Public Release: 

To encourage exercise, losing a financial reward is more effective than gaining one

Results demonstrate the power of using loss aversion to motivate health behavior change

University of Pennsylvania School of Medicine

PHILADELPHIA - Financial incentives aimed at increasing physical activity were most effective when the rewards were put at risk of being lost, according to new research from the Perelman School of Medicine at the University of Pennsylvania. The study, which tested the effectiveness of three methods of financial incentives to increase physical activity among overweight and obese adults, shows that depending on how they are framed, incentives of equal amounts can have significantly different effects on outcomes. Results are published today in the Annals of Internal Medicine.

"Although most people know that exercise is good for their health, more than 50 percent of adults in the United States don't get enough of it," said lead author Mitesh S. Patel, MD, MBA, MS, an assistant professor of Medicine and Health Care Management in Penn's Perelman School of Medicine and The Wharton School, and a staff physician at the Crescenz VA Medical Center. "Workplace wellness programs aimed at increasing physical activity and other healthy behaviors have also become increasingly popular, but there's a lack of understanding about how to design incentives within these programs. Our findings suggest that these programs could result in better outcomes if they designed financial incentives based on principles from behavioral economics such as loss aversion."

In the study, 281 participants were given the goal of reaching 7,000 steps per day for the 26-week study period. For the first 13 weeks, participants were randomly assigned to one of four groups: the control group received no financial incentive; the gain incentive group received $1.40 for every day that the goal was achieved (equal to $42 per month); the lottery incentive group offered entry into a daily lottery with a possible prize that averaged to $1.40 each day that the goal was achieved; and, the loss incentive group which gave participants $42 at the start of each month and took $1.40 away for each day the goal was not achieved. In the second half of the study, participants continued to receive feedback on their performance, but were not offered an incentive.

By providing incentives of equal amounts, the team sought to determine which program design was most effective at motivating participants to increase physical activity and achieve the goal of 7,000 steps per day - roughly 40 percent higher than the average daily step count among U.S. adults (5,000). Progress was tracked using a mobile app which ran in the background on participants' smartphones.

Results from the first 13 weeks of the study show that offering a $1.40 reward each time the goal is achieved (the gain incentive group), or when daily lotteries were offered, were no more effective than not offering a reward at all (the control group). In those groups, participants achieved the daily goal approximately 30 to 35 percent of the time. However, participants who risked losing the reward they'd already been given (the loss incentive group) achieved the goal 45 percent of the time, amounting to an almost 50 percent increase over the control group. According to the authors, these findings suggest that the way in which a financial incentive is framed is important in determining its success.

"Most workplace wellness programs typically offer the reward after the goal is achieved," said senior author Kevin G. Volpp, MD, PhD, a professor of Medicine and Health Care Management and director of the Penn Center for Health Incentives and Behavioral Economics. "Our findings demonstrate that the potential of losing a reward is a more powerful motivator and adds important knowledge to our understanding of how to use financial incentives to encourage employee participation in wellness programs."

The authors noted that 96 percent of participants were still actively enrolled in the study even three months after stopping incentives, which may have important implications for the role that smartphones could play in deploying these programs at broader scale.

"Our findings reveal how wearable devices and apps can play a role in motivating people to increase physical activity, but what really makes the difference is how you design the incentive strategy around those apps," said David A. Asch, MD, MBA, a professor of Medicine and Health Care Management and director of the Penn Center for Health Care Innovation.

The authors say future studies might compare the effectiveness of incentives when combined with other motivators such as team-based designs that rely on peer support and accountability, or designs aimed at determining a more effective reward amount.


Additional Penn authors on the study include Roy Rosin, Dylan Small, Scarlett Bellamy, Jack Heuer, Susan Sproat, Chris Hyson, Lisa Wesby, Karen Hoffer, David Shuttleworth, Devon Taylor, Victoria Hilbert, Jingsan Zhu, Lin Yang, and Xingmei Wang.

Funding for the study was provided by the National Institute on Aging (RC4 AG039114).

Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $5.3 billion enterprise.

The Perelman School of Medicine has been ranked among the top five medical schools in the United States for the past 18 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $373 million awarded in the 2015 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center -- which are recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report -- Chester County Hospital; Lancaster General Health; Penn Wissahickon Hospice; and Pennsylvania Hospital -- the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Chestnut Hill Hospital and Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2015, Penn Medicine provided $253.3 million to benefit our community.

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