Abstract

Background: Regular physical activity (PA) is associated with reduced mortality and lower risks of many diseases, including type 2 diabetes, heart disease, and depression. Guidelines recommend adults should engage in moderate exercise, such as walking, for at least 150 minutes per week in episodes of at least 10 minutes duration. A typical adult can reach this threshold by walking 7,000 steps per day. Unfortunately, only 5% of adults in the United States meet these requirements, and more than 1 in 3 Veterans over age 45 meet the definition of physically inactive. A patient incentive program for PA may help. Behavioral economics suggests that our chronic inability to start and maintain a PA routine may be the result of “present bias,” which is a tendency to value small immediate rewards over large rewards in the distant future. For many people, the immediate gratification of a sedentary activity, such as watching television or surfing the internet, is a more powerful motivator than is the intangible satisfaction of the long-run health consequences of a physically active lifestyle. Patient incentives may overcome present bias by moving the rewards for healthy behaviors forward in time. In a patient incentive program, patients are given tangible, timely rewards for achieving specific health goals, such as walking 7,000 steps per day. Design an incentive PA program for Veterans is complicated by the fact that incentives tested in the literature differ across several dimensions, including the type of incentive (e.g., financial or non-financial), the form (e.g., lottery or loss framed), and the magnitude of the incentive. There is little evidence on what type of incentive works best for Veterans. Objectives: Our objectives are to determine the optimal design of a 12-week patient incentive program to encourage walking among physically inactive Veterans age 50-70. The primary outcomes are optimized components of the intervention, which will be tested against a usual care control group in a future, separate randomized trial. Methods: We propose to study incentives for PA in a novel form of randomized trial—A Multiphase Optimization STrategy (MOST) trial. A MOST trial is ideally suited for situations in which a proposed intervention has many potential intervention components. In the proposed screening phase of the MOST study, we will conduct a 24 factorial designed randomized trial. We enroll 128 physically inactive Veterans. Every Veteran will be given a Fitbit Inspire activity monitor and assigned to a group that receives different components of an incentive program. We will test four different incentive factors: 1) lottery vs. loss framed incentives, 2) financial vs. non- financial incentives, 3) a pre-commitment postcard reminder of patient’s stated intrinsic reason for commitment to PA vs. no pre-commitment postcard, and 4) a request for PA advice from a Veteran vs no request. The primary outcome is change in steps per week from baseline to week 24. The components derived from this screening phase will be used in a refining phase trial that establishes the optimal dose (frequency, duration, and amount) of the incentive. The optimized intervention will then be tested against a usual care control group in the confirming phase trial. The refining and confirming phase trials will be proposed in a separate, future grant submission.

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DRA: Aging, Older Veterans' Health and Care

DRE: TRL - Applied/Translational

Keywords: Exercise, Health Promotion and Education

MeSH Terms: None at this time.