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The economic burden of physical inactivity in Canada is estimated at Can $6.8 billion (US $5 billion) per year. Employers bear a substantial proportion of the economic costs, as they pay more for inactive workers in health care and other organizational costs. In response, many Canadian employers offer wellness programs, though these are often underutilized. While financial health incentives have been proposed as one way of increasing participation, their longer term effects (ie postintervention effects) are not clear.
The objective of this paper is to outline the methodology for a randomized control trial (RCT) examining the longer term impact of an existing physical activity promotion program that is enhanced by adding guaranteed rewards (Can $1 [US $0.74] per day step goal met) in a lower active hospital employee population (less than 10,000 steps per day).
A 12-week, parallel-arm RCT (with a 12-week postintervention follow-up) will be employed. Employees using Change4Life (a fully automated, incentive-based wellness program) and accumulating fewer than 10,000 steps per day at baseline (weeks 1 to 2) will be randomly allocated (1:1) to standard care (wellness program, accelerometer) or an intervention group (standard care plus guaranteed incentives). All study participants will be asked to wear the accelerometer and synchronize it to Change4Life daily, although only intervention group participants will receive guaranteed incentives for reaching tailored daily step count goals (Can $1 [US $0.74] per day; weeks 3 to 12). The primary study outcome will be mean proportion of participant-days step goal reached during the postintervention follow-up period (week 24). Mean proportion of participant-days step goal reached during the intervention period (week 12) will be a secondary outcome.
Enrollment for the study will be completed in February 2017. Data analysis will commence in September 2017. Study results are to be published in the winter of 2018.
This protocol was designed to examine the impact of guaranteed rewards on physical activity maintenance in lower active hospital employees.
ClinicalTrials.gov NCT02638675; https://clinicaltrials.gov/ct2/show/NCT0 2638675 (Archived by WebCite at http://www.webcitation.org/6g4pvZvhW)
There is a substantial economic burden associated with physical inactivity in Canada [
Not surprisingly, Canadian employers bear a significant proportion of the inactivity burden because they pay more for lower active (<10,000 steps per day) workers in health care expenses [
As a result, the majority (72%) of large Canadian companies now offer wellness programs to help reduce overall health care spending and increase productivity [
Behavioral economics recognizes that human decisions are biased in systematic ways and that that these “decision biases” can be leveraged to facilitate healthy decision making [
Of the randomized controlled trials (RCTs) that have recently examined this issue [
Realizing the potential of incentives to promote sustained physical activity, therefore, will be contingent on research that improves the understanding of theoretical (eg, self-determined motivation) and contextual (eg, target group characteristics) factors that may influence incentive program effectiveness. The purpose of this protocol is to outline the design of an RCT that will examine the longer term effects of an existing physical activity promotion program that is enhanced by guaranteed incentives for lower active employees only in a real-world, ecological setting. We hypothesize that targeting lower active employees with incentives for tailored daily step goals (in addition to the generic, one-size-fits-all approach to goal setting that is typically used) may be more likely to create mastery experiences, increase confidence, and promote physical activity maintenance.
A 12-week, parallel-arm RCT with a 12-week postintervention follow-up will be employed to examine the impact of an enhanced (Can $1 [US $0.74] per day) incentive program on objectively measured physical activity among lower active employees (<10,000 steps per day) within a large Canadian hospital network. See the study flow chart in
Study flowchart.
This study will specifically target lower active employees (<10,000 steps per day). Hospital employees (including health care professionals and administrative and business support personnel) enrolled in the Change4Life program will be invited to participate via website notifications and hospital newsletters. Only data from participants who accumulate less than 10,000 steps per day during the “2-Week Run-In” period will be included in the analysis. Further eligibility criteria will include: 18 years of age or older, English speaking, ready Internet access, and without medical conditions exacerbated by physical activity as assessed by the Physical Activity Readiness Questionnaire Plus. Eligible participants will be asked to provide their expressed consent using the online consent form.
Change4Life, a Web- and incentive-based health education and behavior change program, was launched in May 2015 at the hospital network. The hospital network is offering Change4Life to 6500 full-time employees across 8 worksites. Specifically, the Web-based wellness program offers educational information relating to chronic disease prevention via learning modules (ie, series of short articles and quizzes). All employees who sign up for Change4Life are rewarded with points for completing these modules as well as for setting health-related goals, self-reporting health behaviors/outcomes, identifying barriers, and creating action plans—self-regulatory behaviors that have been theorized and empirically proven to promote sustained health behavior change (see the Change4Life Steps Study calendar in
Change4Life Steps Study calendar (ie, tracking page).
Standard care group participants will have access to Change4Life and will receive the standard minimal chance-based incentives (ie, less than 1 in 100 chance of earning Can $5 to $20 [US $3.70-$14.80] vouchers) for completing learning modules and health tasks. In addition, standard care participants will be asked to wear the accelerometer, which tracks steps and 10-minute bouts of MVPA per day, synchronize the device to the Change4Life program daily, and reach tailored daily step count goals for 10 weeks (weeks 3 to 12). Standard care participants will be instructed to increase their daily step counts by 1000 steps above their baseline average every 2 weeks until they reach the target goal of 3000 extra steps at week 7 (see
Daily step count goals across the Change4Life program.
Study week | Step count goal |
Weeks 1-2 | 2-Week Run-In (to confirm lower active status and calculate daily step count average) |
Weeks 3-4 | Increase daily steps by 1000 above baseline average |
Weeks 5-6 | Increase daily steps by 2000 above baseline average |
Weeks 7-8 | Increase daily steps by 3000 above baseline average |
Weeks 9-12 | Maintain steps at 3000 above baseline average |
The only difference between the standard care and intervention groups will be the addition of the guaranteed incentive (Can $1 [US $0.74] per day). During the intervention period (weeks 3 to 12), intervention group participants will be eligible to earn Can $1 (US $0.74) in vouchers (eg, groceries, coffee, or movies) each time tailored daily step goals are achieved. The total amount available over the intervention period will be Can $70 (US $51.82). Previous research suggests that as little as Can $6.75 (US $5) per week may be sufficient to produce favorable lifestyle health behavior changes [
The primary study outcome will be the mean proportion of participant-days that step goals are achieved during week 24 (the postintervention follow-up assessment period, T3). Mean proportion of participant-days that step goals are achieved during week 12 (intervention end point, T2) and volume of steps and 10-minute bouts of MVPA per week at T2 and T3 will be secondary outcomes. Physical activity will be objectively assessed using the StepsCount Piezo Rx accelerometer (StepsCount Inc, Deep River, ON, Canada). The Piezo Rx is a medical-grade device with a single axis piezoelectric sensor. This device has been found to be valid in calculating step counts and MVPA among adult participants [
The adherence outcome variables will be mean number of missing step count entries per week as well as mean number of Change4Life website log-ins in general. Participants’ self-determined motivation to exercise will be examined using the Behavioral Regulation to Exercise Questionnaire-3 (BREQ-3) [
Sample size calculations indicate that a final sample of 158 participants (79 per group) ensures 80% power (
Employees accumulating fewer than 10,000 steps per day during the baseline period (study weeks 1 and 2) will be randomized using a single, constant allocation ratio (1:1) to standard care or intervention groups. Randomization will occur using an online random number generator [
For each participant on each day of the study (participant-day level) continuous step count data will be obtained and screened for outliers (less than 100 steps per day, more than 50,000 steps per day) [
SPSS version 21.0 (IBM Corp) will be used to fit a generalized linear model with participant random effects, a random intercept, time-fixed effects (T1-T3), and treatment-fixed effects (by study group). A binomial distribution with logit link for models using the binary outcome will be used to estimate the adjusted difference in the proportion of participant-days step goal achieved, and the bootstrap procedure and resampling of participants will be used to obtain 95% confidence intervals and
For continuous step count (ie, mean steps per day) and bout minutes (ie, total minutes of MVPA in 10-minute bouts per week) data at T2 and T3, a generalized linear model will be used, as above, except the difference in steps per day and MVPA bout minutes between groups will be obtained using least-squares means. Also, a repeated measures analysis of variance using linear mixed models with first order autoregressive covariance structures will be used to compare changes in self-determined motivation and self-efficacy between groups. Adherence will be analyzed using
Enrollment for the study will be completed in February 2017. Data analysis will commence in September 2017. Study results are to be published in the winter of 2018.
Physical activity maintenance is critical for controlling the human and economic burden of chronic disease [
According to self-determination theory, incentives may help to build self-determined motivation primarily through their action on self-efficacy, especially for lower active people who exhibit fewer intrinsic motives to begin with (less motivation to crowd out) [
The practical implications of this research are also important given the growing popularity of incentive-based wellness programs [
This study protocol is not without limitations. First, given that only employees already enrolled in Change4Life (less than 10% of the eligible employee population) will be assessed for eligibility and invited to participate in the study, the results may not be generalizable. By recruiting only lower active Change4Life enrollees, we will learn more about how a higher risk employee population responds to incentives. Since the hallmark of Web-based health interventions is low engagement [
The objective of this study is to improve the longer term maintenance of physical activity through a better understanding of how to structure and evaluate incentive programs. Incentives are not a panacea, of course, and may not work for all people, but as part of broader package of interventions and under certain conditions incentives may have a role to play in driving sustained health behavior change.
Behavioral Regulation to Exercize Questionnaire
moderate-vigorous physical activity
Self-Efficacy for Exercise
The authors gratefully acknowledge Green Shield Canada Inc, the sponsor of this paper and the trial described within. The sponsor reviewed and approved this manuscript.
Dr Marc Mitchell reports grant support from the Canadian Institutes of Health Research and the University Health Network as well as in-kind research support from Cookson James Loyalty Inc. Further, he is president of the financial health incentive consulting company Incentive Avenue Inc and reports consulting income from Carrot Insights Inc and stock options in Carrot Insights Inc.