Designing Effective and Affordable Behavioral Interventions for Health. Wendy Donlin Washington, Ph.D. University of North Carolina Wilmington

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1 Designing Effective and Affordable Behavioral Interventions for Health Wendy Donlin Washington, Ph.D. University of North Carolina Wilmington

2 What behaviors most impact your health? How sensitive are these behaviors to programmed differential reinforcement and punishment?

3 Preventable Causes of Death Highest Contributors: Smoking & Obesity

4 Smokers Vs Non-Smoker Costs +$4260 More for Smokers Yearly $170+ Billion per year in national healthcare costs ~10% of all healthcare spending

5 Smoking Trends in the US Successful behavioral interventions have been developed for Smoking Cessation by Behavior Analysts like Steve Higgins, Maxine Stitzer, George Bigelow, Jin Yoon, Jesse Dallery, many others

6 Obesity Related Early Death 300,000+ deaths/year due to obesity

7 Under weight Normal Over weight Obese 4'10" < > 139 4'11" < > 144 5' < > 149 5'1" < > 154 5'2" < > 159 5'3" < > 164 5'4" < > 170 5'5" < > 175 5'6" < > 180 5'7" < > 186 5'8" < > 191 5'9" < > 197 5'10" < > 203 5'11" < > 209 6' < > 214 6'1" < > 220 6'2" < > 226 6'3" < > 233 6'4" < > 239 BMI Weight (kg)/ Height 2 (m) BMI Underweight Below 18.5 Overweight Obesity 30.0 and Above

8 Self-Reported Obesity 2015 (CDC) No state has a prevalence of obesity less than 20%

9 Self-Reported Obesity by race/ethnicity (CDC) Hispanic Non-Hispanic White Non-Hispanic Black

10 Obese v. Normal Weight Per Patient Cost $315 Billion extra per year in national healthcare costs ( Distribution of people Medical Costs w/95% confidence intervals Figure from: Cawley, J., Meyerhoefer, C., Biener, A. et al. PharmacoEconomics (2015) 33: 707. doi: /s

11 What Causes Obesity?

12 Physical Fitness The CDC recommends

13 Physical Fitness The simplest rule is to take 10,000 steps a day (~5 miles). However, many adults do not meet any of these recommendations. Only 40% of Americans lead a physically active lifestyle Many Americans could be considered primarily inactive

14 23.7% Adults engage in NO leisure time physical activity

15 Impediments for Physical Activity Current fitness level prevents meeting CDC recommendations The immediate consequences of engaging in physical activity can be aversive

16 Who needs physical activity interventions? Treatment The 24% with NO leisure time physical activity The ~35% of adults considered obese The ~33% of adults that are overweight People with diabetes or cardiovascular risks Prevention Everyone else?

17 How To Motivate? Contingency Management has proven successful at changing health behaviors We need to provide immediate benefits for engaging in healthy behaviors

18 Contingency Management (Differential Reinforcement) Objective measure of ongoing behavior A way to set appropriate goals An effective reinforcer

19 Carole Van Camp, Matt Normand, Ray Miltenberger Jesse Dallery Nancy Petry Kate LaLonde, James Luiselli, Ray Miltenberger

20 Overall Purpose Increase Steps Compare Reinforcers Predictors of Success

21 Data Collection The device shows steps, calories and distance. Wireless updating. Data Downloading Participants could NOT access website.

22 Percentile Schedule The last 7 days of steps used Day Day Day Day Day Day Day Rank Ordered by Steps 1 14% % % % % % % 10875

23 Study 1 Intermittent prizes 10 students 1 week of Baseline Prize draw contingent on wearing Fitbit 1 week of a Percentile Schedule Prize draw contingent on exceeding criteria Percentiles Schedule require steps exceed 5 days of the past week. Recalculated each day. 1 week of Baseline Prize draws contingent only on wearing Fitbit Washington, W. D., Banna, K. M., & Gibson, A. L. (2014). Preliminary efficacy of prize based contingency management to increase activity levels in healthy adults. Journal of Applied Behavior Analysis, 47(2),

24 Prize Draw Probabilities Jumbo 1% (>$100) Large 2% (~$50) Medium - 5% (~$15) Small- 42% (<$5)

25 Steps (in thousands) Anatomy of My Graphs Baseline Intervention Baseline Prize draw goals DAYS

26 >4387 improvement >2845 improvement

27 Group Trends 20 Steps (in thousands) BL1 INT BL2 Condition

28 Study 2 Intermittent Prizes, Bonuses and Multiple Baseline (Logan Gibson s Thesis) Goals target more deficient walkers (<12,000 baseline averages) Can we get more stability with a longer baseline? Can we maintain effects for longer than one week? 16 Students, Faculty & Staff (mean age 22.6, range 18-65), 7 males 5 weeks Baseline draws every 2 days Fitbit worn, no goals up to 3 weeks Intervention prize draws each day for goals; bonus draw for 3 consecutive goals Percentiles 71%, 89% and 100% Do different percentile criteria result in different magnitudes of change?

29 100th percentile 50% increase steps/day 42% increase steps/day 86th percentile

30 Intervention Baseline Subject 26 Still a lot of variability. However you can see when the subject walked

31 Stepcount Improvement >1500 steps Baseline Intervention Did worse in intervention Subject Number

32 Stepcount Improvement >1500 steps Baseline Intervention Did worse in intervention Subject Number

33 Stepcount Improvement >1500 steps Baseline Intervention Did worse in intervention Subject Number

34 No correlation with age noted

35 r = -.14 No correlation with age noted

36 No correlation with age noted r = -.14 *

37 Study 2 Conclusions Variability still high even with longer baselines Only 6 out of 16 participants showed significant improvements. There were initial improvements in 4 additional participants, that drifted back towards baseline levels with extended exposure to the intervention Men & Obese individuals improved more than others Lower baselines = bigger improvements But maybe our prizes weren t that great?

38 Study 3 Is money a better reinforcer? 19 underactive (<10,000steps/day baseline)uncw Faculty, Students and Staff Randomized to 2 groups Deposit Group deposits $25 at end of baseline No Deposit Group no deposit required Donlin Washington, W., McMullen, D., & Devoto, A. (2016). A matched deposit contract intervention to increase physical activity in underactive and sedentary adults. Translational Issues in Psychological Science, 2 (2), 101.

39 Study 3 Is money a better reinforcer? ABA Design Baseline 7-10 days no goals or money available Treatment (21 days) Earn $1.50 per day, $2.65 bonus for meeting criteria on 3 consecutive days. Total of $50 available Baseline (5-10 days) no goals or money available

40 Select Deposit Group

41 Select Non-Deposit Group

42 Group Comparison

43 Study 3 Results Money is an effective reinforcer, regardless of the source A marked decrease in variability in treatment phase (as compared to the prize studies)

44 Prizebowl Money Goal Is intermittent money effective as a reinforcer? 22 Deficient Walkers (<10,000 steps) 82% Female. Average Age 27 (range 18-60) Average BMI (range ) ABA (baselines 1 week, Intervention 3 weeks) Money Draws in Invention No winnings (50%) Small (42%) ($1.50) Medium (5%) ($15) Large (2%) ($25) Jumbo (1%) ($50)

45 Best Subjects

46 Other Representative Subjects

47 Percent of Particpants Improving by at least X% Results All Subjects had higher intervention step counts than compared to baseline % 90% 80% 70% 60% 50% 40% 30% 20% 10% 50% of the participants improved >34% 0% 0% 20% 40% 60% 80% 100% 120% 140% Percent Improvement from Baseline 1 to Intervention

48 Percent of Particpants Improving by at least X% Results All Subjects had higher intervention step counts than compared to baseline % 90% 80% 70% 60% 50% 40% 30% 20% 10% 50% of the participants improved >34% 0% 0% 20% 40% 60% 80% 100% 120% 140% 0 Percent Improvement from Baseline 1 to Intervention Baseline 1 Intervention Baseline 2 Average Step Count

49 Percent of Particpants Improving by at least X% Results All Subjects had higher intervention step counts than compared to baseline % 90% 80% 70% 60% 50% 40% 30% 20% 10% 50% of the participants improved >34% 0% 0% 20% 40% 60% 80% 100% 120% 140% 0 Percent Improvement from Baseline 1 to Intervention Baseline 1 Intervention Baseline 2 Average Step Count Average Improvement was 43%. The lower the baseline step count, the bigger the % improvement. r=-0.75, p<0.05 Seven participants maintained higher stepcounts once contingency removed. Eleven went back to levels close to the initial baseline.

50 Overall Summary Most deficient walkers show most improvement, regardless of reinforcer Money is a better reinforcer than prizes You can get people to pay for their own intervention without a loss of effectiveness. Intermittent money seemed to work as well as money every day. And upon returning to baseline 2, stepcounts were less likely to return to original baseline levels.

51 Average Step Count (thousands) All studies (except 2 nd prizebowl study) had significant increases in stepcounts Deposit$ Prizebowl Money Smokers Money Goals and Money 1st prizes Baseline 1 Intervention Baseline 2 2nd prizes

52 Steps (in Thousands) We re lazy on weekends! (N=107) Baseline 1 Intervention Baseline 2 Sunday Monday Tuesday Wednesday Thursday Friday Saturday

53 Age unimportant?

54 BMI Important (weakly)

55 Baseline Steps are REALLY Important

56 Current Study We re looking at the efficacy of an escalating schedule of reinforcement with a reset contingency to increase walking. Will it help a higher % of people? Will people meet goals on more days? $1.25 $1.00 $ $0.75 $ $0.50 $ $0.25 $

57 Future Directions We need to target the most at-risk populations: overweight/obese, diabetic, smokers and older adults Further explore reinforcer magnitudes & schedules of reinforcement Explore effectiveness of group contingencies, competitions and social media

58 Take Home Message (mostly for the students). The strategies used to treat a problem in one area of behavior analysis can often be applied in a completely different area. (I started out as a pigeon/rat researcher, then did drug cessation studies, now I focus on healthy behavior!)

59 Collaborators and Funding Researchers Kaitlyn Proctor, B.A. Amanda Devoto, M.A. Alex Hatcher, M.A. Amanda Logan Gibson, M.A Derek McMullen, M.A. Matthew Taylor, B.A. Kelly Banna, Ph.D. Carole Van Camp, Ph.D. Lynda Hayes M.A. Assistants Alura Lanoza Austin Franchino Grant Berry Casey Murdoch Sterling Rippy Jeremiah Brown Haleigh Winbourne Sydney Ball Savanna Daughtry Kwame Freeman Madeline Adler Alish Dwyer Kelly Wall Weston Godfrey Brittany Smith Heather Fleuriet Kaitlyn Proctor Dalton Camp David King Denise Masten Javier Martin-Fernandez Katy Wormley Brian Coleman Colleen Kennedy Research Supported by UNCW

60 Thank You!