Cash Incentives Research Articles

Competing for the benefit of offspring eliminates the gender gap in competitiveness

Recent advances have highlighted the evolutionary significance of female competition, with the sexes pursuing different competitive strategies and women reserving their most intense competitive behaviors for the benefit of offspring. Influential economic experiments using cash incentives, however, have found evidence suggesting that women have a lower desire to compete than men. We hypothesize that the estimated gender differences critically depend on how we elicit them, especially on the incentives used. We test this hypothesis through an experiment with adults in China (n = 358). Data show that, once the incentives are switched from monetary to child-benefitting, gender differences disappear. This result suggests that female competition can be just as intense as male competition given the right goals, indicating important implications for policies designed to promote gender equality.

Factors influencing women's preference for health facility deliveries in Jharkhand state, India: a cross sectional analysis.

BackgroundExpanding institutional deliveries is a policy priority to achieve MDG5. India adopted a policy to encourage facility births through a conditional cash incentive scheme, yet 28 % of deliveries still occur at home. In this context, it is important to understand the care experience of women who have delivered at home, and also at health facilities, analyzing any differences, so that services can be improved to promote facility births. This study aims to understand women’s experience of delivery care during home and facility births, and the factors that influence women’s decisions regarding their next place of delivery.MethodA community-based cross-sectional survey was undertaken in a district of Jharkhand state in India. Interviews with 500 recently delivered women (210 delivered at facility and 290 delivered at home) included socio-demographic characteristics, experience of their recent delivery, and preference of future delivery site. Data analysis included frequencies, binary and multiple logistic regressions.ResultsThere is no major difference in the experience of care between home and facility births, the only difference in care being with regard to pain relief through massage, injection and low cost of delivery for those having home births. 75 % women wanted to deliver their next child at a facility, main reasons being availability of medicine (29.4 %) and perceived health benefits for mother and baby (15 %). Women with higher education (AOR = 1.67, 95 % CI = 1.04–3.07), women who were above 25 years (AOR = 2.14, 95 % CI = 1.26–3.64), who currently delivered at facility (AOR = 5.19, 95 % CI = 2.97–9.08) and had health problem post-delivery (AOR = 1.85, 95 % CI = 1.08–3.19) were significant predictors of future facility-based delivery.ConclusionThe predictors for facility deliveries include, availability of medicines and supplies, potential health benefits for the mother and newborn and the perception of good care from the providers. There is a growing preference for facility delivery particularly among women with higher age group, education, income and those who had antennal checkup. In order to uptake facility births, the quality improvement initiatives should regularly assess and address women’s experiences of care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-0839-6) contains supplementary material, which is available to authorized users.

Encouraging Residential Moves to Opportunity Neighborhoods: An Experiment Testing Incentives Offered to Housing Voucher Recipients

This study tests whether mobility counseling and cash incentives will affect a Housing Choice Voucher (HCV) recipient’s move to an opportunity area. Opportunity areas are defined as tracks rated 6-10 on a HUD-created index—factoring in poverty, housing stability, job and transit access, school quality, and employment. This move from a non-opportunity neighborhood (ranked 1-5) to an opportunity neighborhood (ranked 6-10) is considered an “opportunity move.” When a HCV recipient requests to move to a new housing unit, they must work with their Public Housing Authority (PHA). Briefings provided by PHAs are part of this process. For this study, 2,005 voucher holders who requested to move were randomly selected to receive one of three interventions to test any effect on moves to opportunity areas: 1. A “business-as-usual” briefing covering basic information about moving with a voucher. 2. A “business-as-usual” briefing and the promise of a $500 grant if voucher holders used their voucher in an opportunity area. 3. A mobility counseling briefing and an offer of a $500 grant if voucher holders used their voucher in an opportunity area.

'The money is important but all women anyway go to hospital for childbirth nowadays' - a qualitative exploration of why women participate in a conditional cash transfer program to promote institutional deliveries in Madhya Pradesh, India.

BackgroundIn 2005–06, only 39 % of Indian women delivered in a health facility. Given that deliveries at home increase the risk of maternal mortality, it was in this context in 2005, that the Indian Government implemented the Janani Suraksha Yojana program that incentivizes poor women to give birth in a health facility by providing them with a cash transfer upon discharge. JSY helped raise institutional delivery to 74 % in the eight years since its implementation. Despite the success of the JSY in raising institutional delivery proportions, the large number of beneficiaries (105 million), and the cost of the program, there have been few qualitative studies exploring why women participate (or not) in the program. The objective of this paper was to explore this.MethodsIn March 2013, we conducted 24 individual in-depth interviews with women who delivered within the previous 12 months in two districts of Madhya Pradesh, India. Qualitative framework analysis was used to analyze the data.ResultsOur findings suggest that women’s increased participation in the program reflect a shift in the social norm. Drivers of the shift include social pressure from the Accredited Social Health Activist (ASHA) to deliver in a health facility, and a growing individual perception of the importance for ‘safe’ and ‘easy’ delivery which was most likely an expression of the new social norm. While the incentive was an important influence on many women’s choices, others did not perceive it as an important consideration in their decision to deliver in a health facility. Many women reported procedural difficulties to receive the benefit. Retaining the cash incentive was also an issue due to out-of-pocket expenditures incurred at the facility. Non-participation was often unintentional and caused by personal circumstances, poor geographic access or driven by a perception of poor quality of care provided in program facilities.ConclusionsIn summary, while the cash incentive was important for some women in facilitating an institutional birth, the shift in social norm (possibly in part facilitated by the program) and therefore their own perceptions has played a major role in them giving birth in facilities.

Vote Buying and Tax-cut Promises

Abstract Both vote buying and tax-cut promises are attempts to manipulate voters through cash incentives in order to win elections, but only vote buying is illegal. Should we extend the ban on vote buying to tax-cut promises? This article will argue for three conclusions. The first is that tax-cut promises should be understood as a form of vote buying. The second is that campaign promises are a form of vote buying. The third conclusion is that campaign promises, including tax-cut promises, should not be banned. An important distinction is drawn between enforceable wrongful incentives and unenforceable wrongful incentives. The difference between vote buying and tax-cut promises is not wrongfulness but enforceability.

You can't pay me to quit: the failure of financial incentives for smoking cessation in head and neck cancer patients.

A prospective randomised study was conducted at a tertiary care hospital to evaluate the effects of financial incentives for smoking cessation targeted at a high-risk population. Patients with a past history of head and neck cancer were voluntarily enrolled over a two-year period. They were randomised to a cash incentives or no incentive group. Subjects were offered enrolment in smoking cessation courses. Smoking by-product levels were assessed at 30 days, 3 months and 6 months. Subjects in the incentive group received $150 if smoking cessation was confirmed. Over 2 years, 114 patients with an established diagnosis of head and neck cancer were offered enrolment. Twenty-four enrolled and 14 attended the smoking cessation classes. Only two successfully quit smoking at six months. Both these patients were in the financially incentivised group and received $150 at each test visit. Providing a financial incentive for smoking cessation to a population already carrying a diagnosis of head and neck cancer in order to promote a positive behaviour change was unsuccessful.

Conditional cash transfers and uptake of and retention in prevention of mother-to-child HIV transmission care: a randomised controlled trial

Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. We aimed to determine whether small, increasing cash payments, which were conditional on attendance at scheduled clinic visits and receipt of proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care. In this randomised controlled trial, we recruited newly diagnosed HIV-infected women, who were 32 or less weeks pregnant, from 89 antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned (1:1) them to either the intervention group or the control group using computer-based randomisation with varying block sizes of four, six, and eight. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services (US$5, plus US$1 increment at every subsequent visit), whereas the control group received usual care. Outcomes assessed included retention in care at 6 weeks' post partum and uptake of PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services up to 6 weeks' post partum. Analyses were by intention to treat. This trial is registered with ClinicalTrials.org, number NCT01838005. Between April 18, 2013, and Aug 30, 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomly assigned; 217 to the control group and 216 to the intervention group. At 6 weeks' post partum, 174 participants in the intervention group (81%) and 157 in the control group (72%) were retained in care (risk ratio [RR] 1·11; 95% CI 1·00-1·24). 146 participants in the intervention group (68%) and 116 in the control group (54%) attended all clinic visits and accepted proposed services (RR 1·26; 95% CI 1·08-1·48). Results were similar after adjustment for marital status, age, and education. Among women with newly diagnosed HIV, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation. President's Emergency Plan for AIDS Relief and the National Institute of Health and Child Development.

Effect of a post-paid incentive on response rates to a web-based survey

We randomized half of the sample from two southern California medical centers to a post-paid incentive (n = 1,795) and half to no incentive (n = 1,797) for completing a web-based survey about their experiences with health care. Respondents in the incentive group were given the choice between a $5 cash or Target® e-certificate. The characteristics of respondents in the incentive and control groups was similar on age, education, length of membership in the plan, number of emails sent and visits to the primary care doctor in the 12 months prior to sampling, and their global rating of the doctor; the incentive group had more Asians (8% vs. 5%, χ 2 (1 df) = 7.92, p = 0.005) and fewer Blacks/African Americans (2% vs. 4%, χ 2 (1 df) = 11.0, p =0.001) than the no incentive group. Those randomized to the incentive were significantly more likely to respond to the survey than those in the control group (57% vs. 50%, t (df = 3590) = 4.06, p <0.0001). Item non response rates were similar for those in the incentive and the control groups. Those randomized to the incentive condition who completed the survey were more likely to prefer a cash incentive over the e-certificate (69% of the incentives delivered to web respondents were in the form of cash). The unit cost per incentive was $8.32 for cash and $7.49 for the e-certificate. The results of this experiment indicate that a post-paid incentive can significantly increase the response rate to a web-based survey.

Is Health System Giving Life Year Gain to Children In India?

Background: In developing countries, specifically in India, millions of women and newborns die or experience serious health problems related to pregnancy and childbirth each year and many women do not have the good fortune to be attended by skilled personnel during childbirth. This lack of skilled attendance could be considered as one of the major factors in maternal and infantile mortality. Each year 3.3 million babies or may be even more are stillborn, more than 4 million die within 28 days of coming into the world, and a further 6.6 million young children die before their 5th birthday. From 2006 to 2012 the average complicated neonatal admissions with low birth weight children’s in virudhunagar district were 200. Also the researcher would like to found that how the Comprehensive Emergency Obstetric and New Born Care Centre (CEmONC) service gives opportunity to celebrate their 5th birthday for low birth children born in 2007 and to assess the factors determining the place of delivery and is Health system giving life year gain to Children? Methodology: The present study was undertaken in Virudhunagar District of South Tamil Nadu with primary and secondary data. The Secondary data were collected from all CEmONC Centres under Tamil Nadu Health System Project (TNHSP) and beneficiaries under Muthulakshmi Reddy Maternity Benefit Scheme (MRMBS) in 2007. Due to gives life year gain up to 5 years to children through these schemes. The primary data were collected from 200 who delivered their children with low Birth Weight (LBW) (<2.500 kg) in 2007. There are nine Public Hospitals in Virudhunagar district, namely Virudhunagar, Aruppukottai, Tiruchuli, Kariapatti, Rajapalayam, Watrap, Srivilliputtur, Sattur and Sivakasi and for the present study, Virudhunagar, Aruppukottai, Rajapalayam, Srivilliputtur, Sattur and Sivakasi government hospitals were selected as only these hospital have CEmONC services. Results: A sample of 40 (20%) attended Antenatal care (ANC) for previous pregnancy, 120 (60%) had their last delivery in private hospitals, while 80 (40%) had their last delivery at Government Hospital. Determinants of choice of delivery place include free cost of treatment (100%), friendly attitude of community health workers (75%), and good care of doctors, nurses and village health nurses (90%), distance to health care centers (80%), and cash incentive (100%). There is significant differences between age (P 0.001). There is a significant difference between consumption of Iron and Folic Acid (IFA) tablets and Low Birth Weight (LBW) in the study areas (P<0.001). There is a significant difference between mother age at birth and LBW (P<0.001). There is a significant difference between birth interval and LBW (P<0.001). There is a significant difference between income of the respondents and postnatal care (P<0.001). There were 196 children got life year gain above five year through the TNHSP and MRMBS. Lack of care and money is one of the reasons for less than five deaths in the study areas. Conclusion: Female education, female empowerment, attitude of health care workers and distance of health facilities to the people in most communities are factors to be addressed in reducing child morbidity and mortality rates and improving maternal health, thus achieving the Millennium Development Goals (MDGs) 4 and 5. To get this done, policy makers, health personal and community at large should join hands.

A study on utilization of Janani Suraksha Yojana and its association with institutional delivery in the state of West Bengal, India.

India launched the Janani Suraksha Yojana (JSY) on the principles of conditional cash transfer providing monetary incentive to needy women to improve access to institutional childbirth. This study was conducted among JSY-eligible women who delivered between April 2012 and June 2012 to assess the utilization of cash incentives toward institutional delivery, along with other associated factors influencing institutional delivery. It was a cross-sectional, descriptive study conducted between July 2012 and May 2013 on 946 women selected through stratified random sampling of subcentres from better and worse performing districts of West Bengal. 74.7% of the study population was JSY-eligible. 90.2% of those who took three antenatal check-ups (ANCs) and 36.8% JSY-noneligible women received cash. Government institutions were preferred for childbirth among all groups irrespective of JSY eligibility, receipt of cash, and number of antenatal visits. Overall, 78.8% opted for institutional delivery if they had received cash, which was significantly more than those who did not (64.5%). JSY-eligible women were 1.5 times more likely to deliver in government institutions compared to JSY-noneligible women. With no incentive, the likelihood of institutional delivery was halved. The distance of a 24 Χ 7 delivery hub beyond 5 km (74.8% vs. 81.8%), the religion of Islam (62.7% vs. 83.2%), and multiparity (63.9% vs. 83.6%) were significant deterring factors. Despite some inclusion and exclusion errors, cash incentive under JSY was associated with increased institutional delivery, especially in government institutions though there were other factors influencing the decision as well.

Social determinants of motivation to lose weight among literate obese patients: A qualitative study

Background: The study of motivation is central to understanding and identifying patients who are likely to benefit from obesity interventions. Previous studies have demonstrated the efficacy of an outpatient counselling technique in improving motivation to change among literate obese patients. The reasons for this demonstrated efficacy needs to be explored to guide policy and practice of obesity interventions. Methods: A total of 18 obese individuals were recruited by purposive sampling into three groups of six individuals each matched for Readiness to Change (RTC) group based on URICA Score, age group and gender. Focus group discussions using open-ended questions to elucidate which factors could potentially be correlated with participants’ motivation, were moderated between July and October 2012. Data was recorded manually and with an MP3 recorder. Thematic analysis was used to generate themes and a derived model in January 2013. Results: The key themes generated from the focus group discussion include: Pressure from family, friends and society; Dressing, stigmatization and self-esteem; Recognition of risk factors for diseases; Counselling by the physician: Economic factors: and having a weight loss programme in the hospital. Conclusion: Mixed extrinsic and intrinsic factors play a role in motivation to lose weight among literate obese patients in a primary care setting. Extrinsic factors (peer, family and societal pressure; cash incentives; counselling by physician; and hospital weight loss programme) were however predominant. These findings have implications for clinicians involved in weight management programmes, and policy makers seeking public health interventions for obesity prevention need to consider interventions targeted on extrinsic motivations.

Vote Buying and Tax-cut Promises

Both vote buying and tax-cut promises are attempts to manipulate voters through cash incentives in order to win elections, but only vote buying is illegal. Should we extend the ban on vote buying to tax-cut promises? This article will argue for three conclusions. The first is that tax-cut promises should be understood as a form of vote buying. The second is that campaign promises are a form of vote buying. The third conclusion is that campaign promises, including tax-cut promises, should not be banned. An important distinction is drawn between enforceable wrongful incentives and unenforceable wrongful incentives. The difference between vote buying and tax-cut promises is not wrongfulness but enforceability.

The Safe Delivery Incentive Program in Nepal: towards women's empowerment

Background: Providing equal opportunities for the newborn to survive requires a comprehensive approach. One of the approaches to provide equal opportunities for the new born is by promoting birth at the institutions. Nepal faces its unique challenges for meeting the public health goals. While some of the most common barriers toward safe delivery are related to access, cultural practices, lack of healthcare human resource, and inadequate healthcare financing. The government of Nepal in 2005 has initiated an incentive scheme, for the women to deliver at the health facility and to the provider for each delivery attended. Objective: To assess the perspectives of the beneficiaries of Safe Delivery Incentive Program on the domains of benefits, difficulties, use of the cash incentive, and any recommended changes in the program. Materials and Methods: This study utilizes a qualitative methodology by the use of in-depth interviews to learn about the perception of women about the scheme. Thirty in-depth interviews were conducted with the beneficiaries in randomly selected three wards in Khandbari Municipality. Manual qualitative data analysis was carried out using open coding and axial coding techniques according to Grounded Theory approach to derive a conceptual framework eliciting the perceptions. Result: Beneficiaries in this study perceive this program as beneficial but not adequate to address the economic burden of childbirth to poor families and to those who are living in the distant health facilities. They find difficulty in availing the scheme in terms of delay in getting money and lack of proper information about the program. Decision-making was mainly by husband and pattern of utilization hugely deviated from the intended purpose (i.e., transportation). They also suggest providing the incentive beforehand and relaxing the clause of ANC as a part of the incentive. Empowerment, both financial and awareness based, emerged as a dominant theme that the women perceived as a benefit of the program. Conclusion: The findings of the study mention cash transfer mechanism in the program has significantly empowered women. This model for women’s empowerment in developing countries should be explored in greater depth.

A Descriptive Study to Assess The Knowledge Among The Antenatal Mothers Regarding Janani Suraksha Yojana In A Selected Hospital of Bhopal, Madhya Pradesh

Background : Janani Suraksha Yojana (JSY) -a new maternity benefit scheme - was launched by Govt. of India in April 2005 with the objective of reducing maternal and neonatal mortality by promoting institutional deliveries by providing cash incentive to beneficiaries. Each year in India, roughly 30 million women experience pregnancy and 27 million have a live birth. Of these, an estimated 1, 36,000 maternal deaths and one million new born deaths occur each year, thus pregnancy-related mortality and morbidity continues to take a huge toll on the lives of Indian women and their new born. Materials and Methods : A non experimental descriptive study was conducted. A total of 60 ANC registered were interviewed using pre designed questionnaire. Results : Majority 34 (55.66%) of antenatal mothers had moderate knowledge regarding Janani Suraksha Yojana, 17 (28.34%) had inadequate knowledge and only 9 (15%) had adequate knowledge regarding JSY. The mean for overall knowledge of antenatal mothers was 15.6 (S.D= 3.4). Conclusion : There is inadequate knowledge regarding JSY among antenatal mothers especially regarding the money packages.

An Appraisal of Janani Suraksha Yojna (JSY) Assisted Under NRHM Programme in Tamil Nadu State-South India: Some Preliminary Observations

This study is based on the preliminary results obtained from the ongoing evaluation study on Janani Suraksha Yojna (JSY) in Tamil Nadu state of South India. Towards achieving the objectives of the National Rural Health Mission (NRHM), Janani Suraksha Yojana was launched in April 2005 to promote institutional and safe baby deliveries among the poor population, through provisions for cash incentives, free referral, free transport, and free escort services. This scheme also intends to reduce the infant and maternal mortality rate in the country. A cross-sectional community based survey is being done in the selected districts of Tamil Nadu state. As a first phase of the study, socio-demographic factors, antenatal services availed, and stake holder’s opinions have been studied. For the time being, this study has found that there is a strong requirement to create more awareness among rural population about the utilization of this JSY scheme. Stake holders should also take proper geographical specific action plans for the rapid implementation process. Also they must target the remote areas, SC/ST population, and special measures are required to encourage more antenatal visits which is a vital prerequisite to get better impact out of JSY scheme.

Evaluation of availability and utilization of obstetric care services and entitlements under Janani Suraksha Yojana in Mysore, India

Background: To reduce maternal and infant deaths due to preventable causes by promoting institutional delivery, conditional cash transfer scheme, Janani Suraksha Yojana (JSY) program was launched in India. The aim of the study was to assess the availability and utilization of obstetric care services and monetary benefits under the scheme by pregnant women, completeness of services and timeliness of sanction of cash incentives and its effect on institutional deliveries in the study area. Design of the study was community based cross- sectional survey. Methods: Mixed method research done in four Primary Health Centre (PHC)s selected by stratified random sampling method using survey and Focussed Group Discussion methods. Statistical analysis was univariate and bivariate analysis using SPSS. Results: Among 510 mothers interviewed, registration of pregnancies was 100% and 99.6% mothers had more than three ANC check ups. Institutional delivery rate was 98.8%. Among the 484 scheme eligible, 385 (79.5%) had got JSY money. Reason for not getting the money were, lack of documents, bank accounts, not linking UID (Aadhar) number to the bank account and delay was due to shortage of funds in the PHC. Conclusions: CPSMS was the major method of disbursement (65%). Most of the mothers got money after three to four months delay. 63% of the study participants in the study area had got full range of obstetric care services recommended through JSY.

Incentives for increasing prenatal care use by women in order to improve maternal and neonatal outcomes.

Incentives for increasing prenatal care use by women in order to improve maternal and neonatal outcomes.

The unintended effects of cash transfers on fertility: evidence from the Safe Motherhood Scheme in India

India launched the Safe Motherhood Scheme (Janani Suraksha Yojana or JSY) in 2005 in response to persistently high maternal and child mortality rates. JSY provides a cash incentive to socioeconomically disadvantaged women for childbirth at health facilities. This study explores some unintended consequences of JSY. Using data from two large household surveys, we examine a policy variation that exploits the differential incentive structure under JSY across states and population subgroups. We find that JSY may have resulted in a 2.5–3.5 percentage point rise in the probability of childbirth or pregnancy over a 3-year period in states already experiencing high population growth.

Assessment of the Health in Pregnancy Grant policy in Scotland: a natural experiment

BackgroundInterventions during pregnancy and the early years aim to improve infant and child outcomes. In the UK, the Health in Pregnancy (HiP) Grant was introduced in April, 2009, and withdrawn in April, 2011. It was a universal unconditional cash transfer of £190 designed to provide additional financial support in the third trimester. This cash transfer was an incentive for expectant mothers to seek timely health advice from a professional. The present study aimed to assess the effectiveness of the HiP Grant in Scotland: did mothers who received HiP have babies with a different birthweight and have different health behaviours compared with mothers who did not receive HiP? MethodsThe HiP Grant was assessed as a natural experiment to compare outcomes before its introduction (preintervention) and immediately after its withdrawal (postintervention) with those during the intervention period. Routinely collected data on all singleton births in Scotland between Jan 1, 2004, and Dec 31, 2013, at 26–44 weeks’ gestation were used. The outcomes we report on are birthweight, contacting a midwife before 25 weeks of pregnancy, and smoking during pregnancy. Interrupted time-series models were fitted to the individual data, allowing for varying time trends and adjusting for maternal and birth characteristics. A-priori subgroup analyses were conducted for groups most likely to benefit from the intervention including nulliparous women and women from the most deprived areas. Findings272 935 babies were born in the preintervention period, 109 775 in the intervention period, and 144 663 in the postintervention period. Compared with the preintervention period, birthweight remained unchanged in the intervention period (–2·9 g, 95% CI −7·1 to 1·4) and decreased slightly post intervention (–7·9, −14·0 to −1·8). During the intervention period, more women booked before 25 weeks’ (odds ratio 1·17, 95% CI 1·10 to 1·24) whereas smoking was unchanged (0·99, 0·96 to 1·02). Results for subgroup analyses showed broadly similar results. InterpretationThe size of the payment and the null effect on birthweight might indicate that birthweight was an ambitious primary outcome. The positive effects on early booking demonstrate that a cash incentive might help to modify behaviour. These results can inform other policies aiming to change behaviour. FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research Board (PHRB) (project number 12/3070/02). RD, SO, and AL are funded by the Medical Research Council (_UU_12017/5) and the Chief Scientist Office of the Scottish Government Health Directorates (SPHSU2).

Incentives and enablers to improve adherence in tuberculosis.

BackgroundPatient adherence to medications, particularly for conditions requiring prolonged treatment such as tuberculosis (TB), is frequently less than ideal and can result in poor treatment outcomes. Material incentives to reward good behaviour and enablers to remove economic barriers to accessing care are sometimes given in the form of cash, vouchers, or food to improve adherence.ObjectivesTo evaluate the effects of material incentives and enablers in patients undergoing diagnostic testing, or receiving prophylactic or curative therapy, for TB.Search methodsWe undertook a comprehensive search of the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; Science Citation Index; and reference lists of relevant publications up to 5 June 2015.Selection criteriaRandomized controlled trials of material incentives in patients being investigated for TB, or on treatment for latent or active TB.Data collection and analysisAt least two review authors independently screened and selected studies, extracted data, and assessed the risk of bias in the included trials. We compared the effects of interventions using risk ratios (RR), and presented RRs with 95% confidence intervals (CI). The quality of the evidence was assessed using GRADE.Main resultsWe identified 12 eligible trials. Ten were conducted in the USA: in adolescents (one trial), in injection drug or cocaine users (four trials), in homeless adults (three trials), and in prisoners (two trials). The remaining two trials, in general adult populations, were conducted in Timor‐Leste and South Africa.Sustained incentive programmesOnly two trials have assessed whether material incentives and enablers can improve long‐term adherence and completion of treatment for active TB, and neither demonstrated a clear benefit (RR 1.04, 95% CI 0.97 to 1.14; two trials, 4356 participants; low quality evidence). In one trial, the incentive, given as a daily hot meal, was not well received by the population due to the inconvenience of attending the clinic at midday, whilst in the other trial, nurses distributing the vouchers chose to "ration" their distribution among eligible patients, giving only to those whom they felt were most deprived.Three trials assessed the effects of material incentives and enablers on completion of TB prophylaxis with mixed results (low quality evidence). A large effect was seen with regular cash incentives given to drug users at each clinic visit in a setting with extremely low treatment completion in the control group (treatment completion 52.8% intervention versus 3.6% control; RR 14.53, 95% CI 3.64 to 57.98; one trial, 108 participants), but no effects were seen in one trial assessing a cash incentive for recently released prisoners (373 participants), or another trial assessing material incentives offered by parents to teenagers (388 participants).Single once‐only incentivesHowever in specific populations, such as recently released prisoners, drug users, and the homeless, trials show that material incentives probably do improve one‐off clinic re‐attendance for initiation or continuation of anti‐TB prophylaxis (RR 1.58, 95% CI 1.27 to 1.96; three trials, 595 participants; moderate quality evidence), and may increase the return rate for reading of tuberculin skin test results (RR 2.16, 95% CI 1.41 to 3.29; two trials, 1371 participants; low quality evidence).Comparison of different types of incentivesSingle trials in specific sub‐populations suggest that an immediate cash incentive may be more effective than delaying the incentive until completion of treatment (RR 1.11, 95% CI 0.98 to 1.24; one trial, 300 participants; low quality evidence), cash incentives may be more effective than non‐cash incentives (completion of TB prophylaxis: RR 1.26, 95% CI 1.02 to 1.56; one trial, 141 participants; low quality evidence; return for skin test reading: RR 1.13, 95% CI 1.07 to 1.19; one trial, 652 participants; low quality evidence); and higher cash incentives may be more effective than lower cash incentives (RR 1.08, 95% CI 1.01 to 1.16; one trial, 404 participants; low quality evidence).Authors' conclusionsMaterial incentives and enablers may have some positive short term effects on clinic attendance, particularly for marginal populations such as drug users, recently released prisoners, and the homeless, but there is currently insufficient evidence to know if they can improve long term adherence to TB treatment.8 May 2019Update pendingStudies awaiting assessmentThe CIDG is currently examining a new search conducted up to 19 Jul, 2018 for potentially relevant studies. These studies have not yet been incorporated into this Cochrane Review.