Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial.

BACKGROUND: Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. The effectiveness of self-guided treatment is well established, and its use has intensified because of the COVID-19 pandemic. Engagement remains important as dose-response relationships have been observed. Platforms such as Facebook (Meta Platform, Inc), LinkedIn (Microsoft Corp), and X Corp (formerly known as Twitter, Inc) use principles of behavioral economics to increase engagement. We hypothesized that similar concepts would increase engagement in self-guided digital health. OBJECTIVE: This 3-arm randomized controlled trial aimed to test whether members of 2 digital self-health courses for anxiety and depression would engage with behavioral nudges and prompts. Our primary hypothesis was that members would click on 2 features: tips and a to-do checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in arm 2 versus social proof and present bias tips in arm 3. Our tertiary hypothesis was that rotating tips and a to-do checklist would increase completion rates. The results of this study will form a baseline for future artificial intelligence-directed research. METHODS: Overall, 13,224 new members registered between November 2021 and May 2022 for Evolution Health's self-guided treatment courses for anxiety and depression. The control arm featured a member home page without nudges or prompts. Arm 2 featured a home page with a tip-of-the-day section. Arm 3 featured a home page with a tip-of-the-day section and a to-do checklist. The research protocol for this study was published in JMIR Research Protocols on August 15, 2022. RESULTS: Arm 3 had significantly younger members (F2,4564=40.97; P<.001) and significantly more female members (χ24=92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001). CONCLUSIONS: Members engaged with behavioral nudges and prompts. The results of this study may be important because efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/37231.

An experimental investigation into whether choice architecture interventions are considered ethical.

Despite their increasing use, choice architecture interventions have faced criticism for being possibly manipulative and unethical. We empirically explore how an intervention's acceptability differs by the type of intervention used, by the domain, and by the way in which its implementation and benefits are explained. We employ a 5 × 5 × 5 factorial design with three fully crossed predictor variables: domain, type of intervention, and explanation. We measure participants' acceptance of the proposed intervention, perceived threat to autonomy and freedom of choice, and belief that the intervention will be successful. We hypothesized that acceptability of the intervention and perceived threat to autonomy will change as a function of the type of intervention used, the domain in which it is implemented, and the rationale for which its use is presented. We find that acceptability of the intervention, perceived threat to autonomy, and belief that the intervention will be successful differ by the type of intervention used and by the domain in which it is implemented. The rationale for the use of the intervention appears to change acceptability of the intervention depending on the type of intervention that is being used, and the domain in which it is implemented. Exploratory analyses were conducted to investigate differences between specific levels within factors, and interactions between factors. Given the variation in acceptability across the three factors, we believe that the discourse about the ethics of choice architecture should avoid generalizations and should instead be at the level of individual interventions in a specific situation. We conclude with a discussion about areas for future research. PROTOCOL REGISTRATION: The stage 1 protocol for this Registered Report was accepted in principle on 14 October 2022. The protocol, as accepted by the journal, can be found at: https://doi.org/10.6084/m9.figshare.21758666 .

A Randomized Trial of Behavioral Nudges Delivered Through Text Messages to Increase Influenza Vaccination Among Patients With an Upcoming Primary Care Visit.

PURPOSE: To evaluate if nudges delivered by text message prior to an upcoming primary care visit can increase influenza vaccination rates. DESIGN: Randomized, controlled trial. SETTING: Two health systems in the Northeastern US between September 2020 and March 2021. SUBJECTS: 74,811 adults. INTERVENTIONS: Patients in the 19 intervention arms received 1-2 text messages in the 3 days preceding their appointment that varied in their format, interactivity, and content. MEASURES: Influenza vaccination. ANALYSIS: Intention-to-treat. RESULTS: Participants had a mean (SD) age of 50.7 (16.2) years; 55.8% (41,771) were female, 70.6% (52,826) were White, and 19.0% (14,222) were Black. Among the interventions, 5 of 19 (26.3%) had a significantly greater vaccination rate than control. On average, the 19 interventions increased vaccination relative to control by 1.8 percentage points or 6.1% (P = .005). The top performing text message described the vaccine to the patient as "reserved for you" and led to a 3.1 percentage point increase (95% CI, 1.3 to 4.9; P < .001) in vaccination relative to control. Three of the top five performing messages described the vaccine as "reserved for you." None of the interventions performed worse than control. CONCLUSIONS: Text messages encouraging vaccination and delivered prior to an upcoming appointment significantly increased influenza vaccination rates and could be a scalable approach to increase vaccination more broadly.

Testing Behavioral Nudges and Prompts in Digital Courses for the Self-guided Treatment of Depression and Anxiety: Protocol for a 3-Arm Randomized Controlled Trial.

BACKGROUND: Despite showing strong evidence of positive outcomes, a common problem in the field of digital health is poor engagement and adherence. Non-health care, for-profit digital ventures, such as Facebook, LinkedIn, and Twitter, conduct behavioral experiments to increase user engagement. To our knowledge, digital health organizations have not published similar types of experiments in ad libitum environments, and there are limited published data indicating whether nudges and prompts can be leveraged to increase engagement with digital health interventions. OBJECTIVE: The main objective of our 3-arm randomized controlled trial is to test whether registered members in two well-established digital health courses for anxiety and depression will engage with four different types of nudges and prompts, and whether engaging with nudges and prompts increases engagement within the courses. METHODS: New members who register for the self-guided anxiety and depression courses on the Evolution Health platform will be randomized into 1 of 3 arms. The first control arm will feature a member home page without any behavioral nudges or prompts. The second arm will feature a member home page with a Tip-of-the-Day section containing directive content. Arm 3 will feature a member home page with a Tip-of-the-Day section containing social proof and present bias content. The third arm will also feature a to-do item checklist. RESULTS: The experiment was designed in August 2021 and was launched in November 2021. Initially, we will measure engagement with the tips and the to-do checklist by calculating the frequency of use by age and gender. If members do engage, we will then, according to age and gender, examine whether nudges and prompts result in higher course completion rates and whether specific types of prompts and nudges are more popular than others. CONCLUSIONS: Our 3-arm randomized controlled trial will be the first to compare four distinct types of behavioral prompts and nudges in two self-guided digital health courses that were designed to treat mental health issues. We expect the results to generate insights into which types of behavioral prompts and nudges work best in the population. If they are shown to increase engagement, the insights will then be used to apply prompts and nudges to the platform's addiction-focused courses. Based on the results of the experiment, the insights will be applied to using artificial intelligence to train the platform to recognize different usage patterns and provide specific engagement recommendations to stratified users. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37231.

Is it worth it? Cost-effectiveness analysis of a commercial physical activity app.

BACKGROUND: Government interest in investing in commercial physical activity apps has increased with little evidence of their cost-effectiveness. This is the first study to our knowledge to examine the cost-effectiveness of a commercial physical activity app (Carrot Rewards) despite there being over 100,000 in the major app stores. METHODS: A cost-effectiveness analysis was performed to calculate the incremental cost-effectiveness ratio (ICER) of the app compared to a no-intervention reference scenario using a five-year time horizon. Primary data was collected between 2016 and 2017. Data synthesis, model creation, and statistical analyses were conducted between 2019 and 2020. An age-, sex-, and geography-dependent Markov model was developed assuming a public healthcare payer perspective. A closed cohort (n = 38,452) representing the population reached by Carrot Rewards in two Canadian provinces (British Columbia, Newfoundland & Labrador) at the time of a 12-month prospective study was used. Costs and effects were both discounted at 1.5% and expressed in 2015 Canadian dollars. Subgroup analyses were conducted to compare ICERs between provinces, sexes, age groups, and engagement levels. RESULTS: Carrot Rewards had an ICER of $11,113 CAD per quality adjusted life year (QALY), well below a $50,000 CAD per QALY willingness-to-pay (WTP) threshold. Subgroup analyses revealed that the app had lower ICERs for British Columbians, females, highly engaged users, and adults aged 35-64 yrs., and was dominant for older adults (65 + yrs). Deterministic sensitivity analyses revealed that the ICER was most influenced by the relative risk of diabetes. Probabilistic sensitivity analyses revealed varying parameter estimates predominantly resulted in ICERs below the WTP threshold. CONCLUSIONS: The Carrot Rewards app was cost-effective, and dominant for older adults. These results provide, for the first time, rigorous health economic evidence for a commercial physical activity app as part of public health programming.

A megastudy of text-based nudges encouraging patients to get vaccinated at an upcoming doctor's appointment.

Many Americans fail to get life-saving vaccines each year, and the availability of a vaccine for COVID-19 makes the challenge of encouraging vaccination more urgent than ever. We present a large field experiment (N = 47,306) testing 19 nudges delivered to patients via text message and designed to boost adoption of the influenza vaccine. Our findings suggest that text messages sent prior to a primary care visit can boost vaccination rates by an average of 5%. Overall, interventions performed better when they were 1) framed as reminders to get flu shots that were already reserved for the patient and 2) congruent with the sort of communications patients expected to receive from their healthcare provider (i.e., not surprising, casual, or interactive). The best-performing intervention in our study reminded patients twice to get their flu shot at their upcoming doctor's appointment and indicated it was reserved for them. This successful script could be used as a template for campaigns to encourage the adoption of life-saving vaccines, including against COVID-19.

The organisation of spatial and temporal relations in memory.

Episodic memories are comprised of details of "where" and "when"; spatial and temporal relations, respectively. However, evidence from behavioural, neuropsychological, and neuroimaging studies has provided mixed interpretations about how memories for spatial and temporal relations are organised-they may be hierarchical, fully interactive, or independent. In the current study, we examined the interaction of memory for spatial and temporal relations. Using explicit reports and eye-tracking, we assessed younger and older adults' memory for spatial and temporal relations of objects that were presented singly across time in unique spatial locations. Explicit change detection of spatial relations was affected by a change in temporal relations, but explicit change detection of temporal relations was not affected by a change in spatial relations. Younger and older adults showed eye movement evidence of incidental memory for temporal relations, but only younger adults showed eye movement evidence of incidental memory for spatial relations. Together, these findings point towards a hierarchical organisation of relational memory. The implications of these findings are discussed in the context of the neural mechanisms that may support such a hierarchical organisation of memory.

Age-related changes to oscillatory dynamics in hippocampal and neocortical networks.

Recent models of hippocampal function have emphasized its role in relational binding - the ability to form lasting representations regarding the relations among distinct elements or items which can support memory performance, even over brief delays (e.g., several seconds). The present study examined the extent to which aging is associated with changes in the recruitment of oscillatory activity within hippocampal and neocortical regions to support relational binding performance on a short delay visuospatial memory task. Structural magnetic resonance imaging and MEG were used to characterize potential age-related changes in hippocampal volume, oscillatory activity, and subsequent memory performance, and the relationships among them. Participants were required to bind the relative visuospatial positions of objects that were presented singly across time. Subsequently, the objects were re-presented simultaneously, and participants were required to indicate whether the relative spatial positions among the objects had been maintained. Older and younger adults demonstrated similar task accuracy, and older adults had preserved hippocampal volumes relative to younger adults. Age-group differences were found in pre-stimulus theta (∼5Hz) and beta (∼20Hz) oscillations, and this pre-stimulus activity was related to hippocampal volumes in younger adults. Age-group differences were also found in the recruitment of oscillatory activity from the pre-stimulus period to the task. Only younger adults showed a task-related change in theta power that was predictive of memory performance. In contrast, older adults demonstrated task-related alpha (∼10Hz) oscillatory power changes that were not observed in younger adults. These findings provide novel evidence for the role of the hippocampus and functionally connected regions in relational binding that is disrupted in aging. The present findings are discussed in the context of current models regarding the cognitive neuroscience of aging.

Hippocampal and neocortical oscillatory contributions to visuospatial binding and comparison.

Over 50 years of research has revealed a critical role for the hippocampus in the formation of long-term declarative memories. More recent evidence has specified the functions of the hippocampus as the binding and comparison of memory representations that may be used under shorter, as well as longer, delays (Olsen, Moses, Riggs, & Ryan, 2012). Hippocampal neural oscillations (e.g., theta rhythm) have been studied extensively in animals; however, the oscillations that underlie binding, comparison, and their relationship to memory performance remain to be fully explored in humans. Here magnetoencephalography was used to examine theta oscillations within the hippocampus and cortex to address this critical gap in the literature. The task consisted of (a) an encoding phase in which participants had to integrate the relative spatial positions among 3 sequentially presented objects, (b) a delay phase, and (c) a test phase in which all study objects were presented simultaneously in novel locations, and participants had to indicate whether the relative positions had changed. Theta power in the hippocampus and medial prefrontal cortex (PFC) increased across encoding and delay periods during which binding and maintenance processes dominate, while comparison of spatial relations at test was associated with greater theta power in right lateral PFC and intraparietal sulcus for manipulated versus intact trials. Critically, relational memory was positively related to hippocampal theta power increases across the encoding period. These findings provide novel evidence for the role of hippocampal theta in the incremental formation and retention of relations across space and time.