| Financial health incentives, such as paying people to exercise, are being widely implemented despite limited evidence of their effectiveness. Accordingly, the objectives of this work were to (1) examine the efficacy of incentives-for-exercise in adults, (2) determine the potential for incentives to promote long-term exercise adherence (> 6 mo.) and (3) to explore incentive 'acceptability' and efficacy in cardiac rehabilitation (CR). A comprehensive CR outpatient program designed to help individuals recover from and manage their cardiovascular disease (CVD) was a suitable initial target for incentives in Canadian health care since many CVD risk factors are under behavioural control (e.g., physical inactivity). To determine the impact of incentives on exercise adherence in adults a systematic review and meta-analysis of randomized trials was conducted. In this review incentives increased exercise adherence 80% of the time, by about 12% on average (SD 5.61%, 17.50%; test for overall effect z=3.81, p<0.0001). Notably, potentially more effective incentive design features (e.g., certain vs. uncertain incentives) were identified, suggesting incentive effectiveness is influenced by program design. In a qualitative study (Chapter 4), it was determined that opinions around incentives were not necessarily negative but were contingent on incentive structures (e.g., voucher-based incentives preferred over cash). Since opinions regarding incentives appear to vary with design features, a new questionnaire was developed to facilitate the identification of more amenable incentive programs (Chapter 5). The final questionnaire comprised of 23 psychometrically sound items. In Chapter 6, results of an incentives-in-CR feasibility study are presented. In this study several methodological issues were identified that should be addressed before moving onto a confirmatory trial (e.g., low study enrollment). Notably, it is not clear whether self-determined motivation was undermined by the incentive intervention. In summary, this body of work suggests incentives may have a role to play in promoting regular exercise following CR, but further refinement of the intervention and study design are required before conducting a fully powered RCT. |
