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      Monetary incentives for improving smartphone-measured oral hygiene behaviors in young children: A randomized pilot trial

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          Abstract

          Aims

          To assess feasibility, acceptability, and early efficacy of monetary incentive-based interventions on fostering oral hygiene in young children measured with a Bluetooth-enabled toothbrush and smartphone application.

          Design

          A stratified, parallel-group, three-arm individually randomized controlled pilot trial.

          Setting

          Two Los Angeles area Early Head Start (EHS) sites.

          Participants

          36 parent-child dyads enrolled in an EHS home visit program for 0–3 year olds.

          Interventions

          Eligible dyads, within strata and permuted blocks, were randomized in equal allocation to one of three groups: waitlist (delayed monetary incentive) control group, fixed monetary incentive package, or lottery monetary incentive package. The intervention lasted 8 weeks.

          Outcomes

          Primary outcomes were a) toothbrushing performance: mean number of Bluetooth-recorded half-day episodes per week when the child’s teeth were brushed, and b) dental visit by the 2-month follow-up among children with no prior dental visit. The a priori milestone of 20% more frequent toothbrushing identified the intervention for a subsequent trial. Feasibility and acceptability measures were also assessed, including frequency of parents syncing the Bluetooth-enabled toothbrush to the smartphone application and plaque measurement from digital photographs.

          Findings

          Digital monitoring of toothbrushing was feasible. Mean number of weekly toothbrushing episodes over 8 weeks was 3.9 in the control group, 4.1 in the fixed incentive group, and 6.0 in the lottery incentive group. The lottery group had 53% more frequent toothbrushing than the control group and 47% more frequent toothbrushing than the fixed group. Exploratory analyses showed effects concentrated among children ≤24 months. Follow-up dental visit attendance was similar across groups. iPhone 7 more reliably captured evaluable images than Photomed Cannon G16.

          Conclusions

          Trial protocol and outcome measures were deemed feasible and acceptable. Results informed the study protocol for a fully powered trial of lottery incentives versus a delayed control using the smart toothbrush and remote digital incentive program administration.

          Trial registration

          ClinicalTrials.gov identifier NCT03862443.

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          Most cited references34

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          Doing It Now or Later

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            Small sample inference for fixed effects from restricted maximum likelihood.

            Restricted maximum likelihood (REML) is now well established as a method for estimating the parameters of the general Gaussian linear model with a structured covariance matrix, in particular for mixed linear models. Conventionally, estimates of precision and inference for fixed effects are based on their asymptotic distribution, which is known to be inadequate for some small-sample problems. In this paper, we present a scaled Wald statistic, together with an F approximation to its sampling distribution, that is shown to perform well in a range of small sample settings. The statistic uses an adjusted estimator of the covariance matrix that has reduced small sample bias. This approach has the advantage that it reproduces both the statistics and F distributions in those settings where the latter is exact, namely for Hotelling T2 type statistics and for analysis of variance F-ratios. The performance of the modified statistics is assessed through simulation studies of four different REML analyses and the methods are illustrated using three examples.
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              Financial incentive-based approaches for weight loss: a randomized trial.

              Identifying effective obesity treatment is both a clinical challenge and a public health priority due to the health consequences of obesity. To determine whether common decision errors identified by behavioral economists such as prospect theory, loss aversion, and regret could be used to design an effective weight loss intervention. Fifty-seven healthy participants aged 30-70 years with a body mass index of 30-40 were randomized to 3 weight loss plans: monthly weigh-ins, a lottery incentive program, or a deposit contract that allowed for participant matching, with a weight loss goal of 1 lb (0.45 kg) a week for 16 weeks. Participants were recruited May-August 2007 at the Philadelphia VA Medical Center in Pennsylvania and were followed up through June 2008. Weight loss after 16 weeks. The incentive groups lost significantly more weight than the control group (mean, 3.9 lb). Compared with the control group, the lottery group lost a mean of 13.1 lb (95% confidence interval [CI] of the difference in means, 1.95-16.40; P = .02) and the deposit contract group lost a mean of 14.0 lb (95% CI of the difference in means, 3.69-16.43; P = .006). About half of those in both incentive groups met the 16-lb target weight loss: 47.4% (95% CI, 24.5%-71.1%) in the deposit contract group and 52.6% (95% CI, 28.9%-75.6%) in the lottery group, whereas 10.5% (95% CI, 1.3%-33.1%; P = .01) in the control group met the 16-lb target. Although the net weight loss between enrollment in the study and at the end of 7 months was larger in the incentive groups (9.2 lb; t = 1.21; 95% CI, -3.20 to 12.66; P = .23, in the lottery group and 6.2 lb; t = 0.52; 95% CI, -5.17 to 8.75; P = .61 in the deposit contract group) than in the control group (4.4 lb), these differences were not statistically significant. However, incentive participants weighed significantly less at 7 months than at the study start (P = .01 for the lottery group; P = .03 for the deposit contract group) whereas controls did not. The use of economic incentives produced significant weight loss during the 16 weeks of intervention that was not fully sustained. The longer-term use of incentives should be evaluated. clinicaltrials.gov Identifier: NCT00520611.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Project administrationRole: ValidationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: Project administrationRole: Validation
                Role: InvestigationRole: Project administrationRole: SoftwareRole: Validation
                Role: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                30 July 2020
                2020
                : 15
                : 7
                : e0236692
                Affiliations
                [1 ] Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, United States of America
                [2 ] Center to Address Disparities in Children’s Oral Health, University of California San Francisco, San Francisco, California, United States of America
                [3 ] Section of Pediatric Dentistry, School of Dentistry, University of California Los Angeles, Los Angeles, California, United States of America
                [4 ] Institute for Health and Aging, University of California San Francisco, San Francisco, California, United States of America
                [5 ] Department of Preventive and Restorative Dental Sciences, University of California San Francisco, San Francisco, California, United States of America
                [6 ] School of Public Health, San Diego State University, San Diego, California, United States of America
                [7 ] California Protons Cancer Therapy Center, University of California San Diego Health, San Diego, California, United States of America
                [8 ] Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California, United States of America
                The University of Manchester Faculty of Biology Medicine and Health, UNITED KINGDOM
                Author notes

                Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. Gansky’s brother is a 3M employee, in a different division than the one that provided in-kind product. This paper includes discussion of “off-label” use of the following: The US FDA only has approved fluoride varnish as a device to be used for tooth sensitivity in a cavity lining preparation; caries prevention is an off-label use. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-3388-9569
                http://orcid.org/0000-0002-4961-2150
                http://orcid.org/0000-0003-2457-4183
                http://orcid.org/0000-0003-3147-0884
                Article
                PONE-D-19-34569
                10.1371/journal.pone.0236692
                7392266
                32730310
                a8f0aad3-18f5-4380-b84d-824727a881f4
                © 2020 White et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 13 December 2019
                : 10 July 2020
                Page count
                Figures: 6, Tables: 2, Pages: 21
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000072, National Institute of Dental and Craniofacial Research;
                Award ID: UH2-DE025514
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000072, National Institute of Dental and Craniofacial Research;
                Award ID: UH2-DE025507
                Award Recipient :
                Funding for the study was provided by the US National Institutes of Health/National Institute of Dental and Craniofacial Research, Grant No. UH2-DE025514 (FRG, JGK, SAG) and Coordinating Center Grant No. UH2-DE025507 (SAG). Philips Healthcare’s Sonicare for Kids and Colgate-Palmolive provided in-kind support. NIDCR provided comments on the study protocol, but otherwise had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Computer and Information Sciences
                Software Engineering
                Computer Software
                Apps
                Engineering and Technology
                Software Engineering
                Computer Software
                Apps
                Biology and Life Sciences
                Anatomy
                Digestive System
                Teeth
                Medicine and Health Sciences
                Anatomy
                Digestive System
                Teeth
                Biology and Life Sciences
                Anatomy
                Head
                Jaw
                Teeth
                Medicine and Health Sciences
                Anatomy
                Head
                Jaw
                Teeth
                Engineering and Technology
                Equipment
                Communication Equipment
                Cell Phones
                Medicine and Health Sciences
                Pediatrics
                Child Health
                Medicine and Health Sciences
                Public and Occupational Health
                Child Health
                Physical Sciences
                Chemistry
                Chemical Compounds
                Fluorides
                People and Places
                Population Groupings
                Age Groups
                Children
                People and Places
                Population Groupings
                Families
                Children
                Medicine and Health Sciences
                Oral Medicine
                Oral Health
                Medicine and Health Sciences
                Public and Occupational Health
                Behavioral and Social Aspects of Health
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

                Uncategorized
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