Abstract
Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy. In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493. Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12·1, 95% CI 3·7-39·9; p<0·0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14·0, 4·2-46·2; p<0·0001). These differences remained significant with sensitivity analyses. Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown. National Institute for Health Research (RP-PG-0707-10149).
Highlights
Poor adherence to treatment is a widespread problem that reduces the individual and public benefit from numerous health interventions.[1]
We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of hepatitis B virus (HBV) vaccination in individuals receiving opioid substitution therapy
We aimed to assess the effectiveness of contingency management in promoting the completion of HBV vaccination in community drug-treatment settings, comparing the offer of fixed and escalating incentives for on-time attendance at vaccinations with the offer of vaccination without incentive
Summary
Poor adherence to treatment is a widespread problem that reduces the individual and public benefit from numerous health interventions.[1] For addiction, evidencebased treatments exist (eg, opioid substitution treatment),[2] but do not provide their full benefit because of poor adherence and high progressive dropout.[3] Building on the behavioural principles of operant conditioning, contingency management involves the systematic application of positive reinforcement[4] (use of financial or material incentives) to promote adherence to treatment or behaviour consistent with treatment goals and thereby amplify the benefits of existing treatment. Substantial interest exists in the application of contingency management as an adjunct to treatments delivered in various contexts,[4] and within treatment for addictions.[5]. Strong evidence from the USA supports the effectiveness of contingency management to improve outcomes of existing addiction treatments.[6] the generalisability of these findings might be restricted by the extensive use of specialist therapists employed solely to deliver contingency management, and its frequent assessment within specialist research centres.
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