Contributions to the literature
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Despite a global call for action and growing burden of non-communicable diseases (NCD) associated with physical inactivity, effective interventions on a sustained basis to increase community-wide physical activity (PA) remain few.
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Using an implementation science approach, we enrolled almost a million adults of all ages in a multi-level public health experiment rewarding manageable increments in daily walking over several months, within an eco-system supportive of PA and informed by on-going analytics.
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Daily PA was increased at population-level by integrating technology, behavioural economics, gamification, marketing and communications interventions with community linkages in a context- (and climate-) appropriate environment supportive of PA.
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Limitations are acknowledged.
Background
Methods
Study population
Conceptual approach and design
Interventions and modalities
Behavioural science, economics and gamification
NSC wave 1 | NSC wave 2 | NSC wave 3 | |
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Reward structure | 3 tiers of guaranteed rewards | 6 tiers of guaranteed rewards | 6 tiers of guaranteed rewards |
Rewards type Points to be redeemed for transport, food or retail purchases. | Redeemable points for achieving 5000, 7500 and 10,000 steps/day over period equivalent to 60 days > 10,000 steps - Capped at 60 points/day. | Redeemable points for achieving 5000, 7500, 10,000 steps/day over a period, equivalent to > 116 days of > 10,000 steps - Capped at 60 points/day (broken up into more tiers with smaller reward for double the effort). | Redeemable points for achieving 5000, 7500, 10,000 steps/day over a period, equivalent to > 120 days of > 10,000 steps (as in NSC2) - points capped at 40 points/day (harder to achieve each milestone). |
▪ Lucky draw ▪ Allow goal setting for participants ▪ Create positive reinforcement at each milestone | ▪ Modest lucky draw prizes and more expensive top prize offered (i.e. air ticket to New Zealand). ▪ Monthly thematic challenge in the form of fun activities such as walking trails and treasure hunts around shopping malls to keep participants engaged throughout duration of the NSC (new) | ▪ Smaller lucky draw prizes and more expensive top prize offered (i.e. SIA Business Class tickets to Stockholm). ▪ More thematic challenges; ▪ Target setting element introduced to encourage commitment (pledge & win): Pledge to achieve a daily target number of steps over a stipulated number of days to win special prizes. | |
Fitness tracker used (commercial grade accelerometer) | Actxa™ Stride wrist-worn step trackers | Actxa™ Stride fitness trackers (steps + heart rate), AB fitness, Omniband | Actxa™ Stride fitness trackers (steps + heart rate + PA intensity), Careach, Mova, Skytech, Xstep, Tempo. |
Data collection, analytics and feedback
Measures and instruments
Statistical analysis
Results
Population recruitment and characteristics
Baseline characteristics | Wave 1 (7/11/15–31/7/2016) | Wave 2 (1/10/16–31/3/2017) | Wave 3 (28/10/17–30/4/2018) | Singapore 2017 | ||||
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n | % | n | % | n | % | % | (95% CI) | |
Total individuals signed-up | 129,677 | 83% | 364,500 | 100% | 690,233 | 100% | n/a | n/a |
Participants surveyed at baseline | 101,000 | 78% | 311,000 | 85% | 611,000 | 89% | n/a | n/a |
Gender | ||||||||
Female | 59,590 | 59%* | 180,380 | 58%* | 354,380 | 58%* | 51% | (50.0–52.0) |
Male | 41,410 | 41% | 130,620 | 42% | 256,620 | 42% | 49% | (48.0–50.0) |
Age | ||||||||
17–39 years | 53,530 | 53%* | 149,280 | 48%* | 281,060 | 46%* | 39% | (38.0–40.0) |
40–49 years | 19,190 | 19% | 62,200 | 20% | 128,310 | 21%* | 19% | (18.2–19.8) |
50–59 years | 16,160 | 16%* | 49,760 | 16%* | 103,870 | 17%* | 19% | (18.2–19.8) |
60–69 years | 9090 | 9%* | 34,210 | 11%* | 73,320 | 12%* | 15% | (14.3–15.7) |
≥ 70 years | 3030 | 0.5%* | 15,550 | 5%* | 36,660 | 6% | 7% | (6.5–7.5) |
Body Mass Index**(kg/m2) | ||||||||
High risk (≥27.5) | 11,898 | 19% | 39,310 | 16%* | 81,141 | 16%* | 18% | (17.2–18.8) |
Moderate risk (23–27.4) | 21,291 | 34% | 78,621 | 32%* | 162,282 | 32%* | 35% | (34.0–36.0) |
Low risk (18.5–22.9) | 25,048 | 40% | 98,276 | 40% | 192,709 | 38%* | 40% | (39.0–41.0) |
Low weight (≤ 18.5) | 3757 | 6%* | 29,483 | 12%* | 70,998 | 14%* | 8% | (7.4–8.6) |
Non-response on bmi question | 38,380 | 38% | 65,310 | 21% | 103,870 | 17% | n/a | n/a |
Baseline physical activity | ||||||||
< 150 min/week (inactive) | 15,150 | 15%* | 14,140 | 14%* | 91,650 | 21%* | 26% | (25.1–26.9) |
Daily step count (number, sd) | 4512 | (4135) | 6221 | (5400) | 7432 | (5012) | ||
% < 5000 steps/day (sedentary) | 533 | 21% | 326 | 14% | 310 | 15% | n/a | n/a |
% ≥ 5000 steps/day (active) | 1969 | 79% | 2017 | 86% | 1716 | 85% | n/a | n/a |
Wave 1 | Wave 2 | Wave 3 | Total | |||||
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n | % (sd) | n | % (sd) | n | % (sd) | n | % | |
Enrolment cascade | ||||||||
Total number sign-ups (1) | 156,000 | 100% | 364,500 | 100% | 690,233 | 100% | 1,210,733 | 100% |
Total unique (1) individuals enrolled | 129,677 | 83% | 364,500 | 100% | 690,233 | 100% | 1,184,410 | 98% |
Total new participants | 129,677 | 83% | 169,695 | 47% | 487,369 | 71% | 927,947 | 78% |
Paired and used tracker | 77,806 | 60% | 233,280 | 64% | 448,651 | 65% | 759,738 | 64% |
Paired but no tracker use or never paired | 51,871 | 40% | 131,220 | 36% | 241,582 | 35% | 424,673 | 36% |
Challengea completers (end of rewards) | 36,000 | 28% | 150,000 | 88% | 266,000 | 55% | 452,000 | 57% |
Repeat participants (any 2 waves) | 32,645 | 25% | 141,206 | 20% | 41,306 | 3% | 215,157 | 23% |
Loyal participants (all 3 waves) | n/a | n/a | 41,306 | 41,306 | 4% | |||
Physical Activity Outcomes | ||||||||
Tracker worn pre-Challenge (days/week) | 2.4 | (2.3) | 3.9 | (2.4) | 5.3 | (1.5) | n/a | n/a |
Tracker worn in Challenge (days/week) | 5.0 | (2.2) | 5.3 | (2.1) | 6.0 | (2.0) | n/a | n/a |
Daily steps during Challenge (mean, s d) | 8675 | (5505) | 8463 | (8463) | 9077 | (5270) | n/a | n/a |
Mean difference daily steps (mean, sd) | 4163 | (1360) | 2242 | (334) | 1645 | (54) | n/a | n/a |
Population uptake across waves
Wave 1 | Wave 2 | Wave 3 | ||||||||||
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n/mean | sd | t-stat | P-value | n/mean | sd | t-stat | P-value | n/mean | sd | t-stat | P-value | |
Total individuals signed-up | 129,677 | n/a | n/a | n/a | 364,500 | n/a | n/a | n/a | 690,233 | n/a | n/a | n/a |
Total new participants | 129,677 | n/a | n/a | n/a | 169,695 | n/a | n/a | n/a | 487,369 | n/a | n/a | n/a |
All participantsa | 36,000 | 150,000 | 266,000 | |||||||||
Daily baseline steps (all participants) | 4512 | (4135) | 143.5 | p< 0.001 | 6221 | (5400) | 171.4 | p< 0.001 | 7432 | (5012) | 161.0 | p< 0.001 |
Daily steps completers (all participants) | 8675 | (5505) | 8463 | (5066) | 9077 | (5066) | ||||||
Step increase completers (Δ) (all participants) | 4163 | (1360) | 2242 | (334) | 1645 | (54) | ||||||
New participants | 36,000 | 115,000 | 114,000 | |||||||||
Daily baseline steps (new participants) | 4512 | (4135) | 143.5 | p< 0.001 | 6207 | (5400) | 150.7 | p< 0.001 | 7132 | (3706) | 120.4 | p< 0.001 |
Daily steps completers (new participants) | 8675 | (5505) | 8429 | (5066) | 8915 | (5066) | ||||||
Step increase completers (Δ) (new participants) | 4163 | (1360) | 2222 | (334) | 1783 | (1360) | ||||||
Loyalb participants | 38,000 | 38,000 | ||||||||||
Daily baseline steps (loyal participants) | 4545 | (3769) | 205.9 | p< 0.001 | 8115 | (3839) | 73.6 | p< 0.001 | 8424 | (3695) | 61.9 | p< 0.001 |
Daily steps completers (loyal participants) | 9972 | (4220) | 10,003 | (2767) | 10,011 | (3216) | ||||||
Step increase completers (Δ) (loyal participants) | 5427 | (451) | 1888 | (1072) | 1587 | (479) |