Table Of Content„Walk to Beijing‟ – A mixed methods evaluation of a financial
incentive scheme aimed at encouraging physical activity
participation in Sandwell, West Midlands.
Gemma Louise Hurst
A thesis submitted in partial fulfilment of the requirement of Staffordshire University
for the degree of Doctor of Philosophy
May 2013
Acknowledgements
Firstly, I would like extend my sincere gratitude to my PhD supervisors for their
continued guidance, support and encouragement throughout the completion of this
research: to Dr. Christopher Gidlow for your perseverance in getting me to the finish
line; to Professor Sarah Grogan for your encouragement, ability to always highlight the
positives and qualitative expertise; and to Professor David Clark-Carter for your
continued support and statistical expertise. I would also like to thank my original
principal supervisor, Professor Rachel Davey, now at the University of Canberra,
Australia, for your faith in my ability and offering me this PhD position.
Secondly, I would like to thank everyone in Sandwell PCT‘s Physical Activity Team,
especially Dene Stevens and Lindsay Manford. This gratitude is also extended to the
health assessors who were instrumental in delivering the Walk to Beijing intervention.
Special thanks are also reserved for those who took part in the Walk to Beijing
intervention.
Thirdly, thank you to Staffordshire University, the Centre for Sport, Health and
Exercise Research and the Centre for Health Psychology for the continued and
extended support. Special thanks also go to my fellow PhD students, colleagues and
friends, especially: Naomi - I couldn‘t have got through the early years without you;
Phil - you kept me sane(ish) throughout; and Dan - I couldn‘t have finished it without
you.
Finally, I would like to say thank you to my family, for their continued and
unwavering support, with particular thanks going to Charlotte and Tim for keeping me
fed and watered during the final few months.
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Contents
Acknowledgements ............................................................................................................ i
Contents ............................................................................................................................ ii
Abstract .......................................................................................................................... viii
List of Tables.................................................................................................................... ix
List of Figures ................................................................................................................. xii
List of Appendices .......................................................................................................... xv
List of Presentations ....................................................................................................... xvi
List of Acronyms ......................................................................................................... xviii
Glossary ......................................................................................................................... xix
1 Chapter 1: Introduction ......................................................................................... 1
1.1 Introduction ....................................................................................................... 1
1.2 Physical Activity and Public Health ................................................................. 1
1.3 Defining Key Terms .......................................................................................... 2
1.4 Physical Activity Recommendations ................................................................ 4
1.5 Prevalence and Impact of Physical Inactivity ................................................... 5
1.6 Policy and Position Statements ......................................................................... 7
1.7 National Physical Activity Interventions .......................................................... 8
1.8 Summary ......................................................................................................... 10
1.9 Aim .................................................................................................................. 11
1.10 Objectives ........................................................................................................ 11
1.11 Outline of Thesis ............................................................................................. 11
2 Chapter 2: Literature Review .............................................................................. 13
2.1 Introduction ..................................................................................................... 13
2.2 Correlates and Determinants of Physical Activity Behaviour ........................ 13
2.2.1 Personal Characteristics .............................................................................. 14
2.2.2 Environmental and Social Characteristics .................................................. 16
2.3 Physical Activity Promotion ........................................................................... 18
2.3.1 Types of Physical Activity Intervention ..................................................... 18
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2.3.2 Interventions to promote Lifestyle Physical Activity ................................. 20
2.3.3 Physical Activity Interventions in Community Settings ............................. 22
2.4 Theoretical Framework: Models of Behaviour Change and Theories of
Motivation ................................................................................................................... 22
2.4.1 Stage-Based Theory: The Transtheoretical Model of Behaviour Change .. 23
2.4.2 Attitude-Based Theory: Theory of Planned Behaviour .............................. 27
2.4.3 Control-Based Theories: Social Determination Theory and Cognitive
Evaluation Theory ................................................................................................... 29
2.5 Evidence relating to Walk to Beijing Intervention Components .................... 33
2.5.1 Pedometer-based Interventions ................................................................... 34
2.5.2 Health Checks, Health Assessments and Physical Activity Consultations . 35
2.5.3 Brief, Tailored Physical Activity Interventions .......................................... 35
2.5.4 Financial Incentives .................................................................................... 36
2.6 Incentivised Physical Activity Interventions: a Systematic Review ............... 41
2.6.1 Introduction and Review of Methods .......................................................... 41
2.6.2 Results ......................................................................................................... 42
2.6.3 Discussion of Review Findings ................................................................... 62
2.7 Summary ......................................................................................................... 66
3 Chapter 3: Contextualisation and Background to Research ............................ 67
3.1 Introduction ..................................................................................................... 67
3.2 Profile of Sandwell, West Midlands ............................................................... 67
3.2.1 About Sandwell ........................................................................................... 67
3.2.2 Population Demographics ........................................................................... 68
3.2.3 Ethnicity ...................................................................................................... 70
3.2.4 Deprivation .................................................................................................. 70
3.2.5 Health Profile .............................................................................................. 72
3.2.6 Health Behaviour ........................................................................................ 76
3.3 Walk to Beijing – Background and Rationale................................................. 79
3.4 Overview of the Study Design ........................................................................ 80
3.4.1 Using a Mixed Methods Approach ............................................................. 81
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3.4.2 A Quantitative Methodological Approach: Chapter 4 ................................ 84
3.4.3 A Qualitative Methodological Approach: Chapter 5 .................................. 84
3.4.4 A Mixed Methods and Case Study Approach: Chapter 6 ........................... 85
4 Chapter 4: An Outcome Evaluation of the Walk to Beijing Intervention ....... 87
4.1 Introduction ..................................................................................................... 87
4.2 Methods ........................................................................................................... 87
4.2.1 Design ......................................................................................................... 88
4.2.2 Recruitment ................................................................................................. 89
4.2.3 Participants .................................................................................................. 89
4.2.4 Intervention Procedure ................................................................................ 90
4.2.5 Outcome Measures ...................................................................................... 94
4.2.6 Sample Size Estimates and Power Analysis ............................................. 101
4.3 Results ........................................................................................................... 103
4.3.1 Participant Flow ........................................................................................ 103
4.3.2 Recruitment Mapping................................................................................ 105
4.3.3 Baseline Sample Characteristics ............................................................... 106
4.3.4 Baseline Descriptive Statistics .................................................................. 110
4.3.5 Data Analysis ............................................................................................ 121
4.4 Reasons for Participation .............................................................................. 150
4.5 Attrition ......................................................................................................... 150
4.5.1 Baseline to Three-month Attrition ............................................................ 150
4.5.2 Three-month to Six-month Attrition ......................................................... 155
4.6 Pedometer Output.......................................................................................... 159
4.7 Allocation of Incentives ................................................................................ 160
4.8 Summary ....................................................................................................... 161
5 Chapter 5: A Process Evaluation of the Walk to Beijing Intervention .......... 163
5.1 Introduction ................................................................................................... 163
5.2 Methods ......................................................................................................... 163
5.2.1 Reliability and Validity of Qualitative Research ...................................... 163
5.3 Data Collection Techniques .......................................................................... 165
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5.3.1 Semi-Structured Interviews ....................................................................... 165
5.3.2 Focus Groups ............................................................................................ 166
5.3.3 Comparison with Other Qualitative Data Collection Techniques............. 167
5.3.4 Rationale for the Selected Data Collection Method .................................. 169
5.4 Data Analysis: Thematic Analysis ................................................................ 169
5.4.1 The Development of Thematic Analysis................................................... 169
5.4.2 Comparison with other Methods of Qualitative Data Analysis ................ 170
5.4.3 Rationale for the Selected Analysis Method ............................................. 172
5.5 Ethical Considerations .................................................................................. 173
5.5.1 Informed Consent ...................................................................................... 173
5.5.2 Deception .................................................................................................. 174
5.5.3 Anonymity and Confidentiality................................................................. 174
5.5.4 Participant De-Briefing ............................................................................. 174
5.5.5 Withdrawal from the Investigation ........................................................... 174
5.5.6 Protection of Participants .......................................................................... 175
5.5.7 The Right to See Results ........................................................................... 175
5.5.8 Invasion of Privacy ................................................................................... 175
5.6 Process and Methods of Data Collection and Analysis ................................ 176
5.6.1 Setting ....................................................................................................... 176
5.6.2 The Interviewer ......................................................................................... 176
5.6.3 Sampling and Recruitment ........................................................................ 176
5.6.4 Pilot Focus Group Interviews and Semi-structured Interview Schedule
Development ......................................................................................................... 177
5.6.5 Procedure................................................................................................... 178
5.6.6 Process of Analysis ................................................................................... 180
5.7 Results and Discussion .................................................................................. 183
5.8 Summary ....................................................................................................... 224
6 Chapter 6: Exploring the Longitudinal Impact of Walk to Beijing
Intervention Participation: A Case-study Analysis ................................................. 227
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6.1 Introduction ................................................................................................... 227
6.2 Methods ......................................................................................................... 227
6.2.1 The Case Study Approach ......................................................................... 227
6.2.2 Interpretative Phenomenological Analysis (IPA) ..................................... 228
6.2.3 Comparison with Other Methods of Qualitative Data Analysis ............... 229
6.2.4 IPA Data Collection Methods ................................................................... 231
6.3 Rationale ....................................................................................................... 232
6.4 Process of Data Collection and Analysis ...................................................... 232
6.4.1 Setting ....................................................................................................... 232
6.4.2 The Health Assessor .................................................................................. 233
6.4.3 The Interviewer ......................................................................................... 233
6.4.4 Sampling and Recruitment ........................................................................ 233
6.4.5 Procedure................................................................................................... 237
6.4.6 Process of Analysis ................................................................................... 238
6.4.7 The Role of the Researcher ....................................................................... 240
6.5 Case Studies .................................................................................................. 240
6.5.1 Case Study One: Kate ............................................................................... 241
6.5.2 Case Study Two; Julia ............................................................................... 257
6.6 Case Study Discussion .................................................................................. 279
6.6.1 Initial Motivation ...................................................................................... 279
6.6.2 Physical Activity and Behaviour Change ................................................. 280
6.6.3 Intervention Outcomes .............................................................................. 281
6.6.4 Impact of Intervention Components.......................................................... 282
6.6.5 Intervention Evaluation ............................................................................. 284
7 Chapter 7: Discussion and Conclusions ............................................................ 286
7.1 Introduction ................................................................................................... 286
7.2 Summary of Findings .................................................................................... 286
7.2.1 Who Took Part? ........................................................................................ 286
7.2.2 Who Dropped Out? ................................................................................... 288
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7.3 Evaluation of Objectives ............................................................................... 289
7.4 Strengths and Limitations of this Research ................................................... 305
7.4.1 Strengths .................................................................................................... 306
7.4.2 Methodological Issues and Limitations .................................................... 306
7.5 Future Research ............................................................................................. 310
7.6 Recommendations for Practice ..................................................................... 311
7.6.1 Recommendations: Quantitative Evaluation ............................................. 311
7.6.2 Recommendations: Qualitative Evaluation ............................................... 312
7.6.3 Implementation of Recommendations ...................................................... 313
7.7 The Role of the Researcher ........................................................................... 314
7.8 Researcher‘s Reflections ............................................................................... 315
7.8.1 Introduction ............................................................................................... 315
7.8.2 Reflections: The Outcome Evaluation ...................................................... 316
7.8.3 Reflections: The Process Evaluation and the Case Study Approach ........ 318
7.8.4 Real-world Research and the PhD Journey ............................................... 325
7.9 General Conclusions ..................................................................................... 325
References .................................................................................................................... 327
Appendices ................................................................................................................... 355
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Abstract
Background. The many health benefits of physical activity are well established. In
response to the low levels of activity in Sandwell, UK, the ‗Walk to Beijing‘ (WTB)
intervention aimed to increase lifestyle physical activity using financial incentives (in
combination with a health assessment, pedometer and brief advice). Aim. To examine
the benefits of a financial incentive scheme to promote physical activity, specifically
walking, in sedentary adults. Methods. A mixed methods evaluation comprised: (1)
outcome evaluation employing a pre-post intervention design to measure three- and six-
month changes in physical activity, physiological and self-reported health; (2) process
evaluation using semi-structured interviews to explore participant experiences,
motivations towards physical activity, incentivised health schemes and WTB
participation; and (3) mixed methods case-study approach using data at collected at six-
and 12-month follow-up to further explore sustainability of behaviour change. Results.
Three-month data were available for 1082 participants (64.5% of baseline sample). A
statistically significant positive change from baseline to three-month follow-up was
observed for stage of change (p<.001, d=.63), which was maintained (but not further
improved) at six-months (p<.001, d=.64). Significant three- and six-month
improvements were also found in objective (e.g., BMI, waist-hip ratio, waist
circumference and blood pressure) and subjective (e.g., EQ-5D, SF12v2 and Theory of
Planned Behaviour constructs) measures of health status. At baseline, 41.7% of
participants cited the financial incentive as influencing their decision to take part.
Qualitative data also identified that the financial incentive was the primary motivator for
some, but not all, individuals; other intervention components were also motivators.
Conclusion. Data suggested that financial incentives may promote participation in
lifestyle physical activity through aiding uptake and sustaining engagement, however,
other intervention components were also important. This research is the first to conduct
an evaluation of a financial incentive scheme to promote physical activity comprising a
combination of quantitative, qualitative and longitudinal case study methods to gain a
unique and detailed insight into the area. Important implications for future research and
practice were identified.
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List of Tables
Table 1. TTM processes of change ................................................................................ 24
Table 2. A summary table presenting study design, participants, type of incentives
employed and outcomes measures of the 28 included studies ...................................... 44
Table 3. A summary table presenting intervention design and study outcomes of the 28
included studies ............................................................................................................. 51
Table 4. Age and gender distribution of the Sandwell population ................................ 69
Table 5. Ethnic profile of the Sandwell population....................................................... 70
Table 6. Estimated cases of deaths pre year prevented by physical activity by
hypothetical level of physical activity in the population of Sandwell (ages 40-79) ...... 77
Table 7. Criteria for rewards ........................................................................................ 91
Table 8. TTM questionnaire responses and associated stage of change category ....... 95
Table 9. The International classification of adult underweight, overweight and obesity
according to BMI. ......................................................................................................... 96
Table 10. World Health Organisation cut-off points and risk of metabolic
complications ................................................................................................................ 97
Table 11. Classification of Blood Pressure for Adults 18 years or older ..................... 98
Table 12. Participant Recruitment from each area of Sandwell ................................. 105
Table 13. Summary of baseline sample characteristics of WTB participants............. 107
Table 14. Descriptive statistics for age and gender of participants at baseline ......... 108
Table 15. A summary table of dependent variable measures at baseline ................... 110
Table 16. Number of participants in each stage of change (TTM) pre- and post-
intervention (baseline and three-months) ................................................................... 124
Table 17. The BMI Classification, according to WHO (2013), of participants pre- and
post-intervention ......................................................................................................... 126
Table 18. Mean WHR of participants at baseline and three-months .......................... 127
Table 19. Mean waist circumference of participants pre- and post intervention
(baseline and three-months) ........................................................................................ 128
Table 20. Mean systolic and diastolic blood pressure measurements pre- and post-
intervention ................................................................................................................. 130
Table 21. Blood pressure classification for participants pre- and post-intervention . 130
Table 22. Means, standard deviations and standard errors for the TPB subscales ... 131
Table 23. SF12v2 physical and mental component scores pre- and post-intervention
..................................................................................................................................... 133
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