title: The effectiveness of loyalty rewards to promote the use of an Internet-based heart health program.
abstract: BACKGROUND
  Internet-based health programs have been shown to be effective in reducing risk for cardiovascular disease. However, their rates of enrollment and engagement remain low. It is currently unclear whether rewards from established loyalty programs can serve as a conditioned stimulus to improve the use of a freely available Internet-based program.
  
  
  OBJECTIVE
  The objectives of the study were to (1) examine enrollment rates and levels of engagement with the My Health eSupport program between a Conditioned Reward group and a Control group, and (2) investigate the influence of loyalty rewards and participant characteristics on levels of enrollment and program engagement.
  
  
  METHODS
  The study sample (n=142,726) consisted of individuals who were offered enrollment in an Internet-based health intervention (My Health eSupport) after completing the Heart&Stroke Risk Assessment on the Heart and Stroke Foundation website. My Health eSupport programs provided encouragement and tips for lifestyle change. This is a free, self-guided, fully automated program that proactively delivers tailored email messages at 2-week intervals based on the participant's stage of motivational "readiness" and priority for lifestyle change. Participants in the Conditioned Reward group were offered a single exposure of 20 loyalty reward points from the Air Miles loyalty program for completing the Heart&Stroke Risk Assessment (10 reward points) and enrolling in the Internet-based program (10 reward points). Meanwhile, no rewards were given to the Control group participants. All data were collected between February 1, 2011 and February 10, 2012.
  
  
  RESULTS
  In total, 51.38% (73,327/142,726) of individuals in the Conditioned Reward group and 48.62% (69,399/142,726) of individuals in the Control group completed the Heart&Stroke Risk Assessment. Subsequently, significantly more individuals from the Conditioned Reward group (52.96%, 38,835/73,327) enrolled in the My Health eSupport program than Controls (4.07%, 2826/69,399). Regression analyses indicated that individuals were 27.9 times (95% CI 26.4-29.4; P<.001) more likely to join the My Health eSupport program when presented with loyalty rewards controlling for gender, age, education, ethnicity, employment, and number of modifiable risk factors. However, ongoing engagement level was low in both groups and it was not influenced by loyalty rewards. Instead, individuals were more likely to engage with the My Health eSupport program if they were greater than 60 years of age (OR 12.56, 95% CI 5.66-27.8; P<.001), were female (OR 1.27, 95% CI 1.09-1.46; P=.002), or had one or more modifiable risk factors (OR 1.38, 95% CI 1.31-1.45; P<.001).
  
  
  CONCLUSIONS
  Our findings suggest that a single exposure of loyalty rewards may be used to encourage individuals to enroll in an Internet-based preventative health program, but additional strategies are required to maintain engagement level. Future studies need to examine the schedules of loyalty reward reinforcement on the long-term engagement level of Internet-based health programs.
authors.affiliation: Cardiac eHealth Research Unit, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada.
authors.forename: Sam
authors.initials: S
authors.lastname: Liu
authors.forename: Corinne
authors.initials: C
authors.lastname: Hodgson
authors.forename: Ahmad M
authors.initials: AM
authors.lastname: Zbib
authors.forename: Ada Y M
authors.initials: AY
authors.lastname: Payne
authors.forename: Robert P
authors.initials: RP
authors.lastname: Nolan
mesh_terms: D000328:Adult; D000368:Aged; D034742:Electronic Mail; D005260:Female; D015438:Health Behavior; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D020407:Internet; D008019:Life Style; D008297:Male; D008875:Middle Aged; D009042:Motivation; D012201:Reward
keywords: Internet; cardiovascular risk; prevention; rewards