Competitions to Facilitate Health Promotion: Review and Conceptual Analysis

Process Evaluation of a Mobile Weight Loss Intervention for Truck Drivers

BACKGROUND

In a cluster-randomized trial, the Safety and Health Involvement For Truck drivers intervention produced statistically significant and medically meaningful weight loss at 6 months (-3.31 kg between-group difference). The current manuscript evaluates the relative impact of intervention components on study outcomes among participants in the intervention condition who reported for a postintervention health assessment (n = 134) to encourage the adoption of effective tactics and inform future replications, tailoring, and enhancements.

METHODS

The Safety and Health Involvement For Truck drivers intervention was implemented in a Web-based computer and smartphone-accessible format and included a group weight loss competition and body weight and behavioral self-monitoring with feedback, computer-based training, and motivational interviewing. Indices were calculated to reflect engagement patterns for these components, and generalized linear models quantified predictive relationships between participation in intervention components and outcomes.

RESULTS

Participants who completed the full program-defined dose of the intervention had significantly greater weight loss than those who did not. Behavioral self-monitoring, computer-based training, and health coaching were significant predictors of dietary changes, whereas behavioral and body weight self-monitoring was the only significant predictor of changes in physical activity. Behavioral and body weight self-monitoring was the strongest predictor of weight loss.

CONCLUSION

Web-based self-monitoring of body weight and health behaviors was a particularly impactful tactic in our mobile health intervention. Findings advance the science of behavior change in mobile health intervention delivery and inform the development of health programs for dispersed populations.

Promoting Smoking Control through Worksites in the Community Intervention Trial for Smoking Cessation (COMMIT)

This article describes the worksite intervention and assessment aspects of the COMMIT project. Following a brief review of the rationale for worksite smoking control efforts and how planning for such activities can be conducted as part of community-based interventions, we describe the COMMIT worksite protocol. All intervention communities conduct specified activities in the areas of smoking policy, motivational and incentive procedures to encourage smoking cessation, and provision of self-help materials and cessation services for employees. Assessment procedures include a computerized process objectives system, surveys of worksites in each of the 22 COMMIT communities, and work related questions on surveys of community residents. Baseline data that have informed the process objectives for the worksite channel are presented, as are examples of how intervention activities have been tailored to different communities.

Improving Participation in Worksite Wellness Programs: Comparing Health Education Classes, a Menu Approach, and Follow-up Counseling

Findings are presented from a study to compare four types of worksite wellness programs to reduce cardiovascular risks. Using a quasi-experimental design, the study was implemented in four large manufacturing plants, similar in demographic characteristics. At the end of the three-year study period, the two sites that included individual outreach and counseling had engaged about 46 percent of identified smokers and 54 percent of the overweight into smoking cessation and weight loss activities, respectively. This compares with fewer than 10 percent at the site offering health education classes only, and less than one percent at the control site. In order to achieve these results, the outreach and follow-up counseling was coupled with a menu of interventions for smoking cessation and weight loss, to accommodate the needs of people who cannot or will not participate in classes. The menu includes guided self-help, one-to-one counseling, mini-groups, and full classes.

A new health promotion model for lone workers: results of the Safety & Health Involvement For Truckers (SHIFT) pilot study

OBJECTIVE

This study was designed to evaluate the effectiveness of a new health promotion model for lone workers.

METHODS

A single group pre- or posttest design was used to evaluate intervention effectiveness for reducing body weight and increasing healthful and safe behaviors. Truck drivers (n = 29) from four companies participated in a 6-month intervention involving a weight loss and safe driving competition, computer-based training, and motivational interviewing.

RESULTS

Objectively measured body weight reduced by 7.8 lbs (DeltaSD = 11.5, Deltad = 0.68, P = 0.005), and survey measures showed significant reductions in dietary fat and sugar consumption. An objective measure of safe driving also showed significant improvement, and increases in exercise motivational stage and walking fitness approached significance.

CONCLUSIONS

Results suggest that the new intervention model is substantially more engaging and effective with truck drivers than previous education-based tactics.

Competitions and incentives for smoking cessation

BACKGROUND

Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE (January 1966 to September 2004), EMBASE (1980 to 2004/8), CINAHL (1982 to 2004/8) and PsycINFO (1872 to 2004/6). Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking for at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Fifteen studies met our inclusion criteria. None of the studies demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. There was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that different types of incentives were more or less effective. There is some evidence that although cessation rates have not been shown to differ significantly, recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis is not appropriate to this review, since the efficacy of the intervention has not been demonstrated.

AUTHORS' CONCLUSIONS

Incentives and competitions do not appear to enhance long-term cessation rates, with early success tending to dissipate when the rewards are no longer offered. Rewarding participation and compliance in contests and cessation programmes may have more potential to deliver higher absolute numbers of quitters.

Social support and readiness to make dietary changes

This article examines the relationship between reported social support and readiness to increase fruit and vegetable consumption, based on the Transtheoretical Stage of Change Model. Data were collected as part of the baseline assessments for a work site intervention study promoting increased consumption of fruits and vegetables. Among workers who did not live alone, household support was significantly higher for those of Hispanic and African American heritage than other groups, and was also higher among men, nonsmokers, and those living with adults compared to those living only with children. In multivariate analyses, coworker support was significantly associated with being in preparation compared to precontemplation/contemplation. Household support was not significantly related to readiness to change in multivariate analyses. The effectiveness of work site nutrition education interventions is likely to be enhanced by teaching participants to provide social support to coworkers and family members.

The use and impact of incentives in population-based smoking cessation programs: a review

PURPOSE

This review discusses current published literature on population-based smoking cessation interventions that involve incentives and examines whether such interventions are effective in reducing the prevalence of smoking.

SEARCH METHOD

Studies published between 1975 and Spring 1997 were identified through a computerized search of four electronic databases (MEDLINE, HEALTH, CINAHL, and PSYCINFO) and reference lists of key articles using the following key words: (smoking cessation OR quit smoking) AND (contest OR competition OR incentive OR lottery OR quit and win). This search yielded 79 articles. To be included, studies had to be published in English and had to have presented either quit rates or participation rates for an incentive-based program that used population-based recruitment. Of the 79 articles, 17 met these criteria.

FINDINGS

Population-based interventions generally attract 1 to 2% of the target population, but these participation rates can potentially be increased through the use of innovative recruitment techniques. No specific type of recruitment strategy was shown to be consistently more effective than others. There is no evidence that particular types of incentives are able to influence participation or quit rates, but the size of an incentive does appear to be important, with larger incentives viewed as more effectively motivating smokers to quit and stay smoke free than smaller ones. Estimates of the cost per quitter have ranged from less than $20 to over $400. There are some indications that the costs of such programs compare favorably with smoking cessation classes or clinic-based approaches.

CONCLUSION

Incentive-based smoking cessation programs that target an entire community have the advantage of reaching a large and diverse group of smokers. They may, however, attract only smokers who are already motivated to quit. Realistically, incentive-based programs aimed at the general population can expect 1% of all their smokers to quit smoking. Quit rates among participants may initially be high (i.e., mean quit rate of 34% at 1-month follow-up) but decrease over time (i.e., mean rate of 23% at 1 year). The results of this review suggest a continued need to establish standard and valid criteria for the evaluation of smoking cessation interventions. Methodological differences among existing studies make them difficult to compare and interpret.

Results of a year-long incentives-based worksite smoking-cessation program

This study evaluated the impact of a year-long incentives-based worksite smoking-cessation program. Nineteen moderate-sized worksites, employing a total of approximately 1100 smokers, were randomized to Incentive or No Incentive conditions. All identified smokers in the worksite were considered as subjects, whether or not they participated in the intervention. Analyses were conducted at both the worksite and individual level, and using both self-reported and biochemically validated cessation as endpoints. The incentive program did not significantly improve cessation rates at either the 1-year or 2-year follow-up assessments. We conclude that more broadly focused interventions that also address worksite smoking policies, skills training, and cessation resources, or programs that target additional risk factors are needed to substantially enhance quit rates.

Teaching and social support: effects on knowledge, attitudes, and behaviors to prevent low back injuries in industry

An educational program designed to reduce low back injuries was modeled after several well-known back schools and taught to postal workers in a randomized trial of about 4,000 workers. Physical therapists taught 3 hours of class sessions, including knowledge, skills, and individual work station assessment, to small groups of workers and supervisors, with reinforcement every 6 months afterward. At 2 1/2 years, a random sample of 209 workers was surveyed for program impact on intermediate outcomes. We observed increased knowledge among experimental unit workers, but no significant improvements in behaviors associated with back health or in proportion of workers with tired backs. Experimental unit workers who had received training by the time of the survey were less likely to report helping/reinforcement for healthy behaviors than controls or untrained experimental unit workers. The program might have led trained workers to perceive a lack of support and reinforcement for back safety among coworkers and supervisors by sensitizing them to what is possible and raising expectations. There appeared to be group social effects in the dissemination of knowledge and perhaps of helpful behaviors; however, it is apparent that worker social support for change in health behaviors is a complex phenomenon that cannot always be relied upon to enhance program goals.

The impact of incentives and competitions on participation and quit rates in worksite smoking cessation programs

PURPOSE

The purpose of this review is to determine whether incentive-based programs conducted at worksites increase participation and long-term smoking cessation rates.

METHODS

Published studies of workplace smoking cessation programs involving incentives and competition were identified through all available years up to winter of 1992 in MEDLINE (1966-1992), Psychlit (1967-1992), Smoking and Health (1960-1992), and Combined Health Information (1973-1992) computer databases and article reference lists. Programs were considered incentive programs when they involved either cash or other prizes paid to the participant for quitting smoking. Incentive competition programs typically involve groups contesting for prizes by having the greatest smoking cessation rates. Thirty studies were found, out of which 15 quasi-experimental and experimental studies are reviewed. The 15 studies that did not have comparison groups were excluded from this report.

RESULTS

Only eight studies had a comparison group in which the effects of incentives and competition were separated from the effects of other interventions. Only one study separated the effects of competition from incentives. Five of these studies evaluated smoking rates after six months, and three after 12 months from the program start. Three of these studies showed that incentives increased participation rates, and five enhanced smoking reduction. No study showed, however, that incentives and/or competition enhanced smoking cessation past six months.

CONCLUSIONS

It appears that incentives/competition may be useful for increasing participation and smoking reduction. Further research needs to be conducted to determine whether incentives and/or competition enhance long-term quit rates, and what are the most effective types of incentive procedures.

Implementing a year-long, worksite-based incentive program for smoking cessation

BACKGROUND

There have been few reports of the process of implementing ongoing worksite health promotion programs. This article describes the implementation of a year-long smoking cessation program in nine worksites employing a total of approximately 700 smokers.

METHODS

Issues discussed include: forming a partnership with organizations, design of the multicomponent incentive intervention, program promotion, maintaining participation, and the need to modify program components over time.

RESULTS

The program produced high participation rates (29% of smokers joined the program) and moderate cessation rates among participants (during the last half of the program, monthly cessation rates averaged 20%). There was marked variability across worksites on both participation and cessation, and qualitative features of organizations associated with outcome are discussed.

DISCUSSION

The importance of working with employee steering committees to tailor health promotion programs to fit the organization is discussed. The article concludes with recommendations for implementation of similar programs.

Worksite follow-up and engagement strategies for initiating health risk behavior changes

Information is presented from a multiplant study of interventions to improve cardiovascular health among employees. Risk factors targeted were high blood pressure, obesity, and cigarette smoking. The study utilized on-site wellness counselors who periodically contacted all employees identified through screening as having one or more of the three risks. Use of a structured protocol for client outreach resulted in the large majority of clients being seen in follow-up during the three-year intervention period. Drawing from caseload experience and from various theoretical perspectives, seven engagement strategies were used to help guide at-risk clients toward successful behavior changes to reduce health risks. Results showed that of the three at-risk groups, clients with high blood pressure were most likely to be seen in follow-up, and most likely to begin a risk reduction program. For the overweight and smokers, clients seen three or more times were more likely to begin a weight-loss/smoking cessation program than clients seen less often. Frequency of follow-up showed a positive relationship with risk reduction for all three risks, in samples of employees rescreened at the end of the intervention period, but the relationship was not statistically significant for smoking cessation.

A systematic effort to reduce smoking at the worksite

Smoking control is a key element of worksite health promotion. This three-stage study in a large state human services agency included a baseline survey, an assessment of the effects of competition on recruitment to a self-help cessation program, and examination of the outcome of the cessation program. In stage 1, scales for measuring smoking-related attitudes and the social environment were developed and used to study norms for smoking. Regression analysis was used to ascertain correlates of smokers' intentions to quit and to join a self-help program and non-smoker assertiveness. In stage 2, an evaluation using a quasi-experimental design indicated that competition was moderately effective in increasing the recruitment of all employees to the Great American Smoke-Out (70 vs. 17%) and of smokers to a self-help cessation program (28 vs. 6%). In stage 3, the self-reported quit rate at the end of the program was 28% and the biochemically-verified six months' cessation rate was 7%. Efforts are needed to strengthen, using ethical means, the norms for not smoking at the worksite and to increase both the recruitment to and the effectiveness of smoking cessation programs.

Maintaining employee participation in workplace health promotion programs

This article examines the issue of maintaining participation in workplace health promotion programs. The term "maintaining participation" is defined here as both continued program attendance and maintenance of recommended behaviors. The factors associated with participation and approaches to maintaining participation are reviewed. Evidence suggests that combinations of environmental and individual approaches are necessary to address the problem of maintenance. An approach to maintaining participation is suggested that utilizes a preprogram diagnostic interview model to identify and address environmental and individual factors that may cause an employee to drop out of a program or relapse into prior behavioral patterns.

Weight loss competitions at the worksite: how they work and how well

Three studies were conducted to evaluate the effectiveness of competition as a method of weight loss at the worksite. Study 1 found team competitions more effective than either cooperation or individual competition for men, and more effective than individual competition for women. Study 2 replicated the effectiveness of team competitions at 10 worksites. The influence of four variables [gender, age, type of employment (blue-collar vs white-collar), and method of assignment to teams] upon four outcomes (recruitment, attrition, weight loss, and cost/effectiveness), was assessed. This study showed that the results of competition were robust and widely generalizable. Recruitment was high, attrition very low, weight losses large, and cost/effectiveness favorable. Study 3, however, found only limited maintenance of weight loss following competitions.

A statewide survey of dentists' smoking cessation advice

The general practitioners of the Vermont State Dental Society (251) were surveyed in 1986 to determine their smoking cessation activities. Seventy-eight percent of the dentists completed the survey and 87% reported that they discussed concerns about smoking with their patients who smoke. They estimated spending an average of 2.4 minutes addressing cigarette smoking issues. Among those dentists who discussed smoking issues, the majority (60%) provided some advice on ways to change smoking behavior. The remaining 40% provided no guidance regarding smoking behavior change. The larger the proportion of smokers advised about smoking, the greater the dentists' interest in using incentives to help smokers make an attempt to quit.