The benefits of physical activity include a lower risk of some of the major non-communicable diseases, including hypertension, cardiovascular disease, diabetes and cancer. In addition physical activity can have positive effects on maintaining healthy body weight and mental health, with insufficient physical activity associated with a substantial global economic burden (Ding et al., 2016). However, roughly one third of the global adult population is not meeting the minimum weekly level of physical activity recommended by the World Health Organisation (Hallal et al., 2012; Guthold et al., 2018). In recognition of the link between physical activity and reduction of non-communicable diseases, the World Health Organisation (WHO) has established the Global Action Plan on Physical Activity 2018–2030, which aims to promote physical activity, provide updated guidance for countries and establish a framework of effective and feasible policy actions to increase physical activity at all levels (WHO, 2018). With the goal of tackling inactivity, Discovery, a multi-national insurance group based in South Africa, launched two types of incentives to make people more active: (1) Vitality Active Rewards; and (2) Vitality Active Rewards with Apple Watch.
Firstly, Vitality Active Rewards is a weekly gain-framed incentive where individuals are rewarded for tracking and reaching different thresholds of physical activity. Within Vitality Active Rewards, members consent to track their physical activity through a variety of different devices (e.g. fitness tracker, smart phone) and receive so-called Vitality Points and rewards for reaching different activity thresholds, including light, standard or advanced workouts or events. Different workout or activity events (e.g. light, standard and advanced activity) have similar point weightings so variability due to measurement through different devices is not an issue.
Secondly, alongside Vitality Active Rewards, the Vitality Active Rewards with Apple Watch benefit was introduced to Vitality customers around the world in 2016. Born out of collaboration between Vitality and the technology company Apple, the benefit aims to leverage evidence-based insights from behavioural and actuarial science with Apple's technology to create behaviour change. In essence, the Vitality Active Rewards with Apple Watch benefit is a loss-framed incentive where eligible Vitality members can purchase an Apple Watch at a heavily discounted upfront price, but with monthly repayment amounts linked to different levels of physical activity thresholds the individuals reach per month. Those who undertake requisite levels of activity pay low or zero monthly repayments.
The existing evidence on the associations between incentives and physical activity (e.g. Chokshi et al., 2018) suggests that on average loss-framed incentives can increase activity beyond the levels of gain-framed incentives only. The objective of this study is to assess whether the loss-framed Vitality Active Rewards with Apple Watch incentive is associated with enhanced physical activity levels for Vitality members that take up the benefit, compared to those individuals that only participate in the gain-framed Vitality Active Rewards incentive. The study also examines whether these associations persist over time.
Note that independent of participating in the Vitality Active Rewards incentive and Vitality Active Rewards with Apple Watch benefit, Vitality programme members can earn an assortment of longer term rewards—ranging from discounts on healthy food purchases to discounted flights, amongst others—by engaging in validated healthy lifestyle activities, such as health check-ups, healthy food purchases and tracking their activity through various wearable devices. While this study focuses on whether participating in the Vitality Active Rewards with Apple Watch benefit is associated with physical activity enhancement compared to participating in Vitality Active Rewards only, it is possible to examine whether participating in the Vitality Active Rewards incentive is also leading to higher activity rates compared to participating in the Vitality programme only. However, there are some limitations in this analysis regarding the data availability and accurate measurement of activity levels.
The study contributes to the existing literature in this area of research by using statistical regression methods combined with large-scale population data from Vitality programme members, including a data sample of 422,643 individuals over a time period of 2015 to 2018. Previous studies that examined the associations between (financial) incentives and physical activity are based on relatively small samples of specific populations (e.g. ischemic heart-disease patients). For this reason it may be difficult to extent these findings to other populations or contexts.
Using data from Vitality members across three countries—the United Kingdom, the United States and South Africa—we use fixed-effects Poisson regression models to examine whether the uptake of the Active Rewards with Apple Watch benefit leads to an increase in tracked physical-activity across different types of activity levels, compared to participating in Active Rewards only. The statistical approach taken in the analysis adjusts for observed and unobserved individual heterogeneity that is constant over time by examining the same individual, before and after the uptake of the intervention (Vitality Active Rewards with Apple Watch benefit). We conduct a series of robustness checks and also perform a sub-group analysis for an inactive and obese sub-population.
Overall, included in the analytic sample for the United Kingdom are 238,422 individuals, of which 59,237 have taken up the Vitality Active Rewards with Apple Watch benefit. In the sample for the United States, 17,648 individuals are included, of which 8,302 have taken up the Vitality Active Rewards with Apple Watch benefit. For the South African sample, 166,573 individuals are included, of which 23,461 have taken out the benefit. While this analysis is based on a large observational dataset across Vitality programme members of three different countries, and hence increases significantly the sample size and potentially allows the generalisability of the findings to a larger population than previous studies, it has to be highlighted that the Vitality population is not necessarily representative of the full population of a country itself.
Our findings suggest that the uptake of the loss-framed Vitality Active Rewards with Apple Watch benefit is associated with an average 34 percent increase of tracked activity days per month, leading to an additional 4.8 activity days per month in which exercise has been tracked. This is compared to the population of Vitality members that only participate in the gain-framed Vitality Active Rewards incentive. As Table 1 reports, there is some variation across the three country samples, with the largest percentage increase in total activity days in South Africa (44.2 percent), followed by the United States (30.6 percent) and the United Kingdom (27.7 percent). The variation of the associations across countries may be due to a combination of the selectiveness of the populations taking up the Vitality Active Rewards with Apple Watch benefit, but also due to country-specific differences in the incentive structures.
Table 1. Changes in Activity Levels After Uptake of the Vitality Active Rewards with Apple Watch Benefit
|United Kingdom||United States||South Africa|
|Total activity days||27.7%||3.6||30.6%||4.7||44.2%||6.1|
|Light activity days||18.3%||0.8||19.3%||1.4||48.8%||2.1|
|Standard activity days||25.1%||1.1||36.5%||2.0||30.1%||2.3|
|Advanced activity days||37.4%||1.6||52.4%||1.2||71.1%||1.3|
NOTE: Additional days calculated by applying percentage change of activity to average days of activity per month for the Vitality Active Rewards with Apple Watch intervention group pre-intervention.
Looking at the different exercise intensity categories—light, standard and advanced activity—the largest relative increase is among the advanced activity days, suggesting that there is not only an overall increase in activity levels but also an increase in more intense exercise events. The largest absolute increase in advanced activity days is reported in the UK sample, where the uptake of the Vitality Active Rewards with Apple Watch benefit is associated with an average increase of 1.6 days of tracked advanced activity per month, followed by South Africa (1.3 days) and the United States (1.2 days).
Furthermore, a sub-group analysis suggests that the Vitality Active Rewards with Apple Watch benefit may also incentivise sub-populations that initially tend to be more inactive, such as obese individuals, to become more active. In this at-risk sub-population the uptake of the benefit is associated with an average increase in tracked activity levels in the range of 109 percent (South Africa), 160 percent (UK) and 200 percent (United States), which are in relative terms larger than for the whole country-specific samples. These percentage changes correspond to an absolute increase in activity days per month of about 4.5 days (South Africa), 5.7 days (United Kingdom) and 1.8 days (United States). However, it is important to highlight that the uptake rate of the benefit is generally lower among this sub-group compared to the overall sample populations.
In addition, we find that the positive associations between the Vitality Active Rewards with Apple Watch benefit and physical activity persist over time (at least over the intervention period of 24 months, the repayment period of the Apple Watch). Moreover, in addition to an overall increase in tracked activity levels, the benefit also tends to be associated with higher levels of intensive activity over time, measured in the total number of advanced activity days per month.
The findings of this study suggest that incentivising physical activity can lead to increased activity levels. Specifically, this study confirms that a loss-framed incentive such as the Vitality Active Rewards with Apple Watch benefit can improve physical activity levels beyond the incentive induced by a gain-framed incentive that only provides individuals with rewards for physical activity, such as the Vitality Active Rewards incentive. This positive association persists when the person is incentivised to maintain this behaviour-change over time. Though more unhealthy individuals are much less likely to take up an incentive of this nature, when they do, the results can lead—on average—to a more pronounced behaviour-change than we see in individuals who are already relatively more active and healthy. This is important when designing health-promotion programmes.