Study Comparing the Effectiveness of Incentives on Physical Activity Behavior in a Health Insured Population
Condition: Physical Activity Behavior; Wellness Programs
Study type: Interventional

Summary: 
      Background: Physical inactivity and increased sedentary activity are major lifestyle factors
      that contribute to increasing burden of disease globally. There is evidence that the rise in
      prevalence of non-communicable diseases (NCDs) was largely responsible for growth in private
      insurance spending between 1987 and 2002 in the USA. There is renewed interest by health
      plans to implement incentivized health promotion programs, in an effort to change health
      behavior and thereby reduce health care costs related to NCDs. However, the literature on the
      role of incentives and rewards in influencing physical activity behavior, specifically, is
      relatively sparse, and the field of behavioral economics applied to health behavior is
      relatively new.

      Most studies that have been conducted typically report findings with limited, well-defined
      incentives that are offered for a short period. These studies generally have shown a
      moderation in health care costs compared to non-participants. In a cross-sectional study of
      approximately 940,000 members of a national private health insurance, Discovery Health, the
      investigators have previously demonstrated a significant and inverse relationship between
      levels of participation in fitness-related activities and medical claims associated with
      hospital admissions. More recently, in a retrospective, longitudinal analysis over 5 yrs,
      amongst more than 300,000 members, the investigators found that participation in
      fitness-related activities increased over a 5-yr period and was associated with a
      significantly lower probability of hospital admissions and inpatient claims costs.

      Aim: The current study primarily aims to prospectively compare the effectiveness of diverse
      incentives on physical activity behavior, monthly over a 12 month period following
      registration, in a cohort of newly-enrolled, adult members of the Vitality health promotion
      program.

      Study sample and random allocation to groups: Newly enrolled adult members of the Discovery
      Health medical plan and who have, themselves, prospectively registered for the Vitality
      health promotion program, will be eligible for the study, and will be invited to participate
      by Discovery Health. This recruitment, enrollment and random allocation to groups will be
      initiated via a web-based email communication, from Discovery Health, over a period of 5
      months. A final sample of 9000 adult members will be randomly allocated by Discovery Vitality
      (with replacement) to one of six study (incentive) groups (n=1500 per group) and followed
      each month for a period of 12 months.

      The intervention arms include a Control group, in which members will be offered no additional
      incentives, other than the existing incentives, to engage in all points-earning physical
      activity. There will also be a Communication Group, in which members will be offered the base
      program and, in addition, will be sent bi-weekly communications by alternating email and text
      messaging which included information on the importance of physical activity, tips on
      accumulating "fitness points" on the base program, a status update of points earned and
      information on benefits and rewards offered.

      The incentive arms are comprised of a Direct Payment Group, a Charity Incentive Group, a
      Lottery Pay-out Group, and a Choice Group. In each case, members will be offered the base
      program and supplementary communication described above. In addition, individuals will be
      offered the equivalent of one of four possible incentive amounts depending on the level of
      participation in fitness-related activities. Enrollment will be over a period of 5 months,
      and the intervention will take place over a period of 12 months, following registration, with
      a monthly pay-out for the incentive arms of the trial.

      The following outcomes of interest will be measured:

        -  Number of new participants (registration) in the fitness programs of Vitality

        -  Points earned, as a proxy for levels of participation, for engaging in physical activity
           (gym visits)

        -  Self-reported measures of physical activity levels, smoking and healthy eating behaviors

        -  Health care claims (de-personalized) for the 12 month period following the 12 months
           intervention

        -  Survey of attitudes to incentives and rewards in the post-study questionnaire

      Ethical considerations: Ethics approval has been obtained from the University of Cape Town/
      University of Pennsylvania Research Ethics committees. Consent will be obtained from each
      subject, who agree to participate or 'opt out' and agree that their medical claims and
      utilization data may be examined in a de-personalised manner according to their group, and
      level of participation. Further, should a member choose to drop out in the course of the
      study, or refuse to participate, there will be no adverse impact on their medical plan
      coverage and they are free to withdraw without prejudice at any time during the course of the
      study.
    


Intervention name(s): Financial incentives
Intervention type(s): Behavioral
Intervention description(s): The incentive arms comprised a Direct Payment Group, a Charity Incentive Group, a Lottery Pay-out Group, and a Choice Group. Members were offered the base program and supplementary communication described above. In addition, individuals were offered the equivalent of one of four possible incentive amounts depending on the level of participation in fitness-related activities. Enrollment into the trial took place for a period of 5 months, and the intervention took place over a period of 12 months following registration.
Level 1: <150 fitness points per month - equivalent to < 1 gym visit per month - no reward, up to Level 5, which was >3000 fitness points/month - equivalent to >20 gym visits/month.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Prevention
Keywords: Physical activity; health-insured; Financial Incentives; Benefits design