Financial incentives for increasing uptake of HPV vaccinations: a randomized controlled trial.

OBJECTIVE: Uptake of human papillomavirus (HPV) vaccinations by 17- to 18-year-old girls in England is below (<35%) target (80%). This trial assesses (a) the impact of financial incentives on uptake and completion of an HPV vaccination program, and (b) whether impacts are moderated by participants' deprivation level. It also assesses the impact of incentives on decision quality to get vaccinated, as measured by attitudes toward the vaccination and knowledge of its consequences. METHOD: One thousand 16- to 18-year-old girls were invited to participate in an HPV vaccination program: 500 previously uninvited, and 500 unresponsive to previous invitations. Girls randomly received either a standard invitation letter or a letter including the offer of vouchers worth £ 45 (€ 56; $73) for undergoing 3 vaccinations. Girls attending their first vaccination appointment completed a questionnaire assessing decision quality to be vaccinated. Outcomes were uptake of the first and third vaccinations and decision quality. RESULTS: The intervention increased uptake of the first (first-time invitees: 28.4% vs. 19.6%, odds ratio [OR] = 1.63, 95% confidence interval [CI; 1.08, 2.47]; previous nonattenders: 23.6% vs. 10.4%, OR = 2.65, 95% CI [1.61, 4.38]) and third (first-time invitees: 22.4% vs. 12%, OR = 2.15, 95% CI [1.32, 3.50]; previous nonattenders: 12.4% vs. 3%, OR = 4.28, 95% CI [1.92, 9.55]) vaccinations. Impacts were not moderated by deprivation level. Decision quality was unaffected by the intervention. CONCLUSIONS: Although the intervention increased completion of HPV vaccinations, uptake remained lower than the national target, which, in addition to cost effectiveness and acceptability issues, necessitates consideration of other ways of achieving it

Impact of bottle size on in-home consumption of sugar-sweetened beverages: protocol for a feasibility and acceptability study.

BACKGROUND: Intake of free sugars in the population exceeds recommendations, with the largest source in the diet being sugar-sweetened beverages (SSBs). SSB consumption is linked to adverse health consequences and contributes to health inequalities, given greater consumption amongst the most deprived. One possible intervention is to reduce the available sizes of SSB packaging but there is an absence of evidence that this would reduce consumption. Based on evidence from studies targeting food consumption that people consume less when exposed to smaller package sizes, we hypothesise that presenting SSBs in smaller containers reduces consumption. We are planning a crossover randomised controlled trial to assess the impact of presenting a fixed volume of SSB in different bottle sizes on consumption at home. To reduce the uncertainties related to this trial, we propose a preliminary study to assess the feasibility and acceptability of the recruitment, allocation, measurement, retention and intervention procedures. METHODS/DESIGN: Households which purchase at least 2 l of regular cola drinks per week and live in Cambridgeshire, UK will have a set amount of a cola SSB (based on their typical weekly purchasing of cola) delivered to their homes each week by the research team. This total amount of cola will be packaged into bottles of one of four sizes: (i) 1500 ml, (ii) 1000 ml, (iii) 500 ml or (iv) 250 ml. A crossover design will be used in which households will each receive all four of the week-long interventions (the four different bottle sizes) over time, randomised in their order of presentation. Approximately 100 eligible households will be approached to assess the proportion interested in actively participating in the study. Of those interested, 16 will be invited to continue participation. DISCUSSION: The findings will inform the procedures for a crossover randomised controlled trial assessing the impact of presenting a fixed volume of SSB in different bottle sizes on consumption at home. The findings from such a trial are expected to provide the best estimate to date of the effect of container size on beverage consumption and inform ongoing scientific and policy discussions about the effectiveness of this intervention at reducing population intake of free sugars in beverages. TRIAL REGISTRATION: ISRCTN14964130.This is the final version of the article. It first appeared from BioMed Central at http://dx.doi.org/10.1186/s40814-015-0037-8

Impact of sit-stand desks at work on energy expenditure and sedentary time: protocol for a feasibility study

This is the final version of the article. It first appeared from BioMed Central via http://dx.doi.org/10.1186/s40814-016-0071-1${\bf Background:}$ Prolonged sitting, an independent risk factor for disease development and premature mortality, is increasing in prevalence in high- and middle-income countries, with no signs of abating. Adults in such countries spend the largest proportion of their day in sedentary behaviour, most of which is accumulated at work. One promising method for reducing workplace sitting is the use of sit-stand desks. However, key uncertainties remain about this intervention, related to the quality of existing studies and a lack of focus on key outcomes, including energy expenditure. We are planning a randomised controlled trial to assess the impact of sit-stand desks at work on energy expenditure and sitting time in the short and longer term. To reduce the uncertainties related to the design of this trial, we propose a preliminary study to assess the feasibility and acceptability of the recruitment, allocation, measurement, retention and intervention procedures. ${\bf Methods:}$ Five hundred office-based employees from two companies in Cambridge, UK, will complete a survey to assess their interest in participating in a trial on the use of sit-stand desks at work. The workspaces of 100 of those interested in participating will be assessed for sit-stand desk installation suitability, and 20 participants will be randomised to either the use of sit-stand desks at work for 3 months or a waiting list control group. Energy expenditure and sitting time, measured via Actiheart and activPAL monitors, respectively, as well as cardio-metabolic and anthropometric outcomes and other outcomes relating to health and work performance, will be assessed in 10 randomly selected participants. All participants will also be interviewed about their experience of using the desks and participating in the study. ${\bf Discussion:}$ The findings are expected to inform the design of a trial assessing the impact of sit-stand desks at work on short and longer term workplace sitting, taking into account their impact on energy expenditure and the extent to which their use has compensation effects outside the workplace. The findings from such a trial are expected to inform discussions regarding the potential of sit-stand desks at work to alleviate the harm to cardio-metabolic health arising from prolonged sitting.This work was supported by a grant from the Department of Health Policy Research Program (Policy Research Unit in Behaviour and Health [PR-UN-0409-10109]), the Medical Research Council (Unit Programme number MC_UU_12015/3) and the British Heart Foundation (Intermediate Basic Science Research Fellowship grant FS/12/58/29709)

Wine glass size and wine sales: four replication studies in one restaurant and two bars

Funder: National Institute for Health Research; doi: http://dx.doi.org/10.13039/501100000272Abstract: Objective: Previous research suggests that wine glass size affects sales of wine in bars, with more wine purchased when served in larger glasses. The current four studies, conducted in one restaurant (Studies 1 and 2) and two bars (Studies 3 and 4) in Cambridge, England, aim to establish the reproducibility of this effect of glass size on sales. A multiple treatment reversal design was used, involving wine being served in sequential fortnightly periods in different sized glasses of the same design (290 ml, 350 ml, and 450 ml). The primary outcome was daily wine volume (ml) sold. Results: Restaurant: Daily wine volume sold was 13% (95% CI 2%, 24%) higher when served with 350 ml vs. 290 ml glasses in Study 1. A similar direction of effect was seen in Study 2 (6%; 95% CI − 1%, 15%). Bars: Daily wine volume sold was 21% (95% CI 9%, 35%) higher when served with 450 ml vs. 350 ml glasses in Study 3. This effect was not observed in Study 4 (− 7%, 95% CI − 16%, 3%). Meaningful differences were not demonstrated with any other glass comparison. These results partially replicate previous studies showing that larger glasses increase wine sales. Considerable uncertainty remains about the magnitude of any effect and the contexts in which it might occur. Trial registration Study 1: ISRCTN17958895 (21/07/2017), Study 2: ISRCTN17097810 (29/03/2018), Study 3 and 4: ISRCTN39401124 (10/05/2018

Personal financial incentives for changing habitual health-related behaviors: A systematic review and meta-analysis.

OBJECTIVES: Uncertainty remains about whether personal financial incentives could achieve sustained changes in health-related behaviors that would reduce the fast-growing global non-communicable disease burden. This review aims to estimate whether: i. financial incentives achieve sustained changes in smoking, eating, alcohol consumption and physical activity; ii. effectiveness is modified by (a) the target behavior, (b) incentive value and attainment certainty, (c) recipients' deprivation level. METHODS: Multiple sources were searched for trials offering adults financial incentives and assessing outcomes relating to pre-specified behaviors at a minimum of six months from baseline. Analyses included random-effects meta-analyses and meta-regressions grouped by timed endpoints. RESULTS: Of 24,265 unique identified articles, 34 were included in the analysis. Financial incentives increased behavior-change, with effects sustained until 18months from baseline (OR: 1.53, 95% CI 1.05-2.23) and three months post-incentive removal (OR: 2.11, 95% CI 1.21-3.67). High deprivation increased incentive effects (OR: 2.17; 95% CI 1.22-3.85), but only at >6-12months from baseline. Other assessed variables did not independently modify effects at any time-point. CONCLUSIONS: Personal financial incentives can change habitual health-related behaviors and help reduce health inequalities. However, their role in reducing disease burden is potentially limited given current evidence that effects dissipate beyond three months post-incentive removal.This research was funded by the Wellcome Trust as part of a Strategic Award in Biomedical Ethics; program title: “The Centre for the Study of Incentives in Health”; grant number: 086031/Z/08/Z; PI Prof. TM Marteau. The funder did not contribute to any part of this research.This is the final version of the article. It first appeared from Elsevier via http://dx.doi.org/10.1016/j.ypmed.2015.03.00

Does wine glass size influence sales for on-site consumption? A multiple treatment reversal design

Abstract Background Wine glass size can influence both perceptions of portion size and the amount poured, but its impact upon purchasing and consumption is unknown. This study aimed to examine the impact of wine glass size on wine sales for on-site consumption, keeping portion size constant. Methods In one establishment (with separate bar and restaurant areas) in Cambridge, England, wine glass size (Standard; Larger; Smaller) was changed over eight fortnightly periods. The bar and restaurant differ in wine sales by the glass vs. by the bottle (93 % vs. 63 % by the glass respectively). Results Daily wine volume purchased was 9.4 % (95 % CI: 1.9, 17.5) higher when sold in larger compared to standard-sized glasses. This effect seemed principally driven by sales in the bar area (bar: 14.4 % [3.3, 26.7]; restaurant: 8.2 % [−2.5, 20.1]). Findings were inconclusive as to whether sales were different with smaller vs. standard-sized glasses. Conclusions The size of glasses in which wine is sold, keeping the portion size constant, can affect consumption, with larger glasses increasing consumption. The hypothesised mechanisms for these differential effects need to be tested in a replication study. If replicated, policy implications could include considering glass size amongst alcohol licensing requirements. Trial registration ISRCTN registry: ISRCTN12018175 . Registered 12th May 2015

Impact of wine bottle and glass sizes on wine consumption at home: a within- and between- households randomized controlled trial

Background and aims: Reducing alcohol consumption across populations would decrease the risk of a range of diseases, including many cancers, cardiovascular disease and Type 2 diabetes. The aim of the current study was to estimate the impact of using smaller bottles (37.5- versus 75-cl) and glasses (290 versus 370 ml) on consuming wine at home. Design: Randomized controlled trial of households with cross-over randomization to bottle size and parallel randomization to glass size. Setting: UK households. Participants: A total of 260 households consuming at least two 75-cl bottles of wine each week, recruited from the general population through a research agency. The majority consisted of adults who were white and of higher socio-economic position. Intervention: Households were randomized to the order in which they purchased wine in 37.5- or 75-cl bottles, to consume during two 14-day intervention periods, and further randomized to receive smaller (290 ml) or larger (350 ml) glasses to use during both intervention periods. Measurements: Volume (ml) of study wine consumed at the end of each 14-day intervention period, measured using photographs of purchased bottles, weighed on study scales. Findings: Of the randomized households, 217 of 260 (83%) completed the study as per protocol and were included in the primary analysis. There was weak evidence that smaller bottles reduced consumption: after accounting for pre-specified covariates, households consumed on average 145.7 ml (3.6%) less wine when drinking from smaller bottles than from larger bottles [95% confidence intervals (CI) = –335.5 to 43. ml; −8.3 to 1.1%; P = 0.137; Bayes factor (BF) = 2.00]. The evidence for the effect of smaller glasses was stronger: households consumed on average 253.3 ml (6.5%) less wine when drinking from smaller glasses than from larger glasses (95% CI = –517 to 10 ml; −13.2 to 0.3%; P = 0.065; BF = 2.96). Conclusions: Using smaller glasses to drink wine at home may reduce consumption. Greater uncertainty remains around the possible effect of drinking from smaller bottles

Impact of bottle size on in-home consumption of sugar-sweetened beverages: a feasibility and acceptability study.

BACKGROUND: Consumption of sugars-sweetened beverages (SSB) increases energy intake and the risk of obesity. Large packages increase consumption of food, implying that smaller bottle sizes may help curb SSB consumption, but there is a lack of relevant evidence relating to these products. This study explores the feasibility and acceptability of conducting a randomised controlled trial to assess the impact of different bottle sizes on SSB consumption at home. METHODS: Households in Cambridge, England, which purchased at least 2 l of regular cola drinks per week, received a set amount of cola each week for four weeks, in bottles of one of four sizes (1500 ml, 1000 ml, 500 ml, or 250 ml) in random order. The total volume received consisted of a modest excess of households' typical weekly purchasing, but was further increased for half the study households to avoid ceiling effects. Consumption was measured by recording the number of empty bottles at the end of each week. Eligible households were invited to complete a run-in period to assess levels of active participation. RESULTS: Thirty-seven of 111 eligible households with an interest in the study completed the run-in period. The study procedures proved feasible. The target for recruitment (n = 16 households) was exceeded. Measuring consumption was feasible: over three quarters (n = 30/37) of households returned all bottles on the majority (n = 88/101) of the study weeks completed across households. The validity of this measure was compromised by guests from outside the household who drank the study cola (n = 18/37 households on 48/101 study weeks) and consumption of the study cola outside the home. Supplying enhanced volumes of cola to nine households was associated with higher consumption (11,592 ml vs 7869 ml). The intervention and study procedures were considered acceptable. Thirteen households correctly identified the study aims. CONCLUSION: The findings support the feasibility and acceptability of running a randomised controlled trial to assess the impact of presenting a fixed volume of SSB in different bottle sizes on in-home consumption. However, methods that avoid consumption being influenced by the amount of cola supplied weekly by the study and that capture out of home consumption are needed before conducting a randomised controlled trial. TRIAL REGISTRATION: ISRCTN14964130 ; Registered on 18th May, 2015