Behavioral Economic Interventions Research Articles

Addition of Financial Incentives to Mailed Outreach for Promoting Colorectal Cancer Screening

Although screening decreases incidence of and mortality from colorectal cancer (CRC), screening rates are low. Health-promoting financial incentives may increase uptake of cancer screening. To evaluate the relative and absolute benefit associated with adding financial incentives to the uptake of CRC screening. PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to July 31, 2020. Keywords and Medical Subject Headings terms were used to identify published studies on the topic. The search strategy identified 835 studies. Randomized clinical trials (RCTs) were selected that involved adults older than 50 years who were eligible for CRC screening, who received either various forms of financial incentives along with mailed outreach or no financial incentives but mailed outreach and reminders alone, and who reported screening completion by using recommended tests at different time points. Observational or nonrandomized studies and a few RCTs were excluded. The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Data were abstracted and risk of bias was assessed by 2 independent reviewers. Random-effects meta-analysis was conducted, heterogeneity was examined through subgroup analysis and metaregression, and quality of evidence was appraised. The primary outcome was CRC screening completion within 12 months of receiving the intervention. A total of 8 RCTs that were conducted in the United States and reported between January 1, 2014, and December 31, 2020, were included. The trials involved 110 644 participants, of whom 53 444 (48.3%) were randomized to the intervention group (received financial incentives) and 57 200 (51.7%) were randomized to the control group (received no financial incentives). Participants were predominantly male, with 59 113 men (53.4%). Low-quality evidence (rated down for risk of bias and heterogeneity) suggested that adding financial incentives may be associated with a small benefit of increasing CRC screening vs no financial incentives (odds ratio [OR], 1.25; 95% CI, 1.05-1.49). With mailed outreach having a 30% estimated CRC screening completion rate, adding financial incentives may increase the rate to 33.5% (95% CI, 30.8%-36.2%). On metaregression, the magnitude of benefit decreased as the proportion of participants with low income and/or from racial/ethnic minority groups increased. No significant differences were observed by type of behavioral economic intervention (fixed amount: OR, 1.26 [95% CI, 1.05-1.52] vs lottery: OR, 1.06 [95% CI, 0.80-1.40]; P = .32), amount of incentive (≤$5: OR, 1.09 [95% CI, 1.01-1.18] vs >$5: OR, 1.25 [95% CI, 1.02-1.54]; P = .22), or screening modality (stool-based test: OR, 1.14 [95% CI, 0.92-1.41] vs colonoscopy: OR, 1.63 [95% CI, 1.01-2.64]; P = .18). Adding financial incentives appeared to be associated with a small benefit of increasing CRC screening uptake, with marginal benefits in underserved populations with adverse social determinants of health. Alternative approaches to enhancing CRC screening uptake are warranted.

Using Behavioral Economic Interventions with Remote-monitoring Technologies to Increase Physical Activity

Using Behavioral Economic Interventions with Remote-monitoring Technologies to Increase Physical Activity

The Origins of Behavioural Public Policy

The Origins of Behavioural Public Policy

Using behavioral economic interventions with remote-monitoring technologies to increase physical activity

Many workplaces and insurers sponsor programs to increase employees' physical activity, but these programs often fail to create healthy behaviors or else work only temporarily. They typically offer fin ncial incentives without considering cognitive biases that influence whether people will join the programs and remain committed to exercising. We argue that interventions should leverage both insights from behavioral economics and the availability of remote-monitoring technologies, such as automatic step trackers, to be more effective. In this article, we summarize relevant insights from behavioral economics, highlight research findings that show the value of combining behaviorally informed program design with remote monitoring, and suggest strategies for selecting interventions and remote-monitoring devices.

A Pilot Study of Youth With Type 1 Diabetes Initiating Use of a Hybrid Closed-Loop System While Receiving a Behavioral Economics Intervention

ObjectiveMany youth do not use the hybrid closed-loop system for type 1 diabetes effectively. This study evaluated the impact of financial incentives for diabetes-related tasks on use of the 670G hybrid closed-loop system and on glycemia. MethodsAt auto mode initiation and for 16 weeks thereafter, participants received a flat rate for wearing and calibrating the sensor ($1/day), administering at least 3 mealtime insulin boluses per day ($1/day), and uploading ($5/week). Weekly bonuses were given for maintaining at least 70% of the time in auto mode, which were increased for persistent auto mode use from $3/week to a maximum of $13/week. If a participant failed to maintain auto mode for a week, the rewards were reset to baseline. Data from 17 participants aged 15.9 years ± 2.5 years (baseline hemoglobin A1c [HbA1c] 8.6% ± 1.1%) were collected at 6, 12, and 16 weeks. The reinforcers were withdrawn at 16 weeks, with a follow-up assessment at 24 weeks. ResultsWith reinforcers, the participants administered an average of at least 3 mealtime insulin boluses per day and wore the sensor over 70% of the time. However, auto mode use waned. HbA1c levels decreased by 0.5% after 6 weeks, and this improvement was maintained at 12 and 16 weeks (P < .05). Upon withdrawal of reinforcers, HbA1c levels increased back to baseline at 24 weeks. ConclusionCompensation for diabetes-related tasks was associated with lower HbA1c levels, consistent administration of mealtime insulin boluses, and sustained sensor use. These results support the potential of financial rewards for improving outcomes in youth with type 1 diabetes.

Considerations for remote delivery of behavioral economic interventions for substance use disorder during COVID-19 and beyond

The response to the COVID-19 crisis has created direct pressure on health care providers to deliver virtual care, and has created the opportunity to develop innovations in remote treatment for people with substance use disorders. Remote treatments provide an intervention delivery framework that capitalizes on technological innovations in remote monitoring of behaviors and can efficiently use information collected from people and their environment to provide personalized treatments as needed. Interventions informed by behavioral economic theories can help to harness the largely untapped potential of virtual care in substance use treatment. Behavioral economic treatments, such as contingency management, the substance-free activity session, and episodic future thinking, are positioned to leverage remote monitoring of substance use and to use personalized medicine frameworks to deliver remote interventions in the COVID-19 era and beyond.

Before the lunch line: Effectiveness of behavioral economic interventions for pre-commitment on elementary school children's food choices

In this study, we intervened in elementary schools on lunch entrée selection using some of the behavioral economic methods shown to be effective in earlier food choice studies. Unlike many earlier behavioral interventions, which were mostly done in controlled environments and smaller café type settings for one-off interactions, we conducted our interventions in a real-world environment in twelve elementary schools in one school district in South Carolina over nine school weeks. By increasing salience and prominence of the healthy entrée of the day through visual and verbal tools, we nudged students towards selecting healthier options in treatment schools. We estimated the treatment effects using a difference-in-differences setup, comparing changes in the share of students selecting nudged entrées during the treatment period relative to the shares before the treatment period in treatment and comparison schools. Our estimates show that the nudges are effective when present. They increase selection of the healthy option by thirteen to thirty-five percent on the days the entrée is treated. Effects disappear when the nudge is removed, however, and there is evidence for reduced effectiveness of nudges in repeat instances. There is no evidence of habit formation.

Pilot trial investigating a brief behavioral economic intervention as an adjunctive treatment for alcohol use disorder

ObjectiveBehavioral economic research suggests that increasing the salience of a delayed reward may improve capacity for delaying gratification and increase behavior allocated toward obtaining larger, delayed substance-free reward rather than smaller, more immediate reward such as alcohol use. This study aimed to improve the efficacy of outpatient alcohol use disorder (AUD) treatment by adding elements that target behavioral economic mechanisms of change. MethodForty-one (N = 41) adults in outpatient AUD treatment were recruited and 37 participants were retained at follow-up. Following baseline assessment, participants received either the Substance Free Activity Session (SFAS), a single-session behavioral economic–informed intervention focused on increasing future orientation and engagement in values-based substance-free activities or a health education control intervention. Participants in both conditions received weekly prompts (via text or email) relevant to their respective intervention for four weeks. Participants (68.3% male; 70.7% Caucasian, M age = 38.24, SD = 12.69) reported an average of 3.95 (SD = 4.72) binge drinking episodes (4/5 drinks per occasion for a woman/man) and 5.05 (SD = 5.32) drinks per drinking day 30-days prior to treatment entry. ResultsThe study provided initial support for the feasibility and acceptability of implementing the SFAS within a treatment setting. Participants reported high levels of satisfaction with the SFAS (M = 9.08 (SD = 0.94), on a scale of 1–10). At 3-month follow-up, the SFAS was associated with reductions in the proportion of activity participation and enjoyment (reinforcement) related to substance-use relative to substance-free activities and in alcohol demand compared to control. ConclusionThese preliminary results provide initial support for targeting behavioral economic mechanisms of change in an outpatient AUD treatment with a single-session intervention plus remote delivery of booster prompts.

A behavioral economic intervention to increase psychiatrist adherence to tobacco treatment guidelines: a provider-randomized study protocol

BackgroundPeople with a psychiatric diagnosis smoke at high rates, yet are rarely treated for tobacco use. Health care systems often use a “no treatment” default for tobacco, such that providers must actively choose (opt-in) to treat their patients who express interest in quitting. Default bias theory suggests that opt-in systems may reinforce the status quo to not treat tobacco use in psychiatry. We aim to conduct a pilot study testing an opt-out system for implementing a 3As (ask, advise, assist) tobacco treatment model in outpatient psychiatry.MethodsWe will use a mixed-methods, cluster-randomized study design. We will implement a tobacco use clinical reminder for outpatient psychiatrists at the VA New York Harbor Healthcare System. Psychiatrists (N = 20) will be randomized 1:1 to one of the two groups: (1) opt-in treatment approach—psychiatrists will receive a reminder that encourages them to offer cessation medications and referral to cessation counseling; (2) opt-out treatment approach—psychiatrists will receive a clinical reminder that includes a standing cessation medication order and a referral to cessation counseling that will automatically generate unless the provider cancels. Prior to implementation of the reminders, we will hold a 1-h training on tobacco treatment for psychiatrists in both arms. We will use VA administrative data to calculate the study’s primary outcomes: (1) the percent of smokers prescribed a cessation medication and (2) the percent of smokers referred to counseling. During the intervention period, we will also conduct post-visit surveys with a cluster sample of 400 patients (20 per psychiatrist) to assess psychiatrist fidelity to the 3As approach and patient perceptions of the opt-out system. At 6 months, we will survey the clustered patient sample again to evaluate the study’s secondary outcomes: (1) patient use of cessation treatment in the prior 6 months and (2) self-reported 7-day abstinence at 6 months. At the end of the intervention period, we will conduct semi-structured interviews with 12–14 psychiatrists asking about their perceptions of the opt-out approach.DiscussionThis study will produce important data on the potential of opt-out systems to overcome the barriers in implementing tobacco use treatment in outpatient psychiatry.Trial registrationClinicaltrials.gov NCT04071795 (registered on August 28, 2019)

A Combined Behavioral Economics and Cognitive Behavioral Therapy Intervention to Reduce Alcohol Use and Intimate Partner Violence Among Couples in Bengaluru, India: Results of a Pilot Study.

Hazardous drinking is an important contributing factor to intimate partner violence (IPV) occurrence. However, only a limited number of community-based alcohol reduction interventions have been tested in low- and middle-income countries (LMICs) for their efficacy in reducing IPV. This pilot intervention study tested a 1-month combined behavioral economics and cognitive behavioral therapy intervention to reduce hazardous alcohol use and IPV in Bengaluru, India. Sixty couples were randomized to one of three study arms to test the effect of incentives-only and incentives plus counseling interventions compared with a control condition. Alcohol use among male participants was assessed using breathalyzer tests. Violence experienced by female participants was measured using the Indian Family Violence and Control Scale. Couples in the counseling arm participated in four weekly counseling sessions. Male participants in the incentive arms earned a reward for sobriety (breath alcohol concentration [BrAC] <0.01 g/dl). Results showed that while incentives reduced alcohol use, there was a greater proportion of negative BrAC samples among participants in the counseling arm compared with the control group (0.96 vs. 0.76, p = .03). Violence also decreased in both intervention arms. The estimated mean violence score for the counseling arm was 10.8 points lower than the control arm at 4-month follow-up visit (p = .02). This study contributes important evidence to the field of alcohol reduction and IPV prevention approaches in LMIC settings and adds to the growing evidence that alcohol reduction is a modifiable means of addressing IPV.

Improving Medication Adherence in Cardiovascular Disease Prevention: What's New?

Improving Medication Adherence in Cardiovascular Disease Prevention: What's New?

How Behavioral Economics and Nudges Could Help Diminish Irrationality in Suicide-Related Decisions

People regularly make decisions that are not aligned with their own self-interests. These irrational decisions often stem from humans having bounded rationality (e.g., limited computational power), which produces reliable cognitive biases that occur outside of people’s awareness and influences the decisions people make. There are many important decisions leading up to a suicide attempt, and it is likely that these same biases exist within suicide-related decisions. This article presents an argument for the likely existence of cognitive biases within suicide-related decision making and how they may influence people to make irrational decisions. In addition, this article provides new evidence for using a behavioral economic intervention—nudges—as a potential way to combat rising suicide rates. We explore how nudges can help increase means safety, disseminate suicide prevention skills/materials, diminish well-known biases (e.g., confirmation bias), and uncover biases that may be occurring when making suicide-related decisions.

Capsule Commentary on Shapiro et al., Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial.

Capsule Commentary on Shapiro et al., Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial.

Behavioral Economics Intervention to Increase Treatment Seeking in the National Guard

Behavioral Economics Intervention to Increase Treatment Seeking in the National Guard

Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial.

Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations. To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients. Randomized controlled trial. Two hundred seven adults (98% African American or Latino) aged 18 or older with uncontrolled hypertension attending Federally Qualified Health Centers. Six-month intervention, combining financial incentives for measuring home BP, recording medication use, BP improvement, and achieving target BP values with counseling linking hypertension control efforts to participants' personal reasons to stay healthy. Primary outcomes: percentage achieving systolic BP (SBP) < 140mmHg, percentage achieving diastolic BP (DBP) < 90mmHg, and changes in SBP and DBP, all after 6months. Priority secondary outcomes were SBP < 140mmHg, DBP < 90mmHg, and BP change at 12months, 6months after the intervention ended. After 6months, rates of achieving target BP values for intervention and control subjects respectively was 57.1% vs. 40.2% for SBP < 140mmHg (adjusted odds ratio (AOR) 2.53 (1.13-5.70)), 79.8% vs 70.1% for DBP < 90mmHg (AOR 2.50 (0.84-7.44)), and 53.6% vs 40.2% for achieving both targets (AOR 2.04 (0.92-4.52)). However, at 12months, the groups did not differ significantly in these 3 measures: 39.5% vs 35.0% for SBP (AOR 1.20 (0.51-2.83)), 68.4% vs 75.0% for DBP (AOR 0.70 (0.24-2.09)), and 35.5% vs 33.8% for both (AOR 1.03 (0.44-2.42)). Change in absolute SBP and DBP did not differ significantly between the groups at 6 or 12months. Exploratory post hoc analysis revealed intervention benefit only occurred among individuals whose providers intensified their regimens, but not among those with intensification but no intervention. The intervention achieved short-term improvement in SBP control in a highly disadvantaged population. Despite attempts to enhance intrinsic motivation, the effect was not sustained after incentives were withdrawn. Future research should evaluate combined patient/provider strategies to enhance such interventions and sustain their benefit. NCT01402453; http://clinicaltrials.gov/show/NCT01402453.

Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review.

Medication adherence is poor in patients with chronic conditions. Behavioral economic interventions may reduce biases that are associated with poor adherence. The objective of this review is to map the available evidence on behavioral economic interventions to improve medication adherence in adults with chronic conditions in high-income settings. We conducted a scoping review and reported the study using the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Review checklist. We searched PubMed, EMBASE, SCOPUS, PsycINFO, EconLit, and CINAHL from database inception to 29 August, 2018 for peer-reviewed studies and included a search of the gray literature. Data on study characteristics, study design, and study outcomes were extracted by one reviewer. Twenty-five percent of the studies were verified by a second reviewer. Thirty-four studies, targeting diabetes mellitus, human immunodeficiency virus, and cardiovascular and renal diseases met our inclusion criteria. All but two studies were from the USA. The majority of interventions used financial incentives, often in conjunction with other behavioral economic concepts. Non-financial interventions included framing, social influences, reinforcement, and feedback. The effectiveness of interventions was mixed. Behavioral economic informed interventions show promise in terms of improving medication adherence. However, there is no single simple intervention. This review highlighted the importance of targeting non-adherent patients, understanding their reasons for non-adherence, providing reminders and feedback to patients and physicians, and measuring clinical outcomes in addition to medication adherence. Further research in settings that differ from the US health system is needed.

A Trial of Behavioral Economic Interventions Among Food Pantry Clients

A Trial of Behavioral Economic Interventions Among Food Pantry Clients

80-LB: Effect of a Behavioral Economics Intervention on Adherence and Glycemic Outcomes in Youth with T1D

Despite the availability of the first automated hybrid closed-loop (HCL) system for type 1 diabetes (T1D), many youth do not use the automated feature. This 18-week prospective pilot study evaluates the impact of behavioral economic principles on 670G HCL system use in adolescents and young adults with T1D. Small monetary rewards were given for wearing/calibrating the CGM and using “auto mode.” For each of these tasks, participants received $1/day with a $3/week bonus for sustained use, with the bonus increasing by $5/week for every consecutive week the CGM is worn, up to $13/week. Participants were also rewarded for giving at least 3 meal boluses/day ($1/day), and uploading glycemic data ($5/week). However, if participants failed to perform diabetes tasks, rewards decreased to their original values. Data from 16 participants (16.2±2.5 years, 56% F) were collected at baseline, 6, 12, and 18 weeks. Of those not wearing a CGM at enrollment (88%), 86% had used a CGM previously and chose to discontinue its use. Participants used the CGM on most days, and gave at least 4 meal boluses/day consistently. HbA1c decreased by 0.5% from baseline to 6 weeks and was maintained at 12-18 weeks (p&amp;lt;0.05). In this pilot study of youth starting the 670G HCL system, compensation for diabetes tasks was associated with bolus adherence and improved HbA1c. Though most youth had failed CGM use in the past, CGM wear occurred &amp;gt;70% of time during reinforcement. Disclosure L.M. Nally: None. J. Wagner: None. M.A. Van Name: Research Support; Self; Novo Nordisk Inc. J. Sherr: Advisory Panel; Self; Bigfoot Biomedical, Eli Lilly and Company, Insulet Corporation. Consultant; Self; Lexicon Pharmaceuticals, Inc., Medtronic, Sanofi. Research Support; Self; Dexcom, Inc., Insulet Corporation. K. Zajac: None. J.L. Finnegan: None. W.V. Tamborlane: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Medtronic MiniMed, Inc., Novo Nordisk Inc., Sanofi, Takeda Pharmaceutical Company Limited. Funding National Institutes of Health (1DP3DK097705-01)

Simple Eco-Labels to Nudge Customers Toward the Most Environmentally Friendly Warm Dishes: An Empirical Study in a Cafeteria Setting

Abstract Background: Food production and consumption contributes to one third of households’ environmental impact. The environmental impact of different food categories varies and in general environmental footprint of meat is high than fish and vegetable options. Environmental food labels have been suggested as a means to sway consumption patterns. The purpose of this study is to test if different simple eco-labels in combination with posters can influence consumers to select environmentally friendly food options. Method: Three different labeling systems were tested on warm dishes in a University cafeteria in Oslo, Norway. The first system was traffic-light labels with three symbols (red, yellow and green), the second system was a single-green label that only labelled the environmentally friendliest dishes, and the third system was a single-red label that only labelled the least environmentally friendly option. Posters were placed in the cafeteria, explaining the labeling systems and the climate impact of different food categories. Outcome measures was sales share of meat, fish and vegetarian dishes. The intervention period was separated in two; the first 20 days (period 1) and 22 last days (period 2) to evaluate if the effects of the labels was different when first introduced and after some months. Results: The traffic-light labels significantly reduced sales of meat dishes with 9% in the period 1 (p < 0.1) but not in period 2. Sales share of fish or vegetarian dishes were not impacted. Single-green and single-red labeling had no effect on sales share of meat, fish or vegetarian dishes. Posters were present during all interventions. Conclusion: Findings suggests that traffic-light labels in combination with posters can improve the eco-friendliness of customers food choices in a cafeteria setting, at least short-term. Future studies should investigate the long-term effects of simple eco-labels. Additionally, one should study the combined effect of symbols with other changes in the choice architecture. Key words: Food choices, behavioral economics interventions, nudging, eco-labels, simple-labels, environmental impact

Incentives Versus Defaults: Cost-Effectiveness of Behavioral Approaches for HIV Screening.

Many HIV positive individuals are still undiagnosed, which has led health systems to try many approaches to expand HIV testing. In a randomized controlled trial, we found that behavioral economics interventions (opt-out testing and financial incentives) each improved HIV testing rates and these approaches are being implemented by several hospital systems. However, it is unclear if these strategies are cost-effective. We quantified the cost-effectiveness of different behavioral approaches to HIV screening-opt-out testing, financial incentives, and their combination-in terms of cost per new HIV diagnosis and infections averted. We estimated the incremental number of new HIV diagnoses and program costs using a mathematical screening model, and infections averted using and HIV transmission model. We used a 1-year time horizon and a hospital perspective. Switching from opt-into opt-out results in 39 additional diagnoses (56% increase) after 1-year at a cost of $3807 per new diagnosis. Switching from no incentive to a $1, $5, or $10 incentive adds 14, 13, and 28 new diagnoses (20, 19, and 41% increases) at a cost of $11,050, $17,984, and $15,298 per new diagnosis, respectively. Layering on financial incentives to opt-out testing enhances program effectiveness, though at a greater marginal cost per diagnosis. We found a similar pattern for infections averted. This is one of the first cost-effectiveness analyses of behavioral economics interventions in public health. Changing the choice architecture from opt-into opt-out and giving financial incentives for testing are both cost-effective in terms of detecting HIV and reducing transmission. For hospitals interested in increasing HIV screening rates, changing the choice architecture is an efficient strategy and more efficient than incentives.