One Size Does Not Fit All: Financial Incentives Needed to Change Physical Exercise Levels for Different Groups

This study estimated the distribution of willingness to accept (WTA) for a physical activity behavior change intervention entailing the completion of 10,000 steps/day to shed light on which levels of incentives trigger a change in behavior for different proportions of the population and for more at-risk subgroups. An online contingent valuation (CV) survey was administered to 1,130 respondents in the Basque Autonomous Community, Spain. The survey queried respondents about their physical activity levels and intention to engage in physical activity before presenting the WTA questions. Nonparametric WTA values were estimated for the whole sample and for subsamples of active, inactive, and overweight and obese people. One-quarter of respondents would engage with the hypothetical program even without payment, but if a monetary incentive was offered them, they would take it. The median WTA for committing to complete 10,000 steps/day is €0.23 for the full sample, €0.21 for active, €0.25 for inactive, and €0.23 for overweight and obese people. The WTA at 75th percentile is €4 for the full sample, €1.70 for active, €10.80 for inactive, and €5 for overweight and obese respondents. WTA is positively affected by a person’s lack of disposable time to increase their physical activity and, for inactive people, by their poor intention to become physically active.

Norms and Social Network–Centric Behavior Change Intervention (Nam Nalavazhvu) for Improved Toilet Usage in Peri-Urban Communities of Tamil Nadu: Protocol for a Cluster-Randomized Controlled Trial

Background Inconsistent toilet usage is a continuing challenge in India. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norm-centric behavior change interventions to increase toilet use in low-income settings. Objective The objective of this paper is to detail the rationale and design of an ex ante, parallel cluster-randomized trial evaluating the impact of a demand-side, norm-centric behavior change intervention on exclusive toilet use and maintenance in peri-urban Tamil Nadu, India. Methods Following formative research, we developed an evidence-based norm-centric behavior change intervention called Nam Nalavazhvu (Tamil for “our well-being”). The multilevel intervention aims to improve toilet usage by shifting empirical expectations or beliefs about other relevant people’s sanitation practices. It also provides action-oriented information to aid individuals to set goals and overcome barriers to own, consistently use, and maintain their toilets. This trial includes 76 wards in the Pudukkottai and Karur districts, where half were randomly assigned to receive the intervention and the remaining served as counterfactuals. Results We enrolled wards and conducted a baseline survey among randomly selected individuals in all 76 wards. The 1-year behavior change intervention is currently ongoing. At the endline, we will collect relevant data and compare results between study arms to determine the impacts of the Nam Nalavazhvu intervention on sanitation-related behavioral, health, and well-being outcomes and potential moderators. This study is powered to detect differences in the prevalence of exclusive toilet use between study arms. We are also conducting a process evaluation to understand the extent to which the intervention was implemented as designed, given the special pandemic context. Conclusions Findings from this trial will inform norm-centric behavior change strategies to improve exclusive toilet usage. Trial Registration ClinicalTrials.gov NCT04269824; https://www.clinicaltrials.gov/ct2/show/NCT04269824 International Registered Report Identifier (IRRID) DERR1-10.2196/24407

A Peer-to-Peer Live-Streaming Intervention for Children During COVID-19 Homeschooling to Promote Physical Activity and Reduce Anxiety and Eye Strain: Cluster Randomized Controlled Trial

Background The COVID-19 pandemic has led to worldwide school closures, with millions of children confined to online learning at home. As a result, children may be susceptible to anxiety and digital eye strain, highlighting a need for population interventions. Objective The objective of our study was to investigate whether a digital behavior change intervention aimed at promoting physical activity could reduce children’s anxiety and digital eye strain while undergoing prolonged homeschooling during the COVID-19 pandemic. Methods In this cluster randomized controlled trial, homeschooled grade 7 students at 12 middle schools in southern China were recruited through local schools and randomly assigned by the school to receive (1:1 allocation): (1) health education information promoting exercise and ocular relaxation, and access to a digital behavior change intervention, with live streaming and peer sharing of promoted activities (intervention), or (2) health education information only (control). The primary outcome was change in self-reported anxiety score. Secondary outcomes included change in self-reported eye strain and sleep quality. Results On March 16, 2020, 1009 children were evaluated, and 954 (94.5%) eligible children of consenting families were included in the intention-to-treat analysis. Children in the intervention (n=485, 6 schools) and control (n=469, 6 schools) groups were aged 13.5 (SD 0.5) years, and 52.3% (n=499) were male. The assigned interventions were completed by 896 children (intervention: n=467, 96.3%; control: n=429, 91.5%). The 2-week change in square-root–transformed self-reported anxiety scores was greater in the intervention (–0.23, 95% CI –0.27 to –0.20) vs control group (0.12, 95% CI 0.09-0.16; unadjusted difference –0.36, 95% CI –0.63 to –0.08; P=.02). There was a significant reduction in square-root–transformed eye strain in the intervention group (–0.08, 95% CI –0.10 to 0.06) compared to controls (0.07, 95% CI 0.05-0.09; difference –0.15, 95% CI –0.26 to –0.03; P=.02). Change in sleep quality was similar between the two groups. Conclusions This digital behavior change intervention reduced children’s anxiety and eye strain during COVID-19–associated online schooling. Trial Registration ClinicalTrials.gov NCT04309097; http://clinicaltrials.gov/ct2/show/NCT04309097

Informing Content and Feature Design of a Parent-Focused HPV Vaccination Digital Behavior Change Intervention: Synchronous Text-Based Focus Groups (Preprint)

BACKGROUND Human papillomavirus is a common and preventable sexually transmitted infection but vaccination rates in the U.S. among the target age group, 11-12 years old, are lower than national goals. Interventions that address the barriers and facilitators to vaccination are important in improving HPV vaccination rates. Online text-based focus groups are becoming a promising method that may be well-suited for conducting formative research to inform the design of digital behavior change intervention content and features that address HPV vaccination decision making. OBJECTIVE This study explores parental HPV vaccination decision-making processes using an online text-based focus group protocol in order to inform content and feature recommendations for an HPV prevention digital behavior change intervention. METHODS We conducted four online text-based synchronous focus groups via Skype with parents of 11-13-year-old patients within a large urban U.S. pediatric clinic network. RESULTS The 22 parents were majority female, white non-Hispanic, had a graduate or professional degree and had private health insurance for their children. Fifty-six percent of the parents’ 11-13-year-old children had initiated HPV vaccination. Most parents had experience using Skype (82%). Parents requested a text-only chat format (47%) over an audio-visual call format (6%) for their focus group. The three main themes from the qualitative data were (1) HPV vaccination misinformation and confusion; (2) HPV beliefs and attitudes; and (3) facilitators to vaccination. Eleven intervention content and feature recommendations emerged from the themes including: address HPV knowledge barriers using trusted sources; design for a family audience; focus on the framing of messages; report reputable HPV research in a digestible format; and expand the clinic visit experience. CONCLUSIONS Synchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision making. Among well-educated and well-resourced parents, there is misinformation about HPV and knowledge barriers that influence HPV attitudes and beliefs. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child’s pediatrician. In addition, parents want an enhanced clinic visit experience which lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive digital behavior change intervention to address HPV vaccination decision making among parents.