Project Acronym: Credits4Health
Title: Credits-based, people-centric approach for the adoption
of healthy life-styles and balanced Mediterranean diet in the frame of social
participation and innovation for health promotion.
Contract/Grant agreement number: 602386
Starting date: 01/09/2013
Duration: 36 months
Presentation by Prof. Maria Luisa Brandi
Presentation overview
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Goals of the Project
The Consortium
The C4H Model
The C4H Concept
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People Empowerment
The Nudge/Libertarian paternalism approach
The personalized paths
A multi-stakeholder rewarding system
Field-tests and Target Users
The context: 4 Study Areas
The C4H roadmap
Main issues to face
Current and upcoming results
Goals of the project
• The problem statement of C4H is to fight the
increasing prevalence of lifestyle-related diseases
through an innovative multi-stakeholder approach
based on people empowerment.
• C4H is a social innovation and health promotion
project aimed at designing, developing, and testing a
preventive healthcare system with the following aims:
o Reduce sedentary behaviours.
o Enhance the level of physical activity.
o Foster the adoption of healthy dietary styles in people
living in the Euro-Mediterranean Countries.
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The Consortium
Scientific Group
Technical Group
Communication Group
Institutional Group
The C4H Model
• The C4H approach is based on evidence-based
interventions aimed at stimulating people to become
more physically active and follow a Mediterranean
diet. These interventions are delivered through an
ICT platform.
• Through the platform C4H aims to enhance people
engagement, motivation, planning and selfmonitoring, and further reinforce their motivation
through an incentive system consisting of discounts
on goods and services (related to health, nutrition,
social and leisure activities, etc.).
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Screenshot of user dashboard
in the C4H platform:
• Simple and intuitive user
interface.
• Easy navigation through
the various functionalities.
• Personal profile accessed
via username and password
to safeguard privacy.
• A gamified approach to
enhance user engagement
• A social forum to communicate
with other participants and
create group events.
• Tool for planning physical
activities and food consumption.
• Data uploaded from a PA tracker.
The C4H Model
The main features of the model are as follows:
• A baseline screening for identifying each user’s personal profile (anthropometric,
socio-psychological, nutritional and physical activity status).
• A goal-setting system related to diet and physical activity, tailored to participants
on the basis of the screening.
• The personalized paths, to support the users in reaching their goals by:
o Enhancing their motivation by means of psychological interventions;
o Providing them with evidence-based tools, information, and suggestions to
enhance their knowledge and reach their goals;
o Supporting them to plan and monitor their diet and physical activities.
• Social and peer support. A social network that allows users to communicate and
chat with other participants, and organize group activities.
• A rewards system, which allows users to gain credits on the basis of their
performance, and eventually to get discounts on goods and services delivered by
C4H commercial partners.
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The C4H Concept: 1. People Empowerment
The C4H approach relies on one fundamental concept: people
empowerment. This represents a radical shift in societal mindset, the shift from a one-way delivered healthcare to a multistakeholder approach in which people play the pivotal role,
being actively involved in maintaining and improving their health
status, being responsible for their well-being, and committing
themselves knowingly to an active lifestyle and a healthy diet.
In brief, C4H is all about supporting people to be the authors of
their own health and well-being, by providing them the right
stimuli, the knowledge and the tools they need for reaching their
personal goals.
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The C4H Concept:
2. The Nudge/Libertarian Paternalism Approach
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C4H project is inspired by the so-called “nudge” and “libertarian paternalism”
concepts, originally described by Thaler and Sunstein in the book Nudge: Improving
Decisions about Health, Wealth, and Happiness.
To nudge is “to push mildly or poke [someone] gently in the ribs”, to try to move
people in certain directions.
With “libertarian paternalism” the authors refer to nudges which are designed to
make people’s life healthier and better (paternalism), but this happens while
preserving the liberty to choose what one likes (libertarian).
C4H explicit aim is to gently support people to pursue a healthy lifestyle without
any form of coercion nor forbidding any possible option: our specific approach
aims at reinforcing the cognitive system on a long-term basis by providing
knowledge to people, and at supporting their decision-making processes during a
short- or middle-term intervention (through social and psychological support).
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The C4H Concept:
3. The Personalized Paths
The interventions delivered through the platform deal with three major
domains: psychology, nutrition, and physical activity. Both the assessment
and the personalized interventions are based on evidence-based tools and
methodologies.
1. Psychological baseline assessment to define the motivational status of the
participant towards nutrition and physical activity.
• Baseline screening to identify clusters of people.
• Psychological intervention aimed to motivate them in improving their
behaviours related to both nutrition and physical activity. The treatment
uses important mediators of behaviour change (risk perception, outcome
expectancies, perceived self-efficacy, planning, and action control/selfmonitoring).
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The C4H Concept:
3. The Personalized Paths
2. Nutrition
• A baseline assessment questionnaire (assessing 21 nutritional
performance indicators), to identify dietary behaviours which are
not in line with Mediterranean Diet recommendations.
• A goal setting system to help people improve these behaviours (e.g.
increase fruit consumption, increase legume consumption, and so
on) within the context of the Mediterranean Diet.
• Evidence-based nutrition intervention pathways, including, among
others, information content, suggestions for recipes and meal
planning.
• Monitoring system with periodic short questionnaires to assess
performance in the nutrition behavioural goals.
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The C4H Concept:
3. The Personalized Paths
3. Physical activity
• A baseline assessment questionnaire to segment users in four
categories (Inactive, Moderately Inactive, Moderately Active,
and Active) and assess MET expenditure.
• Planning system allowing user to choose activity, duration and
intensity in line with the required MET expenditure over the
incoming week (completely customizable).
• A PA tracker (accelerometer device) to monitor physical
activity (to both foster self-monitoring and enable the
Consortium to assess users’ actual adherence to the exercise
plans).
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The C4H Concept:
4. A multi-stakeholder rewarding system
1. Current usage of credits systems. The use of material or financial incentives has been
increasingly adopted by public bodies to stimulate the adoption of behaviours deemed
beneficial both to the individuals and the society in which they live (e.g. “Time credits”
in London City; fitness tax credits in USA).
2. Types of incentives and credits in C4H. Taxing unhealthy products, like cigarettes, can
be considered a negative incentive. C4H approach uses positive incentives, that are
used to promote specific practices (e.g. subsidizing healthy food to facilitate their
consumption).
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People benefit individually, since they are more prone to buy goods which are beneficial for their health.
The use of positive incentives follows a much more egalitarian approach.
3. Credits: are they effective?
For what concerns the effectiveness of incentives in promoting behavioural change, in
particular in the health domain, the current evidence is quite encouraging, but still
needs further analyses and testing on the field.
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The C4H Concept:
4. A multi-stakeholder rewarding system
Discounted products/services we are working to introduce into the C4H credits system as
rewards:
Primary products/services, related to the main health sectors involved by the C4H system:
• Healthcare and wellbeing
• Sport and Physical activity Industry
• Food industry
• Entertainment and social interactions
Secondary products/services, which are not strictly related to health, but highly valued by
users:
• Household and Personal products
• Information technology and electronics
• Telecommunication services
• Consumer durables and apparel
• Financials, like insurances
• Charity donations
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Field-tests and target users
A phased approach. Complex web-based interventions like C4H need a phased
approach to gradually test each component of the final system. C4H is designed
on the basis of a such a framework:
• Two pilot studies aiming at testing the proposed system, the interventions
and the evaluation parameters (Pilots 1 and 2);
• A Randomized Controlled Trial (Pilot 3), aiming at assessing the effectiveness
of the intervention (platform + credits) with respect to the objectives of the
research study.
The target users of the final product are European citizens willing to improve or
maintain their health status.
The product will be testes on a total of around 3,000 participants recruited in
4 Euro-Mediterranean study areas (Florence and Salento in Italy, Girona in Spain,
and Pylos Nestoras in Greece).
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The context: The 4 Study Areas
Three Studies involving around 3,000 people in four Study Areas:
1. City of Florence (Italy)
300,000 pop.
39.54 square miles
2. Region of Salento (Italy)
1,500,000 pop. 2,057 square miles
3. City of Girona (Spain)
97,000 pop.
15.11 square miles
4. Pylos Nestoras municipality (Greece) 21,000 pop.
213 square miles
The C4H roadmap
High-level
objectives
Pilot 1
Pilot 2
Pilot 3
• Evaluate the effectiveness
of the personalized paths
(interventions) and refine
them in Pilot 2.
• Assess the platform
usability and actual usage
to refine the platform in
pilot 2.
• Assess the drop-out rate
to tackle it in Pilot 2.
• SAME GOALS OF PILOT 1
• Introduce and assess the
credits system to refine it
in Pilot 3.
A Randomized Controlled
Trial to:
• Assess the effectiveness of
the personalized paths in
enhancing participants’
physical activity and
nutritional habits.
• Assess the effectiveness of
the credits system.
450
2100
Participants 450
Duration
3 months
3 months
8 months
Study
procedures
and main
features
• Recruitment
(Incl/excl. criteria assessment)
• Baseline assessment
• Platform activities
• Final assessment
• Recruitment
• Baseline assessment
• Platform activities
+ credits system
• Final assessment
• Recruitment
• Baseline assessment
• Platform activities
+ credits system
• Final assessment
Credits4Health Pilot 1 Flow Diagram (overall)
Some Preliminary Descriptive Statistics
Age Distributions
Body Mass Distributions
Main issues to face
• Ethics: 3 Countries (Italy, Spain, Greece) with different approaches
Each Country has its own approach towards the incentives. Some are more used to them (like UK),
for others it is considered a novelty. In clinical trials the ethics rules are very strict, and this means
the need to further explore the Ethics Committees’ cultural approach towards incentives.
• Drop-out
The first two pilots are also dedicated to assess the drop out rates and find out the reasons why
participants dropped-out. All of this with a view of facing it with appropriate methods.
• Objective measurements
Measuring adherence and performance of participants is a crucial issue. We focus on a mixture of
self-reporting (in line with the general aim of empowering people) and objective tools (mainly the
PA tracker, and anthropometric and blood tests) to measure the actual performance of users.
• Design with a view for commercialization
The aim of the project is to provide an effective tool that could be used by people in the future.
This means having a proper go-to-market strategy, but also design with a view of the possible
future commercialization of the product. All the relevant stakeholders (scientists, commercial
partners, end-users etc.) are involved in the design phase. The first two pilot studies will collect
inputs and feedback from stakeholders in order to refine our end-product and lead to its
sustainability, scalability, and actual implementation.
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Current and upcoming results
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Ethical approval: we defined a protocol for Pilot 1 and 2, which has successfully been
submitted in the four local areas. This enabled us to run the first Pilot and to prepare a
second protocol to be submitted for Pilot 3 (the RCT).
Platform: we developed the platform with all the recruitment tools (questionnaires)
integrated. The platform has been launched in January 2015, and will be refined till
the RCT.
Data mining: through the assessment of participants and data on their actual usage of
the platform, we’ll collect a huge amount of data enabling us to find correlations amongst
their social, psychological and physical status.
Scientific studies: we produced surveys which are leading to possible scientific
publications: in particular a study on psychological segmentation has been submitted as a
spin-off publication to the Journal of British Health Psychology and it is going to be
published in the following days.
Validation of a C4H nutrition questionnaire: the baseline assessment questionnaire for
nutrition has been designed by nutrition experts coming from the Countries involved.
This questionnaire will be validated during the project duration in order to further add to
the scientific relevance of the upcoming results of the project.
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Thank you from the C4H Group