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1.  Impact on alcohol purchasing of a ban on multi-buy promotions: a quasi-experimental evaluation comparing Scotland with England and Wales 
Addiction (Abingdon, England)  2014;109(4):558-567.
Aims
To evaluate the impact of the 2011 Scottish ban on multi-buy promotions of alcohol in retail stores.
Design and setting
Difference-in-differences analysis was used to estimate the impact of the ban on the volume of alcohol purchased by Scottish households, compared with those in England and Wales, between January 2010 and June 2012.
Participants
A total of 22 356 households in Scotland, England and Wales.
Measurements
Records of alcohol purchasing from each of four categories (beer and cider, wine, spirits and flavoured alcoholic beverages), as well as total volume of pure alcohol purchased.
Findings
Controlling for general time trends and household heterogeneity, there was no significant effect of the multi-buy ban in Scotland on volume of alcohol purchased either for the whole population or for individual socio-economic groups. There was also no significant effect on those who were large pre-ban purchasers of alcohol. Most multi-buys were for beer and cider or for wine. The frequency of shopping trips involving beer and cider purchases increased by 9.2% following the ban (P < 0.01), while the number of products purchased on each trip decreased by 8.1% (P < 0.01). For wine, however, these effects were not significant.
Conclusions
Banning multi-buy promotions for alcohol in Scotland did not reduce alcohol purchasing in the short term. Wider regulation of price promotion and price may be needed to achieve this.
doi:10.1111/add.12419
PMCID: PMC4227589  PMID: 24251415
Alcohol consumption; alcohol purchasing; difference-in-differences analyses; price promotions; regulation; Scottish ban on multi-buys
2.  Incentivizing Blood Donation: Systematic Review and Meta-Analysis to Test Titmuss’ Hypotheses 
Health Psychology  2013;32(9):941-949.
Objectives: Titmuss hypothesized that paying blood donors would reduce the quality of the blood donated and would be economically inefficient. We report here the first systematic review to test these hypotheses, reporting on both financial and nonfinancial incentives. Method: Studies deemed eligible for inclusion were peer-reviewed, experimental studies that presented data on the quantity (as a proxy for efficiency) and quality of blood donated in at least two groups: those donating blood when offered an incentive, and those donating blood with no offer of an incentive. The following were searched: MEDLINE, EMBASE and PsycINFO using OVID SP, CINAHL via EBSCO and CENTRAL, the Cochrane Library, Econlit via EBSCO, JSTOR Health and General Science Collection, and Google. Results: The initial search yielded 1100 abstracts, which resulted in 89 full papers being assessed for eligibility, of which seven studies, reported in six papers, met the inclusion criteria. The included studies involved 93,328 participants. Incentives had no impact on the likelihood of donation (OR = 1.22 CI 95% 0.91–1.63; p = .19). There was no difference between financial and nonfinancial incentives in the quantity of blood donated. Of the two studies that assessed quality of blood, one found no effect and the other found an adverse effect from the offer of a free cholesterol test (β = 0.011 p < .05). Conclusion: The limited evidence suggests that Titmuss’ hypothesis of the economic inefficiency of incentives is correct. There is insufficient evidence to assess their likely impact on the quality of the blood provided.
doi:10.1037/a0032740
PMCID: PMC3920088  PMID: 24001244
blood donation; incentives; motivational crowding-out; behavioral economics; policy
3.  An observational study of retail availability and in-store marketing of e-cigarettes in London: potential to undermine recent tobacco control gains? 
BMJ Open  2013;3(12):e004085.
Objectives
E-cigarette companies and vendors claim the potential of e-cigarettes to help smokers reduce or quit tobacco use. E-cigarettes also have the potential to renormalise smoking. The purpose of this study was to describe the availability and in-store marketing of e-cigarettes in London, UK stores selling tobacco and alcohol.
Design
Observational study.
Setting
Small and large stores selling alcohol and tobacco in London, UK.
Primary and secondary outcome measures
The number of stores selling e-cigarettes, the number of stores with an interior or exterior e-cigarette advertisement, the number of stores with an e-cigarette point-of-sale movable display, store size, deprivation index score for store's corresponding lower super output area.
Results
Audits were completed in 108 of 128 selected stores. 62 of the audited stores (57%) sold e-cigarettes. E-cigarette availability was unrelated to store size. There was a statistically non-significant trend towards increased availability in more deprived areas (p=0.069). 31 of the 62 stores (50%) selling e-cigarettes had a point-of-sale movable display, with all but one found in small stores. Two small stores had interior advertisements and eight had exterior advertisements. No advertisements were observed in large stores.
Conclusions
This audit revealed widespread availability of e-cigarettes and in-store marketing in London, UK. Even if e-cigarettes prove to be an effective cessation aid, their sale and use are resulting in an increasing public presence of cigarette-like images and smoking behaviour. After decades of work to denormalise smoking, these findings raise the question of whether e-cigarettes are renormalising smoking.
doi:10.1136/bmjopen-2013-004085
PMCID: PMC3884782  PMID: 24366581
electronic cigarette; e-cigarette; point-of-sale marketing; store audits; tobacco industry; tobacco control policy
4.  Why don't poor men eat fruit? Socioeconomic differences in motivations for fruit consumption☆ 
Appetite  2015;84:271-279.
Highlights
•The study examined intake, implicit and explicit liking, and perceptions of fruit.•Lower SES males reported eating less fruit and lower implicit liking of fruit.•Results differed for explicit liking of fruit, however, with no differences by SES.•Social patterning was also seen in perceived satiety and value for money of fruit.•Neither liking nor perceptions of fruit mediated social patterning of fruit intake.
Background: Those of lower socioeconomic status (SES) tend to have less healthy diets than those of higher SES. This study aimed to assess whether differences in motivations for particular foods might contribute to socioeconomic differences in consumption. Methods: Participants (n = 732) rated their frequency of consumption and explicit liking of fruit, cake and cheese. They reported eating motivations (e.g., health, hunger, price) and related attributes of the investigated foods (healthiness, expected satiety, value for money). Participants were randomly assigned to an implicit liking task (Single Category Implicit Association Task) for one food category. Analyses were conducted separately for different SES measures (income, education, occupational group). Results: Lower SES and male participants reported eating less fruit, but no SES differences were found for cheese or cake. Analyses therefore focused on fruit. In implicit liking analyses, results (for income and education) reflected patterning in consumption, with lower SES and male participants liking fruit less. In explicit liking analyses, no differences were found by SES. Higher SES participants (all indicators) were more likely to report health and weight control and less likely report price as motivators of food choices. For perceptions of fruit, no SES-based differences were found in healthiness whilst significant interactions (but not main effects) were found (for income and education) for expected satiety and value for money. Neither liking nor perceptions of fruit were found to mediate the relationship between SES and frequency of fruit consumption. Conclusions: There is evidence for social patterning in food motivation, but differences are modified by the choice of implicit or explicit measures. Further work should clarify the extent to which these motivations may be contributing to the social and gender patterning in diet.
doi:10.1016/j.appet.2014.10.022
PMCID: PMC4262578  PMID: 25451584
Socioeconomic status; Liking; Motivation; Fruit; Consumption
5.  Future Health Applications of Genomics 
Despite the quickening momentum of genomic discovery, the communication, behavioral, and social sciences research needed for translating this discovery into public health applications has lagged behind. The National Human Genome Research Institute held a 2-day workshop in October 2008 convening an interdisciplinary group of scientists to recommend forward-looking priorities for translational research. This research agenda would be designed to redress the top three risk factors (tobacco use, poor diet, and physical inactivity) that contribute to the four major chronic diseases (heart disease, type 2 diabetes, lung disease, and many cancers) and account for half of all deaths worldwide. Three priority research areas were identified: (1) improving the public’s genetic literacy in order to enhance consumer skills; (2) gauging whether genomic information improves risk communication and adoption of healthier behaviors more than current approaches; and (3) exploring whether genomic discovery in concert with emerging technologies can elucidate new behavioral intervention targets. Important crosscutting themes also were identified, including the need to: (1) anticipate directions of genomic discovery; (2) take an agnostic scientific perspective in framing research questions asking whether genomic discovery adds value to other health promotion efforts; and (3) consider multiple levels of influence and systems that contribute to important public health problems. The priorities and themes offer a framework for a variety of stakeholders, including those who develop priorities for research funding, interdisciplinary teams engaged in genomics research, and policymakers grappling with how to use the products born of genomics research to address public health challenges.
doi:10.1016/j.amepre.2010.01.027
PMCID: PMC4188632  PMID: 20409503
6.  Financial incentives to encourage healthy behaviour: an analysis of UK media coverage 
Background
Policies to use financial incentives to encourage healthy behaviour are controversial. Much of this controversy is played out in the mass media, both reflecting and shaping public opinion.
Objective
To describe UK mass media coverage of incentive schemes, comparing schemes targeted at different client groups and assessing the relative prominence of the views of different interest groups.
Design
Thematic content analysis.
Subjects
National and local news coverage in newspapers, news media targeted at health-care providers and popular websites between January 2005 and February 2010.
Setting
UK mass media.
Results
The study included 210 articles. Fifteen separate arguments favourable towards schemes, and 19 unfavourable, were identified. Overall, coverage was more favourable than unfavourable, although most articles reported a mix of views. Arguments about the prevalence and seriousness of the health problems targeted by incentive schemes were uncontested. Moral and ethical objections to such schemes were common, focused in particular on recipients such as drug users or the overweight who were already stereotyped as morally deficient, and these arguments were largely uncontested. Arguments about the effectiveness of schemes and their potential for benefit or harm were areas of greater contestation. Government, public health and other health-care provider interests dominated favourable coverage; opposition came from rival politicians, taxpayers’ representatives, certain charities and from some journalists themselves.
Conclusions
Those promoting incentive schemes for people who might be regarded as ‘undeserving’ should plan a media strategy that anticipates their public reception.
doi:10.1111/j.1369-7625.2011.00719.x
PMCID: PMC4180042  PMID: 21771227
conditional cash transfer; health incentives; mass media; public opinion; public response
7.  Adherence to and Consumption of Nicotine Replacement Therapy and the Relationship With Abstinence Within a Smoking Cessation Trial in Primary Care 
Nicotine & Tobacco Research  2013;15(9):1537-1544.
Introduction:
Nicotine replacement therapy (NRT) medications have been shown to be effective in increasing smoking cessation rates. There is, however, a lack of good evidence describing how individuals in primary care use these medications and which factors are likely to affect this. The study objectives are to describe adherence and consumption, examine key factors that may determine use, and examine the relationship between consumption of NRT and abstinence from smoking.
Methods:
Secondary analysis of data from a randomized controlled trial conducted in smoking cessation services in primary care. Adult smokers (n = 633) starting a quit attempt within smoking cessation clinics were followed for 6 months, with NRT use closely monitored for an initial treatment period of 4 weeks. The main outcomes were 4-week adherence to prescribed NRT, mean daily consumption of NRT over the 4-week period, and abstinence from smoking at 4 weeks.
Results:
Levels of adherence to prescribed NRT were high: more than 94% in participants who completed the treatment period. After controlling for possible confounders, prescribing higher doses of patch and oral NRT was associated with higher mean daily consumption of NRT. Using an inhalator to deliver oral NRT was associated with both higher adherence and higher consumption. The amount of NRT consumed predicted future abstinence when reverse causation was accounted for.
Conclusions:
Most individuals within a clinical trial in primary care who persisted with a quit attempt adhered closely to their prescription. Prescribing higher doses of NRT led to higher consumption and higher consumption to higher abstinence.
doi:10.1093/ntr/ntt010
PMCID: PMC3741059  PMID: 23430709
8.  Explaining Behavior Change after Genetic Testing: The Problem of Collinearity between Test Results and Risk Estimates 
Genetic testing  2008;12(3):381-386.
This paper explores whether and how the behavioral impact of genotype disclosure can be disentangled from the impact of numerical risk estimates generated by genetic tests. Secondary data analyses are presented from a randomized controlled trial of 162 first-degree relatives of Alzheimer’s disease (AD) patients. Each participant received a lifetime risk estimate of AD. Control group estimates were based on age, gender, family history, and assumed ε4-negative apolipoprotein E (APOE) genotype; intervention group estimates were based upon the first three variables plus true APOE genotype, which was also disclosed. AD-specific self-reported behavior change (diet, exercise, and medication use) was assessed at 12 months. Behavior change was significantly more likely with increasing risk estimates, and also more likely, but not significantly so, in ε4-positive intervention group participants (53% changed behavior) than in control group participants (31%). Intervention group participants receiving ε4-negative genotype feedback (24% changed behavior) and control group participants had similar rates of behavior change and risk estimates, the latter allowing assessment of the independent effects of genotype disclosure. However, collinearity between risk estimates and ε4-positive genotypes, which engender high-risk estimates, prevented assessment of the independent effect of the disclosure of an ε4 genotype. Novel study designs are proposed to determine whether genotype disclosure has an impact upon behavior beyond that of numerical risk estimates.
doi:10.1089/gte.2007.0103
PMCID: PMC2925186  PMID: 18666860
9.  Maximising recruitment and retention of general practices in clinical trials: a case study 
Background
There is limited evidence regarding the factors that facilitate recruitment and retention of general practices in clinical trials. It is therefore pertinent to consider the factors that facilitate research in primary care.
Aim
To formulate hypotheses about effective ways of recruiting and retaining practices to clinical trials, based on a case study.
Design of study
Case study of practice recruitment and retention to a trial of delivering antenatal sickle cell and thalassaemia screening.
Setting
Two UK primary care trusts with 123 practices, with a high incidence of sickle cell and thalassaemia, and high levels of social deprivation.
Method
Practices were invited to take part in the trial using a research information sheet for practices. Invitations were sent to all practice managers, GPs, practice nurses, and nurse practitioners. Expenses of approximately £3000 per practice were available. Practices and the research team signed research activity agreements, detailing a payment schedule based on deliverables. Semi-structured interviews were completed with 20 GPs who participated in the trial. Outcome measures were the number of practices recruited to, and completing, the trial.
Results
Four practices did not agree to randomisation and were excluded. Of 119 eligible practices, 29 expressed an interest in participation. Two practices withdrew from the trial and 27 participated (two hosted pilot studies and 25 completed the trial), giving a retention rate of 93% (27/29). The 27 participating practices did not differ from non-participating practices in list size, number of GPs, social deprivation, or minority ethnic group composition of the practice population.
Conclusion
Three factors appeared important in recruiting practices: research topic, invitation method, and interest in research. Three factors appeared important in retaining practices: good communication, easy data-collection methods, and payment upon meeting pre-agreed targets. The effectiveness of these factors at facilitating recruitment and retention requires assessment in experimental studies.
doi:10.3399/bjgp08X319666
PMCID: PMC2573972  PMID: 19000399
clinical trials; primary health care; recruitment; retention
10.  Public acceptability of population-level interventions to reduce alcohol consumption: A discrete choice experiment 
Social Science & Medicine (1982)  2014;113(100):104-109.
Public acceptability influences policy action, but the most acceptable policies are not always the most effective. This discrete choice experiment provides a novel investigation of the acceptability of different interventions to reduce alcohol consumption and the effect of information on expected effectiveness, using a UK general population sample of 1202 adults. Policy options included high, medium and low intensity versions of: Minimum Unit Pricing (MUP) for alcohol; reducing numbers of alcohol retail outlets; and regulating alcohol advertising. Outcomes of interventions were predicted for: alcohol-related crimes; alcohol-related hospital admissions; and heavy drinkers. First, the models obtained were used to predict preferences if expected outcomes of interventions were not taken into account. In such models around half of participants or more were predicted to prefer the status quo over implementing outlet reductions or higher intensity MUP. Second, preferences were predicted when information on expected outcomes was considered, with most participants now choosing any given intervention over the status quo. Acceptability of MUP interventions increased by the greatest extent: from 43% to 63% preferring MUP of £1 to the status quo. Respondents' own drinking behaviour also influenced preferences, with around 90% of non-drinkers being predicted to choose all interventions over the status quo, and with more moderate than heavy drinkers favouring a given policy over the status quo. Importantly, the study findings suggest public acceptability of alcohol interventions is dependent on both the nature of the policy and its expected effectiveness. Policy-makers struggling to mobilise support for hitherto unpopular but promising policies should consider giving greater prominence to their expected outcomes.
Highlights
•Novel UK-representative study predicting the acceptability of alcohol interventions.•Acceptability varied by policy: regulating advertising was the most popular option.•Acceptability increased for all policies with information on expected effectiveness.•Information on expected effectiveness changed the order of preference for policies.
doi:10.1016/j.socscimed.2014.05.010
PMCID: PMC4065329  PMID: 24858928
UK; Public acceptability; Alcohol; Health policy
11.  Delay between pregnancy confirmation and sickle cell and thalassaemia screening: a population-based cohort study 
Background
Antenatal sickle cell and thalassaemia screening sometimes occurs too late to allow couples a choice regarding termination of affected fetuses. The target gestational age for offering the test in the UK is 10 weeks.
Aim
To describe the proportion of women screened before 70 days' (10 weeks') gestation and the delay between pregnancy confirmation in primary care and antenatal sickle cell and thalassaemia screening.
Design of study
Cohort study of reported pregnancies.
Setting
Twenty-five general practices in two UK inner-city primary care trusts offering universal screening.
Method
Anonymised data on all pregnancies reported to participating general practices was collected for a minimum of 6 months.
Results
There were 1441 eligible women intending to proceed with their pregnancies, whose carrier status was not known. The median (interquartile range [IQR]) gestational age at pregnancy confirmation was 7.6 weeks (6.0–10.7 weeks) and 74% presented before 10 weeks. The median gestational age at screening was 15.3 weeks (IQR = 12.6–18.0 weeks), with only 4.4% being screened before 10 weeks. The median delay between pregnancy confirmation and screening was 6.9 weeks (4.7–9.3 weeks) After allowing for practice level variation, there was no association between delay times and maternal age, parity, and ethnic group.
Conclusion
About 74% of women consulted for pregnancy before 10 weeks' gestation but fewer than 5% of women were screened before the target time of 10 weeks. Reducing the considerable delay between pregnancy confirmation in primary care and antenatal sickle cell and thalassaemia screening requires methods of organising and delivering antenatal care that facilitate earlier screening to be developed and evaluated.
doi:10.3399/bjgp08X277267
PMCID: PMC2249790  PMID: 18318968
Anaemia; genetic screening; pregnancy; primary health care; sickle cell; thalassaemia
12.  Sales impact of displaying alcoholic and non-alcoholic beverages in end-of-aisle locations: An observational study 
Social Science & Medicine (1982)  2014;108(100):68-73.
In-store product placement is perceived to be a factor underpinning impulsive food purchasing but empirical evidence is limited. In this study we present the first in-depth estimate of the effect of end-of-aisle display on sales, focussing on alcohol. Data on store layout and product-level sales during 2010–11 were obtained for one UK grocery store, comprising detailed information on shelf space, price, price promotion and weekly sales volume in three alcohol categories (beer, wine, spirits) and three non-alcohol categories (carbonated drinks, coffee, tea). Multiple regression techniques were used to estimate the effect of end-of-aisle display on sales, controlling for price, price promotion, and the number of display locations for each product. End-of-aisle display increased sales volumes in all three alcohol categories: by 23.2% (p = 0.005) for beer, 33.6% (p < 0.001) for wine, and 46.1% (p < 0.001) for spirits, and for three non-alcohol beverage categories: by 51.7% (p < 0.001) for carbonated drinks, 73.5% (p < 0.001) for coffee, and 113.8% (p < 0.001) for tea. The effect size was equivalent to a decrease in price of between 4% and 9% per volume for alcohol categories, and a decrease in price of between 22% and 62% per volume for non-alcohol categories. End-of-aisle displays appear to have a large impact on sales of alcohol and non-alcoholic beverages. Restricting the use of aisle ends for alcohol and other less healthy products might be a promising option to encourage healthier in-store purchases, without affecting availability or cost of products.
Highlights
•An estimated 30% of supermarket sales come from aisle-ends, providing an impetus to evaluate the influence of such locations.•This novel analysis within one UK store suggested that placing beverages in end-of-aisle locations uplifts sales sharply.•This sales uplift was larger for non-alcoholic beverages (by 52–114%) than for alcoholic beverages (by 23–46%).•Restricting aisle-end displays of alcohol or sugar-sweetened beverages may be as effective as some pricing interventions.•Although currently limited to product-level effects, this initial evidence highlights the influence of aisle-end displays.
doi:10.1016/j.socscimed.2014.02.032
PMCID: PMC4008933  PMID: 24632050
United Kingdom; Alcohol; Non-alcoholic beverages; End-of-aisle display; Grocery store; Primary prevention
13.  Does incentivising pill-taking ‘crowd out’ risk-information processing? Evidence from a web-based experiment☆ 
Social Science & Medicine (1982)  2014;106(100):75-82.
The use of financial incentives for changing health-related behaviours raises concerns regarding their potential to undermine the processing of risks associated with incentivised behaviours. Uncertainty remains about the validity of such concerns. This web-based experiment assessed the impact of financial incentives on i) willingness to take a pill with side-effects; ii) the time spent viewing risk-information and iii) risk-information processing, assessed by perceived-risk of taking the pill and knowledge of its side-effects. It further assesses whether effects are moderated by limiting cognitive capacity. Two-hundred and seventy-five UK-based university staff and students were recruited online under the pretext of being screened for a fictitious drug-trial. Participants were randomised to the offer of different compensation levels for taking a fictitious pill (£0; £25; £1000) and the presence or absence of a cognitive load task (presentation of five digits for later recall). Willingness to take the pill increased with the offer of £1000 (84% vs. 67%; OR 3.66, CI 95% 1.27–10.6), but not with the offer of £25 (79% vs. 67%; OR 1.68, CI 95% 0.71–4.01). Risk-information processing was unaffected by the offer of incentives. The time spent viewing the risk-information was affected by the offer of incentives, an effect moderated by cognitive load: Without load, time increased with the value of incentives (£1000: M = 304.4sec vs. £0: M = 37.8sec, p < 0.001; £25: M = 66.6sec vs. £0: M = 37.8sec, p < 0.001). Under load, time decreased with the offer of incentives (£1000: M = 48.9sec vs. £0: M = 132.7sec, p < 0.001; £25: M = 60.9sec vs. £0: M = 132.7sec, p < 0.001), but did not differ between the two incentivised groups (p = 1.00). This study finds no evidence to suggest incentives “crowd out” risk-information processing. On the contrary, incentives appear to signal risk, an effect, however, which disappears under cognitive load. Although these findings require replication, they highlight the need to maximise cognitive capacity when presenting information about incentivised health-related behaviours.
Highlights
•Concerns exist that health incentives undermine risk-information processing.•We assessed these concerns in the context of taking a pill with side-effects.•Financial incentives did not undermine the processing of risk-information.•Incentives increased risk-information viewing time, implying a cautionary effect.•This cautionary effect disappeared under cognitive load.
doi:10.1016/j.socscimed.2014.01.020
PMCID: PMC3969102  PMID: 24534735
Financial incentives; Risk-information; Side-effects; Risks; Pill-taking; Health incentives; Medication adherence
14.  When Do Financial Incentives Reduce Intrinsic Motivation? Comparing Behaviors Studied in Psychological and Economic Literatures 
Health Psychology  2013;32(9):950-957.
Objective: To review existing evidence on the potential of incentives to undermine or “crowd out” intrinsic motivation, in order to establish whether and when it predicts financial incentives to crowd out motivation for health-related behaviors. Method: We conducted a conceptual analysis to compare definitions and operationalizations of the effect, and reviewed existing evidence to identify potential moderators of the effect. Results: In the psychological literature, we find strong evidence for an undermining effect of tangible rewards on intrinsic motivation for simple tasks when motivation manifest in behavior is initially high. In the economic literature, evidence for undermining effects exists for a broader variety of behaviors, in settings that involve a conflict of interest between parties. By contrast, for health related behaviors, baseline levels of incentivized behaviors are usually low, and only a subset involve an interpersonal conflict of interest. Correspondingly, we find no evidence for crowding out of incentivized health behaviors. Conclusion: The existing evidence does not warrant a priori predictions that an undermining effect would be found for health-related behaviors. Health-related behaviors and incentives schemes differ greatly in moderating characteristics, which should be the focus of future research.
doi:10.1037/a0032727
PMCID: PMC3906839  PMID: 24001245
incentives; health behavior; motivation; motivation crowding out; review
16.  Altering micro-environments to change population health behaviour: towards an evidence base for choice architecture interventions 
BMC Public Health  2013;13:1218.
Background
The idea that behaviour can be influenced at population level by altering the environments within which people make choices (choice architecture) has gained traction in policy circles. However, empirical evidence to support this idea is limited, especially its application to changing health behaviour. We propose an evidence-based definition and typology of choice architecture interventions that have been implemented within small-scale micro-environments and evaluated for their effects on four key sets of health behaviours: diet, physical activity, alcohol and tobacco use.
Discussion
We argue that the limitations of the evidence base are due not simply to an absence of evidence, but also to a prior lack of definitional and conceptual clarity concerning applications of choice architecture to public health intervention. This has hampered the potential for systematic assessment of existing evidence. By seeking to address this issue, we demonstrate how our definition and typology have enabled systematic identification and preliminary mapping of a large body of available evidence for the effects of choice architecture interventions. We discuss key implications for further primary research, evidence synthesis and conceptual development to support the design and evaluation of such interventions.
Summary
This conceptual groundwork provides a foundation for future research to investigate the effectiveness of choice architecture interventions within micro-environments for changing health behaviour. The approach we used may also serve as a template for mapping other under-explored fields of enquiry.
doi:10.1186/1471-2458-13-1218
PMCID: PMC3881502  PMID: 24359583
Choice architecture; Nudge; Nudging; Behaviour change; Health behaviour
17.  Exposure of Children and Adolescents to Alcohol Marketing on Social Media Websites 
Aims: In 2011, online marketing became the largest marketing channel in the UK, overtaking television for the first time. This study aimed to describe the exposure of children and young adults to alcohol marketing on social media websites in the UK. Methods: We used commercially available data on the three most used social media websites among young people in the UK, from December 2010 to May 2011. We analysed by age (6–14 years; 15–24 years) and gender the reach (proportion of internet users who used the site in each month) and impressions (number of individual pages viewed on the site in each month) for Facebook, YouTube and Twitter. We further analysed case studies of five alcohol brands to assess the marketer-generated brand content available on Facebook, YouTube and Twitter in February and March 2012. Results: Facebook was the social media site with the highest reach, with an average monthly reach of 89% of males and 91% of females aged 15–24. YouTube had a similar average monthly reach while Twitter had a considerably lower usage in the age groups studied. All five of the alcohol brands studied maintained a Facebook page, Twitter page and YouTube channel, with varying levels of user engagement. Facebook pages could not be accessed by an under-18 user, but in most cases YouTube content and Twitter content could be accessed by those of all ages. Conclusion: The rise in online marketing of alcohol and the high use of social media websites by young people suggests that this is an area requiring further monitoring and regulation.
doi:10.1093/alcalc/agt174
PMCID: PMC3932831  PMID: 24293506
18.  Financial Incentives for Increasing Uptake of HPV Vaccinations: A Randomized Controlled Trial 
Health Psychology  2014;34(2):160-171.
Objective: Uptake of human papillomavirus (HPV) vaccinations by 17- to 18-year-old girls in England is below (<35%) target (80%). This trial assesses (a) the impact of financial incentives on uptake and completion of an HPV vaccination program, and (b) whether impacts are moderated by participants’ deprivation level. It also assesses the impact of incentives on decision quality to get vaccinated, as measured by attitudes toward the vaccination and knowledge of its consequences. Method: One thousand 16- to 18-year-old girls were invited to participate in an HPV vaccination program: 500 previously uninvited, and 500 unresponsive to previous invitations. Girls randomly received either a standard invitation letter or a letter including the offer of vouchers worth £45 (€56; $73) for undergoing 3 vaccinations. Girls attending their first vaccination appointment completed a questionnaire assessing decision quality to be vaccinated. Outcomes were uptake of the first and third vaccinations and decision quality. Results: The intervention increased uptake of the first (first-time invitees: 28.4% vs. 19.6%, odds ratio [OR] = 1.63, 95% confidence interval [CI; 1.08, 2.47]; previous nonattenders: 23.6% vs. 10.4%, OR = 2.65, 95% CI [1.61, 4.38]) and third (first-time invitees: 22.4% vs. 12%, OR = 2.15, 95% CI [1.32, 3.50]; previous nonattenders: 12.4% vs. 3%, OR = 4.28, 95% CI [1.92, 9.55]) vaccinations. Impacts were not moderated by deprivation level. Decision quality was unaffected by the intervention. Conclusions: Although the intervention increased completion of HPV vaccinations, uptake remained lower than the national target, which, in addition to cost effectiveness and acceptability issues, necessitates consideration of other ways of achieving it.
doi:10.1037/hea0000088
PMCID: PMC4312136  PMID: 25133822
financial incentives; vouchers; HPV vaccination; human papillomavirus
19.  Correction: Choosing between an Apple and a Chocolate Bar: the Impact of Health and Taste Labels 
PLoS ONE  2013;8(10):10.1371/annotation/12ecd041-f8c7-4615-a898-9ee60d2d78a7.
doi:10.1371/annotation/12ecd041-f8c7-4615-a898-9ee60d2d78a7
PMCID: PMC3806870  PMID: 24194814
20.  Choosing between an Apple and a Chocolate Bar: the Impact of Health and Taste Labels 
PLoS ONE  2013;8(10):e77500.
Increasing the consumption of fruit and vegetables is a central component of improving population health. Reasons people give for choosing one food over another suggest health is of lower importance than taste. This study assesses the impact of using a simple descriptive label to highlight the taste as opposed to the health value of fruit on the likelihood of its selection. Participants (N=439) were randomly allocated to one of five groups that varied in the label added to an apple: apple; healthy apple; succulent apple; healthy and succulent apple; succulent and healthy apple. The primary outcome measure was selection of either an apple or a chocolate bar as a dessert. Measures of the perceived qualities of the apple (taste, health, value, quality, satiety) and of participant characteristics (restraint, belief that tasty foods are unhealthy, BMI) were also taken. When compared with apple selection without any descriptor (50%), the labels combining both health and taste descriptors significantly increased selection of the apple (’healthy & succulent’ 65.9% and ‘succulent & healthy’ 62.4%), while the use of a single descriptor had no impact on the rate of apple selection (‘healthy’ 50.5% and ‘succulent’ 52%). The strongest predictors of individual dessert choice were the taste score given to the apple, and the lack of belief that healthy foods are not tasty. Interventions that emphasize the taste attributes of healthier foods are likely to be more effective at achieving healthier diets than those emphasizing health alone.
doi:10.1371/journal.pone.0077500
PMCID: PMC3796478  PMID: 24155964
21.  Economic Instruments for Population Diet and Physical Activity Behaviour Change: A Systematic Scoping Review 
PLoS ONE  2013;8(9):e75070.
Background
Unhealthy diet and low levels of physical activity are common behavioural factors in the aetiology of many non-communicable diseases. Recent years have witnessed an upsurge of policy and research interest in the use of taxes and other economic instruments to improve population health.
Objective
To assemble, configure and analyse empirical research studies available to inform the public health case for using economic instruments to promote dietary and physical activity behaviour change.
Methods
We conducted a systematic scoping review of evidence for the effects of specific interventions to change, or general exposure to variations in, prices or income on dietary and physical activity behaviours and corollary outcomes. Systematic electronic searches and parallel snowball searches retrieved >1 million study records. Text mining technologies were used to prioritise title-abstract records for screening. Eligible studies were selected, classified and analysed in terms of key characteristics and principal findings, using a narrative, configuring synthesis focused on implications for policy and further research.
Results
We identified 880 eligible studies, including 192 intervention studies and 768 studies that incorporated evidence for prices or income as correlates or determinants of target outcomes. Current evidence for the effects of economic instruments and exposures on diet and physical activity is limited in quality and equivocal in terms of its policy implications. Direct evidence for the effects of economic instruments is heavily skewed towards impacts on diet, with a relative lack of evidence for impacts on physical activity.
Conclusions
The evidence-based case for using economic instruments to promote dietary and physical activity behaviour change may be less compelling than some proponents have claimed. Future research should include measurement of people’s actual behavioural responses using study designs capable of generating reliable causal inferences regarding intervention effects. Policy implementation needs to be carefully aligned with evaluation planning and design.
doi:10.1371/journal.pone.0075070
PMCID: PMC3782495  PMID: 24086440
22.  Impact of Personalised Feedback about Physical Activity on Change in Objectively Measured Physical Activity (the FAB Study): A Randomised Controlled Trial 
PLoS ONE  2013;8(9):e75398.
Background
Low levels of physical activity are a major public health concern, and interventions to promote physical activity have had limited success. Whether or not personalised feedback about physical activity following objective measurement motivates behaviour change has yet to be rigorously examined.
Methods
And Findings: In a parallel group, open randomised controlled trial, 466 healthy adults aged 32 to 54 years were recruited from the ongoing population-based Fenland Study (Cambridgeshire, UK). Participants were randomised to receive either no feedback until the end of the trial (control group, n=120) or one of three different types of feedback: simple, visual, or contextualised (intervention groups, n=346). The primary outcome was physical activity (physical activity energy expenditure (PAEE) in kJ/kg/day and average body acceleration (ACC) in m/s2) measured objectively using a combined heart rate monitor and accelerometer (Actiheart®). The main secondary outcomes included self-reported physical activity, intention to increase physical activity, and awareness of physical activity (the agreement between self-rated and objectively measured physical activity). At 8 weeks, 391 (83.9%) participants had complete physical activity data. The intervention had no effect on objectively measured physical activity (PAEE: β=-0.92, 95% CI=-3.50 to 1.66, p=0.48 and ACC: β=0.01, 95% CI=-0.00 to 0.02, p=0.21), self-reported physical activity (β=-0.39, 95% CI=-1.59 to 0.81), or intention to increase physical activity (β=-0.05, 95% CI=-0.22 to 0.11). However, it was associated with an increase in awareness of physical activity (OR=1.74, 95% CI=1.05 to 2.89). Results did not differ according to the type of feedback.
Conclusions
Personalised feedback about physical activity following objective measurement increased awareness but did not result in changes in physical activity in the short term. Measurement and feedback may have a role in promoting behaviour change but are ineffective on their own.
Trial Registration
Current Controlled Trials ISRCTN92551397 http://www.controlled-trials.com/ISRCTN92551397
doi:10.1371/journal.pone.0075398
PMCID: PMC3774634  PMID: 24066178
23.  Enhancing Informed Choice to Undergo Health Screening: A Systematic Review 
Objective
To assess the effectiveness of health screening interventions aimed at enhancing informed choice.
Methods
Studies were selected if (1) they were randomized controlled trials conducted between January 1, 2000, and March 30, 2010, (2) participants in one arm underwent a prescreening intervention aimed at improving informed choice, and (3) informed choice was the primary outcome.
Results
Eight studies that met the inclusion criteria involved screening for prostate, colorectal and breast cancer, and diabetes. Five of the 8 prescreening interventions led to greater informed choice.
Conclusions
With researchers mindful of the limited number of studies, findings were encouraging, but conclusions regarding the most effective ways of facilitating informed choice for screening are at best tentative.
doi:10.5993/AJHB.37.3.8
PMCID: PMC3761400  PMID: 23985182
prescreening interventions; health screening; randomized control trials; informed choice; systematic review
24.  Socioeconomic differences in purchases of more vs. less healthy foods and beverages: Analysis of over 25,000 British households in 2010☆ 
Social Science & Medicine (1982)  2013;92(100):22-26.
Socioeconomic inequalities in diet-related health outcomes are well-recognised, but are not fully explained by observational studies of consumption. We provide a novel analysis to identify purchasing patterns more precisely, based on data for take-home food and beverage purchases from 25,674 British households in 2010. To examine socioeconomic differences (measured by occupation), we conducted regression analyses on the proportion of energy purchased from (a) each of 43 food or beverage categories and (b) major nutrients. Results showed numerous small category-level socioeconomic differences. Aggregation of the categories showed lower SES groups generally purchased a greater proportion of energy from less healthy foods and beverages than those in higher SES groups (65% and 60%, respectively), while higher SES groups purchased a greater proportion of energy from healthier food and beverages (28% vs. 24%). At the nutrient-level, socioeconomic differences were less marked, although higher SES was associated with purchasing greater proportions of fibre, protein and total sugars, and smaller proportions of sodium. The observed pattern of purchasing across SES groups contributes to the explanation of observed health differences between groups and highlights targets for interventions to reduce health inequalities.
Highlights
•We give a novel, detailed account of purchasing by SES in 25,000 British households.•Lower SES groups purchased a greater proportion of less healthy food and drink.•Higher SES groups purchased proportionally more high-fat dairy and alcohol.•Overall, SES differences were less marked for nutrients than for food groups.•We highlight food groups to target for interventions to reduce health inequalities.
doi:10.1016/j.socscimed.2013.05.012
PMCID: PMC3726935  PMID: 23849275
Britain; Socioeconomic status; Diet; Purchasing; Scanner data; Attitudes; Health inequalities
25.  Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis 
BMC Public Health  2013;13:756.
Background
Governments can intervene to change health-related behaviours using various measures but are sensitive to public attitudes towards such interventions. This review describes public attitudes towards a range of policy interventions aimed at changing tobacco and alcohol use, diet, and physical activity, and the extent to which these attitudes vary with characteristics of (a) the targeted behaviour (b) the intervention and (c) the respondents.
Methods
We searched electronic databases and conducted a narrative synthesis of empirical studies that reported public attitudes in Europe, North America, Australia and New Zealand towards interventions relating to tobacco, alcohol, diet and physical activity. Two hundred studies met the inclusion criteria.
Results
Over half the studies (105/200, 53%) were conducted in North America, with the most common interventions relating to tobacco control (110/200, 55%), followed by alcohol (42/200, 21%), diet-related interventions (18/200, 9%), interventions targeting both diet and physical activity (18/200, 9%), and physical activity alone (3/200, 2%). Most studies used survey-based methods (160/200, 80%), and only ten used experimental designs.
Acceptability varied as a function of: (a) the targeted behaviour, with more support observed for smoking-related interventions; (b) the type of intervention, with less intrusive interventions, those already implemented, and those targeting children and young people attracting most support; and (c) the characteristics of respondents, with support being highest in those not engaging in the targeted behaviour, and with women and older respondents being more likely to endorse more restrictive measures.
Conclusions
Public acceptability of government interventions to change behaviour is greatest for the least intrusive interventions, which are often the least effective, and for interventions targeting the behaviour of others, rather than the respondent him or herself. Experimental studies are needed to assess how the presentation of the problem and the benefits of intervention might increase acceptability for those interventions which are more effective but currently less acceptable.
doi:10.1186/1471-2458-13-756
PMCID: PMC3765153  PMID: 23947336
Health behaviour; Attitude; Public opinion; Policy

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