Evaluation of the Effectiveness of Behavioral Economic Incentive Programs for Goal Achievement on Healthy Diet, Weight Control and Physical Activity: A Systematic Review and Network Meta-analysis.

BACKGROUND: Healthy diet, weight control and physical activity to reduce obesity can be motivated by financial incentives (FI). Behavioral-economic approaches may improve the incentivization effectiveness. This study compares and ranks the effectiveness of standard and behavioral incentivization for healthy diet, weight control, and physical activity promotion. PURPOSE: To investigate whether behavioral-economic insights improve incentivization effectiveness. METHODS: A systematic search of Medline and Scopus was performed from database inception to December 2020. Study characteristics, program designs, and risk ratio (RR) were extracted. A two-stage network meta-analysis pooled and ranked intervention effects. RESULTS: There were 35 eligible RCTs. For diet-weight control, standard FI, deposit contract (deposit), lottery-based incentive (lottery), and standard-FI + lottery increased goal achievement compared to no-FI but only deposit was statistically significant with pooled RRs and 95% confidence intervals (CI) of 1.21 (0.94, 1.56), 1.79 (1.04, 3.05), 1.45 (0.99, 2.13), and 1.73 (0.83, 3.63). For physical activity, standard-FI, deposit, and lottery significantly increased goal achievement compared to no-FI, with pooled RRs of 1.38 (1.13, 1.68), 1.63 (1.24, 2.14) and 1.43 (1.14, 1.80), respectively. In a follow-up period for physical activity, only deposit significantly increased goal achievement compared to no-FI, with pooled RRs of 1.39 (1.11, 1.73). CONCLUSION: Deposit, followed by lottery, were best for motivating healthy diet, weight control and physical activity at program end. Post-intervention, deposit then standard-FI were best for motivating physical activity. Behavioral insights can improve incentivization effectiveness, although lottery-based approaches may offer only short-term benefit regarding physical activity. However, the imprecise intervention effects were major concerns.

Healthy diet, weight control and physical activity to reduce obesity can be motivated by financial incentives (FI). Behavioral-economic approaches may improve the effectiveness of FI programs. This study aims to investigate whether behavioral-economic insights improve incentivization effectiveness for healthy diet, weight control, and physical activity promotion. We conducted a systematic review of published randomized controlled trials (RCTs), then pooled the interested results, compared and ranked the effectiveness of standard and behavioral incentivization programs by a two-stage network meta-analysis. There were 35 eligible RCTs. For diet-weight control, standard FI, deposit contract (deposit), lottery-based incentive (lottery), and standard-FI + lottery increased goal achievement compared to no-FI but only deposit was statistically significant. For physical activity, standard-FI, deposit, and lottery significantly increased goal achievement compared to no-FI. In a follow-up period for physical activity, only deposit significantly increased goal achievement compared to no-FI. In conclusion, deposit, followed by lottery, were best for motivating healthy diet, weight control and physical activity at program end. Post-intervention, deposit then standard-FI were best for motivating physical activity. This shows that behavioral insights can improve incentivization effectiveness, although lottery-based approaches may offer only short-term benefit regarding physical activity.

Learnings from the forced transition of an industry supported educational programme for young experts in urology and oncology from face-to-face to digital during the COVID-19 pandemic.

When the COVID-19 pandemic caused face-to-face meetings to be cancelled, an industry-sponsored educational programme, designed to develop skills and expand knowledge of young experts in oncology and urology, was forced to partially move from face-to-face setting to virtual meetings. In our outcomes analysis, we aimed to better understand what drives behavioural change following a series of educational interventions based on the physical or virtual formats. Therefore, we performed a structured outcomes evaluation for each educational intervention, including the perspectives of the learner and the teaching faculty. Our main findings were that "relevance" is the strongest driver of recall, satisfaction and behavioural change. Social interactions amongst learners and between faculty and learners are possible in the digital world, and we observed a trend of the young learners in favour of digital learning, especially with improved technical platforms enabling social interaction. Other findings were that new skills are required by the teaching faculty and that hybrid formats were identified by all participants as the model of the future. When developing future educational programmes, these specific needs of learners and faculty need to be considered and offer opportunities to develop more personalised programmes in order to increase learning impact.

Testing the content for a targeted age-relevant intervention to promote cervical screening uptake in women aged 50-64 years.

OBJECTIVES: Low uptake of cervical screening in women in their 50s and 60s leaves them at elevated risk of cancer in older age. An age-targeted intervention could be an effective way to motivate older women to attend cervical screening. Our primary objective was to test the impact of different candidate messages on cervical screening intention strength. DESIGN: A cross-sectional online survey with randomized exposure to different candidate messages. METHODS: Women aged 50-64 years who were not intending to be screened when next invited were recruited through an online panel. Those meeting the inclusion criteria (n = 825) were randomized to one of three groups: (1) control group, (2) intervention group 1, (3) intervention group 2. Each intervention group saw three candidate messages. These included a descriptive social norms message, a diagram illustrating the likelihood of each possible screening outcome, a response efficacy message, a risk reduction message and an acknowledgement of the potential for screening discomfort. We tested age-targeted versions (vs. generic) of some messages. The primary outcome was screening intention strength. RESULTS: After adjusting for baseline intention, social norms (p = .425), outcome expectancy (p = .367), risk reduction (p = .090), response efficacy (p = .136) and discomfort acknowledgement messages (p = .181) had no effect on intention strength. Age-targeted messages did not result in greater intention than generic ones. CONCLUSIONS: There was no evidence that a single message used to convey social norms, outcome expectancy, risk reduction or response efficacy had an impact on intention strength for older women who did not plan to be screened in future.

Can targeting women with behavioural science 'nudges' help black men to find out more about their high risk of contracting prostate cancer?

OBJECTIVE: Prostate cancer is now deadlier than breast cancer in the UK, with more than 12,000 men dying from it in the country in 2018. Black men are nearly three times more likely to suffer prostate cancer, with one in four contracting the disease in their lifetime. Despite being a high risk group very few black men aged 45 and over visit their GP to discuss the pros and cons of screening. This is a problem as early onset of the disease presents no symptoms and when symptoms do appear, such as urinary problems, and men do visit a doctor it is often too late to reverse the cancer's spread. This study investigates using the strong social norm of wives and girlfriends being the guardian of black men's health as a way of influencing their behaviour. METHODS: Using a historically controlled study via email we tested the social norm nudge in the field with 13 Afro-Caribbean organisations across the UK. RESULTS: The trial found the social norm nudge produced a 15.5 per cent click-through rate, which was significantly higher than the historical controls. Meanwhile, the messenger effect saw a click-through rate of 38.5 per cent on men. CONCLUSION: At a national level the social norm nudge would equate to 37,315 black women taking positive action to find out more information about their husband or boyfriend's high risk of contracting prostate cancer. PRACTICE IMPLICATIONS: Use clinicians as messengers in correspondence to promote engagement with information about prostate cancer screening.

Behavioral economics informed message content in text message reminders to improve cervical screening participation: Two pragmatic randomized controlled trials.

The objective of the reported research was to assess the impact of text message (SMS) reminders and their content on cervical screening rates. Women invited for cervical screening in Northwest London from February-October 2015 were eligible. 3133 women aged 24-29 (Study 1) were randomized (1, 1) to 'no SMS' (control), or a primary care physician (PCP) endorsed SMS (SMS-PCP). 11,405 women aged 30-64 (Study 2), were randomized (1, 1:1:1:1:1:1) to either: no SMS, an SMS without manipulation (SMS), the SMS-PCP, an SMS with a total or proportionate social norm (SMS-SNT or SMS-SNP), or an SMS with a gain-framed or loss-framed message (SMS-GF and SMS-LF). The primary outcome was participation at 18 weeks. In Study 1 participation was significantly higher in the SMS-PCP arm (31.4%) compared to control (26.4%, aOR, 1.29, 95%CI: 1.09-1·51; p = 0.002). In Study 2 participation was highest in the SMS-PCP (38.4%) and SMS (38.1%) arms compared to control (34.4%), (aOR: 1.19, 95%CI: 1.03-1.38; p = 0.02 and aOR: 1.18, 95%CI: 1.02-1.37; p = 0.03, respectively). The results demonstrate that behavioral SMSs improve cervical screening participation. The message content plays an important role in the impact of SMS. The results from this trial have already been used to designing effective policy for cervical cancer screening. The NHS Cervical Screening Programme started running a London-wide screening SMS campaign which was based on the cervical screening trial described here. According to figures published by Public Health England, after six months attendance increased by 4.8%, which is the equivalent of 13,400 more women being screened at 18 weeks.

Mixed methods study of clinicians' perspectives on barriers to implementation of treat to target in psoriatic arthritis.

OBJECTIVES: In treat to target (T2T), the patient is treated to reach and maintain specified and sequentially measured goals, such as remission or low disease activity. T2T in psoriatic arthritis (PsA) has demonstrated improved clinical and patient-reported outcomes and is recommended in European guidelines. However, most clinicians do not use T2T in PsA. This study examined the barriers and enablers to implementation in practice. METHODS: Sequential mixed methods comprising a qualitative design (interviews and focus group) to inform a quantitative design (survey). Qualitative data were analysed thematically, and quantitative statistics were analysed descriptively. RESULTS: Nineteen rheumatology clinicians participated in telephone interviews or a face-to-face focus group. An overarching theme 'Complexity' (including 'PsA vs Rheumatoid Arthritis', 'Measurement' and 'Resources') and an underpinning theme 'Changes to current practice' (including 'Reluctance due to organisational factors' and 'Individual determination to make changes') were identified. 153 rheumatology clinicians responded to an online survey. Barriers included limited clinical appointment time to collect outcome data (54.5%) and lack of training in assessing skin disease (35%). Enablers included provision of a protocol (86.4%), a local implementation lead (80.9%), support in clinic to measure outcomes (83.3%) and training in T2T (69.8%). The importance of regular audit with feedback, specialist PsA clinics and a web-based electronic database linked to hospital/national information technology (IT) systems were also identified as enablers. CONCLUSIONS: Implementation of T2T in PsA requires an integrated approach to address the support, training and resource needs of individual clinicians, rheumatology teams, local IT systems and service providers to maximise success.

Treat-to-target in PsA: methods and necessity.

With increasing recognition of the high burden and impact of psoriatic arthritis (PsA) and the growing number of therapeutic options, there has been an intensifying focus on treatment strategy in recent years. In 2015, the Tight Control of Psoriatic Arthritis study confirmed the clinical benefit of using a treat-to-target approach in PsA. This randomised controlled trial found benefits in both arthritis and psoriasis disease activity as well as lower disease impact reported by patients, although participants allocated to tight control experienced a higher rate of serious adverse events. European and international recommendations support the use of a treat-to-target approach in PsA and have offered specific advice on how to do this using outcomes such as the minimal disease activity criteria. However, implementation of this approach in routine practice is low, with real-world data highlighting undertreatment as a result. Recent qualitative work with physicians in the UK has helped researchers to understand the barriers to implementation of treat-to-target in PsA. We now need to address these barriers, provide education and support to non-specialist clinicians in routine practice, and aid the translation of optimal care to the clinic.

Acceptability of risk-stratified breast screening: Effect of the order of presenting risk and benefit information.

Objective: To test whether reduced-frequency risk-stratified breast screening would be perceived more favourably by transposing the order of information on benefits and risks. Methods: After reading vignettes describing non-stratified three-yearly screening and a risk-stratified alternative with five-yearly invitations for women at low risk, 698 women completed an online survey. Participants were allocated at random to information on screening benefits followed by risks, or vice versa, and asked to state preferences for either screening system. Participants also rated perceived magnitude of screening benefits and risks, and breast cancer susceptibility. Results: Binomial logistic regression did not find order effects on preferences (p = 0.533) or perceived benefits of screening (p = 0.780). Perceived screening risks were greater when risks were presented first (p < 0.0005). Greater perceived susceptibility was associated with lower proportions preferring risk-stratified screening (15% vs. 39% in highest and lowest groups; p = 0.002), as were greater perceived screening benefits (e.g. 13% vs. 45% in highest and lowest groups; p < 0.0005). Conclusions: No information order effect on preferences was observed. Information order did affect screening risk perceptions. Efforts to improve perceptions may need to be more intensive than those tested. Women perceiving themselves as high risk or perceiving greater benefits of screening may be particularly averse to less frequent screening.

Correction: Testing the decoy effect to increase interest in colorectal cancer screening.

[This corrects the article DOI: 10.1371/journal.pone.0213668.].

Testing verbal quantifiers for social norms messages in cancer screening: evidence from an online experiment.

BACKGROUND: Studies have shown that presenting correct information about group norms to correct misperceptions of norms can influence health behaviours. In two online studies we investigated how different ways of communicating the current uptake of 43% of the English Bowel Scope Screening (BSS) programme affects intention among disinclined men and women. METHODS: In the first study, 202 participants were asked to interpret eight quantifiers for 43% uptake ('few', 'many', 'a considerable number', 'a large number', 'a great number', 'a lot', 'numerous' and 'nearly half') and to indicate how misleading they perceived each of them to be. In the second study, with 1245 participants, we compared the motivational impact of two quantifiers ('a large number' and 'nearly half' which were associated with the highest perceived uptake (48.9%) and considered least misleading in study 1 respectively) with a control message that did not contain any information on uptake, and a message which communicated actual uptake as a proportion (43%). RESULTS: While we found that both verbal quantifiers increased screening intentions compared with the control group (from 7.8 to 12.5%, aOR 1.72; 95%CI 1.00-2.96 in the case of 'a large number' and 14.3%, aOR 2.02; 95%CI 1.20-3.38 for 'nearly half'), simply communicating that 43% do the test, however, had no impact on intentions (9.9% vs. 7.8% aOR 1.25; 95%CI 0.73-2.16). CONCLUSION: Verbal quantifiers can be used to improve the perception of low uptake figures and avoid a demotivating effect.

The impact of descriptive norms on motivation to participate in cancer screening - Evidence from online experiments.

OBJECTIVE: The current study tested in two online experiments whether manipulating normative beliefs about cancer screening uptake increases intention to attend colorectal screening among previously disinclined individuals. METHODS: 2461 men and women from an Internet panel (Experiment 1 N = 1032; Experiment 2, N = 1423) who initially stated that they did not intend to take up screening were asked to guess how many men and women they believe to get screened for colorectal cancer. Across participants, we varied the presence/absence of feedback on the participant's estimate, as well as the stated proportion of men and women doing the screening test. RESULTS: Across the two experiments, we found that receiving one of the experimental messages stating that uptake is higher than estimated significantly increased the proportion of disinclined men and women becoming intenders. While, we found a positive relationship between the communicated uptake and screening intentions, we did not find evidence that providing feedback on the estimate has an added benefit. CONCLUSION: Screening intention can be effectively manipulated through a high uptake message. PRACTICE IMPLICATIONS: Communication of high screening uptake is an easy and effective way to motivate disinclined individuals to engage in colorectal cancer screening.

Testing the decoy effect to increase interest in colorectal cancer screening.

Literature on consumer choice has demonstrated that the inclusion of an inferior alternative choice (decoy) can increase interest in a target product or action. In two online studies, we tested the impact of decoys on the probability of previous non-intenders to have a screening test which could significantly lower their chances of dying of colorectal cancer. We find that the presence of a decoy increased the probability to choose screening at the target hospital (over no screening) from 39% to 54% and 37% to 59% depending on how many hospital attributes were communicated and how strongly the decoy was dominated by the target. We also show that the presence of the decoy was associated with lower levels of reported decisional complexity while not undermining information seeking and knowledge acquisition. These findings offer a 'proof of principle' that decoys have the potential to increase screening uptake without negatively influencing informed choice.

A randomised trial of the effect of appearance versus health-framed messages on engagement with an online brief screening and alcohol reduction intervention.

Objectives: To compare the impact of appearance versus health-framed messages on engagement in a brief web-based risk screening and alcohol reduction intervention. Design: Randomised trial delivered via Drinkaware's website. Visitors were exposed to appearance (n = 51,588) or health-framed messages (n = 52,639) directing them towards an AUDIT-C risk screening questionnaire. Users completing this questionnaire were given feedback on their risk level and extended frame-congruent information. Outcomes: The primary outcome is completion of the AUDIT-C questionnaire. The secondary outcome is whether the participant accessed any of four further resources. Results: The appearance-framed message led to a small but significant increase in the number of users completing the AUDIT-C compared to the health-framed message (n = 3,537, 6.86% versus n = 3,355, 6.37%, p < 0.01). Conversely, following subsequent risk feedback, users exposed to extended health-framed information were more likely to access further resources (n = 1,146, 2.17% versus n = 942, 1.83%, p < 0.01). Conclusions: Physical appearance-framed messages increased the likelihood of engagement with an online alcohol screening and brief intervention tool, whereas health-framed messages increased the likelihood of accessing further resources. This highlights the potential for the use of multi-level approaches in alcohol reduction interventions.

Impulsivity predicts weight loss after obesity surgery.

OBJECTIVE: There is evidence that executive function, and specifically inhibitory control, is related to obesity and eating behavior. The goal of this study was to determine whether personality traits and inhibitory control predict weight loss after bariatric procedures. Although the impressive weight reduction after bariatric surgery has been shown in short- and medium-term studies, the effect of personality traits on this reduction is uncertain. Specifically, the effect of impulsivity is still largely unknown. SETTING: Patients attending either a multidisciplinary information session or outpatient clinic at the Imperial Weight Management Centre were recruited with informed consent into the trial over a 4-month period from January to April 2013. Participants were invited to attend behavioral testing on an outpatient basis in a silent room invigilated by a single researcher. METHODS: Forty-five bariatric patients participated in the study (25 patients had a gastric bypass, with a mean BMI of 41.8 and age of 39.0 years; 20 had a sleeve gastrectomy, with a mean BMI of 47.2 and age of 49.0 years). All patients completed personality measures of impulsivity-Barratt's Impulsivity Scale, as well as behavioral measures of impulsivity-the stop-signal reaction-time (SSRT) task measuring inhibitory control and the temporal discounting task measuring reward processing. Those measures were examined in relation to weight loss 6 months after surgery. RESULTS: The surgical procedure and changes in the behavioral measure of inhibitory control (SSRT) were found to be significant predictors of reduction in body mass index (BMI) in patients undergoing bariatric surgery. The sleeve gastrectomy group found a reduction in BMI of 14.1%, which was significantly less than the 25% reduction in BMI in the gastric bypass group. The direction (parameter estimate) of the significant effect was positive for SSRT change, which indicates that pre- and postreduction in impulsivity predicts reduction in BMI. CONCLUSION: Impulsivity measures predict weight reduction in patients undergoing bariatric surgery. This result has implications for predicting outcomes from surgical treatments of obesity.

"Contemplating the Next Maneuver": Functional Neuroimaging Reveals Intraoperative Decision-making Strategies.

OBJECTIVE: To investigate differences in the quality, confidence, and consistency of intraoperative surgical decision making (DM) and using functional neuroimaging expose decision systems that operators use. SUMMARY BACKGROUND DATA: Novices are hypothesized to use conscious analysis (effortful DM) leading to activation across the dorsolateral prefrontal cortex, whereas experts are expected to use unconscious automation (habitual DM) in which decisions are recognition-primed and prefrontal cortex independent. METHODS: A total of 22 subjects (10 medical student novices, 7 residents, and 5 attendings) reviewed simulated laparoscopic cholecystectomy videos, determined the next safest operative maneuver upon video termination (10 s), and reported decision confidence. Video paradigms either declared ("primed") or withheld ("unprimed") the next operative maneuver. Simultaneously, changes in cortical oxygenated hemoglobin and deoxygenated hemoglobin inferring prefrontal activation were recorded using Optical Topography. Decision confidence, consistency (primed vs unprimed), and quality (script concordance) were assessed. RESULTS: Attendings and residents were significantly more certain (P < 0.001), and decision quality was superior (script concordance: attendings = 90%, residents = 78.3%, and novices = 53.3%). Decision consistency was significantly superior in experts (P < 0.001) and residents (P < 0.05) than novices (P = 0.183). During unprimed DM, novices showed significant activation of the dorsolateral prefrontal cortex, whereas this activation pattern was not observed among residents and attendings. During primed DM, significant activation was not observed in any group. CONCLUSIONS: Expert DM is characterized by improved quality, consistency, and confidence. The findings imply attendings use a habitual decision system, whereas novices use an effortful approach under uncertainty. In the presence of operative cues (primes), novices disengage the prefrontal cortex and seem to accept the observed operative decision as correct.

"Priming" hand hygiene compliance in clinical environments.

INTRODUCTION: Effective hand hygiene is the single most important procedure in preventing hospital-acquired infections. Traditional information/education-based interventions have shown only modest benefits on compliance. This study set out to investigate whether priming via olfactory and visual cues influences hand hygiene compliance. METHOD: Randomized controlled trial set in a surgical intensive care unit (SICU) at a teaching hospital in Miami, Florida. The primary outcome data involved observations-a mix of health professionals and service users were observed entering the SICU by 2 trained observers and their hand hygiene compliance was independently verified. Interventions included either an olfactory prime (clean, citrus smell) or visual prime (male or female eyes). The primary outcome measure was hand hygiene compliance (HHC) measured by the visitor using the hand gel dispenser. RESULTS: At a 5% level there was significant evidence that a clean, citrus smell significantly improves HHC (46.9% vs. 15.0%, p = .0001). Compared to the control group, a significant improvement in HHC was seen when a picture of "male eyes" was placed over the hand gel dispenser (33.3% vs. 15.0%, p < .038). No significant improvement in HHC was seen when a picture of female eyes was placed over the same hand gel dispenser (10.0% vs. 15.0%, p = .626). CONCLUSIONS: This is one of the first studies to demonstrate that priming can influence HHC in a clinical setting. The findings suggest that priming interventions could be used to change other behaviors relevant to public health.