Background: Financial incentives are a promising tool to help people increase their physical activity, but they are expensive to provide. Deposit contracts are a type of financial incentive in which participants pledge their own money. However, low uptake is a crucial obstacle to the large-scale implementation of deposit contracts. Therefore, we investigated whether (1) matching the deposit 1:1 (doubling what is deposited) and (2) allowing for customizable deposit amounts increased the uptake and short term effectiveness of a deposit contract for physical activity. Methods: In this randomized controlled trial, 137 healthy students (age M = 21.6 years) downloaded a smartphone app that provided them with a tailored step goal and then randomized them to one of four experimental conditions. The deposit contract required either a €10 fixed deposit or a customizable deposit with any amount between €1 and €20 upfront. Furthermore, the deposit was either not matched or 1:1 matched (doubled) with a reward provided by the experiment. During 20 intervention days, daily feedback on goal progress and incentive earnings was provided by the app. We investigated effects on the uptake (measured as agreeing to participate and paying the deposit) and effectiveness of behavioral adoption (measured as participant days goal achieved). Findings: Overall, the uptake of deposit contracts was 83.2%, and participants (n = 113) achieved 14.9 out of 20 daily step goals. A binary logistic regression showed that uptake odds were 4.08 times higher when a deposit was matched (p = .010) compared to when it was not matched. Furthermore, uptake odds were 3.53 times higher when a deposit was customizable (p = .022) compared to when it was fixed. Two-way ANCOVA showed that matching (p = .752) and customization (p = .143) did not impact intervention effectiveness. However, we did find a marginally significant interaction effect of deposit matching X deposit customization (p = .063, ηp2 = 0.032). Customization decreased effectiveness when deposits were not matched (p = .033, ηp2 = 0.089), but had no effect when deposits were matched (p = .776, ηp2 = 0.001). Conclusions: We provide the first experimental evidence that both matching and customization increase the uptake of a deposit contract for physical activity. We recommend considering both matching and customization to overcome lack of uptake, with a preference for customization since matching a deposit imposes significant additional costs. However, since we found indications that customizable deposits might reduce effectiveness (when the deposits are not matched), we urge for more research on the effectiveness of customizable deposit contracts. Finally, future research should investigate which participant characteristics are predictive of deposit contract uptake and effectiveness. Pre-registration: OSF Registries, https://osf.io/cgq48.

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Background: Gamification and deposit contracts (a financial incentive in which participants pledge their own money) can enhance effectiveness of mobile behavior change interventions. However, to assess their potential for improving population health, research should investigate implementation of gamified deposit contracts outside the research setting. Therefore, we analyzed data from StepBet, a smartphone application originally developed by WayBetter, Inc. Objective: To perform a naturalistic evaluation of StepBet gamified deposit contracts, for whom they work best, and under which conditions they are most effective to help increase physical activity. Methods: WayBetter provided data of StepBet participants that participated in a stepcount challenge between 2015 and 2020 (N = 72,974). StepBet challenges were offered on the StepBet smartphone application. The modal challenge consisted of a $40 deposit made prior to a 6-week challenge period during which participants needed to reach daily and weekly step goals in order to regain their deposit. Participants who met their goals also received additional earnings which were paid out from the money lost by those who failed their challenge. Challenge step goals were tailored on a 90-day historic step count retrieval that was also used as the baseline comparison for this study. Primary outcomes were increase in step count (continuous) and challenge success (dichotomous). Results: Overall, average daily step counts increased by 31.2 % (2423 steps, SD = 3462) from 7774 steps (SD = 3112) at baseline to 10,197 steps (SD = 4162) during the challenge. The average challenge success rate was 73 %. Those who succeeded in their challenge (n = 53,281) increased their step count by 44.0 % (3465 steps, SD = 3013), while those who failed their challenge (n = 19,693) decreased their step count by −5.3 % (−398 steps, SD = 3013). Challenges started as a New Year's resolution were slightly more successful (77.7 %) than those started during the rest of the year (72.6 %). Discussion: In a real-world setting, and among a large and diverse sample, participating in a gamified deposit contract challenge was associated with a large increase in step counts. A majority of challenges were successful and succeeding in a challenge was associated with a large and clinically relevant increase in step counts. Based on these findings, we recommend implementing gamified deposit contracts for physical activity where possible. An interesting avenue for future research is to explore possible setback effects among people who fail a challenge, and how setbacks can be mitigated. Pre-registration: Open Science Framework (doi:10.17605/OSF.IO/D237C).

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The authors regret that the Standard Deviation (SD) for those who failed their challenge (n = 19,693) was erroneously reported in the Abstract (page 1) and Table 2 of the Results section (page 6) as 3013 steps. The correct Standard Deviation that should have been reported there is 2993 steps. Furthermore, in the Results section under header 3.3 Exploratory Analyses (page 6) we erroneously state that exploratory analyses were performed on a subsample of 29,001 participants. The correct number that should have been reported there is 29,002 participants. The authors would like to apologise for any inconvenience caused.

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BACKGROUND: Financial incentive interventions for improving physical activity have proven to be effective but costly. Deposit contracts (in which participants pledge their own money) could be an affordable alternative. In addition, deposit contracts may have superior effects by exploiting the power of loss aversion. Previous research has often operationalized deposit contracts through loss framing a financial reward (without requiring a deposit) to mimic the feelings of loss involved in a deposit contract. OBJECTIVE: This study aimed to disentangle the effects of incurring actual losses (through self-funding a deposit contract) and loss framing. We investigated whether incentive conditions are more effective than a no-incentive control condition, whether deposit contracts have a lower uptake than financial rewards, whether deposit contracts are more effective than financial rewards, and whether loss frames are more effective than gain frames. METHODS: Healthy participants (N=126) with an average age of 22.7 (SD 2.84) years participated in a 20-day physical activity intervention. They downloaded a smartphone app that provided them with a personalized physical activity goal and either required a €10 (at the time of writing: €1=US $0.98) deposit up front (which could be lost) or provided €10 as a reward, contingent on performance. Daily feedback on incentive earnings was provided and framed as either a loss or gain. We used a 2 (incentive type: deposit or reward) × 2 (feedback frame: gain or loss) between-subjects factorial design with a no-incentive control condition. Our primary outcome was the number of days participants achieved their goals. The uptake of the intervention was a secondary outcome. RESULTS: Overall, financial incentive conditions (mean 13.10, SD 6.33 days goal achieved) had higher effectiveness than the control condition (mean 8.00, SD 5.65 days goal achieved; P=.002; ηp2=0.147). Deposit contracts had lower uptake (29/47, 62%) than rewards (50/50, 100%; P<.001; Cramer V=0.492). Furthermore, 2-way analysis of covariance showed that deposit contracts (mean 14.88, SD 6.40 days goal achieved) were not significantly more effective than rewards (mean 12.13, SD 6.17 days goal achieved; P=.17). Unexpectedly, loss frames (mean 10.50, SD 6.22 days goal achieved) were significantly less effective than gain frames (mean 14.67, SD 5.95 days goal achieved; P=.007; ηp2=0.155). CONCLUSIONS: Financial incentives help increase physical activity, but deposit contracts were not more effective than rewards. Although self-funded deposit contracts can be offered at low cost, low uptake is an important obstacle to large-scale implementation. Unexpectedly, loss framing was less effective than gain framing. Therefore, we urge further research on their boundary conditions before using loss-framed incentives in practice. Because of limited statistical power regarding some research questions, the results of this study should be interpreted with caution, and future work should be done to confirm these findings. TRIAL REGISTRATION: Open Science Framework Registries osf.io/34ygt; https://osf.io/34ygt.

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Background: Lifestyle support is essential in preventing and treating cardiovascular diseases (CVD), and eHealth may be an easy and affordable solution to provide this support. However, CVD patients vary in their ability and interest to use eHealth. This study investigates demographic characteristics determining CVD patients' online and offline lifestyle support preferences. Methods: We used a cross-sectional study design. 659 CVD patients (Harteraad panel) completed our questionnaire. We assessed demographic characteristics and preferred lifestyle support type (coach, eHealth, family/friends, self-supportive). Results: Respondents mostly preferred being self-supportive (n = 179, 27.2%), and a coach in a group or individually (n = 145, 22.0%; n = 139, 21.1%). An app/internet to work independently (n = 89, 13.5%) or being in touch with other CVD patients (n = 44, 6.7%) was least preferred. Men were more likely to prefer being supported by family/friends (p = .016) or self-supportive (p < .001), while women preferred a coach individually or via an app/internet (p < .001). Older patients mostly preferred self-support (p = .001). Patients with low social support were more likely to prefer being coached individually (p < .001), but not support from family/friends (p = .002). Conclusion: Men and older patients are more interested in being self-supportive, and patients with lower levels of social support could need extra support outside their social network. eHealth could provide a solution, but attention should be paid to spike interest for digital interventions among certain groups.

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Background: Cardiovascular diseases (CVDs) pose a significant health threat and reduce both people's life expectancy and quality of life. Healthy living is a key component in the effective prevention and treatment of CVD. However, health care professionals (HCPs) experience difficulties in supporting lifestyle changes among their patients. eHealth can provide a solution to these barriers. Objective: This study aims to provide insights into the factors HCPs find important in the support of patients with CVD in the uptake of and adherence to a healthy lifestyle and the perceived facilitators of and barriers to using eHealth to provide lifestyle support to patients with CVD. Methods: In-depth interviews were conducted with 16 Dutch HCPs specializing in lifestyle support in cardiac care. Results: We identified 13 themes, of which the first 12 concerned lifestyle support in general and were related to intervention, patient, or health care. Throughout these themes, the use of eHealth reoccurred as a potential facilitator of or solution to barriers to lifestyle support. Our final theme specifically concerned barriers to the adoption and usability of eHealth. Conclusions: HCPs do recognize the potential advantages of eHealth while experiencing barriers to using digital tools. Incorporating their needs and values in the development of lifestyle support programs, especially eHealth, could increase their use and lead to a more widespread adoption of eHealth into health care.

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Low socioeconomic status (SES) is associated with a higher prevalence of unhealthy lifestyles compared to a high SES. Health interventions that promote a healthy lifestyle, like eHealth solutions, face limited adoption in low SES groups. To improve the adoption of eHealth interventions, their alignment with the target group's attitudes is crucial. This study investigated the attitudes of people with a low SES toward health, healthcare, and eHealth. We adopted a mixed-method community-based participatory research approach with 23 members of a community center in a low SES neighborhood in the city of Rotterdam, the Netherlands. We conducted a first set of interviews and analyzed these using a grounded theory approach resulting in a group of themes. These basic themes' representative value was validated and refined by an online questionnaire involving a different sample of 43 participants from multiple community centers in the same neighborhood. We executed three focus groups to validate and contextualize the results. We identified two general attitudes based on nine profiles toward health, healthcare, and eHealth. The first general attitude, optimistically engaged, embodied approximately half our sample and involved light-heartedness toward health, loyalty toward healthcare, and eagerness to adopt eHealth. The second general attitude, doubtfully disadvantaged, represented roughly a quarter of our sample and was related to feeling encumbered toward health, feeling disadvantaged within healthcare, and hesitance toward eHealth adoption. The resulting attitudes strengthen the knowledge of the motivation and behavior of people with low SES regarding their health. Our results indicate that negative health attitudes are not as evident as often claimed. Nevertheless, intervention developers should still be mindful of differentiating life situations, motivations, healthcare needs, and eHealth expectations. Based on our findings, we recommend eHealth should fit into the person's daily life, ensure personal communication, be perceived usable and useful, adapt its communication to literacy level and life situation, allow for meaningful self-monitoring and embody self-efficacy enhancing strategies.@en

Background: Healthy living is key in the prevention and rehabilitation of cardiovascular disease (CVD). Yet, supporting and maintaining a healthy lifestyle is exceptionally difficult and people differ in their needs regarding optimal support for healthy lifestyle interventions. Objective: The goals of this study were threefold: to uncover stakeholders’ needs and preferences, to translate these to core values, and develop eHealth technology based on these core values. Our primary research question is: What type of eHealth application to support healthy living among people with (a high risk of) CVD would provide the greatest benefit for all stakeholders? Methods: User-centered design principles from the CeHRes roadmap for eHealth development were followed to guide the uncovering of important stakeholder values. Data were synthesized from various qualitative studies (i.e., literature studies, interviews, think-aloud sessions, focus groups) and usability tests (i.e., heuristic evaluation, cognitive walkthrough, think aloud study). We also developed an innovative application evaluation tool to perform a competitor analysis on 33 eHealth applications. Finally, to make sure to take into account all end-users needs and preferences in eHealth technology development, we created personas and a customer journey. Results: We uncovered 10 universal values to which eHealth-based initiatives to support healthy living in the context of CVD prevention and rehabilitation should adhere to (e.g., providing social support, stimulating intrinsic motivation, offering continuity of care). These values were translated to 14 desired core attributes and then prototype designs. Interestingly, we found that the primary attribute of good eHealth technology was not a single intervention principle, but rather that the technology should be in the form of a digital platform disseminating various interventions, i.e., a ‘one-stop-shop’. Conclusion: Various stakeholders in the field of cardiovascular prevention and rehabilitation may benefit most from utilizing one personalized eHealth platform that integrates a variety of evidence-based interventions, rather than a new tool. Instead of a one-size-fits-all approach, this digital platform should aid the matchmaking between patients and specific interventions based on personal characteristics and preferences.

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Background: A promising new approach to support lifestyle changes in patients with cardiovascular disease (CVD) is the use of financial incentives. Although financial incentives have proven to be effective, their implementation remains controversial, and ethical objections have been raised. It is unknown whether health care professionals (HCPs) involved in CVD care find it acceptable to provide financial incentives to patients with CVD as support for lifestyle change. Objective: This study aims to investigate HCPs’ perspectives on using financial incentives to support healthy living for patients with CVD. More specifically, we aim to provide insight into attitudes toward using financial incentives as well as obstacles and facilitators of implementing financial incentives in current CVD care. Methods: A total of 16 semistructured, in-depth, face-to-face interviews were conducted with Dutch HCPs involved in supporting patients with CVD with lifestyle changes. The topics discussed were attitudes toward an incentive system, obstacles to using an incentive system, and possible solutions to facilitate the use of an incentive system. Results: HCPs perceived an incentive system for healthy living for patients with CVD as possibly effective and showed generally high acceptance. However, there were concerns related to focusing too much on the extrinsic aspects of lifestyle change, disengagement when rewards are insignificant, paternalization and threatening autonomy, and low digital literacy in the target group. According to HCPs, solutions to mitigate these concerns included emphasizing intrinsic aspects of healthy living while giving extrinsic rewards, integrating social aspects to increase engagement, supporting autonomy by allowing freedom of choice in rewards, and aiming for a target group that can work with the necessary technology. Conclusions: This study mapped perspectives of Dutch HCPs and showed that attitudes are predominantly positive, provided that contextual factors, design, and target groups are accurately considered. Concerns about digital literacy in the target group are novel findings that warrant further investigation. Follow-up research is needed to validate these insights among patients with CVD.

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