bmj open€¦ · 19 whilst randomised controlled trials (rcts) are regarded as the gold standard...

For peer review only

Barriers and enablers to the delivery and impact of an incentive-based behaviour change strategy targeting child

obesity: Protocol for a process evaluation

Journal: BMJ Open

Manuscript ID bmjopen-2016-012536

Article Type: Protocol

Date Submitted by the Author: 05-May-2016

Complete List of Authors: Enright, Gemma; Cardiovascular Divsion Gyani, Alex; NSW Department of Premier and Cabinet, Behavioural Insights Unit

Raadsma, Simon; NSW Department of Premier and Cabinet, Behavioural Insights Unit Allman-Farinelli, Margaret; University of Sydney, Faculty of Science Rissel, Chris; Ministry of Health, NSW Office of Preventative Health, Innes-Hughes, Christine; Ministry of Health, NSW Office of Preventative Health, Lukeis, Sarah; The Better Health Company Rodgers, Anthony; The George Institute for Global Health, Sydney Medical School, University of Sydney, Redfern, Julie; The George Institute for Global Health, Sydney Medical School, University of Sydney, Cardiovascular Division

Primary Subject

Heading: Public health

Secondary Subject Heading: Qualitative research, Health policy

Keywords: Community child health < PAEDIATRICS, PUBLIC HEALTH, QUALITATIVE RESEARCH

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Barriers and enablers to the delivery and impact of an incentive-based 1

behaviour change strategy targeting child obesity: Protocol for a process 2

evaluation 3

4

Gemma Enright1, 2, Alex Gyani2, Simon Raadsma2, Margaret Allman-Farinelli3, Chris 5

Rissel4, Christine Innes-Hughes4, Sarah Lukeis5, Anthony Rodgers1, Julie Redfern1 6

7

1 The George Institute for Global Health (Cardiovascular Division), Sydney Medical 8

School, University of Sydney, Australia 9

2 NSW Department of Premier and Cabinet, Behavioural Insights Unit, Sydney, 10

Australia 11

3 Charles Perkins Centre, University of Sydney, Australia 12

4 Ministry of Health, NSW Office of Preventative Health, Sydney, Australia 13

5 The Better Health Company, Melbourne, Australia 14

15

Corresponding author 16

Gemma Enright 17

Level 10, King George V Building, 83-117 Missenden Rd, Camperdown, NSW 18

Australia, 2050 19

T +61 2 8052 4505 20

E [email protected] 21

22

ABSTRACT 23

Introduction: Community-based weight management programs are important in 24

addressing childhood obesity. However, the mechanisms that lead to behaviour 25

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change within the programs are rarely studied within the context of the programs 1

themselves once they have been implemented. This means that further potential 2

gains in the effectiveness of the program are often not made and any potential 3

losses of efficacy are often not noticed. Qualitative research alongside randomised 4

controlled trials (RCTs) can tell us the context in which these programs are 5

implemented and elucidate potential mediators or modifiers of the programs’ 6

effectiveness. The aim of this evaluation is to evaluate the barriers and enablers to 7

the delivery and impact of an incentive-based behaviour change strategy targeting 8

child obesity to inform future translation. 9

Methods and analysis: Mixed methods qualitative analysis including stakeholder 10

and family interviews, focus groups and a survey will be used. The research will be 11

conducted in collaboration with policy makers, researchers, and community health 12

professionals. Participants will be selected from program providers, and parents/ 13

carers and children participating in an Australian community weight management 14

program during an RCT examining the effectiveness of incentives for improving 15

behaviour change. A maximum variation sampling method based on participant 16

demographics and group characteristics will be used. Thematic analysis will be 17

carried out inductively based on emergent themes, using NVivo 9. 18

Ethics and dissemination: 19

This research is approved by the South West Sydney Human Ethics Committee 20

review body (HREC/14/LPOOL/480). The evaluation will provide information about 21

the contextual and influencing factors related to the outcomes of the RCT. The 22

results will assist researchers, community health practitioners and policy makers 23

regarding the development, implementation and translation of behaviour change 24

strategies in community initiatives for obese children. Insights gained may be 25

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applicable to a range of chronic conditions where similar preventative intervention 1

approaches are indicated. 2

3

STRENGTHS AND LIMITATIONS OF THIS STUDY 4

Strengths 5

• A mixed methods qualitative design enables the collection of detailed 6

perspectives from many stakeholders and many participating families. 7

• Analyses will be grounded in the data, enabling new theories explaining 8

behaviour change related to incentives and goal setting to emerge. 9

• The evaluation design allows for comparisons between the intervention and 10

control group between sites, which will facilitate conclusions related to the 11

generalisability of the findings. 12

• Conducting the evaluation immediately after the follow-up health assessments 13

of the RCT allows for data collection whilst the program is still fresh in 14

participants’ minds, whilst minimising contamination to the RCT itself. 15

16

Limitations 17

• There will be no opportunity in this design to carry out structured observations 18

of the intervention during the implementation phase itself. Data will be 19

collected in retrospect. 20

21

KEYWORDS 22

Childhood obesity, public health, incentives, behaviour change, qualitative 23

24

BACKGROUND 25

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Childhood obesity is a global priority that many countries are currently trying to 1

address. In 2013 the number of overweight children under the age of five was 2

estimated to be over 42 million.[1] Overweight and obese children are likely to stay 3

obese into adulthood [2] and are more likely to develop chronic diseases like 4

diabetes and cardiovascular diseases at a younger age.[3] The increasing 5

prevalence also has implications for current and future health service.[4] Therefore 6

improving the management of childhood obesity is extremely important, alongside 7

preventive measures. Community-based weight-management programs are an 8

important response to address childhood obesity, however child-focused obesity 9

services are limited and there is scope for optimising attendance and outcomes, and 10

for translation into the broader context.[5] Although, the specific behaviours required 11

for effective weight-loss are well established,[6 - 11] associated implementation 12

challenges mean they are often not up-scaled and translated into a natural 13

context.[5, 9, 12] 14

15

Difficulties associated with facilitating health-related behaviour change has led to an 16

increased emergence of research investigating whether incentive schemes (based 17

on psychological and behavioural theory and research) might be a potential solution. 18

As such, promising research in adults has found that incentives can positively 19

influence health-related behaviour change in the short term.[13 - 15] For example, 20

several systematic reviews have demonstrated positive outcomes as a result of 21

financial incentives in terms of healthy eating,[16 - 18] and positive effects on 22

exercise behaviour.[19, 20] However, robust research investigating the value of 23

incentives focused on improving health-related behaviours in children is still limited. 24

25

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Several studies have highlighted the potential value of behavioural incentives in 1

children. One non-randomised study (n=1589) has demonstrated that an incentive-2

program, based on lottery-style tickets, increased the probability of children bike 3

riding to school by 16%.[21] Three randomised studies (across 40 elementary 4

schools) have reported that small rewards (such as stickers or low value financial 5

rewards) doubled the number of children consuming a serving of fruit or vegetables 6

with their school lunch,[22 - 24] and two of these studies found evidence of sustained 7

effects at two months [23] and six months [24] after the intervention. However, these 8

studies are based on small samples, the duration of the intervention and follow-up 9

tends to be short and inconsistent between studies (e.g. intervention duration ranged 10

from two to five weeks, and follow-up duration ranged from four weeks to six 11

months), they investigate a single health-related behaviour (i.e. either diet or 12

exercise) and there is no known qualitative research associated with the trials. There 13

is also no systematic review of good quality trials focusing on incentives and health-14

related behaviours in children and therefore, robustly designed research is needed to 15

provide more information on for whom and in what context incentive schemes might 16

be most effective. 17

18

Whilst Randomised Controlled Trials (RCTs) are regarded as the gold standard for 19

establishing the effectiveness of interventions, RCTs are incompatible with 20

understanding how complex interventions work in context.[25] Effect sizes alone do 21

not provide policy makers with information on how an intervention might be 22

replicated in their specific context, whether intervention outcomes will be reproduced, 23

or the broader impact on participants’ lives.[26] Conducting a process evaluation 24

alongside a RCT provides a deep understanding of how interventions are 25

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implemented, what worked and didn’t work, and in which contexts it was most and 1

least effective and why.[27] In particular, qualitative research is extremely valuable 2

for understanding the more subjective nature of participants’ experiences and 3

determining what kind of change has occurred.[26, 28] Therefore, completion of a 4

detailed qualitative process evaluation will facilitate the translation of knowledge from 5

clinical research with children, and help guide how effective incentive strategies 6

could be optimally implemented into routine practice for addressing childhood 7

obesity. Furthermore, using knowledge translation frameworks within the process 8

evaluation will enable us to identify active components of the intervention that 9

change behaviour, causal mechanisms of change, effective modes of delivery, and 10

the intended population.[29] This will facilitate integration of the interventions into 11

community health settings, and policy. 12

13

In summary, managing childhood obesity is a global priority, and there is a gap in the 14

evidence base on the impact of incentives on health behaviours in children, and 15

qualitative research identifying contextual factors associated with variation in 16

intervention delivery and outcomes. The aim of this study is to qualitatively evaluate 17

the barriers and enablers to delivery, mechanisms of impact, and the broader 18

impacts of an incentive-based behaviour change intervention to improve sustained 19

behaviour change in overweight and obese children, to build the evidence base and 20

inform policy and practice. Specific aims of this research are to: 21

1. Determine the degree to which the goals and rewards intervention was 22

implemented as intended (process evaluation). 23

2. Understand the contextual factors influencing intervention outcomes and the 24

broader impact on participants’ lives (impact evaluation). 25

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3. Identify the mechanisms of impact through which the various components of 1

the intervention were effective (evaluation of behavioural concepts 2

underpinning the intervention). 3

4

MEHODS/ DESIGN 5

Setting 6

The evaluation will be conducted at the six and 12-month data collection points of a 7

RCT conducted in New South Wales (NSW) Australia. The details of the RCT design 8

are described elsewhere.[30] In summary, the intervention (n=524 children and 38 9

community-based program sites across five Local Health Districts (LHDs)) is a 10

cluster RCT testing the use of incentives linked to goal setting for sustained 11

behaviour change in overweight and obese children aged 7-13. The RCT is set 12

within the context of an existing Australian community-based weight management 13

program. 14

15

The weight management program, ‘Go4Fun’, is a free, voluntary program run by 16

health professionals, addressing weight-related behaviour and self-esteem for 17

overweight or obese children aged 7-13 years. Go4Fun is based on the Mind 18

Exercise Nutrition Do-it (MEND) child weight management program in the UK, which 19

has demonstrated efficacy in weight outcomes (reduced waist and body mass index 20

(BMI) measures, and improvements in physical activity and self-esteem).[31] The 21

program is multidisciplinary and evidence-based, and incorporates elements 22

recognised as important to achieve long-term behaviour changes, such as family 23

involvement, practical education in nutrition and diet, and increasing physical 24

activity.[8, 9] Control sites in the trial delivered the standard weight management 25

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program content consisting of weekly two-hour group sessions for 10 weeks during 1

the school term. Intervention sites delivered the standard program together with an 2

enhanced goal setting and structured incentive scheme for goal achievement. This 3

was supported in the six months following the program by weekly text messages and 4

a lucky-draw style incentive. 5

6

How the outcomes in the RCT relate to this evaluation 7

The RCT is measured by the following outcomes: 8

• Primary outcomes: BMI and waist circumference at end of the community 9

weight management program (10 weeks) 10

• Secondary outcomes: nutrition and physical activity behaviours, and self-11

esteem at end of program (10 weeks) 12

• Attendance rates: Completion of >75% of sessions 13

• Achievement of physical activity and nutrition goals during the program 14

• Sustained health outcomes: primary and secondary health outcomes at six 15

and 12 months after the program 16

These outcomes will serve as focus points in this evaluation, which aims to provide 17

the context for better understanding variation in RCT outcomes. 18

19

Participants 20

The participants in this evaluation will come from these two groups: 21

First, existing participants in the RCT (parents/ carers and their children), who have 22

consented to being invited to further research. These will be recruited for the 23

evaluation via a brief survey given to parents/ carers during the six-month health 24

assessments in the RCT. All children participating in the RCT are aged 7-13 years, 25

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have a BMI greater than the 85th percentile for their age and gender (according to 1

the Centre for Disease Control classification of overweight/ obesity in children,[32]) 2

were enrolled in and met the criteria to participate in the community weight 3

management program at one of the sites participating in the study. Families self-4

referred via a toll-free phone number, text message or online registration to the 5

program, and secondary referrals were accepted from health professionals, 6

organisations and community members. Eligibility was assessed at the time of 7

referral or contact with LHDs and based on anthropometric measures and a medical 8

questionnaire completed by a parent/ carer, who also provided written consent for 9

their child to participate in the research. A maximum variation sampling method 10

based on the community weight management program participant demographics and 11

program group characteristics will be used. In the sample of parents/ carers and 12

children we will aim to include; high and low attendance (</>50%) in the weight 13

management program, single child and multiple sibling families, participants from 14

smaller program groups (<six children) and larger program groups (>eight children). 15

A variation of ethnicity, culturally and linguistically diverse (CALD) and 16

socioeconomic status (SES) characteristics will also be included. 17

Second, participants in the evaluation shall be stakeholders involved in the delivery 18

of the RCT, including; public servants, policy makers, behavioural specialists, 19

program managers for Local Health Districts, and community health professionals 20

(see Table 3). These shall be selected, beginning with core stakeholders directly 21

involved in the design and implementation of the RCT, and informed by the research 22

data collection as it progresses. 23

24

Design 25

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Logic model 1

The logic model (Figure 1) shows the aspects most critical to the success of the 2

RCT, to guide this evaluation. The logic model shows the intended inputs and 3

activities involved in implementing the intervention as well as the intended outcomes 4

and broader impacts. 5

6

Levels of evaluation and how they relate to the Logic model 7

Three levels of evaluation will be conducted: (1) process, (2) impact, and (3) 8

theoretical analysis. The evaluation plan is summarised in Table 1. 9

10

Table 1. Evaluation plan 11

Aim

Levels of evaluation and how they relate to Logic model

Evaluation component

Data source

Timing of data collection

1. Determine the degree the goals and rewards intervention was implemented as intended by the trial Working Group

Level: Process evaluation. Relates to intended activities and outputs in the logic model

Content delivery Engagement Reach

A combination of: Focus groups with parents/ carers Family interviews Stakeholder interviews Survey of parents/ carers

One month after the six month health assessments as part of the RCT The survey will be administered during participation in the six month health assessments

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2. Understand the contextual factors influencing intervention outcomes and the broader impact on participants’ lives

Level: Impact evaluation. Relates to intended outcomes and impacts in the logic model

The broader environment Key participant characteristics Program factors

Family interviews

One month after the twelve month health assessments as part of the RCT

3. Identify the mechanisms of impact through which the various components of the intervention were effective

Evaluation of behavioural concepts

Evaluation of causal assumptions underpinning interventions

Discourse analysis

On completion of objectives 1 and 2

1

Aim 1. Process evaluation 2

To determine the degree the intervention was implemented as intended the 3

evaluation will aim to document how the intervention was delivered and received 4

from the perspectives of those delivering and receiving the intervention, and 5

compare this with intended implementation by the trial Stakeholder Working Group 6

(see Acknowledgements). 7

8

The Normalisation Process Theory model (NPT) [33] was used to guide the design 9

of the process evaluation. NPT provides a conceptual framework for understanding 10

the processes by which interventions are implemented and integrated into everyday 11

practice. The model explores factors involved in the dynamics between people 12

delivering and receiving the intervention in order to account for outcomes of the 13

implementation process, and differences between expected and observed outcomes 14

in real settings. In implementing an intervention in a real setting NPT argues that 15

people need to continuously make sense of the work they are doing (coherence), 16

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engage with it (cognitive participation), enact it (collective action), and reflect on it 1

(reflective monitoring). With an emphasis on exploring these concepts the process 2

evaluation will look at three components. These are: content delivery, engagement, 3

and reach, and are shown in Table 1. Content delivery refers to the delivery of each 4

individual input component of the intervention. Engagement will explore the variation 5

in the goal achievement outcome measure for the intervention. Reach refers to the 6

proportion of the intended target audience who participated in the intervention. The 7

process evaluation will explore reasons expressed for discontinuing the program. 8

9

Aim 2. Impact evaluation 10

The Realistic Evaluation model [34] will be used to inform the investigation of 11

contextual factors that affect the trial outcomes. To ascertain which contextual 12

factors played a role in trial outcomes the impact evaluation will identify the 13

environmental and social factors associated with participation in the intervention, as 14

well as individual attitudes and beliefs about healthy living and associated barriers 15

and enablers to adapting to new behaviours and forming new habits. 16

17

Table 1 outlines the three key components the investigation will focus on. These are: 18

the broader environment, participant characteristics, and program factors. The 19

broader environment refers to other health activity, particularly other interventions 20

and healthy eating programs the family was involved in at the time of the 21

intervention, as well as barriers and enablers to participation and engagement in the 22

community weight management program associated with the home environment and 23

the families’ lifestyle. Participant characteristics were identified at baseline in the trial 24

and include; age, gender, single or separated family status, single or multiple sibling 25

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family. Program factors to be explored include; size of the community weight 1

management program group, regional or metro site location, venue type, and day the 2

program sessions were held (weekday or a weekend day), and will also be informed 3

by the process evaluation. 4

5

The impact evaluation will focus on primary and secondary intended behavioural 6

changes (reduced BMI, waist circumference, nutrition, physical activity and self-7

esteem), and other intended outcomes (increased program attendance rates and 8

improved goal achievement during the program). The impact evaluation will identify 9

for whom the incentive program was most and least effective in terms of having a 10

sustained positive impact on participants’ lives 12 months after the community 11

weight management program, and will assess the strength of the evidence for 12

informing translation into policy and future program delivery. 13

14

Aim 3. Evaluation of behavioural concepts 15

The design of the intervention draws upon behavioural literature on the impact of 16

incentives on health-related behaviour, and this evaluation will focus on which 17

components of the intervention participants and stakeholders felt were most 18

effective. 19

20

The intervention was developed iteratively in 2014 using a review of the relevant 21

literature, workshops, focus groups and field visits. The review of the literature and 22

program staff advice highlighted the importance of incentivising behaviour (e.g. 23

exercise, healthier lunches, less snacking etc.) rather than outcomes (e.g. weight 24

loss)[35, 36] for longer-term positive outcomes. The community program leaders 25

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also indicated during field research that while goal setting as part of the program was 1

usually specific, measureable, achievable, relevant, and timely (SMART), it was 2

likely to be of value to enhance the goal setting process, including resetting/ 3

stretching goals if they are achieved too easily, as linking goal achievement to 4

incentives. Table 2 summarises the key concepts that informed the behavioural 5

interventions. The presence of behaviours relating to these concepts will be 6

thoroughly explored in this research. 7

8

Table 2. Key behavioural concepts used and corresponding interventions developed 9

in the RCT 10

*Corresponds with Inputs (Material resources) and Activities in the Logic model 11

Behavioural concept Intervention* Reference Incentivising behaviour rather than outcomes has potential for a sustained impact Reward linked to goal attainment has a more positive longer term effect than rewarding outcomes

• Enhanced goal setting process including re-setting and stretching goals (with modified SMART goals handout)

• Rewards scheme linked to weekly nutrition and exercise goal attainment

• Fryer (2011)[35] • Gneezy et al

(2011)[37] • Anderson et al

(2011)[38]

People are motivated to complete a goal when they can see their progress Small and frequent rewards can increase task perseverance

• Group Goals and Rewards Tracker

• Low value weekly rewards

• Kivetz et al (2006)[39]

An implementation intention can help people achieve a goal

• Modified Goals and Rewards Contract (between parent/ carer and child)

• Adriaanse et al (2011)[40]

• Gollwitzer & Sheeran (2006)[41]

• Bellanger-Gavel et al (2013)[42]

Lucky draw-style rewards may be an effective mechanism for up-scaling

• Prize draw incentive at six months post community weight management

• Giles et al (2014)[43] • Strohacker et al

(2013)[19]

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program • Cuffe et al (2012)[21] Text message prompts can improve health behaviours

• SMS scheme linked to six month prize draw

• Hallsworth et al (2015)[44]

1

Data Sources 2

The evaluation will use a mixed methods qualitative analysis, which will explore 3

multiple groups of people’s perspectives on the benefits, acceptability, and other 4

ways in which incentives could be used for behaviour change. Data collection will 5

include a combination of focus groups, family and stakeholder interviews, and a 6

survey. Table 3 provides details of the data sources and their aims. 7

8

Table 3. Summary of data sources and their aims 9

Data source Scope Recruited by Aim 1.Survey of parents/ carers who participated in the community program

A 5-minute written survey of 10 questions with a mix of open-ended, single and multiple response questions. One per parent/ carer (control and treatment)

Distributed and collected at the six month health assessments

Obtain top of mind feedback on core elements of the intervention, and invite families to consent to be contacted for a focus group or family interview

2. Focus groups with parents/ carers

4-6 groups, lasting 30-60mins, with 6-8 participants depending on thematic saturation

Brief survey. Selection will be based on quota specifications around key participant and group characteristics (see ‘Participants’)

Explore experiences, perceptions and engagement in the specific intervention components

3. Family interviews with parents/ carers and their children who participated in the community program, and other family members

10-20 interviews lasting 30-60mins, depending on thematic saturation

Brief survey. Selection will be based on quota specifications around key participant and group characteristics (see

Gain insights into the impacts of the intervention in the context of the unique characteristics of the family’s lifestyle.

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(e.g. siblings) ‘Participants’)

4. Stakeholder interviews

10 individual or group interviews depending on thematic saturation

Phone calls made by GE. Stakeholders will be targeted according to quotas based on roles in the various design and implementation stages of the RCT

Understand issues specifically around the intended and actual delivery of the intervention

1

Discussions in the focus groups and interviews will follow standard methodology [45] 2

and will be recorded and transcribed verbatim. Participants will be made aware of 3

this at the start of the group or interview and their consent obtained. All discussions 4

will be confidential. GE will conduct the focus groups and interviews in a private room 5

within a facility near to the participants’ residence (such as a community centre) or 6

place of work. A second researcher will also be present in the room in an 7

observatory capacity to take notes during the group discussion. Refreshments and 8

parking reimbursement will be provided for focus group participants. To optimise 9

attendance, a $40 (e.g. a supermarket voucher) will be offered to each family who 10

participates in an interview. 11

12

Data analysis and synthesis 13

Data analysis and synthesis will be based on the Grounded Theory approach.[46 - 14

48] The outcome will be a set of probability statements about the relationship 15

between concepts, or a set of conceptual hypotheses [47]. The analysis will identify 16

the factors that participants felt led to behaviour change, and the behaviours that 17

informed the interventions (highlighted in Table 2 above) will be investigated. The 18

mechanisms of the incentives-based behaviour change strategy that lead to 19

behaviour change and habit formation may be influenced by factors outside of those 20

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identified in the previous literature. The researchers will also explore other 1

mechanisms that might have an impact. 2

3

Qualitative data from focus groups, family and stakeholder interviews, and the 4

survey will be transcribed and systematically coded, drawing out the key points. 5

Similar codes will be grouped into concepts and categories based on emergent 6

themes. The coding process will begin with the first interview and be repeated for 7

each subsequent interview or focus group with the use of field notes, memos and 8

constant comparison to accumulate ideas about how concepts relate to each other. 9

For each transcript examples will be extracted that either confirm or contradict the 10

emerging themes. Once thematic saturation occurs, no further interviews and focus 11

groups will which will be necessary. 12

Two researchers will conduct the analysis, and if at any stage consensus cannot be 13

reached, a third researcher will review those aspects. NVivo software will be used to 14

assist with qualitative data management. 15

16

Timing of data collection 17

The timing of the data collection is shown in Table 1. Data will be collected at two 18

points: (1) one month after the six-month health assessments in the trial, where the 19

process evaluation shall be undertaken; and (2) one month after the twelve-month 20

health assessment, when the impact evaluation shall be undertaken. Conducting the 21

fieldwork close to the follow-up assessments will minimise corruption of the 22

concurrent trial as the evaluation fieldwork will prompt people to remember their 23

experiences during a pre-scheduled intervention point. Research will commence in 24

late June 2016. 25

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1

DISCUSSION 2

This paper details a qualitative mixed methods evaluation to be conducted alongside 3

a RCT aimed at increasing behaviour change in overweight and obese children 4

participating in a community-based obesity program. The evaluation aims to 5

investigate the challenges of public health interventions and provide information 6

about the contextual factors related influencing the effect of the behaviour change 7

interventions. This will aid the interpretation of the RCT, which will focus on the 8

quantitative impact of the intervention. 9

10

Process evaluations can considerably add value to the interpretation of outcomes of 11

the incentives-based RCT,[26] to inform future implementation and translation as a 12

behaviour change strategy for managing obesity in overweight children, should the 13

interventions be effective. 14

15

This evaluation will explore the relationships between intervention delivery, 16

contextual factors influencing outcomes, and the mechanisms of impact. The results 17

will assist researchers, community health practitioners and policy makers in 18

implementing behaviour change strategies in community initiatives for overweight 19

and obese children and their families. The knowledge will also aid the development 20

of further strategies for health-related behavior change in children, supporting 21

positive change in tackling the growing global problem of obesity. 22

23

DECLARATIONS 24

Ethics approval and consent to participate 25

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The study has been approved by the South West Sydney Human Ethics Committee 1

review body (HREC/14/LPOOL/480). Appropriate site-specific approvals have been 2

obtained from relevant research governance offices. Consent was obtained from 3

existing RCT participants during the trial to be contacted for qualitative research. 4

5

Competing interests 6

None known 7

8

Authors’ contributions 9

GE led the drafting of all sections of the article in consultation with all the co-authors. 10

JR/ GE led the application for funding for this work. All authors provided substantial 11

contribution to the concept and design of the evaluation, drafting the protocol paper 12

and reviewing critically for important intellectual content and final approval of the 13

version for publication. 14

15

Funding 16

This research is funded in-kind provided by the George Institute for Global Health 17

and the Department for Premier and Cabinet. GE is funded by a PhD scholarship 18

through the George Institute for Global Health within the NHMRC program grant 19

ID1052555. JR is funded by a Career Development and Future Leader Fellowship 20

co-funded by the National Health and Medical Research Council and the National 21

Heart Foundation. AR is funded by an NHMRC Principal Research Fellowship 22

APP1124780. JR and AR are investigators on NHMRC program grant ID1052555. 23

24

Acknowledgements 25

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This evaluation would not have been possible without the contributions of the RCT 1

investigator team and Working Group. Investigators and Working Group members 2

who are not co-authors on this paper, and their affiliates are listed below: 3

• Office of Preventative Health: Anita Cowlishaw; Santosh Kanal; Nicholas 4

Petrunoff 5

• Behavioural Insights Unit, Department of Premier and Cabinet: Shirley Dang 6

• Western Sydney LHD: Christine Newman; Michelle Nolan; Deborah Benson, 7

Kirsti Cunningham 8

• South Western Sydney LHD: Mandy Williams; Leah Choi; Kate Jesus; 9

Stephanie Baker 10

• South Eastern Sydney LHD: Myna Hua; Linda Trotter; Lisa Franco 11

• North Sydney LHD: Paul Klarenaar; Jonothan Noyes; Sakara Branson 12

• Hunter New England LHD: Karen Gillham; Dr John Wiggers; Silvia Ruano-13

McLerie 14

• Mid North Coast LHD: Ros Tockley; Margo Johnson 15

• Better Health Company; Madeline Freeman; Bec Thorp 16

• The George Institute for Global Health; Sarah Eriksson; Caroline Wu 17

In addition we thank the Go4Fun program leaders, and representatives from our 18

funding partner organisations, including the Heart Foundation, who have contributed 19

to the development and implementation of the RCT. 20

21

REFERENCES 22

1. World Health Organisation: Global Strategy on Diet, Physical Activity and Health; 23

http://www.who.int/dietphysicalactivity/childhood/en/. Accessed 15 Dec 2015. 24

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Inputs

Resources available for

the intervention

Stakeholder resources • Collaboration on trial

design, incentive

selection and

implementation • Randomisation • Recruitment of LHDs

and participants • Training: webinar

training for Go4Fun

leaders • Site visits (ensuring

fidelity)

Material resources • Group attendance and

Goals and Rewards tracker

• Goals and Rewards

Contract • SMART handout • SMS protocol

Activities

Adaptation to standard

Go4Fun program

During 10-week program Support of parents and

children to: • Identify healthy

aspirations • Set SMART and

stretching goals • Link goals and

incentives

Post 10-week program • Identify on-going goals

for six-months • Sustain engagement

through weekly SMS • Link goals and

incentives

Outcomes

Products of activities,

measured objectively

Health outcomes • Primary health

measure: BMI and

waist circumference (z

scores) at end of the

program (10 weeks) • Secondary health

outcomes: Nutrition and

physical activity

behaviours (self

reported by parent/

carer), self-esteem (self

reported by child) at

end of program (10

weeks) • Sustained health

outcomes: Primary and

secondary health

outcomes at six and 12

months after the

program

Other outcomes • Increased attendance

rates: Completion of

>75% of sessions • Improved achievement

of physical activity and

nutrition goals during

the program

Impacts

Fundamental change

occurring as a result of the

intervention • Positive impact on

health behaviours at 12

months • Translation into wider

policy

Intended results Planned work

Figure 1. Behavioural incentives intervention logic model

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Evaluating factors influencing the delivery and outcomes of an incentive-based behaviour change strategy targeting

child obesity: Protocol for a qualitative process and impact evaluation

Journal: BMJ Open

Manuscript ID bmjopen-2016-012536.R1


Date Submitted by the Author: 03-Aug-2016

Complete List of Authors: Enright, Gemma; Cardiovascular Divsion Gyani, Alex; NSW Department of Premier and Cabinet, Behavioural Insights Unit Raadsma, Simon; NSW Department of Premier and Cabinet, Behavioural Insights Unit Allman-Farinelli, Margaret; University of Sydney, Faculty of Science Rissel, Chris; Ministry of Health, NSW Office of Preventative Health, Innes-Hughes, Christine; Ministry of Health, NSW Office of Preventative Health, Lukeis, Sarah; The Better Health Company

Rodgers, Anthony; The George Institute for Global Health, Sydney Medical School, University of Sydney, Redfern, Julie; The George Institute for Global Health, Sydney Medical School, University of Sydney, Cardiovascular Division

Primary Subject Heading:

Public health




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1

Evaluating factors influencing the delivery and outcomes of an incentive-1

based behaviour change strategy targeting child obesity: Protocol for a 2

qualitative process and impact evaluation 3



6




Australia 10


4 Ministry of Health, NSW Office of Preventive Health, Sydney, Australia 12


14


Gemma Enright 16


Australia, 2050 18

T +61 2 8052 4505 19


21

ABSTRACT 22




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2






effectiveness. The aim of this evaluation is to determine the barriers and enablers to 6



Methods and analysis: Qualitative analysis including stakeholder and family 9

interviews, focus groups and a survey will be used. The research will be conducted 10

in collaboration with policy makers, researchers, and community health 11














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3

applicable to a range of chronic conditions where similar preventive intervention 1


3


Strengths 5

• Qualitative design enables the collection of detailed perspectives from many 6

stakeholders and many participating families, allowing for triangulation of 7

findings. 8

• Analyses will be grounded in the data. This will allow potential for qualitative 9

information to add to our understanding of existing techniques for behaviour 10

change, as well as identify alternative causal pathways explaining behaviour 11

change related to goal setting and incentives 12

• .The evaluation design allows comparisons between the intervention and 13

control group sites, which will inform conclusions related to the generalisability 14

of the findings. 15

• The analysis is guided by the Behaviour Change Technique Taxonomy (BCTT 16

v1) [41] which will add to the robustness of the evaluation and increase the 17

possibly of identifying specific active components of the incentives scheme 18

and how they were effective. This will optimise translation of the effective 19

components and maximise the effectiveness of future interventions. 20

• Conducting the qualitative research shortly after the follow-up health 21

assessments of the associated RCT allows for data collection whilst the 22

program is still fresh in participants’ minds, whilst minimising contamination to 23

the RCT itself. 24

25

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4

Limitations 1


of the intervention during the implementation phase itself since the trial has 3

been completed. However, project management materials such as decision 4

logs generated during the trial will be used as supporting data sources in the 5

process evaluation. 6

7

KEYWORDS 8


10

BACKGROUND 11






prevalence also has implications for current and future health services.[4] Therefore 17

improving both the management and prevention of childhood obesity is extremely 18

important. 19

Community-based weight-management programs are an important response to 20

address childhood obesity, however although the specific behaviours required for 21

effective weight-loss and long-term behaviour change are well established,[5-10] 22

facilitating health-related behaviour change remains an on-going challenge. The 23

reasons for this are broadly twofold in that; (i) individuals (and particularly children) 24

find it difficult to make lasting health-related behaviour changes,[11,12] and (ii) 25

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5

associated implementation challenges mean health behaviour change interventions 1

based on behaviour change theory are often not up-scaled and translated into a 2

natural context.[8,12-14] 3

4


increased emergence of research investigating whether incentive schemes, based 6

on behavioural theory such as operant conditioning,[15] might be a potential solution. 7


influence health-related behaviour change in the short term.[16-18] For example, 9


financial incentives in terms of healthy eating,[19-21] and positive effects on exercise 11

behaviour.[22, 23] Many of the studies included in the reviews have acknowledged 12

the need for more research to determine specific information on the type, timing and 13

magnitude of incentives needed to motivate individuals to change their behaviour, as 14

well as disincentives.[19] There are also mixed findings on whether incentives are 15

more useful for simple one-off behaviours (e.g. attendance at a vaccination) rather 16

than complex health behaviours such as dietary behaviour change, and if specific 17

groups may benefit more from incentive schemes.[17] This highlights the need to 18

fully understand not only the cognitive influences on behaviour change, but also 19

social and environmental factors as well when designing and evaluating behaviour 20

change interventions, 21

22

Despite the growing body of evidence in adults, robust research investigating the 23

value of incentives focused on improving health-related behaviours in children is still 24

lacking. Several (uncontrolled) studies have highlighted the potential value of 25

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6

behavioural incentives in children and these studies have been summarised in a 1

recent narrative review.[24] One non-randomised study (n=1589) has demonstrated 2

that an incentive-program, based on lottery-style tickets, increased the probability of 3

children bike riding to school by 16%.[25] Three randomised studies (across 40 4

elementary schools) have reported that small rewards (such as stickers or low value 5

financial rewards) doubled the number of children consuming a serving of fruit or 6

vegetables with their school lunch,[26-28] and two of these studies found evidence of 7

sustained effects at two months [27] and six months [28] after the intervention. 8

However, these studies are based on small samples, the duration of the intervention 9

and follow-up tends to be short and inconsistent between studies (e.g. intervention 10

duration ranged from two to five weeks, and follow-up duration ranged from four 11

weeks to six months), they investigate a single health-related behaviour (i.e. either 12

diet or exercise) and there is no known qualitative research associated with the trials. 13

Before a systematic review can be performed and provide meaningful information on 14

the effectiveness of incentives for health-related behaviour in children, there is a 15

need for robustly designed trials to provide more evidence on for whom and in what 16

context incentive schemes might be most effective. 17

18








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7




determining what kind of change has occurred.[31,32]. As a relevant example, there 4

is a debate about whether extrinsic incentives can discourage the development of 5

intrinsic motivation and undermine the development of longer term habit 6

formation.[33] Qualitative research can provide invaluable information about the 7

disadvantages of using rewards to modify eating and exercise behaviour, which 8

should be fully considered in the design of behaviour change schemes for children. 9

Therefore, completion of a detailed qualitative process evaluation will facilitate the 10

translation of knowledge from clinical research with children, and help guide how 11

effective incentive strategies could be optimally implemented into routine practice for 12

addressing childhood obesity. Furthermore, using a framework for deconstructing 13

and specifying various intervention components within a process evaluation will 14

enable the active components of the intervention that change behaviour to be 15

isolated, along with underlying mediators of action, effective modes of delivery, and 16

the most receptive populations.[34 ] This will facilitate replication of the interventions 17

into community health settings, inform resource allocation, and advance intervention 18

science . 19

20

In summary, managing childhood obesity is a global priority. There is a gap in the 21


qualitative research can provide rich contextual information to help the interpretation 23

of child-focused obesity intervention delivery and outcomes. The overall aim of this 24

research is to provide detailed information on the barriers and enablers to the 25

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8

intended delivery and outcomes of a child-focused incentives-based scheme, and 1

determine whether the scheme is an acceptable intervention to improve behaviour 2

change in overweight and obese children. This qualitative information will be used to 3

build the evidence base and inform policy and practice. Specific aims of this 4

research are to: 5

1. Identify what factors influenced implementation fidelity of the scheme to; 6

a. determine whether the incentives scheme was implemented as 7

intended; 8

b. determine whether the model of goal-setting and incentives enhances 9

an existing community weight management program; 10

c. understand how the implementation process might be improved. 11

2. Identify what factors influenced intervention outcomes and the broader impact 12

on participants’ lives to; 13

a. determine for whom and in what context the incentives scheme was 14

effective. 15

3. Identify the active components of the intervention that influenced behaviour, 16

to: 17

a. determine which intervention components were the most effective; 18

b. determine any components that are unnecessary; 19

c. identify components that were non effective but may be useful. 20

21

MEHODS/ DESIGN 22

Setting 23

This qualitative evaluation research will be conducted shortly after the follow-up six-24

month data collection point of a RCT conducted in New South Wales Australia from 25

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9

2014 to mid-2016. The details of the RCT design are described elsewhere.[35] In 1

summary, the RCT intervention (n=524 children and 38 community-based program 2

sites across five local health districts) is a cluster RCT which tested the use of 3

incentives linked to goal setting for sustained behaviour change in overweight and 4

obese children aged 7-13. The RCT was set within the context of an existing 5

Australian community-based weight management program. 6

7






measures, and improvements in physical activity and self-esteem).[36] The program 13

is multidisciplinary and evidence-based, and incorporates elements recognised as 14

important to achieve long-term behaviour changes, such as family involvement, 15

practical education in nutrition and diet, and increasing physical activity.[7, 8] Control 16

sites in the trial delivered the standard weight management program content 17

consisting of weekly two-hour group sessions for 10 weeks during the school term. 18

Intervention sites delivered the standard program together with an enhanced goal 19

setting and structured incentive scheme for goal achievement. This was supported in 20

the six months following the program by weekly text messages and a lucky-draw 21

style incentive. 22

23

Participants 24

The participants in this evaluation will come from two groups. 25

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consented to being invited to further research. These were recruited for the 2

evaluation via a brief survey given to parents/ carers during the six-month follow-up 3

health assessments in the RCT. All children who participated in the RCT were aged 4

7-13 years at the time of the trial, had a body mass index greater than the 85th 5

percentile for their age and gender (according to the Centre for Disease Control 6

classification of overweight/ obesity in children,[37]) were enrolled in and met the 7

criteria to participate in the community weight management program at one of the 8

sites that participated in the study. Families self-referred via a toll-free phone 9

number, text message or online registration to the program, and secondary referrals 10

were accepted from health professionals, organisations and community members. 11

Eligibility was assessed at the time of referral or contact with local health districts 12

and based on anthropometric measures and a medical questionnaire completed by a 13

parent/ carer, who also provided written consent for their child to participate in the 14

research. 15

A maximum variation sampling method based on the community weight 16

management program participant demographics and program group characteristics 17

will be used in the evaluation. In the sample of parents/ carers and children we will 18

aim to include; high and low attendance (</>50%) in the weight management 19

program, single child and multiple sibling families, participants from smaller program 20

groups (<six children) and larger program groups (>eight children). A variation of 21

ethnicity, culturally and linguistically diverse (CALD) and socioeconomic status (SES) 22

characteristics will also be included. 23

Second, participants in the evaluation shall be stakeholders who were involved in the 24

delivery of the RCT, including; public servants, policy makers, behavioural 25

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specialists, program managers for local health districts, and community health 1

professionals. These shall be selected, beginning with core stakeholders who were 2

directly involved in the design and implementation of the RCT, and informed by the 3

research data collection as it progresses. 4

5

Design 6

Logic model 7



activities involved in implementing the incentives-based intervention as well as the 10

intended outcomes and broader impacts 11

12


To address each of the three aims, three levels of qualitative evaluation will be 14

conducted: (i) process, (ii) impact, and (iii) intervention deconstruction. The 15

evaluation plan is summarised in Table 1. 16

17


Aim



Data source Timing of data collection

1. Identify what factors influenced implementation fidelity

Level: Process evaluation Relates to intended activities and

Content delivery (stakeholders) Content engagement

Combination of: Stakeholder interviews

Within two months after the six month follow-up health assessments

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outputs in the logic model

(participants) Reach

Survey of parents/ carers Focus groups with parents/ carers Family interviews Decision logs, implementation plans and other project management documentation

of the RCT (estimated to commence Aug/ Sept 2016) The survey of parents/ carers was distributed and collected from all parents/ carers during the six month health assessments (May/ June 2016)

2. Identify what factors influenced behaviour change and the broader impact on participants’ lives

Level: Impact evaluation Relates to intended outcomes and impacts in the logic model


Combination of: Focus groups with parents/ carers Family interviews

Within two months after the six month follow-up health assessments as part of the RCT (estimated to commence Aug/ Sept 2016)

3. Identify the active components of the intervention that influenced behaviour

Intervention deconstruction

Behaviour change intervention components

Transcripts generated from focus groups and interviews

On completion of aims 1 and 2 (estimated early 2017)

1


The process evaluation will determine the degree the incentives-based intervention 3

was implemented as intended (implementation fidelity). The evaluation will document 4

factors influencing how the different components of the intervention were delivered 5

and received from the perspectives of those delivering and receiving the intervention, 6

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and compare this with intended implementation by the trial Stakeholder Working 1

Group (see Acknowledgements). 2

3

The framework used to guide the design of the process evaluation was the 4

Normalisation Process Theory.[38] Normalisation Process Theory provides a 5

conceptual framework for understanding the processes by which interventions are 6

implemented and integrated into everyday practice. The model explores factors 7

involved in the dynamics between people delivering and receiving an intervention in 8

order to account for outcomes of the implementation process, and differences 9

between expected and observed outcomes in real settings. In implementing an 10

intervention in a natural setting Normalisation Process Theory argues that people 11

need to continuously make sense of the work they are doing (coherence), engage 12

with it (cognitive participation), enact it (collective action), and reflect on it (reflective 13

monitoring). With an emphasis on exploring these concepts the process evaluation 14

will look at three evaluation components. These are: (i) content delivery, (ii) content 15

engagement, and (iii) reach, and are shown in Table 1. Content delivery refers to the 16

delivery and receipt of each individual input component of the intervention from the 17

perspective of those delivering the intervention. Content engagement refers to the 18

delivery and receipt of each component of the intervention from the perspective of 19

those receiving the intervention. Reach refers to the proportion of the intended target 20

audience who participated in the intervention, and the process evaluation will 21

specifically explore reasons expressed for discontinuing the program. 22

23

Information collected from stakeholders (those implementing the intervention) will 24

include perceptions on the roles and activities involved in the implementation of the 25

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intervention, from initial discussions through to intervention design, set-up, project 1

management and facilitation. Perceptions on the acceptability, including integration 2

and disruption to the standard community program, benefits and impacts of the 3

intervention and suggestions for improvement will also be collected. 4

Information collected from participants (parents/ carers and children receiving the 5

intervention) will include perceptions on how specific components of the intervention 6

were understood and engaged with, and recounts of their experiences of interacting 7

with the intervention materials, other families and facilitators. Perceived benefits, 8

strengths/ weaknesses and suggested improvements will also be collected. 9

10


The impact evaluation will determine the contextual factors that influenced trial 12

outcomes and broader impacts, and identify for whom the incentive scheme was 13

most and least effective in terms of having an effect during the community weight 14

management program and sustained impacts after the program. Investigations will 15

include the environmental and social context associated with participation in the 16

intervention, individual attitudes and beliefs about healthy living, and associated 17

barriers and enablers to adapting to new behaviours and forming new habits 18

19

The Realistic Evaluation model [39] was used to inform the design of the impact 20

evaluation and Table 1 outlines the three evaluation components the investigation 21

will focus on. These are: the broader environment, participant characteristics, and 22

program factors. The broader environment refers to other health activity, particularly 23

other interventions and healthy eating programs the family was involved in at the 24

time of the intervention, as well as barriers and enablers to participation and 25

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engagement in the community weight management program associated with the 1

home environment and the families’ lifestyle. Participant characteristics were 2

identified at baseline in the trial and include; age, gender, single or separated family 3

status, single or multiple sibling family. This information will be used to recruit 4

participants for focus groups and family interviews (with the aim of including a mix of 5

characteristics), and will also be factored into analyses. Program factors to be 6

explored include; size of the community weight management program group, 7

regional or metro site location, venue type, and day the program sessions were held 8

(weekday or a weekend day), and will also be informed by the process evaluation. 9

10

Information collected will draw from those receiving the intervention (children and 11

their parents/ carers), and include lifestyles, attitudes and health behaviours, 12

perceptions on what has changed in their lives since the program, habits retained, 13

and behaviours that have proven difficult to integrate into their lifestyles. Specific 14

impacts of the individual intervention components will be explored in depth. 15

All intended primary and secondary outcomes of the trial will be considered in the 16

investigation of contextual factors. The primary measure in the RCT was body mass 17

index at the end of the community weight management program (10 weeks) and at 18

six months. Secondary outcomes included: Waist circumference; nutrition and 19

physical activity behaviours and self-esteem (by survey) at the end of program (10 20

weeks) and at six months. Attendance rates during the program (completion of >75% 21

of sessions) was also measured in the trial. The evaluation will also compare 22

perceptions of the incentives scheme in relation to the outcomes in the absence of 23

the intervention (control group). This will help determine how the intervention 24

influenced outcomes, and whether the effects were intended. 25

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1

Aim 3.Intervention deconstruction 2

The intervention deconstruction will explore and describe which specific components 3

of the incentives-based intervention were most impactful and why. The incentives 4

intervention was developed iteratively in 2014 drawing from a review of the relevant 5

literature, workshops, focus groups and field visits. Combined literature review and 6

advice from community program leaders highlighted the importance of incentivising 7

goals and activities (e.g. having healthier lunches) rather than outcomes (e.g. weight 8

loss) for greater impact on behaviour change.[40,11] For example, in a series of 9

RCTs across 203 elementary schools, it was reported that providing incentives for 10

reading books was more effective than providing incentives for outcomes such as 11

scores on a test.[40] Community program leaders indicated during field research that 12

while goal setting as part of the program was usually specific, measureable, 13

achievable, relevant, and timely (SMART), it was likely to be of value to enhance the 14

goal setting process, including resetting/ stretching goals if they are achieved too 15

easily, and linking goal achievement to incentives. The importance of choosing the 16

appropriate size, type and timing of incentives was also highlighted as critical for 17

motivating change. For example, a study in children [26] found that a larger financial 18

reward (a US quarter rather than a nickel) combined with receiving it on the same 19

day as the behaviour was performed produced the largest behaviour change. The 20

key behavioural concepts that informed the design of the individual intervention 21

components (inputs in the logic model) are summarised below in Table 2. 22

23

The Behaviour Change Technique Taxonomy (BCTTv1) [41] will be used as a 24

framework for deconstructing the behaviour change intervention components used in 25

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the trial. The purpose of this is threefold: (i) to optimise the robustness and 1

replication potential of the research by using a common language to recognise and 2

specify the components of the intervention that are changing behaviour (use of the 3

taxonomy supports the CONSORT guidelines for the reporting of behaviour change 4

interventions,[42] (ii) to facilitate translation of the interventions for the greatest effect 5

on child obesity outcomes by separating the active ingredients within the intervention 6

components and the conditions under which they are effective, from components 7

that may be less necessary and (iii) to understand more about any intervention 8

components that may be useful but were not sufficient in dose to produce an impact 9

on outcomes.[34] It will also be useful to refer to the full list of 93 items in the 10

Behaviour Change Technique Taxonomy [41] in the analysis of how and why specific 11

components worked or didn’t work. The behaviour change technique mappings 12

shown below in Table 2 have been mapped in retrospect as a starting point to guide 13

analysis. For this exercise careful attention was paid to the coding definitions 14

specified in the Behaviour Change Technique Taxonomy,[41] and the “BCT 15

taxonomy” app was downloaded through Apple to guide coding. 16

17

Table 2. Behavioural concepts and corresponding behaviour change intervention 18

components, mapped to the Behaviour Change Technique Taxonomy. 19

*Corresponds with Inputs (material resources) and Activities in the logic model 20

Concept to illicit behaviour change

Behaviour change intervention component developed for the trial*

Mapped to the Behaviour Change Technique Taxonomy [41]

Incentivising behaviours and activities rather than outcomes is more effective for sustained behaviour change than rewarding outcomes [33,40,43]

Enhanced goal setting process including establishing a "big wish” (the overall outcome), then deciding on small achievable weekly goals which were re-set and stretched each week (with modified SMART goals handout)

Goals and Planning (1.4 action planning) Note 8.3 Habit formation and 8.7Graded tasks may also apply

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Rewards scheme linked to weekly nutrition and exercise goal attainment

Reward and Threat (10.1 material reward (behaviour)

People are motivated to complete a goal when they can see their progress [44]

Group “Goals and Rewards Tracker”

Feedback and monitoring (2.5 monitoring of outcomes of behaviour without feedback)

Small and frequent rewards can increase task perseverance [44]

Low value weekly rewards


An implementation intention can help people achieve a goal [45-47)

Modified “Goals and Rewards Contract”(between parent/ carer and child)

Goals and Planning –(1.8 behavioural contract )

Lucky draw-style rewards may increase effectiveness of incentives [17,22,25]

Prize draw incentive six months after community weight management program

Reward and Threat –(anticipation of future reward – not categorised by the app used to code)

Text message prompts w can improve health behaviours [48]

SMS scheme linked to six month prize draw

Feedback and Monitoring (10.4 social reward)

1

Data Sources 2

The evaluation will use a qualitative analysis, which will explore multiple groups of 3

people’s perspectives on the benefits, acceptability, and other ways in which 4

incentives could be used for behaviour change. Data collection will include a 5

combination of focus groups, family and stakeholder interviews, and a survey. Table 6

3 provides details of the data sources and their aims. 7

8



A 5-minute written survey of 10 questions with a mix of open-ended, single and multiple response questions. One per parent/ carer (control and

Distribution and collection at the six month health assessments of the trial

Focus: overall barriers and enablers to behaviour change, and recruitment Obtain top of mind feedback on core elements of the intervention, and

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treatment) invite families to consent to be contacted for a focus group or family interview




Focus: process evaluation Explore experiences, perceptions and engagement in the specific intervention component

3. Family interviews with parents/ carers and their children who participated in the community program, and other family members (e.g. siblings)

10-20 interviews lasting 30-60mins, depending on thematic saturation


Focus: impact evaluation Gain insights into the contextual factors influencing outcomes




Focus: process evaluation Understand issues associated with the intended and actual delivery of the intervention

5.Project management materials

Decision logs, implementation plans and other project management documentation

Retracing project management activity, stored securely at the Department of Premier and Cabinet)

Collect additional insight into issues, mitigations, processes and learnings documented by the project team throughout the trial

1

The focus groups and interviews will follow a semi-structured approach, and 2

facilitation will be supported by bullet-pointed topic guides to facilitate natural 3

conversation between moderator and participants by emphasising topics, objectives 4

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and flow. Each focus group and interview will be recorded and transcribed verbatim. 1

Participants will be made aware of this at the start of the group or interview and their 2

consent obtained. All discussions will be confidential. GE will conduct the focus 3

groups and interviews in a private room within a facility near to the participants’ 4

residence (such as a community centre) or place of work. A second researcher will 5

also be present in the room in an observatory capacity to take notes during the group 6

discussion. Refreshments and parking reimbursement will be provided for focus 7

group participants. To optimise attendance a $40 (e.g. a supermarket voucher) will 8

be offered to each family who participates in an interview. 9

10


Data analysis and synthesis will be based on the Grounded Theory approach.[49-51] 12









groups will be necessary. Two researchers will conduct the analysis, and if at any 21

stage consensus cannot be reached, a third researcher will review those aspects. 22

NVivo software will be used to assist with qualitative data management. The overall 23

output will be a set of probability statements about the relationship between 24

concepts, or a set of conceptual hypotheses [50] about the barriers and enablers to 25

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implementation of the incentives scheme, and its impact on the behaviour of 1

participants. 2

3

The analysis will be conducted in three waves, corresponding to the three levels of 4

evaluation in this research - the process, impact and behaviour change component 5

evaluations. Specifically, for the process evaluation the coding process will refer 6

back to the individual input and activity components in the logic model. Each focus 7

group and interview transcript will be scanned for themes relating to the delivery and 8

receipt of each component of the incentives scheme. Project management materials 9

will also be reviewed and examples identified to support or contradict themes 10

emerging from the transcribed data. For the impact evaluation the coding process 11

will be related back to the intended outcomes and impacts of the intervention, as per 12

the logic model. Each focus group and interview transcript will be scanned for 13

themes associated with broader environmental influences on the effects of the 14

incentive scheme, and in relation to different participant characteristics and program 15

factors. The output will include typologies to describe for whom and how incentives 16

may impact behaviour. The intervention deconstruction will be guided by the 17

Behaviour Change Technique Taxonomy [41] as a basis for describing the active 18

intervention components and exploring whether the perceived impacts of the 19

intervention support or contradict the behavioural concepts underlying the design of 20

intervention. The specific mechanisms of the incentives-based behaviour change 21

scheme that lead to behaviour change may be associated with behavioural concepts 22

outside of those identified in the literature and influenced by unanticipated factors, 23

which the researchers will explore throughout the analysis. 24

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The findings will be triangulated, drawing on the variety of data sources and 1

perspectives, and with comparison to the trial control group to determine whether the 2

trial outcomes can be attributed to the intervention. Issues and potential biases in the 3

design of the trial will be carefully factored in to interpretations. 4

5


The timing of the data collection is shown above in Table 1. Data will be collected at 7

two points: (i) during the six-month follow-up assessments in the RCT (which is 8

complete), (ii) one to two months after the six-month assessments. Conducting the 9

fieldwork close to the follow-up assessments will minimise corruption of the RCT as 10

the evaluation data collection will prompt people to remember their experiences 11

during a pre-scheduled intervention point. Focus groups and stakeholder and family 12

interviews are estimated to commence in August 2016. 13

14

DISCUSSION 15

This paper details the protocol for a qualitative evaluation to be conducted shortly 16

following a RCT aimed at increasing behaviour change in overweight and obese 17

children participating in a community-based obesity program. The research aims to 18

address the challenges of public health interventions and provide information about 19

the barriers and enablers to the implementation of an incentives-based intervention 20

and its impact on health-related behaviour change in children. This research will 21

determine the relationships between intervention delivery, contextual factors 22

influencing outcomes, and the mechanisms of behaviour change, and provide 23

detailed information on the acceptability of the incentives-based scheme and its 24

potential as an obesity-reducing strategy in children in a range of contexts. It has 25

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potential to add considerable value to the interpretation of the quantitative-based 1

RCT outcomes and inform future implementation and translation as a behaviour 2

change strategy for managing obesity in overweight children, should the 3

interventions be deemed acceptable. The knowledge will also advance the 4

development of further strategies for health-related behavior change in children, 5

supporting positive change in tackling the growing global problem of obesity. 6

7

DECLARATIONS 8

Ethics approval and consent to participate 9

The study has been approved by the South West Sydney Human Ethics Committee 10

review body (HREC/14/LPOOL/480). Appropriate site-specific approvals have been 11

obtained from relevant research governance offices. Consent was obtained from 12

existing RCT participants during the trial to be contacted for qualitative research. 13

14


None known 16

17







24

Funding 25

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8

Acknowledgements 9




• Office of Preventive Health: Anita Cowlishaw; Santosh Kanal; Nicholas 13

Petrunoff 14



Kirsti Cunningham 17


Stephanie Baker 19




McLerie 23



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5

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Figure 1.

346x210mm (300 x 300 DPI)

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Evaluating factors influencing the delivery and outcomes of an incentive-based behaviour change strategy targeting

child obesity: Protocol for a qualitative process and impact evaluation

Journal: BMJ Open

Manuscript ID bmjopen-2016-012536.R2


Date Submitted by the Author: 13-Oct-2016

Complete List of Authors: Enright, Gemma; Cardiovascular Divsion Gyani, Alex; NSW Department of Premier and Cabinet, Behavioural Insights Unit Raadsma, Simon; NSW Department of Premier and Cabinet, Behavioural Insights Unit Allman-Farinelli, Margaret; University of Sydney, Faculty of Science Rissel, Chris; Ministry of Health, NSW Office of Preventative Health, Innes-Hughes, Christine; Ministry of Health, NSW Office of Preventative Health, Lukeis, Sarah; The Better Health Company

Rodgers, Anthony; The George Institute for Global Health, Sydney Medical School, University of Sydney, Redfern, Julie; The George Institute for Global Health, Sydney Medical School, University of Sydney, Cardiovascular Division

Primary Subject Heading:

Public health




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Evaluating factors influencing the delivery and outcomes of an incentive-1

based behaviour change strategy targeting child obesity: Protocol for a 2

qualitative process and impact evaluation 3



6




Australia 10


4 Ministry of Health, NSW Office of Preventive Health, Sydney, Australia 12


14


Gemma Enright 16


Australia, 2050 18

T +61 2 8052 4505 19


21

ABSTRACT 22




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effectiveness. The aim of this evaluation is to determine the barriers and enablers to 6



Methods and analysis: Qualitative analysis including stakeholder and family 9

interviews, focus groups and a survey will be used. The research will be conducted 10

in collaboration with policy makers, researchers, and community health 11














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applicable to a range of chronic conditions where similar preventive intervention 1


3


Strengths 5

• Qualitative data collection of multiple perspectives allows for triangulation of 6

findings. 7

• This process evaluation will enhance our understanding of implementation 8

and identify causal pathways explaining behaviour change. 9

• Comparison between the intervention and control group sites will inform 10

generalisability of the findings. 11

• Considering behaviour change theory will increase the possibly of identifying 12

specific active components of the incentives scheme and how they were 13

effective. 14

Limitations 15


of the intervention during the implementation phase 17

18

KEYWORDS 19


21

BACKGROUND 22




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prevalence also has implications for current and future health services.[4] Therefore 3

improving both the management and prevention of childhood obesity is extremely 4

important. 5

Community-based weight-management programs are an important response to 6

address childhood obesity, however although the specific behaviours required for 7

effective weight-loss and long-term behaviour change are well established,[5-10] 8

facilitating health-related behaviour change remains an on-going challenge. The 9

reasons for this are broadly twofold in that; (i) individuals (and particularly children) 10

find it difficult to make lasting health-related behaviour changes,[11,12] and (ii) 11

associated implementation challenges mean health behaviour change interventions 12

based on behaviour change theory are often not up-scaled and translated into a 13

natural context.[8,12-14] 14

15


increased emergence of research investigating whether incentive schemes, based 17

on behavioural theory such as operant conditioning,[15] might be a potential solution. 18


influence health-related behaviour change in the short term.[16-18] For example, 20


financial incentives in terms of healthy eating,[19-21] and positive effects on exercise 22

behaviour.[22, 23] Many of the studies included in the reviews have acknowledged 23

the need for more research to determine specific information on the type, timing and 24

magnitude of incentives needed to motivate individuals to change their behaviour, as 25

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well as disincentives.[19] There are also mixed findings on whether incentives are 1

more useful for simple one-off behaviours (e.g. attendance at a vaccination) rather 2

than complex health behaviours such as dietary behaviour change, and if specific 3

groups may benefit more from incentive schemes.[17] This highlights the need to 4

fully understand not only the cognitive influences on behaviour change, but also 5

social and environmental factors as well when designing and evaluating behaviour 6

change interventions, 7

8

Despite the growing body of evidence in adults, robust research investigating the 9

value of incentives focused on improving health-related behaviours in children is still 10

lacking. Several (uncontrolled) studies have highlighted the potential value of 11

behavioural incentives in children and these studies have been summarised in a 12

recent narrative review.[24] One non-randomised study (n=1589) has demonstrated 13

that an incentive-program, based on lottery-style tickets, increased the probability of 14

children bike riding to school by 16%.[25] Three randomised studies (across 40 15

elementary schools) have reported that small rewards (such as stickers or low value 16

financial rewards) doubled the number of children consuming a serving of fruit or 17

vegetables with their school lunch,[26-28] and two of these studies found evidence of 18

sustained effects at two months [27] and six months [28] after the intervention. 19

However, these studies are based on small samples, the duration of the intervention 20

and follow-up tends to be short and inconsistent between studies (e.g. intervention 21

duration ranged from two to five weeks, and follow-up duration ranged from four 22

weeks to six months), they investigate a single health-related behaviour (i.e. either 23

diet or exercise) and there is no known qualitative research associated with the trials. 24

Before a systematic review can be performed and provide meaningful information on 25

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the effectiveness of incentives for health-related behaviour in children, there is a 1

need for robustly designed trials to provide more evidence on for whom and in what 2

context incentive schemes might be most effective. 3

4











determining what kind of change has occurred.[31,32]. As a relevant example, there 15

is a debate about whether extrinsic incentives can discourage the development of 16

intrinsic motivation and undermine the development of longer term habit 17

formation.[33] Qualitative research can provide invaluable information about the 18

disadvantages of using rewards to modify eating and exercise behaviour, which 19

should be fully considered in the design of behaviour change schemes for children. 20

Therefore, completion of a detailed qualitative process evaluation will facilitate the 21

translation of knowledge from clinical research with children, and help guide how 22

effective incentive strategies could be optimally implemented into routine practice for 23

addressing childhood obesity. Furthermore, using a framework for deconstructing 24

and specifying various intervention components within a process evaluation will 25

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enable the active components of the intervention that change behaviour to be 1

isolated, along with underlying mediators of action, effective modes of delivery, and 2

the most receptive populations.[34 ] This will facilitate replication of the interventions 3

into community health settings, inform resource allocation, and advance intervention 4

science . 5

6

In summary, managing childhood obesity is a global priority. There is a gap in the 7


qualitative research can provide rich contextual information to help the interpretation 9

of child-focused obesity intervention delivery and outcomes. The overall aim of this 10

research is to provide detailed information on the barriers and enablers to the 11

intended delivery and outcomes of a child-focused incentives-based scheme, and 12

determine whether the scheme is an acceptable intervention to improve behaviour 13

change in overweight and obese children. This qualitative information will be used to 14

build the evidence base and inform policy and practice. Specific aims of this 15

research are to: 16

1. Identify what factors influenced implementation fidelity of the scheme to; 17

a. determine whether the incentives scheme was implemented as 18

intended; 19

b. determine whether the model of goal-setting and incentives enhances 20

an existing community weight management program; 21

c. understand how the implementation process might be improved. 22

2. Identify what factors influenced intervention outcomes and the broader impact 23

on participants’ lives to; 24

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a. determine for whom and in what context the incentives scheme was 1

effective. 2

3. Identify the active components of the intervention that influenced behaviour, 3

to: 4

a. determine which intervention components were the most effective; 5

b. determine any components that are unnecessary; 6

c. identify components that were non effective but may be useful. 7

8

MEHODS/ DESIGN 9

Setting 10

This qualitative evaluation research will be conducted shortly after the follow-up six-11

month data collection point of a RCT conducted in New South Wales Australia from 12

2014 to mid-2016. The details of the RCT design are described elsewhere.[35] In 13

summary, the RCT intervention (n=524 children and 38 community-based program 14

sites across five local health districts) is a cluster RCT which tested the use of 15

incentives linked to goal setting for sustained behaviour change in overweight and 16

obese children aged 7-13. The RCT was set within the context of an existing 17

Australian community-based weight management program. 18

19






measures, and improvements in physical activity and self-esteem).[36] The program 25

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is multidisciplinary and evidence-based, and incorporates elements recognised as 1

important to achieve long-term behaviour changes, such as family involvement, 2

practical education in nutrition and diet, and increasing physical activity.[7, 8] Control 3

sites in the trial delivered the standard weight management program content 4

consisting of weekly two-hour group sessions for 10 weeks during the school term. 5

Intervention sites delivered the standard program together with an enhanced goal 6

setting and structured incentive scheme for goal achievement. This was supported in 7

the six months following the program by weekly text messages and a lucky-draw 8

style incentive. 9

10

Participants 11

The participants in this evaluation will come from two groups. 12


consented to being invited to further research. These were recruited for the 14

evaluation via a brief survey given to parents/ carers during the six-month follow-up 15

health assessments in the RCT. All children who participated in the RCT were aged 16

7-13 years at the time of the trial, had a body mass index greater than the 85th 17

percentile for their age and gender (according to the Centre for Disease Control 18

classification of overweight/ obesity in children,[37]) were enrolled in and met the 19

criteria to participate in the community weight management program at one of the 20

sites that participated in the study. Families self-referred via a toll-free phone 21

number, text message or online registration to the program, and secondary referrals 22

were accepted from health professionals, organisations and community members. 23

Eligibility was assessed at the time of referral or contact with local health districts 24

and based on anthropometric measures and a medical questionnaire completed by a 25

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parent/ carer, who also provided written consent for their child to participate in the 1

research. 2

A maximum variation sampling method based on the community weight 3

management program participant demographics and program group characteristics 4

will be used in the evaluation. In the sample of parents/ carers and children we will 5

aim to include; high and low attendance (</>50%) in the weight management 6

program, single child and multiple sibling families, participants from smaller program 7

groups (<six children) and larger program groups (>eight children). A variation of 8

ethnicity, culturally and linguistically diverse (CALD) and socioeconomic status (SES) 9

characteristics will also be included. 10

Second, participants in the evaluation shall be stakeholders who were involved in the 11

delivery of the RCT, including; public servants, policy makers, behavioural 12

specialists, program managers for local health districts, and community health 13

professionals. These shall be selected, beginning with core stakeholders who were 14

directly involved in the design and implementation of the RCT, and informed by the 15

research data collection as it progresses. 16

17

Design 18

Logic model 19



activities involved in implementing the incentives-based intervention as well as the 22

intended outcomes and broader impacts 23

24


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To address each of the three aims, three levels of qualitative evaluation will be 1

conducted: (i) process, (ii) impact, and (iii) intervention deconstruction. The 2

evaluation plan is summarised in Table 1. 3

4


Aim



Data source Timing of data collection

1. Identify what factors influenced implementation fidelity

Level: Process evaluation Relates to intended activities and outputs in the logic model

Content delivery (stakeholders) Content engagement (participants) Reach

Combination of: Stakeholder interviews Survey of parents/ carers Focus groups with parents/ carers Family interviews Decision logs, implementation plans and other project management documentation

Within two months after the six month follow-up health assessments of the RCT (estimated to commence Aug/ Sept 2016) The survey of parents/ carers was distributed and collected from all parents/ carers during the six month health assessments (May/ June 2016)

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2. Identify what factors influenced behaviour change and the broader impact on participants’ lives

Level: Impact evaluation Relates to intended outcomes and impacts in the logic model


Combination of: Focus groups with parents/ carers Family interviews

Within two months after the six month follow-up health assessments as part of the RCT (estimated to commence Aug/ Sept 2016)

3. Identify the active components of the intervention that influenced behaviour

Intervention deconstruction

Behaviour change intervention components

Transcripts generated from focus groups and interviews

On completion of aims 1 and 2 (estimated early 2017)

1


The process evaluation will determine the degree the incentives-based intervention 3

was implemented as intended (implementation fidelity). The evaluation will document 4

factors influencing how the different components of the intervention were delivered 5

and received from the perspectives of those delivering and receiving the intervention, 6

and compare this with intended implementation by the trial Stakeholder Working 7

Group (see Acknowledgements). 8

9

The framework used to guide the design of the process evaluation was the 10

Normalisation Process Theory.[38] Normalisation Process Theory provides a 11

conceptual framework for understanding the processes by which interventions are 12

implemented and integrated into everyday practice. The model explores factors 13

involved in the dynamics between people delivering and receiving an intervention in 14

order to account for outcomes of the implementation process, and differences 15

between expected and observed outcomes in real settings. In implementing an 16

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intervention in a natural setting Normalisation Process Theory argues that people 1

need to continuously make sense of the work they are doing (coherence), engage 2

with it (cognitive participation), enact it (collective action), and reflect on it (reflective 3

monitoring). With an emphasis on exploring these concepts the process evaluation 4

will look at three evaluation components. These are: (i) content delivery, (ii) content 5

engagement, and (iii) reach, and are shown in Table 1. Content delivery refers to the 6

delivery and receipt of each individual input component of the intervention from the 7

perspective of those delivering the intervention. Content engagement refers to the 8

delivery and receipt of each component of the intervention from the perspective of 9

those receiving the intervention. Reach refers to the proportion of the intended target 10

audience who participated in the intervention, and the process evaluation will 11

specifically explore reasons expressed for discontinuing the program. 12

13

Information collected from stakeholders (those implementing the intervention) will 14

include perceptions on the roles and activities involved in the implementation of the 15

intervention, from initial discussions through to intervention design, set-up, project 16

management and facilitation. Perceptions on the acceptability, including integration 17

and disruption to the standard community program, benefits and impacts of the 18

intervention and suggestions for improvement will also be collected. 19

Information collected from participants (parents/ carers and children receiving the 20

intervention) will include perceptions on how specific components of the intervention 21

were understood and engaged with, and recounts of their experiences of interacting 22

with the intervention materials, other families and facilitators. Perceived benefits, 23

strengths/ weaknesses and suggested improvements will also be collected. 24

25

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The impact evaluation will determine the contextual factors that influenced trial 2

outcomes and broader impacts, and identify for whom the incentive scheme was 3

most and least effective in terms of having an effect during the community weight 4

management program and sustained impacts after the program. Investigations will 5

include the environmental and social context associated with participation in the 6

intervention, individual attitudes and beliefs about healthy living, and associated 7

barriers and enablers to adapting to new behaviours and forming new habits 8

9

The Realistic Evaluation model [39] was used to inform the design of the impact 10

evaluation and Table 1 outlines the three evaluation components the investigation 11

will focus on. These are: the broader environment, participant characteristics, and 12

program factors. The broader environment refers to other health activity, particularly 13

other interventions and healthy eating programs the family was involved in at the 14

time of the intervention, as well as barriers and enablers to participation and 15

engagement in the community weight management program associated with the 16

home environment and the families’ lifestyle. Participant characteristics were 17

identified at baseline in the trial and include; age, gender, single or separated family 18

status, single or multiple sibling family. This information will be used to recruit 19

participants for focus groups and family interviews (with the aim of including a mix of 20

characteristics), and will also be factored into analyses. Program factors to be 21

explored include; size of the community weight management program group, 22

regional or metro site location, venue type, and day the program sessions were held 23

(weekday or a weekend day), and will also be informed by the process evaluation. 24

25

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Information collected will draw from those receiving the intervention (children and 1

their parents/ carers), and include lifestyles, attitudes and health behaviours, 2

perceptions on what has changed in their lives since the program, habits retained, 3

and behaviours that have proven difficult to integrate into their lifestyles. Specific 4

impacts of the individual intervention components will be explored in depth. 5

All intended primary and secondary outcomes of the trial will be considered in the 6

investigation of contextual factors. The primary measure in the RCT was body mass 7

index at the end of the community weight management program (10 weeks) and at 8

six months. Secondary outcomes included: Waist circumference; nutrition and 9

physical activity behaviours and self-esteem (by survey) at the end of program (10 10

weeks) and at six months. Attendance rates during the program (completion of >75% 11

of sessions) was also measured in the trial. The evaluation will also compare 12

perceptions of the incentives scheme in relation to the outcomes in the absence of 13

the intervention (control group). This will help determine how the intervention 14

influenced outcomes, and whether the effects were intended. 15

16

Aim 3.Intervention deconstruction 17

The intervention deconstruction will explore and describe which specific components 18

of the incentives-based intervention were most impactful and why. The incentives 19

intervention was developed iteratively in 2014 drawing from a review of the relevant 20

literature, workshops, focus groups and field visits. Combined literature review and 21

advice from community program leaders highlighted the importance of incentivising 22

goals and activities (e.g. having healthier lunches) rather than outcomes (e.g. weight 23

loss) for greater impact on behaviour change.[40,11] For example, in a series of 24

RCTs across 203 elementary schools, it was reported that providing incentives for 25

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reading books was more effective than providing incentives for outcomes such as 1

scores on a test.[40] Community program leaders indicated during field research that 2

while goal setting as part of the program was usually specific, measureable, 3

achievable, relevant, and timely (SMART), it was likely to be of value to enhance the 4

goal setting process, including resetting/ stretching goals if they are achieved too 5

easily, and linking goal achievement to incentives. The importance of choosing the 6

appropriate size, type and timing of incentives was also highlighted as critical for 7

motivating change. For example, a study in children [26] found that a larger financial 8

reward (a US quarter rather than a nickel) combined with receiving it on the same 9

day as the behaviour was performed produced the largest behaviour change. The 10

key behavioural concepts that informed the design of the individual intervention 11

components (inputs in the logic model) are summarised below in Table 2. 12

13

The Behaviour Change Technique Taxonomy (BCTTv1) [41] will be used as a 14

framework for deconstructing the behaviour change intervention components used in 15

the trial. The purpose of this is threefold: (i) to optimise the robustness and 16

replication potential of the research by using a common language to recognise and 17

specify the components of the intervention that are changing behaviour (use of the 18

taxonomy supports the CONSORT guidelines for the reporting of behaviour change 19

interventions,[42] (ii) to facilitate translation of the interventions for the greatest effect 20

on child obesity outcomes by separating the active ingredients within the intervention 21

components and the conditions under which they are effective, from components 22

that may be less necessary and (iii) to understand more about any intervention 23

components that may be useful but were not sufficient in dose to produce an impact 24

on outcomes.[34] It will also be useful to refer to the full list of 93 items in the 25

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Behaviour Change Technique Taxonomy [41] in the analysis of how and why specific 1

components worked or didn’t work. The behaviour change technique mappings 2

shown below in Table 2 have been mapped in retrospect as a starting point to guide 3

analysis. For this exercise careful attention was paid to the coding definitions 4

specified in the Behaviour Change Technique Taxonomy,[41] and the “BCT 5

taxonomy” app was downloaded through Apple to guide coding. 6

7

Table 2. Behavioural concepts and corresponding behaviour change intervention 8

components, mapped to the Behaviour Change Technique Taxonomy. 9

*Corresponds with Inputs (material resources) and Activities in the logic model 10

Concept to illicit behaviour change

Behaviour change intervention component developed for the trial*

Mapped to the Behaviour Change Technique Taxonomy [41]

Incentivising behaviours and activities rather than outcomes is more effective for sustained behaviour change than rewarding outcomes [33,40,43]

Enhanced goal setting process including establishing a "big wish” (the overall outcome), then deciding on small achievable weekly goals which were re-set and stretched each week (with modified SMART goals handout)

Goals and Planning (1.4 action planning) Note 8.3 Habit formation and 8.7Graded tasks may also apply

Rewards scheme linked to weekly nutrition and exercise goal attainment


People are motivated to complete a goal when they can see their progress [44]

Group “Goals and Rewards Tracker”

Feedback and monitoring (2.5 monitoring of outcomes of behaviour without feedback)

Small and frequent rewards can increase task perseverance [44]

Low value weekly rewards


An implementation intention can help people achieve a goal [45-47)

Modified “Goals and Rewards Contract”(between parent/ carer and child)

Goals and Planning –(1.8 behavioural contract )

Lucky draw-style rewards may increase effectiveness of incentives [17,22,25]

Prize draw incentive six months after community weight management program

Reward and Threat –(anticipation of future reward – not categorised by the app used to code)

Text message prompts w SMS scheme linked to Feedback and Monitoring

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can improve health behaviours [48]

six month prize draw (10.4 social reward)

1

Data Sources 2

The evaluation will use a qualitative analysis, which will explore multiple groups of 3

people’s perspectives on the benefits, acceptability, and other ways in which 4

incentives could be used for behaviour change. Data collection will include a 5

combination of focus groups, family and stakeholder interviews, and a survey 6

(interview schedules and the survey are included as supplements to this paper). 7

Table 3 provides details of the data sources and their aims. 8

9



A 5-minute written survey of 10 questions with a mix of open-ended, single and multiple response questions. One per parent/ carer (control and treatment)

Distribution and collection at the six month health assessments of the trial

Focus: overall barriers and enablers to behaviour change, and recruitment Obtain top of mind feedback on core elements of the intervention, and invite families to consent to be contacted for a focus group or family interview




Focus: process evaluation Explore experiences, perceptions and engagement in the specific intervention component

3. Family interviews with parents/ carers

10-20 interviews lasting 30-60mins, depending on

Brief survey. Selection will be based on quota

Focus: impact evaluation Gain insights into

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and their children who participated in the community program, and other family members (e.g. siblings)

thematic saturation specifications around key participant and group characteristics (see ‘Participants’)

the contextual factors influencing outcomes




Focus: process evaluation Understand issues associated with the intended and actual delivery of the intervention

5.Project management materials

Decision logs, implementation plans and other project management documentation

Retracing project management activity, stored securely at the Department of Premier and Cabinet)

Collect additional insight into issues, mitigations, processes and learnings documented by the project team throughout the trial

1

The focus groups and interviews will follow a semi-structured approach, and 2

facilitation will be supported by bullet-pointed topic guides to facilitate natural 3

conversation between moderator and participants by emphasising topics, objectives 4

and flow. Each focus group and interview will be recorded and transcribed verbatim. 5

Participants will be made aware of this at the start of the group or interview and their 6

consent obtained. All discussions will be confidential. GE will conduct the focus 7

groups and interviews in a private room within a facility near to the participants’ 8

residence (such as a community centre) or place of work. A second researcher will 9

also be present in the room in an observatory capacity to take notes during the group 10

discussion. Refreshments and parking reimbursement will be provided for focus 11

group participants. To optimise attendance a $40 (e.g. a supermarket voucher) will 12

be offered to each family who participates in an interview. 13

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1


Data analysis and synthesis will be based on the Grounded Theory approach.[49-51] 3









groups will be necessary. Two researchers will conduct the analysis, and if at any 12

stage consensus cannot be reached, a third researcher will review those aspects. 13

NVivo software will be used to assist with qualitative data management. The overall 14

output will be a set of probability statements about the relationship between 15

concepts, or a set of conceptual hypotheses [50] about the barriers and enablers to 16

implementation of the incentives scheme, and its impact on the behaviour of 17

participants. 18

19

The analysis will be conducted in three waves, corresponding to the three levels of 20

evaluation in this research - the process, impact and behaviour change component 21

evaluations. Specifically, for the process evaluation the coding process will refer 22

back to the individual input and activity components in the logic model. Each focus 23

group and interview transcript will be scanned for themes relating to the delivery and 24

receipt of each component of the incentives scheme. Project management materials 25

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will also be reviewed and examples identified to support or contradict themes 1

emerging from the transcribed data. For the impact evaluation the coding process 2

will be related back to the intended outcomes and impacts of the intervention, as per 3

the logic model. Each focus group and interview transcript will be scanned for 4

themes associated with broader environmental influences on the effects of the 5

incentive scheme, and in relation to different participant characteristics and program 6

factors. The output will include typologies to describe for whom and how incentives 7

may impact behaviour. The intervention deconstruction will be guided by the 8

Behaviour Change Technique Taxonomy [41] as a basis for describing the active 9

intervention components and exploring whether the perceived impacts of the 10

intervention support or contradict the behavioural concepts underlying the design of 11

intervention. The specific mechanisms of the incentives-based behaviour change 12

scheme that lead to behaviour change may be associated with behavioural concepts 13

outside of those identified in the literature and influenced by unanticipated factors, 14

which the researchers will explore throughout the analysis. 15

The findings will be triangulated, drawing on the variety of data sources and 16

perspectives, and with comparison to the trial control group to determine whether the 17

trial outcomes can be attributed to the intervention. Issues and potential biases in the 18

design of the trial will be carefully factored in to interpretations. 19

20


The timing of the data collection is shown above in Table 1. Data will be collected at 22

two points: (i) during the six-month follow-up assessments in the RCT (which is 23

complete), (ii) one to two months after the six-month assessments. Conducting the 24

fieldwork close to the follow-up assessments will minimise corruption of the RCT as 25

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the evaluation data collection will prompt people to remember their experiences 1

during a pre-scheduled intervention point. Focus groups and stakeholder and family 2

interviews are estimated to commence in August 2016. 3

4

DISCUSSION 5

This paper details the protocol for a qualitative evaluation to be conducted shortly 6

following a RCT aimed at increasing behaviour change in overweight and obese 7

children participating in a community-based obesity program. The research aims to 8

address the challenges of public health interventions and provide information about 9

the barriers and enablers to the implementation of an incentives-based intervention 10

and its impact on health-related behaviour change in children. This research will 11

determine the relationships between intervention delivery, contextual factors 12

influencing outcomes, and the mechanisms of behaviour change, and provide 13

detailed information on the acceptability of the incentives-based scheme and its 14

potential as an obesity-reducing strategy in children in a range of contexts. It has 15

potential to add considerable value to the interpretation of the quantitative-based 16

RCT outcomes and inform future implementation and translation as a behaviour 17

change strategy for managing obesity in overweight children, should the 18

interventions be deemed acceptable. The knowledge will also advance the 19

development of further strategies for health-related behavior change in children, 20

supporting positive change in tackling the growing global problem of obesity. 21

22

DECLARATIONS 23

Ethics and dissemination 24

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This study will adhere to the National Health and Medical Research Council ethical 1

guidelines for human research. The study has been approved by the South West 2

Sydney Human Ethics Committee review body (HREC/14/LPOOL/480). Appropriate 3

site-specific approvals have been obtained from relevant research governance 4

offices. Consent was obtained from existing RCT participants during the trial to be 5

contacted for qualitative research. The findings of this study will be disseminated via 6

the usual scientific forums including peer-reviewed publications and presentations at 7

international conferences. The study will be administered by the George Institute for 8

Global Health, with the design and conduct overseen by a Steering Committee. 9

Unpublished data from the study such as anonymised transcripts and coded survey 10

dataset may be requested from the corresponding author at 11

[email protected]. Consent will be obtained from study participants for 12

transcripts prior to dissemination. 13

14


None known 16

17







24

Funding 25

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8

Acknowledgements 9




• Office of Preventive Health: Anita Cowlishaw; Santosh Kanal; Nicholas 13

Petrunoff 14



Kirsti Cunningham 17


Stephanie Baker 19




McLerie 23



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5

REFERENCES 6




A review of the literature. Preventive Medicine 1993;22 (2):167-77. 10

3. Biro FM, Wien M. Childhood obesity an adult morbidities. Am J Clin Nutr 2010;91 11

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Paediatrics 2001;127:214-222. 5




Pediatrics 2010;157:388-394. 9



12. Epstein LH, Wrotniak BH. Future directions for pediatric obesity treatment. 12

Obesity 2010;18(Supplement 1):S8 - S12. 13

13. Glasgow RE, Emmons KM. How can we increase translation of research into 14


14. Watson PM, Dugdill L, Murphy R, et al. Moving forward in childhood obesity 16

treatment: A call for translational research. Health Educ J 2013;72(2):230-9. 17

15. Skinner BF. The behaviour of organisms. New York: Appleton – Century Crofts; 18

1938. 19



Preventive Medicine 2015;75:75-85. 22



2014;9(3):e90347. 25

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18. Sutherland K, Christianson JB, Leatherman S. Impact of targeted financial 1


Rev 2008;65(6Suppl):S65-78S. 3

19. Purnell JQ, Gernes R, Sherraden MS et al. A systematic review of financial 4


20. Paul-Ebhohimhen V, Avenell A. Systematic review of the use of financial 6


367. 8



2006;64(12):518-31. 11

22. Strohacker K, Galarraga O, Williams DM. The Impact of Incentives on Exercise 12

Behavior: A Systematic Review of Randomized Controlled Trials. Ann Behav 13

Med 2013;1-8. 14



2013;45(5):658-67. 17

24. Enright G, Redfern J. Summary of the evidence for the role of incentives in 18

health-related behavior change: Implications for addressing childhood obesity. 19

Annals of Public Health and Research 2016. In Press, accepted 7th June 2016. 20



2012;31:1028-36. 23

26. Just DR, Price J. Using Incentives to Encourage Healthy Eating in Children. J 24

Human Resources 2013;48:855-72. 25

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27. Loewenstein G, Price J, Volpp K. Habit formation in children: Evidence from 1















study. Trials 2014;15:215. 16

33. Gneezy U, Meier S, Rey-Biel P. When and why incentives (don’t) work to modify 17

behaviour. J Economics Perspectives 2011;25:191-209. 18

34. Tate DF, Lytle LA, Sherwood NE et al. Deconstructing interventions: approaches 19

to studying behavior change techniques across obesity interventions. Behav. 20

Med Pract Policy Res. 2016; 6: 236. 21




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38. May C, Finch T: Implementation, embedding, and integrating practices: an outline 7

of normalization theory. Sociology 2009;43(3):535-554. 8

39. Pawson RT, Tilley N. Realistic Evaluation. London: Sage;1997. 9



41. Michie S., Richardson M., Johnston M. et al. The Behavior Change Technique 12

Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an 13

International Consensus for the Reporting of Behavior Change Interventions. 14

ann. behav. med. 2013; 46: 81. 15

42. Boutron I, Moher D, Altman DG, et al. Extending the CONSORT statement to 16

randomized trials of non-pharmacologic treatment: Explanation and 17

elaboration. Ann Intern Med. 2008;148:295-309. 18


2011;16:107-33. 20




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46. Gollwitzer PM, Sheeran P. Implementation intentions and goal achievement: A 4

meta-analysis of effects and processes. Advances in experimental social 5

psychology 2006;38:69-119. 6

47. Belanger- Gravel A, Godin G, Amireault S. A meta-analytic review of the effect of 7

implementation intentions on physical activity. Health Psychology Review 8

2013;7(1): 23-54. 9




49. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for 13






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Figure 1.

346x210mm (300 x 300 DPI)

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Discussionguide_familyinterview_v105.08.15

DiscussionguideforfamilyinterviewDuration:60mins

1.Introduction 5mins

• Welcome,thankyoufortakingpart• ExplainwhoIamandtoday’spurpose:tounderstandyourthoughtsand

livessixmonthsonfromtheGo4Funprogramme.• Explaintherearenorightorwronganswers,nojudgment,theinterview

isstrictlyconfidential,itwillberecordedandtranscribedforresearchpurposes

• Signingandcollectionofconsentform.Tellmethreethingsaboutyourselves:

• Whatyouallliketodoinyoursparetime-theymightbedifferentthings!• Favouriteoridealholiday• Somethingthatreallybothersyou

PARTONE:Theirlivesandattitudes 35mins2.Theirlives (10mins)

• Howwouldyoudescribeyourlife?[Encourageadjectives:fun,busy,relaxed,stressful,enjoyable,revolvedaroundthekids,nofreetime]

• Whatwouldyouliketobedoingmoreof–onyourownandasafamily?• Whatwouldyouprefertobedoinglessof–onyourownandasafamily?• Howwouldyoudescribeyourhomeandlivingarea?

o Favouriteandleastfavouriteplaces–whatdoyoulikeabouttheseplaces?Howdoyoufeelthere?Whodoyougotherewith?

o Whatwouldyouchangeaboutwhereyoulive?• Howmuchtimedoyouspendasafamily?Whatmakesiteasierorharder

todothingstogether?• Dothekidsdoanyafterschoolorweekendactivities?Whatmakesit

easierorhardertodotheseactivities?• Howdoyoubalancework/schoollife,sociallife,familytime,hobbies,

studying,andallthedifferentpartsofyourlife?3.Attitudestowardhealthandhealthbehaviours (25mins)

• LETTHEKIDSSHOUTOUTFIRST:WhatcomestomindwhenIsay“health”(capturetheirlanguageandexploreassociations)

Objective:Determinethecontextualfactorsinfluencingtheinterventionoutcomesandbroaderimpactonparticipants’lives:

- Explorelifestyle- Explorewhathaschangedinthepastsixmonthssincetheprogramme- Observedynamicsbetweenfamilymembers

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• PERSONIFICATION:If“health”walkedintotheroomrightnowwhatwouldtheylooklike?

o Maleorfemale/ageo Whataretheywearing?Whatjobdotheydo(ifanadult),where

dotheylive?o Whatarethebestthingsabouttheirpersonality?o Andthenotsogoodthings?o Describetheirfamilyandfriendso Whatisyourrelationshiptothem?o Whatwouldtheysaytoyou?o Wouldyouliketobelikethisperson–why/whynot?

• Whatdoesitmeantobe“healthy”?[Promptemotional,social,spiritual,

intellectualaswellasphysicalhealth]o Whatarethebenefitsofbeinghealthy?o Arethereanycompromises?o Whatemotionscomewithbeinghealthy?

• Howabout“unhealthy?o Whataretheconsequencesofbeingunhealthy?o Inwhatcircumstancesdoyouthinksomeonebecomesunhealthy?

Arethereanybenefitsofbeingunhealthy?[E.g.yougettoeatchocolate]

o Whatemotionscomewithbeingunhealthy?

• Howeasyisittofitineatinghealthilyandkeepingactive?o Arethereanyshortcutstobeingactive?o Arethereanytipsandtrickstoeatinghealthily?

Theirdiets• How“healthy”wouldyousayyourdietsare?Whatdoyoubasethison?• Doyoutendtoeatthesamethingsasafamily?• Doyouevereattogether?Whatdeterminesthis?• Doyoupackaworklunch?• Howoftendoyoucookathome?Whodoesthecooking?• Wheredoyoubuyyourgroceries?Howoften?Whodoestheshopping

usually?• HowhasyourdietandeatinghabitschangedsincetheGo4Fun

programme?(ifatall)• Whathashelpedorgotteninthewayofthischange?• Howdoyoufeelabouthealthyeatingnow?

Theiractivitylevels• Howactiveareyouall?• Doyouthinkyouaremoreorlessactivethantheaveragefamilyofyour

ages?• HowhaveyouractivitylevelsorhobbieschangedsincetheGo4Fun

programme?• Howeasyhasitbeentomakethesechangesandsticktothem?

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• Whathashelpedorgottenintheway?• Howdoyoufeelaboutactivelivingnow?

PARTTWO:Specificimpactoftheinterventions 20mins4.Overallperceptions (10mins)

• LETTHEKIDSSHOUTOUTFIRST:WhatwordscometomindwhenyouthinkabouttheGo4Funprogramme?

• Thinkingbackoverthewholetenweekprogramme,whichsessionsstandouttoyoumost?

o Whatwerethebestbits?Whatdidyoulikeaboutit?o Andthenotsogoodbits?Whydoyousaythis?

• HowhaveyourliveschangedasaresultofGo4Fun?(ifatall)• Whathasbeenthebiggestbenefitoftheprogrammetoyou?• Whatareaofyourliveshasitimpactedthemost?[Promptemotional,

social,intellectual,spiritualandphysical]• Howhaveyourattitudestowardshealthyeatingbeenaffected?(ifatall)• Howhaveyourattitudestowardsexerciseandbeingactivebeeneffected

(ifatall)• Whatareyoudoingnowspecificallythatisdifferenttobeforeyou

participatedintheGo4Funprogramme?(ifanything)• Whichpartsoftheprogrammedoyouthinkledtothesechanges?• Howdoyoufeelsixmonthsonfromtheprogramme?

5.ImpactofSMARTgoalsettingandrewards (10mins)

• DoyourememberhowtosetaSMARTgoalnow?• Howhaveyoubeenfeelingaboutgoalsettinganddoinggoalssincethe

programmeended?• Howeasyhasitbeentofitthesix-monthgoalsintoyourlifesincethe

programme?• Whathashelpedorhinderedyou?• Howmuchdidtherewardshelptomotivateyouduringtheprogramme?• Havethetextmessagesinthelastsixmonthshelpedatall?Inwhatway?• Howhaveyoufoundcarryingonwiththegoalswithouttherewards?• Haveyoucarriedonwithgivingrewardsinthefamily?• Whichhaveyoufoundeasier/harder-thenutritiongoalsorexercise

goals?Whyisthis?• Whichbehaviourshavecontinuedthemostsincetheprogramme?• Whathashelpedyoukeepitup?• Whathasgottenintheway?• Whatelsewouldmakeiteasiertocarryonthesameactivitiesorhealthy

eating?Thankandclose

• Anythingelsetoadd?• WhathasbeenthebiggestimpactoftheGo4Funprogrammeonyour

lives?

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Discussionguide_parentfocusgroup_v105.08.15

DiscussionguideforparentfocusgroupDuration:60mins


• Welcome,thankparticipantsfortakingpart• ExplainwhoIamandtoday’spurpose:tounderstandyourthoughtson

andexperiencesoftheGo4Funprogramme.• Explaintherearenorightorwronganswers,nojudgment,thefocus

groupisstrictlyconfidential,itwillberecordedandtranscribedforresearchpurposes

• Signingandcollectionofconsentform.

GroupIntroductions:Askthegrouptointroducethemselvesonebyoneandgivethreefactsaboutthemselves:

1. Whatyouliketodoinyoursparetime2. Favouriteoridealholiday3. Somethingthatreallybothersyou

PARTONE:Theirlivesandattitudes 15mins2.Theirlives (10mins)

• FLIPCHART:Howwouldwedescribeourlives?[Encourageadjectives:busy,relaxed,stressful,enjoyable,revolvedaroundthekids,nofreetime…]

• Whatwouldweliketobedoingmoreof?• Whatwouldweprefertobedoinglessof?• BRIEFLYGOROUNDGROUP&DRAWONFLIPCHART:Describewhata

typicaldaylookslikeforyou[Prompttimegetup,breakfastroutine,gettingreadyforschool,daytime/work,collectingkids,afterschool,snacks,afterschoolactivities/play/homework,dinner,kidsbed,adultseveningandbed…]

• Howdoesthisdiffertotheweekend?3.Attitudestowardhealth (5mins)

• FLIPCHART:Whatcomestomindwhenwethinkof“health”(capturetheirlanguageandexploreassociations)

• Howdowefeelabouthealth?• PERSONIFICATION:If“healthwalkedintotheroomrightnowwhat

wouldtheylooklike?o Maleorfemale/age

Overallobjective:Determinethedegreethegoalsandrewardsinterventionwasimplementedasintended:

- Explorehowwellspecificinterventioncomponentswerereceivedandengaged

- Exploreunderstanding,motivation,perceivedbenefits,strengths,andweaknessesoftheinterventions,andsuggestionsforimprovement

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o Whataretheywearing?Whatjobdotheydo(ifanadult),wheredotheylive?

o Whatarethebestthingsabouttheirpersonality?o Andthenotsogoodthings?o Describetheirfamilyandfriendso Whatisyourrelationshiptothem?o Whatwouldtheysaytoyoupersonally?o Wouldweliketobelikethisperson–why/whynot?

• Whatdoesitmeantobe“healthy”?• Howabout“unhealthy?Whataretheproblemswithbeingunhealthy?

PARTTWO:Perceptionsoftheinterventions 40mins4.Overallperceptions (10mins)

• FLIPCHART:WhatwordscometomindwhenwethinkoftheGo4Funprogramme?

• Thinkingbackoverthewholeten-weekprogramme,whichsessionsstandoutmost?

o Whatwerethebestbits?Whatdidwelikeaboutthem?o Andthenotsogoodbits?Whydoyousaythis?

• Howdidwefirsthearabouttheprogramme?o Howdidwegetinvolved?Whatwastheprocesslike?Whatwas

the‘sellingfactor’?• Howmanysessionsdidweeachattend?

o Whatkeptuscomingbackeachweek?o Whatgotinthewayofcoming?

• Whathasbeenthebiggestbenefitoftheprogramme?[Promptmakingfriends,losingweight,educationaboutfood,gettingfitter…]

• Whoexactlyhasbenefittedfromtheprogramme?• HowhaveourliveschangedasaresultofGo4Fun?(ifatall)• Wasthereanythingmissingfromtheprogramme?• Anythingwewouldchangeabouttheprogrammeifwecould?• Howdowefeelabouttheleaders?• Whatwasitlikebeingtogetherinagroup?

o Hasanyonesocialisedwithanyonefromthegroupduringorsincetheprogramme?

• WhatdowerememberaboutDPCresearcherscomingintohelp?• Whohavewetalkedtoabouttheprogramme?Whatdidwesayaboutit?• Whatwouldwesaytosomeonenowwhoisthinkingofjoiningthe

programmenextteam?5.SMARTgoalsettingandrewards (15mins)

• HowwelldidweunderstandtheSMARTgoalsetting?o Whatcouldhavemadeiteasier/moreenjoyable?o Howdidwefeelabouthavingthehandoutwiththeexample

SMARTgoalsontheback?–wasithelpful,annoying…wheredideveryonekeepit?Didweuseit?How/whendidweuseit?

o Howwelldidtheleaderexplainit?

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o Dowethinkthekidsunderstoodit/andengagedwithit?o Isitanimportantpartofthegoalsetting?o Whatquestionsdowestillhaveaboutit?

• Howdidwefeelaboutthegoalsettingpartoftheprogramme?[Prompt

easy/hard,boring/interesting…]o Dowestillfeelthiswaynow?o Howhelpfulwastheleader?o Howinvolveddidyoupersonallyget?o Whatelsewouldhavehelped?o Werethereanyothergoodornotsogoodthingsaboutthegoal

setting?

• Howdidwefeelabouttherewards?o Whichrewardsdidourkidslike?o Werethereanyweortheydidn’tlike?o Howdowefeelabouttherewardsbeinggivenoutforattendance?o Howmuchdidtherewardsmotivateourkidstocomebackto

Go4Funeachweek?o Howdowefeelabouttherewardsbeinggivenoutforachieving

thegoalseachweek?o HowmuchdidtheymotivatethefamilytocomebacktoGo4Fun?o Howmuchdidtheymotivateourkidstodothegoals?

6.Doingthegoals (10mins)

• Howeasyorhardwasittodothegoalseachweekduringtheprogramme?

o Howinvolvedwereweathomeinourkidsdoingthegoals?o Whatkindsofconversationsdidwehavewithourkids?o Whatwouldhavehelpeduswiththegoals?o Howoftendidtheleadercheckin?Weretheyhelpful?o Howoftendidwestretchourgoals?Didwerememberhowto

makethegoalsSMART?Werethekidsengagedwiththis?o Werethegoalstooeasy/toohard?o Howdowefeelthisallfitwiththerestoftheprogramme?o Dowefeelcompletingthegoalshashelpedourkidsinanyway?In

whatwayhavetheyhelpedornothelped?o Whatwasitlikeworkingtogetherwiththekidsonthegoals?

Describewhatitwaslikedoingthemeachweek–didwehavetoprompt,howdidothersiblingsfitin…

o Werethenutritionorexerciseeasiertodo?Explore.o FLIPCHART:Forwhatreasonswereweunabletodothegoals

sometimes?

• Howhavewefounddoingthegoalsoverthepastsixmonths?o Whathavebeenthebiggestobstacles?[Promptmotivation,

weather,cultural,lifestyleetc.]

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7.Thetextmessages (5mins)• Howdowefeelaboutthetextmessages?

o Havethekidsbeenseeingthem?o Howmotivatinghavetheybeen?[Exploremotivationfordoingthe

goalsandmaintainingattitude]o Howwelldidweunderstandwhatweneededtodo?o Howmotivatingwastheprizedrawattheend?[Explore

motivationfortextingbackanddoingthegoals]o Howmuchdidwediscussthetextsandgoalsasafamily?Who

normallypromptedtheseconservations?o Didweeverfeelinneedofmorehelp?Whatdidwedoaboutthis?o Whatwouldwechangeabouttheprocess?

Thankandclose

• Anythingelsetoadd?• GOAROUNDINDIVIDUALLY:Whatoneimprovementwouldyoumaketo

thegoalsettingandrewardspartoftheGo4Funprogramme?

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Discussionguide_stakeholders_v105.08.15

DiscussionguideforstakeholdersDuration:30-60mins


• Explainaimofinterview:tounderstandyourthoughtsonthebehaviouralincentivestrialanditsimplementationintheGo4Funprogramme.

• Explainconfidentiality,recordingforresearchpurposes,sign/collectconsent.

• Tellmealittleaboutyourbackgroundandyourrolenow.Whatareyourfavourite/leastpreferredpartsofyourjob?

2.PerceptionsofandroleintheGo4Funprogramme 10mins

• WhatwordscometomindwhenyouthinkoftheGo4Funprogramme?• Whatarethemainbenefitsoftheprogramme?Towhom?• Whatarethemostimportantcomponentsoftheprogramme?• Inyourviewisanythingmissingfromtheprogrammecontent?• Whataretheweaknessesoftheprogramme?[promptpartswithlow

engagement,lowunderstanding,nutritioncontent,structure/flow,leadership,management…]

• DRAWIT:Whoisresponsibleforthemanagementoftheprogramme?[promptkeymanagers,thenpeopleatalllevels]–canyoudrawamanagementstructure,includingeveryoneinvolved?

• Howwellistheprogrammemanaged?• Whatarethestrengthsandweaknessesinthemanagementofthe

programme?• Whatisyourusualroleinmanagingtheprogramme?

3.Theirroleintheintervention 10mins

• Describeyourroleintheincentivesintervention• Atwhatpointdidyougetinvolved?Whichfurtherpointsthroughoutthe

trialwereyouinvolved?• Howdidyoufirsthearaboutthetrial?• Whatwereyourfirstthoughtsaboutthetrial?• Didyouhaveanyreservations?• Howdidyoucommunicatethese?• Howdidyouovercomethereservations,ordotheystillexist?• Whatotherissuesdidyouhaveatanypointinthetrial?• Howdidyouworkthroughthese?• Whodidyouworkwith?

4.Deliveringtheintervention 20mins

• Whatareyourthoughtsonthedeliveryoftheintervention?

Objective:Understandactivitiesandtheprocessesinvolvedintheimplementationofthebehaviouralincentivesintervention,frominitialdiscussionsthroughtointerventiondesign,setup,projectmanagementandfacilitation.Exploreperceptionsonacceptabilityoftheinterventionandsuggestionsforimprovement.

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Discussionguide_stakeholders_v105.08.15

• Describetheprocessesinvolvedasyouseethem• Howwouldyoudescribethecollaborationsinvolved?• Wereyouawareoforpersonallyinvolvedinanyconflictingviews

throughouttheimplementationoftheintervention?[Prompttheethicsprocess,designingthenewresources,replacingexistingresources,introducingthegoal-settingandrewardsschemeandworkingthroughthesewithfamilies,recordinggoals,standardisingattendanceincentives,selectingandprocuringtherewardsthemselves].

• Whowasinvolvedintheconflictingviews?• Tellmeaboutanydisruptionyoufeeltherewastothenormalprogramme

[explorespecificcomponents]• Whatdidyoufeelworkedespeciallywell?Whydoyouthinkthiswent

well?• Whatworkedlesswell?Tellmeaboutthemainproblemsandhowthey

wereovercome.• Areyouawareofanyproblemsexperiencedorfeedbackfromthe

participatingfamilies?Howwereyoumadeawareofthis?Wastherearesponse?

Specificcomponents

a) GoalsandRewardsGroupTrackerb) SMARTgoalsettingandstructuredrewardsc) Attendancerewardsd) Goalachievementrewardse) Sixmonthgoalsettingandtextmessages

• Howwelldoyoufeeleachcomponentwasintegratedintotheexisting

programme?• Howwelldidyouandtheleadersunderstanditandhowwellwasit

facilitated?• Whatwouldhaveimprovedtheprocess?

5.Perceptionsontheimpactoftheintervention 15mins

• Towhatextenddoyoufeeltheenhancedgoalsettingandrewardsschememotivatedfamiliestodothegoalsathome?

• Towhatextenddoyoufeeltherewards(attendanceorthoselinkedtogoals)motivatedfamiliestoattendtheprogramme?

• Whatroledoyoufeeltheprogrammeleaderplayedinmotivatingfamiliestoattendandachievegoals?

• Whatimpactdoyouthinktheinterventionhadforfamilies?• TowhatextenddoestheinterventionimprovetheGo4Funprogramme?• Towhatextentdoestheinterventionaddressweaknesseswiththe

existingprogramme?• Whatwouldyousuggesttoimprovetheintervention?Whatwouldyou

addorremove?Thankandclose-anythingelsetoadd?

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Survey_parents_v230.09.15

Briefsurveyforparents/guardiansWheredidyouattendGo4Fun?Q1.WhatthreewordscometomindwhenyouthinkofyourGo4Funexperience?(OE)1.2.3.Q2.Whichpartsoftheprogrammedidyougetthemostvaluefrom?(OE)Q3.Whatwerethebiggestobstaclestodoingthegoals?Tickanythatapply.(MR)a.Weather b.Culturalreasons c.Renovation,movinghouseorbeingonholiday d.Illness e.Lackofmotivation f.Goalswereunrealistic g.OtherWriteithere:Q4.HowwouldyouimprovetheGo4Funprogramme?(OE)Q5.DidyoureceiveweeklytextmessagesfromGo4Funoverthepastsixmonths?(SR)a.Yes–GotoQ6.b.No–GotoQ9

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Survey_parents_v230.09.15

Q6.Howmotivatingweretherewardsfordoingthegoalseachweek?(SR)a.Verymotivating b.Motivating c.Neithermotivatingnordemotivating d.Demotivating e.Verydemotivating Q7.HowhasthegoalsettingandrewardscomponentofGo4Funhelpedyourchildorchildrenliveahealthierlife?Tickanythatapply.(MR)a.Asafamilywehaveahealthierattitudetowardsfood b.Asafamilyweeatmorefruitandvegetables c.Ipersonallyhaveahealthierattitudetowardsfood d.Mychildorchildrenaremoreactivenow e.Ihaven’tnoticedachangeinmychild’sbehaviour f.Ihaven’tnoticedachangeinmyfamily’sbehaviour Q8.WouldyoubehappytoparticipateinafamilyintervieworfocusgroupaboutGo4Fun?Tickoneorbothifyou’dlikeandifyouprovideyourcontactdetailsGemmaEnrightwillcontactyousoontoarrangeatime.a.I’dliketoparticipateinafamilyinterview b.I’dliketoparticipateinafocusgroup Mycontactdetailsare:Name:_______________________________________________________________Email:______________________________________________________________Phone:______________________________________________________________c.Nothankyou. Q9.Anyothercomments?Feelfreetotellusanyotherthoughtsyouhaveabouttheprogramme!

Thankyousomuchfortakingthetimetocompletethesurvey!

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bmj open€¦ · 19 whilst randomised controlled trials (rcts) are regarded as the gold standard...

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