Asymmetric Paternalism to Improve Health Behaviors

Loewenstein, George; Brennan, Troyen A.; Volpp, Kevin G.

doi:10.1001/jama.298.20.2415

Cited by 494 publications

(368 citation statements)

References 21 publications

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“…27 Financial incentives in this study were designed using insights from behavioral economics to leverage individuals' tendencies to avoid regret, overestimate small probabilities, and to be more engaged by variable reinforcement. 21,22,54 Our finding that the combined incentive was most effective suggests that team-based incentives may be better designed if they balance rewarding individual accomplishments and reinforcing accountability and peer support to the team. While individual rewards have been shown in a variety of contexts to be effective, they may have been less effective here because in the context of a team-based structure they did not provide adequate social reinforcement.…”

Section: Discussionmentioning

confidence: 94%

“…19,20 Insights from behavioral economics reveal that the design and the delivery of incentives have an important influence on their effectiveness. 21,22 Evidence also suggests that behavioral change programs may be more effective when individuals participate together, 23,24 and when they are more socially connected. 25,26 While a team-based model might enhance social incentives, 27,28 the optimal combination of individual and team-based financial incentives is unknown.…”

Section: Introductionmentioning

confidence: 99%

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Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial

et al. 2016

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BACKGROUND: More than half of adults in the United States do not attain the minimum recommended level of physical activity to achieve health benefits. The optimal design of financial incentives to promote physical activity is unknown. OBJECTIVE: To compare the effectiveness of individual versus team-based financial incentives to increase physical activity. DESIGN: Randomized, controlled trial comparing three interventions to control. PARTICIPANTS: Three hundred and four adult employees from an organization in Philadelphia formed 76 four-member teams. INTERVENTIONS: All participants received daily feedback on performance towards achieving a daily 7000 step goal during the intervention (weeks 1-13) and follow-up (weeks 14-26) periods. The control arm received no other intervention. In the three financial incentive arms, drawings were held in which one team was selected as the winner every other day during the 13-week intervention. A participant on a winning team was eligible as follows: $50 if he or she met the goal (individual incentive), $50 only if all four team members met the goal (team incentive), or $20 if he or she met the goal individually and $10 more for each of three teammates that also met the goal (combined incentive). MAIN MEASURES: Mean proportion of participantdays achieving the 7000 step goal during the intervention. KEY RESULTS: Compared to the control group during the intervention period, the mean proportion achieving the 7000 step goal was significantly greater for the com- There were no significant differences between arms during the follow-up period (weeks 14-26). CONCLUSIONS: Financial incentives rewarded for a combination of individual and team performance were most effective for increasing physical activity. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02001194.

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Section: Discussionmentioning

confidence: 94%

Section: Introductionmentioning

confidence: 99%

Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial

et al. 2016

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“…However, thus far there is limited evidence of interventions that use these devices to effectively sustain behavior change among high‐risk patients 13, 15, 16. Our previous work found that financial incentive‐based approaches that use mobile technologies can be effective in increasing physical activity,17, 18, 19 but only if they are designed to appropriately leverage insights from behavioral economics—a field that incorporates insights from psychology to design interventions that address predictable barriers to behavior change 20, 21. For example, we found that the framing of financial incentives significantly impacted their effectiveness 18.…”

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confidence: 99%

Loss‐Framed Financial Incentives and Personalized Goal‐Setting to Increase Physical Activity Among Ischemic Heart Disease Patients Using Wearable Devices: The ACTIVE REWARD Randomized Trial

Chokshi

Adusumalli

Small

et al. 2018

JAHA

124

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BackgroundRegular physical activity reduces the risk of cardiovascular events, but most ischemic heart disease (IHD) patients do not obtain enough.Methods and ResultsACTIVE REWARD (A Clinical Trial Investigating Effects of a Randomized Evaluation of Wearable Activity Trackers with Financial Rewards) was a 24‐week home‐based, remotely monitored, randomized trial with a 16‐week intervention (8‐week ramp‐up incentive phase and 8‐week maintenance incentive phase) and an 8‐week follow‐up. Patients used wearable devices to track step counts and establish a baseline. Patients in control received no other interventions. Patients in the incentive arm received personalized step goals and daily feedback for all 24 weeks. In the ramp‐up incentive phase, daily step goals increased weekly by 15% from baseline with a maximum of 10 000 steps and then remained fixed. Each week, $14 was allocated to a virtual account; $2 could be lost per day for not achieving step goals. The primary outcome was change in mean daily steps from baseline to the maintenance incentive phase. Ischemic heart disease patients had a mean (SD) age of 60 (11) years and 70% were male. Compared with control, patients in the incentive arm had a significantly greater increase in mean daily steps from baseline during ramp‐up (1388 versus 385; adjusted difference, 1061 [95% confidence interval, 386–1736]; P<0.01), maintenance (1501 versus 264; adjusted difference, 1368 [95% confidence interval, 571–2164]; P<0.001), and follow‐up (1066 versus 92; adjusted difference, 1154 [95% confidence interval, 282–2027]; P<0.01).ConclusionsLoss‐framed financial incentives with personalized goal setting significantly increased physical activity among ischemic heart disease patients using wearable devices during the 16‐week intervention, and effects were sustained during the 8‐week follow‐up.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02531022.

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“…This approach has been termed "asymmetric paternalism" because people are indeed nudged toward the ultimately beneficial choice (which would have been inaccessible to them for various reasons) but the incentive does not eliminate the choice to lead a more unhealthy life-20 style if the person chooses to do so, anyway [Loewenstein, Brennan, and Volpp 2007]. Of course, more research has to be conducted with respect to the optimal size of the incentive, i.e., identifying the point where the marginal benefit is just offset by the marginal cost, and this is fertile ground for future researchers.…”

Section: Discussionmentioning

confidence: 99%

Who responds to financial incentives for weight loss? Evidence from a randomized controlled trial

Paloyo

Reichert

Reuß‐Borst³

et al. 2015

Social Science & Medicine

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There is a paucity of evidence on the heterogeneous impacts of financial incentives on weight loss. Between March 2010 and January 2012, in a randomized controlled trial, we assigned 700 obese persons to three experimental arms. We test whether particular subgroups react differently to financial incentives for weight loss. Two treatment groups obtained a cash reward (€150 and €300 with 237 and 229 participants, respectively) for achieving an individually-assigned target weight within four months; the control group (234 participants) was not incentivized. Participants and administrators were not blinded to the intervention. We find that monetary rewards effectively induced obese individuals to reduce weight across all subgroups. However, there is no evidence for treatment-effect heterogeneity for those groups that were incentivized. Among those who were in the €300 group, statistically significant and large weight losses were observed for women, singles, and those who are not working (all above 4 kg in four months). In addition, the magnitude of the reward matters only for women and migrants. The effectiveness of financial incentives to reduce weight nevertheless raises sensitive ethical issues that should be taken into consideration by policymakers. In a randomized controlled trial involving 700 obese persons assigned to three experimental arms, we test whether financial incentives have heterogeneous effects over subgroups on weight reduction. Two treatment groups obtained a cash reward (€150 and €300 with 237 and 229 participants, respectively) for achieving an individually-assigned target weight within four months; the control group (234 participants) was not incentivized. Participants and administrators were not blinded to the intervention. We find that monetary rewards effectively induced obese individuals to reduce weight across all subgroups. However, there is no evidence for treatment-effect heterogeneity for those groups that were incentivized. Among those who were in the €300 group, statistically significant and large weight losses were observed for women, singles, and those who are not working (all above 4 kg in four months). In addition, the magnitude of the reward matters only for women and migrants.

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Asymmetric Paternalism to Improve Health Behaviors

Cited by 494 publications

References 21 publications

Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial

Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial

Loss‐Framed Financial Incentives and Personalized Goal‐Setting to Increase Physical Activity Among Ischemic Heart Disease Patients Using Wearable Devices: The ACTIVE REWARD Randomized Trial

Who responds to financial incentives for weight loss? Evidence from a randomized controlled trial

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