Abstract
Family-based treatment (FBT) is recommended for childhood obesity, but even when sought, attrition is high. Extrinsic incentives, which have been effective for improving adult health, could improve FBT engagement. To assess parents' preferences for FBT incentives. Survey study of parents of children aged 6 to 17 years with obesity (body mass index in ≥95th percentile for age and sex). Parents' preferences for FBT incentive program attributes were assessed in a discrete choice experiment conducted using a nationally representative, web-based survey in March 2018. Attributes included (1) the monetary value of the incentive, (2) the payment structure, (3) the goal being incentivized, and (4) the person(s) being incentivized. A fractional factorial design was used to create a set of profiles representing hypothetical FBT incentives. Parents were presented with 10 pairs of profiles and asked which would most motivate them in FBT. Parents were also asked about preferences between a small, guaranteed incentive and a lottery for a large incentive. Analyses used a hierarchical Bayesian model and linear regressions. Parents' preference for different incentive program attributes and levels. The nationally representative survey had a 41.4% eligibility rate (n = 339) and a 89.7% completion rate (n = 304). A total of 53.3% of respondents (weighted percentage) were non-Hispanic white, 42.6% had an annual household income less than $50 000, and 28.3% had a bachelor's degree. Parents preferred higher incentives, although they were willing to accept lower-value incentives if both the parent and the child (vs the child alone) were required to meet the goal (mean difference [MD], -$108; 95% CI, -$132 to -$84), if the incentive used a gain-framed vs loss-framed payment structure (MD, -$72; 95% CI, -$85 to -$59), and if physical activity goals were incentivized over weight loss (MD, -$63; 95% CI, -$82 to -$44) or dietary monitoring (MD, -$5; 95% CI, -$1 to $28). Only 20.6% of parents preferred a lottery over a guaranteed payment. Preferences did not vary among demographic or health subgroups. In this study, parent-stated preferences did not align with FBT best practices or behavioral economic theory. A randomized clinical trial could examine whether aligning incentives with preferences or best practices would maximize FBT engagement and behavior change.
Highlights
Family-based treatment (FBT) is a weight management approach for children with obesity involving in-person behavioral counseling for diet and physical activity behavior change with parent-child dyads
A total of 53.3% of respondents were non-Hispanic white, 42.6% had an annual household income less than $50 000, and 28.3% had a bachelor’s degree. They were willing to accept lowervalue incentives if both the parent and the child were required to meet the goal, if the incentive used a gain-framed vs lossframed payment structure (MD, −$72; 95% CI, −$85 to −$59), and if physical activity goals were incentivized over weight loss (MD, −$63; 95% CI, −$82 to −$44) or dietary monitoring (MD, −$5; 95% CI, −$1 to $28)
In this study, parent-stated preferences did not align with FBT best practices or behavioral economic theory
Summary
Family-based treatment (FBT) is a weight management approach for children with obesity involving in-person behavioral counseling for diet and physical activity behavior change with parent-child dyads. Best practices for FBT involve at least 26 hours of in-person counseling during a 6-month period.[1] In addition to intervention sessions, families participating in FBT are frequently encouraged to provide children with the opportunity to get more than 60 minutes of moderate to vigorous physical activity daily, reduce screen time, keep a record of all foods the parent and child consume as well as the moderate to vigorous physical activity engaged in, and change the home food environment.[1] Family-based treatment results in sustained improvements in parent and child body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) and is recommended by expert panels.[1,2]. Given the intervention’s intensity, FBT can be challenging and time-consuming.[3,4,5] Barriers to FBT engagement include child motivation and high out-of-pocket expenditures.[3,4,5,6,7,8] Attrition rates from pediatric weight management programs range from 27% to 73%.4 The longer families stay in FBT, the more effective it is.[9,10,11] Strategies to reduce attrition and motivate families within this effective treatment program are needed.[9]
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