior in a virtual environment

We introduce a new experimental approach to measuring the effects of health insurance policy alternatives on behavior and health outcomes over the life course. In a virtual environment with multi-period lives, subjects earn virtual income and allocate spending, to maximize utility, which is converted into cash payment. We compare behavior across age, income and insurance plans-one priced according to an individual's expected cost and the other uniformly priced through employer-implemented cost sharing. We find that 1) subjects in the employer-implemented plan purchased insurance at higher rates; 2) the employer-based plan reduced differences due to income and age; 3) subjects in the actuarial plan engaged in more health-promoting behaviors, but still below optimal levels, and did save at the level required, so did realize the full benefits of the plan. Subjects had more difficulty optimizing choices in the Actuarial treatment, because it required more long term planning and evaluating benefits that compounded over time. Contrary, to model predictions, the actuarial priced insurance plan did not increase utility relative to the employer-based plan.

Evaluation of a voucher scheme to increase child physical activity in participants of a school physical activity trial in the Hunter region of Australia

BACKGROUND

Global population data suggest that physical activity levels in children remain unacceptably low. Improved participation in organised sport has been recommended by the WHO as one strategy to improve population levels of physical activity. In 2018, in the state of New South Wales, Australia, the government introduced the Active Kids scheme, to help families meet the cost of getting children into organized sport. The aim of this study is to describe the uptake of Active Kids and assess the impact of the scheme on organized sport participation and child physical activity in a region of New South Wales.

METHODS

A pragmatic longitudinal study was undertaken of parents/carers from primary school aged children (5-12 years) in the Hunter region of NSW, Australia. Baseline data were collected between Oct-Dec 2017, with follow-up 12 months later. A telephone survey occurred at both time points, asking questions regarding registration and redemption of an Active Kids voucher for their child, child participation in organised sports and child physical activity levels.

RESULTS

Of the 974 parents/carers who consented to participate, 511 (52.5%) completed the telephone surveys at both time points. A very large proportion of children (n = 454, 89.0%) were reported by their parents/carers at baseline as meeting the minimum physical activity guideline of 60 min per day. Of participating parents/carers in this study, 407 (96.0%) reported redeeming an Active Kids voucher. Children who redeemed a voucher had three times the odds to participate in organized team sports from baseline to follow-up (p = 0.009). Sub group analyses identified that females who redeemed a voucher had four times the odds to participate in organized team sports (p = 0.012).

CONCLUSIONS

Given the already active nature of this sample, no significant improvements in physical activity levels were noted, but the positive contribution community sport can have on health and wellbeing amongst children is reinforced. Whilst voucher schemes can address financial burdens across all socio-economic groups, more population targeting is needed to deliver voucher schemes to the most disadvantaged and inactive segments of the population in order to increase physical activity.

Using financial incentives to increase physical activity among employees as a strategy of workplace health promotion: protocol for a systematic review

INTRODUCTION

Shifts towards sedentary occupations in high-income countries (HIC) over the last decades and the health burden associated with physical inactivity have led to innovative strategies to promote physical activity (PA) among the working population. Financial rewards have been proposed to incentivise participation in programmes promoting PA or the achievement of PA-related goals. This review will assess (1) effects of financial incentives provided by employers to promote PA on programme adherence/compliance, PA and closely linked outcomes (eg, days of sick leave), (2) effects according to age, gender, implementation and study quality and (3) intervention costs and cost-effectiveness.

METHODS AND ANALYSIS

We will search for relevant studies in eight academic databases, two grey literature resources, two trial registers and on five organisational websites (oldest record/content to present). We will include (cluster) randomised controlled studies with a financial incentive to promote PA as intervention (≥1 months), conducted among employees in HIC and reporting data on at least one primary outcome in stages of screening (title/abstract, full text). To assess study quality and potential bias, we will use the revised Cochrane risk-of-bias tool (RoB 2). We will extract study data into prepiloted extraction sheets. Each task in screening, quality assessment and data extraction will be done by two authors independently. If a sufficient number of studies provide homogeneous data (ie, similar follow-up) for primary outcomes, meta-analyses will be carried out. We will report GRADE ratings to provide information on the certainty of the evidence.

ETHICS AND DISSEMINATION

For this review, no ethical approval will be required because only data of studies in which informed consent was obtained will be considered and analysed. The final review manuscript will be published in an Open Access journal. To ensure effective promotion of this review project, we will disseminate major findings through relevant communication channels.

PROSPERO REGISTRATION NUMBER

CRD42020184345.

Economics of physical activity in low-income and middle- income countries: a systematic review

BACKGROUND

Promotion of physical activity (PA) among populations is a global health investment. However, evidence on economic aspects of PA is sparse and scattered in low-income and middle-income countries (LMICs).

OBJECTIVE

The objective of this study was to summarise the available evidence on economics of PA in LMICs, identify potential target variables for policy and report gaps in the existing economic evidence alongside research recommendations.

DATA SOURCES

A systematic review of the electronic databases (Scopus, Web of Science and SPORTDiscus) and grey literature.

STUDY ELIGIBILITY CRITERIA

Cost-of-illness studies, economic evaluations, interventions and descriptive studies on economic factors associated with PA using preset eligibility criteria.

STUDY APPRAISAL AND SYNTHESIS OF METHODS

Screening, study selection and quality appraisal based on standard checklists performed by two reviewers with consensus of a third reviewer. Descriptive synthesis of data was performed.

RESULTS

The majority of the studies were from upper-middle-income countries (n=16, 88.8%) and mainly from Brazil (n=9, 50%). Only one economic evaluation study was found. The focus of the reviewed literature spanned the economic burden of physical inactivity (n=4, 22%), relationship between PA and costs (n=6, 46%) and socioeconomic determinants of PA (n=7, 39%). The findings showed a considerable economic burden due to insufficient PA, with LMICs accounting for 75% of disability-adjusted life years (DALYs) globally due to insufficient PA. Socioeconomic correlates of PA were identified, and inverse relationship of PA with the cost of chronic diseases was established. Regular PA along with drug treatment as a treatment scheme for chronic diseases showed advantages with a cost-utility ratio of US$3.21/quality-adjusted life year (QALY) compared with the drug treatment-only group (US$3.92/QALY) by the only economic evaluation conducted in the LMIC, Brazil.

LIMITATIONS

Meta-analysis was not performed due to heterogeneity of the studies.

CONCLUSIONS AND RECOMMENDATIONS

Economic evaluation studies for PA promotion interventions/strategies and local research from low-income countries are grossly inadequate. Setting economic research agenda in LMICs ought to be prioritised in those areas.

PROSPERO REGISTRATION NUMBER

CRD42018099856.

Evaluation of the effectiveness of behavioural economic incentive programmes for the promotion of a healthy diet and physical activity: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Obesity and being overweight are major risk factors for metabolic syndrome and non-communicable diseases. Despite the recommendation that a healthy diet and physical activity can reduce the severity of these diseases, many fail to adhere to these measures. From a behavioural economic perspective, adherence to such measures can be encouraged through financial incentives. However, additional related behavioural economic approaches may improve the effectiveness of an incentive programme. As such, we have developed a protocol for a systematic review and network meta-analysis to summarise the current evidence from financial incentive programmes with and without behavioural economic insights for promoting healthy diet and physical activity.

METHODS AND ANALYSIS

Previous systematic reviews, meta-analyses and individual studies were identified from Medline and Scopus in June 2020 and will be updated until December 2020. Individual studies will be selected and data extracted by two reviewers. Disagreement will be resolved by consensus or adjudicated by a third reviewer. A descriptive analysis will summarise the effectiveness of behavioural economic incentive programmes for promoting healthy diet and physical activity. Moreover, individual studies will be pooled using network meta-analyses where possible. I² statistics and Cochran's Q test will be used to assess heterogeneity. Risk of bias and publication bias, if appropriate, will be evaluated, as well as the overall strength of the evidence.

ETHICS AND DISSEMINATION

Ethics approval for a systematic review and meta-analysis is not required. The findings will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020198024.

Behavior Change

Despite rapid growth in the empirical research on behavior change, modern science has yet to produce a coherent set of recommendations for individuals and organizations eager to align everyday actions with enduringly valued goals. We propose the process model of behavior change as a parsimonious framework for organizing strategies according to where they have their primary impact in the generation of behavioral impulses. To begin, individuals exist in objective situations, only certain features of which attract attention, which in turn lead to subjective appraisals, then finally give rise to response tendencies. Unhealthy habits develop when conflicting impulses are consistently resolved in favor of momentary temptations instead of valued goals. To change behavior for the better, we can strategically modify objective situations, where we pay attention, how we construct appraisals, and how we enact responses. Crucially, behavior change strategies can be initiated either by the individual (i.e., self-control) or by others (e.g., a benevolent employer).

"It gets people through the door": a qualitative case study of the use of incentives in the care of people at risk or living with HIV in British Columbia, Canada

Background

There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care—each one representing an interconnecting step in the "HIV Cascade."

Methods

The main objective of this qualitative case study was to document the experiences of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes.

Results

Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve (and sustain) viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional—thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional.

Conclusions

We identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care—an area of life previously not subject to monetary exchanges.

Association between behavioral phenotypes and response to a physical activity intervention using gamification and social incentives: Secondary analysis of the STEP UP randomized clinical trial

Participants often vary in their response to behavioral interventions, but methods to identify groups of participants that are more likely to respond are lacking. In this secondary analysis of a randomized clinical trial, we used baseline characteristics to group participants into distinct behavioral phenotypes and evaluated differential responses to a physical activity intervention. Latent class analysis was used to segment participants based on baseline participant data including demographics, validated measures of psychosocial variables, and physical activity behavior. The trial included 602 adults from 40 U.S. states with body mass index ≥25 who were randomized to control or one of three gamification interventions (supportive, collaborative, or competitive) to increase physical activity. Daily step counts were monitored using a wearable device for a 24-week intervention with 12 weeks of follow-up. The model segmented participants into three classes named for key defining traits: Class 1, extroverted and motivated; Class 2, less active and less social; Class 3, less motivated and at-risk. Adjusted regression models were used to test for differences in intervention response relative to control within each behavioral phenotype. In Class 1, only participants in the competitive arm increased their mean daily steps during the intervention (adjusted difference, 945; 95% CI, 352-1537; P = .002), but it was not sustained during follow-up. In Class 2, participants in all three gamification arms significantly increased their mean daily steps compared to control during the intervention (supportive arm adjusted difference 1172; 95% CI, 363-1980; P = .005; collaborative arm adjusted difference 1119; 95% CI, 319-1919; P = .006; competitive arm adjusted difference 1179; 95% CI, 400-1957; P = .003) and all three had sustained impact during follow-up. In Class 3, none of the interventions had a significant effect on physical activity. Three behavioral phenotypes were identified, each with a different response to the interventions. This approach could be used to better target behavioral interventions to participants that are more likely to respond to them.

Changes in Coverage, Access, and Health Following Implementation of Healthy Behavior Incentive Medicaid Expansions vs. Traditional Medicaid Expansions

BACKGROUND

Several states expanded Medicaid under the Affordable Care Act using Section 1115 waivers to implement healthy behavior incentive (HBI) programs, but the impact of this type of expansion relative to traditional expansion is not well understood.

OBJECTIVE

To examine whether Medicaid expansion with healthy behavior incentive programs and traditional Medicaid expansion were associated with differential changes in coverage, access, and self-rated health outcomes among low-income adults.

DESIGN

Difference-in-differences analysis of American Community Survey and Behavioral Risk Factor Surveillance System data from 2011 to 2017.

PARTICIPANTS

Low-income adults ages 19-64 in the Midwest Census region (American Community Survey, n = 665,653; Behavioral Risk Factor Surveillance System, n = 71,959).

INTERVENTIONS

Exposure to either HBI waiver or traditional Medicaid expansion in the state of residence.

MAIN MEASURES

Coverage: Medicaid, private, or any health insurance coverage; access: routine checkup, personal doctor, delaying care due to cost; health: cancer screening, preventive care, healthy behaviors, self-reported health.

KEY RESULTS

Healthy behavior incentive (HBI) and traditional expansion (TE) states experienced reductions in uninsurance (- 5.6 [- 7.5, - 3.7] and - 6.2 [- 8.1, - 4.4] percentage points, respectively) and gains in Medicaid (HBI, + 7.6 [2.4, 12.8]; TE, + 9.7 [5.9, 13.4] percentage points) relative to non-expansion states. Both expansion types were associated with increases in rates of having a personal doctor (HBI, + 3.8 [2.0, 5.6]; TE, + 5.9 [2.2, 9.6] percentage points) and mammography (HBI, + 5.6 [0.6, 10.6]; TE, + 7.3 [0.7, 13.9] percentage points). Meanwhile, checkups increased more in HBI than in TE states (p < 0.01), but no other changes in health care services differed between expansion types.

CONCLUSIONS

Medicaid expansion was associated with improvements in coverage and access to care with few differences between expansion types.

trips4health: Protocol of a single-blinded randomised controlled trial incentivising adults to use public transport for physical activity gain

Background

Public transport (PT) users typically accumulate more physical activity (PA) than private motor vehicle users yet redressing physical inactivity through transport-related PA (TRPA) interventions has received limited attention. Further, incentive-based strategies can increase leisure-time PA but their impact on TRPA, is unclear. This study's objective is to determine the impact of an incentive-based strategy on TRPA in a regional Australian setting.

Methods

trips4health is a single-blinded randomised controlled trial with a four-month intervention phase and subsequent six-month maintenance phase. Participants will be randomised to: an incentives-based intervention (bus trip credit for reaching bus trip targets, weekly text messages to support greater bus use, written PA guidelines); or an active control (written PA guidelines only). Three hundred and fifty adults (≥18 years) from southern Tasmania will be recruited through convenience methods, provide informed consent and baseline information, then be randomised. The primary outcome is change in accelerometer measured average daily step count at baseline and four- and ten-months later. Secondary outcomes are changes in: measured and self-reported travel behaviour (e.g. PT use), PA, sedentary behaviour; self-reported and measured (blood pressure, waist circumference, height, weight) health; travel behaviour perspectives (e.g. enablers/barriers); quality of life; and transport-related costs. Linear mixed model regression will determine group differences. Participant and PT provider level process evaluations will be conducted and intervention costs to the provider determined.

Discussion

trips4health will determine the effectiveness of an incentive-based strategy to increase TRPA by targeting PT use. The findings will enable evidence-informed decisions about the worthwhileness of such strategies.

Trial registration

ACTRN12619001136190.

Universal trial number

U1111-1233-8050.

Examining Responsiveness to an Incentive-Based Mobile Health App: Longitudinal Observational Study

Background

The Carrot Rewards app was developed as part of a public-private partnership to reward Canadians with loyalty points for downloading the app, referring friends, completing educational health quizzes, and health-related behaviors with long-term objectives of increasing health knowledge and encouraging healthy behaviors. During the first 3 months after program rollout in British Columbia, a number of program design elements were adjusted, creating observed differences between groups of users with respect to the potential impact of program features on user engagement levels.

Objective

This study examines the impact of reducing reward size over time and explored the influence of other program features such as quiz timing, health intervention content, and type of reward program on user engagement with a mobile health (mHealth) app.

Methods

Participants in this longitudinal, nonexperimental observational study included British Columbia citizens who downloaded the app between March and July 2016. A regression methodology was used to examine the impact of changes to several program design features on quiz offer acceptance and engagement with this mHealth app.

Results

Our results, based on the longitudinal app use of 54,917 users (mean age 35, SD 13.2 years; 65.03% [35,647/54,917] female), indicated that the key drivers of the likelihood of continued user engagement, in order of greatest to least impact, were (1) type of rewards earned by users (eg, movies [+355%; P<.001], air travel [+210%; P<.001], and grocery [+140%; P<.001] relative to gas), (2) time delay between early offers (−64%; P<.001), (3) the content of the health intervention (eg, healthy eating [−10%; P<.001] vs exercise [+20%, P<.001] relative to health risk assessments), and (4) changes in the number of points offered. Our results demonstrate that reducing the number of points associated with a particular quiz by 10% only led to a 1% decrease in the likelihood of offer response (P<.001) and that each of the other design features had larger impacts on participant retention than did changes in the number of points.

Conclusions

The results of this study demonstrate that this program, built around the principles of behavioral economics in the form of the ongoing awarding of a small number of reward points instantly following the completion of health interventions, was able to drive significantly higher engagement levels than those demonstrated in previous literature exploring the intersection of mHealth apps and financial incentives. Previous studies have demonstrated the presence of incentive matters to user engagement; however, our results indicate that the number of points offered for these reward point–based health interventions is less important than other program design features such as the type of reward points being offered, the timing of intervention and reward offers, and the content of the health interventions in driving continued engagement by users.

The Impact of Financial Incentives on Physical Activity: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effects of financial incentives on physical activity (PA).

DATA SOURCES

MEDLINE, Embase, 7 other databases, and 2 trial registries until July 17, 2019.

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized controlled trials with adults aged ≥18 years assessing the effect of financial incentives on PA. Any comparator was eligible provided the only difference between groups was the incentive strategy.

DATA EXTRACTION

Two independent reviewers extracted data and assessed study quality. Of 5765 records identified, 57 records (51 unique trials; n = 17 773 participants) were included.

DATA SYNTHESIS

Random-effects models pooling data for each of the 5 PA domains.

RESULTS

Financial incentives increase leisure time PA (gym or class attendance; standardized mean difference [95% CI], 0.46 [0.28-0.63], n = 5057) and walking behavior (steps walked; 0.25 [0.13-0.36], n = 3254). No change in total minutes of PA (0.52 [-0.09 to 1.12], n = 968), kilocalories expended (0.19 [-0.06 to 0.44], n = 247), or the proportion of participants meeting PA guidelines (risk ratio [95% CI] 1.53 [0.53-4.44], n = 650) postintervention was observed. After intervention has ceased, incentives sustain a slight increase in leisure time PA (0.10 [0.02-0.18], n = 2678) and walking behavior (0.11 [0.00-0.22], n = 2425).

CONCLUSIONS

Incentives probably improve leisure time PA and walking at intervention end, and small improvements may be sustained over time once incentives have ceased. They lead to little or no difference in kilocalories expended or minutes of PA. It is uncertain whether incentives change the likelihood of meeting PA guidelines because the certainty of the evidence is low.

The effect of regulatory focus and time preference on the dual process of physical activity: A cross-sectional study among nurses

AIMS

To examine the dual process of physical activity adoption among nurses and its relationships with two personal orientations-regulatory focus-the tendency to focus on promotion (vs. prevention) goals and time preference as measured by delay discounting: the tendency to overvalue immediate rewards over long-term ones.

BACKGROUND

The dual process theory suggests that both conscious and non-conscious processes influence the adoption of physical activity. However, the role of regulatory focus and time preference in this process was not yet examined.

DESIGN

A cross-sectional online survey among 143 nurses during August-November 2017.

METHODS

Validated measures were used to estimate physical activity habit strength (a non-conscious process) and intention, planning and behaviour control (conscious processes), physical activity level, regulatory focus and time preference. Multivariable ordered logit and logistic models were specified to examine determinants of both processes.

RESULTS

Promotion focus was positively associated with having a strong habit of physical activity among nurses with moderate-to-low activity levels, but it was negatively associated with habit for active nurses. As for time preference, higher delay discounting was negatively associated with nurses' conscious intention to adopt physical activity and with their action planning.

CONCLUSION

Promotion focus and time preference are associated with both conscious and non-conscious processes of physical activity adoption among nurses and should be considered in future health promotion interventions targeted to this population.

IMPACT

Promotion focus and time preference have a significant role in this dual process. Enhancing physical activity of health providers by adjusting the intervention to personal orientations may improve public health.

Variable Magnitude and Frequency Financial Reinforcement is Effective at Increasing Adults' Free-Living Physical Activity

Financial rewards can increase health behaviors, but little research has quantified the effects of different reinforcement schedules on this process. This analysis compares the average moderate-to-vigorous physical activity (MVPA) associated with six distinct positive reinforcement schedules implemented within a physical activity promotion clinical trial. In this trial, participants (N = 512) wore an accelerometer for 1 year and were prescribed one of two types of MVPA goals: a static 30-min goal or an adaptive goal based on the MVPA produced over the previous 9 days. As participants met goals, they transitioned through a sequence of reinforcement stages, beginning with a continuous-fixed magnitude (CRF-FM), then CRF-variable magnitude (CRF-VM), followed by a series of variable ratio-VM (VR-VM) schedules. The average accumulation of MVPA bouts over the last 24 days of each stage was compared to each other. Average MVPA during stage transitions was also examined. The results indicated that immediate reinforcement resulted in more MVPA relative to a comparison group and that the relative effectiveness of adaptive versus static goals was dependent on the magnitude of daily MVPA goals. Schedule effects were qualitatively different for individuals who frequently met their daily goals (Large Intervention Effect subgroup) versus those who did not (Small Intervention Effect subgroup). For the Large Intervention Effect group, the CRF-VM schedule produced the most MVPA, in particular within the adaptive goal condition, with increases observed immediately upon encountering this schedule. In contrast, the CRF-FM schedule produced small amounts of MVPA. This pattern was reversed for the Small Intervention Effect subgroup, where the most MVPA was associated with the CRF-FM stage. Future interventions should focus on discriminating small versus large intervention effects as quickly as possible so that the optimal reinforcement schedule can be used.

Engagement with Health Risk Assessments and Commitment to Healthy Behaviors in Michigan's Medicaid Expansion Program

BACKGROUND

Health risk assessments (HRAs) and healthy behavior incentives are increasingly used by state Medicaid programs to promote enrollees' health.

OBJECTIVE

To evaluate enrollee experiences with HRAs and healthy behavior engagement in the Healthy Michigan Plan (HMP), a state Medicaid expansion program.

DESIGN

Telephone survey conducted in Michigan January-October 2016.

PARTICIPANTS

A random sample of HMP enrollees aged 19-64 with ≥ 12 months of enrollment, stratified by income and geographic region.

MAIN MEASURES

Self-reported completion of an HRA, reasons for completing an HRA, commitment to a healthy behavior, and choice of healthy behavior.

KEY RESULTS

Among respondents (N = 4090), 49.3% (95% CI 47.3-51.2%) reported completing an HRA; among those with a primary care provider (PCP) (n = 3851), 85.2% (95% CI 83.5-86.7%) reported visiting their PCP during the last 12 months. Most enrollees having a recent PCP visit reported discussing healthy behaviors with them (91.1%, 95% CI 89.6-92.3%) and were more likely to have completed an HRA than enrollees without a recent PCP visit (52.7%, 95% CI 50.5-52.8% vs. 36.2%, 95% CI 31.7-41.1%; p < 0.01). Among enrollees completing an HRA, nearly half said they did it because their PCP suggested it (45.9%, 95% CI 43.2-48.7%), and most reported it helped their PCP understand their health needs (89.7%). Awareness of financial incentives was limited (28.1%, 95% CI 26.3-30.0%), and very few reported it as the primary reason for HRA completion (2.5%, 95% CI 1.8-3.4%). Most committed to a healthy behavior (80.7%, 95% CI 78.5-82.8%), and common behaviors chosen were nutrition/diet (57.2%, 95% CI 54.2-60.2%) and exercise/activity (52.6%, 95% CI 49.5-55.7%).

CONCLUSIONS

In the Healthy Michigan Plan, PCPs appeared influential in enrollees' completion of HRAs and healthy behavior engagement, while knowledge of financial incentives was limited. Additional study is needed to understand the relative importance of financial incentives and PCP engagement in impacting healthy behaviors in state Medicaid programs.

Validation of wearable activity monitors for real-time cadence

The purpose of this study is to establish evidence of validity for wearable activity monitors providing real-time cadence against a criterion measure. Thirty-six healthy adults, aged 18-65 years, participated in the study. Four activity monitors including 2 watch-based monitors and 2 cadence sensors attaching to shoelaces were tested. Each participant completed the study protocol consisting of 2 distinct components: (1) treadmill protocol and (2) overground protocol. Lin's concordance correlation and mean absolute percentage error (MAPE) were calculated for the comparisons between the criterion and measures of the monitors. Bland-Altman analysis was performed to determine the mean bias and 95% limits of agreement. All activity monitors showed high correlations with the criterion measures (p < .01). Lower correlations were observed at slow walking speeds in the watch-based monitors. In contrast, consistent and strong correlations were found with both cadence sensors regardless of walking speeds (p < .01). Similar patterns were observed in the MAPE scores. Greater than 90% of the participants were able to maintain prescribed walking intensity using real-time cadence. The results suggest that the wearable activity monitors are an acceptable measure of real-time cadence and provide the potential to improve intensity-based prescription of physical activity using the monitors.

A personalized behavioral intervention implementing mHealth technologies for older adults: A pilot feasibility study

Sedentary behavior has been associated with adverse health outcomes such as disturbed sleep in older adults. We conducted a single-group pretest and posttest study to evaluate the feasibility of a personalized behavioral intervention program using mobile health technology in improving physical activity and sleep in older adults. The four-week intervention included: personalized physical activity training, real-time physical activity self-monitoring, interactive prompts and feedback with a smartwatch, phone consultation with an exercise trainer and research team members, and weekly financial incentives for achieving weekly physical activity goals. Eight cognitively intact older adults were recruited and completed the study. Findings suggested that the intervention was feasible in this sample of older adults and provided favorable changes in levels of physical activity during the intervention and at post-intervention. Future studies will include a fully powered trial to evaluate the efficacy of this intervention in sedentary older adults.

Mediators of Behavior Change Maintenance in Physical Activity Interventions for Young and Middle-Aged Adults: A Systematic Review

Background

Regular physical activity is important for maintaining physical and mental health. Benefits are optimized when physical activity is maintained. Understanding causal mechanisms is important to inform future interventions.

Purpose

To investigate mediators of physical activity maintenance.

Methods

Six databases were searched (Medline, EMBASE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, and Web of Science). Eligibility criteria included adult nonclinical populations, validated measure of physical activity behavior at baseline and at least 6 months postbaseline, control/comparison group(s), and reported mediators of physical activity behavior change. Mediators were examined according to (i) formal mediation tests, (ii) mediator association with physical activity outcome, and (iii) intervention effects on mediators.

Results

There were few formal mediation tests conducted (n = 12/39 included studies), and various other methodological limitations were identified. There was some evidence that effective mediators in formal mediation tests at 6 months and later included the "behavioral processes of change" (n = 5/6). Many of the included interventions were not effective for changing targeted mediators (only 34% of 413 tests of mediator changes were significant).

Conclusions

There were a number of methodological and statistical limitations in the evidence base. In future, prespecified formal mediation tests should be carried out and could be aided by a formal framework. Social and environmental variables should be considered in addition to intrapersonal variables. Improving knowledge of how to change hypothesized mediators, based on theory and evidence, will reveal how physical activity behavior change maintenance can be achieved. Maintenance research would be enhanced by establishing a formal definition of behavior change "maintenance." PROSPERO registration: PROSPERO 2015:CRD- 42015025462.

Effect of Different Financial Incentive Structures on Promoting Physical Activity Among Adults: A Randomized Clinical Trial

IMPORTANCE

Few adults engage in recommended levels of physical activity. Financial incentives can promote physical activity, but little is known about how the structure of these incentives influences their effectiveness (eg, how incentives are disbursed over time).

OBJECTIVE

To determine if it is more effective to disburse fixed total financial incentives at a constant, increasing, or decreasing rate to encourage physical activity.

DESIGN, SETTING, AND PARTICIPANTS

A 2-week randomized clinical trial was conducted from June 2 to 15, 2014, using an online platform that automatically records daily steps of pedometer-wearing users and awards points redeemable for cash. The study population comprised 3515 adult users of the online platform in the lower 70th percentile of steps taken among all users before treatment. Data analyses were performed from August 20, 2014, to February 1, 2018. Analysis was performed on an intent-to-treat basis.

INTERVENTIONS

Participants were randomized to either a control group or to 1 of 3 intervention groups during the 2 weeks of the study. Participants in the control group received a constant daily rate of $0.00001 per step. The 3 intervention groups received a 20-fold incentive increase ($0.00020 per step) distributed differently during the 2 weeks of the study: at a constant, increasing, or decreasing rate. Reminder emails explaining incentive schedules were sent the day before the intervention and halfway through the 2-week intervention.

MAIN OUTCOMES AND MEASURES

Change in mean daily steps during the 2-week intervention and 3 weeks after the intervention. The study had 80% power to detect a difference of 280 steps per day during the intervention at α = .05.

RESULTS

The study included 3515 participants (879 in the control condition, 879 in the constant incentive condition, 881 in the increasing incentive condition, and 876 in the decreasing incentive condition). During the intervention, compared with participants in the control group, participants receiving constant incentives logged 306.7 more steps per day (95% CI, 91.5-521.9 steps; P = .005), those receiving decreasing incentives logged 96.9 more steps per day (95% CI, 15.3-178.5 steps; P = .02), and those receiving increasing incentives logged no significant change in steps per day (1.5 steps per day; 95% CI, -81.6 to 84.7 steps; P = .97). One week after the intervention, compared with participants in the control group, only participants receiving constant incentives logged significantly more steps per day (329.5; 95% CI, 20.6-638.4; P = .04). Two and 3 weeks after the intervention, there were no significant differences compared with participants in the control group. Overall, for each $1 spent, participants in the constant incentives group logged 475.4 more steps than those in the increasing incentives group and 429.3 more steps than those in the decreasing incentives group.

CONCLUSIONS AND RELEVANCE

This study found that financial incentives for physical activity were more effective during a payment period when they were offered at a constant rate rather than an increasing or decreasing rate. However, this effectiveness dissipated shortly after the incentives were removed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02154256.

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.

Chronically ill patients' preferences for a financial incentive in a lifestyle intervention. Results of a discrete choice experiment

BACKGROUND

The preferences of diabetes type 2 patients and cardiovascular disease patients for a financial incentive added to a specified combined lifestyle intervention were investigated.

METHODS

A discrete choice experiment questionnaire was filled out by 290 diabetes type 2 patients (response rate 29.9%). Panel-mixed-logit models were used to estimate the preferences for a financial incentive. Potential uptake rates of different financial incentives and relative importance scores of the included attributes were estimated. Included attributes and levels were: form of the incentive (cash money and different types of vouchers), value of the incentive (ranging from 15 to 100 euros), moment the incentive is received (start, halfway, after finishing the intervention) and prerequisite for receiving the incentive (registration, attendance or results at group or individual level).

RESULTS

Prerequisites for receiving the financial incentive were the most important attribute, according to the respondents. Potential uptake rates for different financial incentives ranged between 37.9% and 58.8%. The latter uptake rate was associated with a financial incentive consisting of cash money with a value of €100 that is handed out after completing the lifestyle program with the prerequisite that the participant attended at least 75% of the scheduled meetings.

CONCLUSIONS

The potential uptake of the different financial incentives varied between 37.9% and 58.8%. The value of the incentive does not significantly influence the potential uptake. However, the potential uptake and associated potential effect of the financial incentive is influenced by the type of financial incentive. The preferred type of incentive is €100 in cash money, awarded after completing the lifestyle program if the participant attended at least 75% of the scheduled meetings.

Physical Activity Behavior Change Driven by Engagement With an Incentive-Based App: Evaluating the Impact of Sweatcoin

Background

Physical inactivity, now the fourth leading cause of death, is a primary element of noncommunicable diseases. Despite a great number of attempts, there is still a lack of effective approaches that can motivate sedentary populations to increase their levels of physical activity over a sustained period. Incentives for exercise can provide an immediate reward for increasing activity levels, but because of limited funding to provide rewards, previous programs using this approach have only shown short-term changes in behavior. Sweatcoin (Sweatco Ltd, UK) is an app-based platform that converts physical movement into virtual currency. The currency can be exchanged for goods and services on their marketplace, providing a continuous incentive to be active. This study investigates the physical activity behavior change observed in Sweatcoin users over a 6-month period of app usage.

Objective

The aim of this study was to investigate the change in physical activity (measured using daily step count) of a sample of Sweatcoin users, the longevity of the change, and whether this change can be predicted by demographic and other lifestyle variables.

Methods

Activity data from a sample of 5892 Sweatcoin users were used to analyze daily step count. Activity change was measured in terms of the percentage change in average daily step count for each month after registration, relative to that in the 3 months before using the app. Users were grouped according to having no or negative, moderate, or high activity change. A subset of users completed a questionnaire that allowed differences between groups in terms of activity and demographic status to be investigated using regression analyses.

Results

Daily step count increased by 19% on average over the 6 months following registration (P<.001). Of the questionnaire respondents, 728 were valid responses. A multinomial logistic regression identified the key drivers of moderate and high activity behavior change relative to no or negative change based on the defined groupings. There was a clear impact of seasonality, with those registering for the app in winter (odds ratio [OR] 4.67; P=.001) and spring (OR 5.05; P=.001) being more likely to show high positive activity behavior change than those registering in summer. More striking were the results identifying those classified as overweight (measured through body mass index [BMI]; OR 1.83; P=.02) and less active (based on a self-reported scale of physical activity; OR 0.88; P=.048), being most likely to show high levels of physical activity change following registration with the app.

Conclusions

The results highlight that an incentives-based app can induce significant physical activity behavior change, sustained over a 6-month period. Importantly, the results suggest that those typically lacking motivation to exercise (sedentary and high BMI) are most likely to be incentivized to increase their activity levels.

The effect of commitment-making on weight loss and behaviour change in adults with obesity/overweight; a systematic review

Background

Adherence to weight loss interventions is crucial to successful outcomes, yet little is known about how best to improve it. This suggests a need for developing and improving adherence strategies, such as formal commitments. This review aims to identify the effect of including a commitment device alongside lifestyle interventions on weight loss, and identify the most appropriate delivery mechanisms and target behaviours.

Methods

We searched five databases and hand-searched reference lists for trials of behavioural interventions to achieve weight loss among adults with excess weight or obesity. Interventions incorporating commitment devices were included in a narrative review and meta-analysis where appropriate. Commitment devices with financial incentives were excluded.

Results

Of 2675 unique studies, ten met the inclusion criteria. Data from three randomised trials including 409 participants suggests that commitment interventions increases short-term weight loss by a mean of 1.5 kg (95% CI: 0.7, 2.4). Data from two randomised trials including 302 patients suggests that benefits were sustained at 12 months (mean difference 1.7 kg; 95% CI: 0.0, 3.4). Commitment devices appeared most successful when made publicly, and targeting diet rather than physical activity.

Conclusions

Using commitment devices, such as behavioural contracts, as part of a weight loss intervention may be useful in improving weight loss outcomes and dietary changes, at least in the short-term. However, evidence is limited and of variable quality so results must be interpreted with caution. Poor reporting of intervention details may have limited the number of identified studies. More rigorous methodology and longer term follow-ups are required to determine the effectiveness of behavioural contracts given their potential for use in public health interventions.

Younger Adolescents' Perceptions of Physical Activity, Exergaming, and Virtual Reality: Qualitative Intervention Development Study

Background

Novel strategies to promote physical activity (PA) in adolescence are required. The vEngage study aims to test whether a virtual reality (VR) exergaming intervention can engage younger adolescents (aged 13 to 15 years) with PA.

Objective

This study aimed to gather adolescents’ views of using VR to encourage PA and identify the key features they would like to see in a VR exergaming intervention via interviews.

Methods

Participants were recruited through 2 schools in London, United Kingdom. Semistructured interviews were conducted with adolescents about their views on PA and what might work to increase PA, technology, knowledge and experience of VR, and desired features in a VR exergaming intervention. Data were analyzed using Framework Analysis.

Results

A total of 31 participants aged between 13 and 15 years (58% female, 62% from nonwhite ethnicities) participated in this interview study. The vast majority had no awareness of government PA recommendations but felt they should be more thoroughly informed. All participants were positive about the use of VR in PA promotion. Rewards, increasing challenges, and a social or multiplayer aspect were identified by participants as crucial aspects to include in a VR exercise game. Barriers were related to cost of high-end systems. Being able to exercise at home was very appealing. VR exergaming was viewed as a way to overcome multiple perceived social and cultural barriers to PA, particularly for girls.

Conclusions

Key elements that should be incorporated into a VR game for health intervention were identified and described. These also included the use of rewards, novelty and enjoyment in immersive game play, multiplayer options, and real-world elements, as well as continual updates and new challenge levels. The use of VR to promote PA in adolescents is promising, but some barriers were raised.

The impact of the Luton social prescribing programme on energy expenditure: a quantitative before-and-after study

OBJECTIVES

The objective of this study was to assess the change in energy expenditure levels of service users after participation in the Luton social prescribing programme.

DESIGN

Uncontrolled before-and-after study.

SETTING

This study was set in the East of England (Luton).

PARTICIPANTS

Service users with complete covariate information and baseline measurements (n=146) were included in the analysis.

INTERVENTION

Social prescribing, which is an initiative that aims to link patients in primary care with sources of support within the community sector to improve their health, well-being and care experience. Service users were referred to 12 sessions (free of charge), usually provided by third sector organisations.

PRIMARY OUTCOME MEASURE

Energy expenditure measured as metabolic equivalent (MET) minutes per week.

RESULTS

Using a Bayesian zero-inflated negative binomial model to account for a large number of observed zeros in the data, 95% posterior intervals show that energy expenditure from all levels of physical activities increased post intervention (walking 41.7% (40.31%, 43.11%); moderate 5.0% (2.94%, 7.09%); vigorous 107.3% (98.19%, 116.20%) and total 56.3% (54.77%, 57.69%)). The probability of engaging in physical activity post intervention increased, in three of four MET physical activity levels, for those individuals who were inactive at the start of the programme. Age has a negative effect on energy expenditure from any physical activity level. Similarly, working status has a negative effect on energy expenditure in all but one MET physical activity level. No consistent pattern was observed across physical activity levels in the association between gender and energy expenditure.

CONCLUSION

This study shows that social prescribing may have the potential to increase the physical activity levels of service users and promote the uptake of physical activity in inactive patient groups. Results of this study can inform future research in the field, which could be of use for commissioners and policy makers.

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.

Combined financial incentives and behavioral weight management to enhance adherence with gestational weight gain guidelines: a randomized controlled trial

BACKGROUND

Excessive gestational weight gain, particularly among overweight and obese women, is associated with adverse perinatal outcomes. Current interventions to limit gestational weight gain have achieved only modest success.

OBJECTIVE

We sought to improve adherence to gestational weight gain guidelines with a dual intervention of financial incentives and antenatal behavioral weight management.

STUDY DESIGN

This was a prospective randomized controlled trial at a single academic medical center in which women were assigned randomly to the intervention group or standard care. The primary outcome was adherence to gestational weight gain guidelines. Secondary outcomes included total gestational weight gain, mode of delivery, birthweight, neonatal intensive care unit admission, and development of gestational diabetes mellitus and hypertensive disorders of pregnancy.

RESULTS

A total of 136 women were assigned randomly, with data available for analysis of 124 women. Gestational weight gain within the Institutes of Medicine guidelines was similar (30% vs 29%) in the intervention and standard care groups, respectively. There were no statistically significant differences in total gestational weight gain or perinatal outcomes. There was a nonstatistically significant decrease in macrosomia in the intervention compared with standard care condition.

CONCLUSION

A combined financial incentive and behavioral weight management intervention did not improve adherence to gestational weight gain guidelines. Modifications to the intervention may achieve improved results.

A Cluster-Randomized Trial on Small Incentives to Promote Physical Activity

INTRODUCTION

There has been limited research investigating whether small financial incentives can promote participation, behavior change, and engagement in physical activity promotion programs. This study evaluates the effects of two types of small financial incentives within a physical activity promotion program of a Swiss health insurance company.

STUDY DESIGN

Three-arm cluster-randomized trial comparing small personal financial incentives and charity financial incentives (10 Swiss Francs, equal to US$10.40) for each month with an average step count of >10,000 steps per day to control. Insureds' federal state of residence was the unit of randomization. Data were collected in 2015 and analyses were completed in 2018.

SETTING/PARTICIPANTS

German-speaking insureds of a large health insurer in Switzerland were invited. Invited insureds were aged ≥18 years, enrolled in complementary insurance plans and registered on the insurer's online platform.

MAIN OUTCOME MEASURES

Primary outcome was the participation rate. Secondary outcomes were steps per day, the proportion of participant days in which >10,000 steps were achieved and non-usage attrition over the first 3 months of the program.

RESULTS

Participation rate was 5.94% in the personal financial incentive group (OR=1.96, 95% CI=1.55, 2.49) and 4.98% in the charity financial incentive group (OR=1.59, 95% CI=1.25, 2.01) compared with 3.23% in the control group. At the start of the program, the charity financial group had a 12% higher chance of walking 10,000 steps per day than the control group (OR=1.68, 95% CI=1.23, 2.30), but this effect dissipated after 3 months. Steps per day and non-usage attrition did not differ significantly between the groups.

CONCLUSIONS

Small personal and charity financial incentives can increase participation in physical activity promotion programs. Incentives may need to be modified in order to prevent attrition and promote behavior change over a longer period of time.

TRIAL REGISTRATION

This study is registered at www.isrctn.com ISRCTN24436134.

Investigating Intervention Components and Exploring States of Receptivity for a Smartphone App to Promote Physical Activity: Protocol of a Microrandomized Trial

Background

Smartphones enable the implementation of just-in-time adaptive interventions (JITAIs) that tailor the delivery of health interventions over time to user- and time-varying context characteristics. Ideally, JITAIs include effective intervention components, and delivery tailoring is based on effective moderators of intervention effects. Using machine learning techniques to infer each user’s context from smartphone sensor data is a promising approach to further enhance tailoring.

Objective

The primary objective of this study is to quantify main effects, interactions, and moderators of 3 intervention components of a smartphone-based intervention for physical activity. The secondary objective is the exploration of participants’ states of receptivity, that is, situations in which participants are more likely to react to intervention notifications through collection of smartphone sensor data.

Methods

In 2017, we developed the Assistant to Lift your Level of activitY (Ally), a chatbot-based mobile health intervention for increasing physical activity that utilizes incentives, planning, and self-monitoring prompts to help participants meet personalized step goals. We used a microrandomized trial design to meet the study objectives. Insurees of a large Swiss insurance company were invited to use the Ally app over a 12-day baseline and a 6-week intervention period. Upon enrollment, participants were randomly allocated to either a financial incentive, a charity incentive, or a no incentive condition. Over the course of the intervention period, participants were repeatedly randomized on a daily basis to either receive prompts that support self-monitoring or not and on a weekly basis to receive 1 of 2 planning interventions or no planning. Participants completed a Web-based questionnaire at baseline and postintervention follow-up.

Results

Data collection was completed in January 2018. In total, 274 insurees (mean age 41.73 years; 57.7% [158/274] female) enrolled in the study and installed the Ally app on their smartphones. Main reasons for declining participation were having an incompatible smartphone (37/191, 19.4%) and collection of sensor data (35/191, 18.3%). Step data are available for 227 (82.8%, 227/274) participants, and smartphone sensor data are available for 247 (90.1%, 247/274) participants.

Conclusions

This study describes the evidence-based development of a JITAI for increasing physical activity. If components prove to be efficacious, they will be included in a revised version of the app that offers scalable promotion of physical activity at low cost.

Trial Registration

ClinicalTrials.gov NCT03384550; https://clinicaltrials.gov/ct2/show/NCT03384550 (Archived by WebCite at http://www.webcitation.org/74IgCiK3d)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11540

The economics of physical activity in low-income and middle-income countries: protocol for a systematic review

INTRODUCTION

Evidence on the economic costs of physical inactivity and the cost-effectiveness of physical activity interventions in low-income and middle-income countries (LMICs) is sparse, and fragmented where they are available. This is the first review aimed to summarise available evidence on economics of physical activity in LMICs, identify potential target variables for policy, and identify and report gaps in the current knowledge on economics of physical activity in LMICs.

METHODS AND ANALYSIS

Peer-reviewed journal articles of observational, experimental, quasi-experimental and mixed-method studies on economics of physical activity in LMICs will be identified by a search of electronic databases; Scopus, Web of Science and SPORTDiscus. Websites of WHO, the National Institute for Health and Care Excellence international, World Bank and reference lists of included studies will be searched for relevant studies. The study selection process will be a two-stage approach; title and abstract screen for inclusion, followed by a review of selected full-text articles by two independent reviewers. Disagreements will be resolved by consensus and discussion with a third reviewer. Data will be extracted using standardised piloted data extraction forms. Risk of bias will be critically appraised using standard checklists based on study designs. Descriptive synthesis of data is planned. Where relevant, summaries of studies will be classified according to type of economic analysis, country or country category, population, intervention, comparator, outcome and study design. Meta-analysis will be performed where appropriate. This protocol for systematic review is prepared according to the Preferred Reporting Items for Systematic review and Meta-analysis for Protocols -2015 statement.

ETHICS AND DISSEMINATION

Ethical approval is not obtained as original data will not be collected as part of this review. The completed review will be submitted for publication in a peer-reviewed journal and presented at conferences.

PROSPERO REGISTRATION NUMBER

CRD42018099856.

Effectiveness of financial incentives for long-acting injectable antipsychotic adherence in patients with psychotic and bipolar disorders: a systematic review protocol

REVIEW QUESTION

The question of this review is: what is the effectiveness of financial compensation for receiving a dose of long-acting injectable antipsychotic medication on the rate of medication adherence in adult patients with psychotic and bipolar disorders in an outpatient/community setting?