Abstract
BackgroundFinancial incentives are often used to influence professional practice, yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood. In keeping with clinical guidelines, Childsmile (Scotland’s oral health improvement programme) advocates twice yearly fluoride varnish application (FVA) for children in dental practice. To support implementation Childsmile offered dental practitioners a fee-per-item payment for varnishing 2–5-year-olds’ teeth through a pilot. In October 2011 payment was extended to all dental practitioners. This paper compares FVA pre- and post-roll-out and explores the financial incentive’s behavioural mechanisms.MethodsA natural experimental approach using a longitudinal cohort of dental practitioners (n = 1090) compared FVA pre- (time 1) and post- (time 2) financial incentive. Responses from practitioners who did not work in a Childsmile pilot practice when considering their 2–5-year-old patients (novel incentive group) were compared with all other responses (continuous incentive group). The Theoretical Domains Framework (TDF) was used to measure change in behavioural mechanisms associated with the incentive. Analysis of covariance was used to investigate FVA rates and associated behavioural mechanisms in the two groups.ResultsAt time 2, 709 74%, of eligible responders, were followed up. In general, FVA rates increased over time for both groups; however, the novel incentive group experienced a greater increase (β [95% CI] = 0.82 [0.72 to 0.92]) than the continuous incentive group. Despite this, only 33% of practitioners reported ‘always’ varnishing increased risk 2–5-year-olds’ teeth following introduction of the financial incentive, 19% for standard risk children. Domain scores at time 2 (adjusting for time 1) increased more for the novel incentive group (compared to the continuous incentive group) for five domains: knowledge, social/professional role and identity, beliefs about consequences, social influences and emotion.ConclusionsIn this large, prospective, population-wide study, a financial incentive moderately increased FVA in dental practice. Novel longitudinal use of a validated theoretical framework to understand behavioural mechanisms suggested that financial incentives operate through complex inter-linked belief systems. While financial incentives are useful in narrowing the gap between clinical guidelines and FVA, multiple intervention approaches are required.
Highlights
Financial incentives are often used to influence professional practice, yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood
Despite ‘popular opinion’ and frequent implementation, robust evidence of the effectiveness of financial incentives as a professional behaviour change strategy is limited [10,11,12], and there is evidence that financial incentives are modified through indirect belief pathways [13], the mechanisms through which they operate are not fully understood [10]
This paper focuses on a key component of Childsmile—the application of fluoride varnish to children’s teeth in dental practice
Summary
Financial incentives are often used to influence professional practice, yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood. Despite widespread agreement that guidelines are an essential foundation for effective health care delivery [2, 4], studies frequently demonstrate low compliance with guidelines [5,6,7] This has led to an increasing emphasis on attempts to identify and influence the determinants of practice associated with guideline adherence [2, 7,8,9]. Within this context, the ability of financial incentives to influence professional practice and improve patient outcomes has been widely considered. Despite ‘popular opinion’ and frequent implementation, robust evidence of the effectiveness of financial incentives as a professional behaviour change strategy is limited [10,11,12], and there is evidence that financial incentives are modified through indirect belief pathways [13], the mechanisms through which they operate are not fully understood [10]
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