Incentive-based Interventions Research Articles

Financial Incentives for Smoking Cessation Among Socioeconomically Disadvantaged Adults

Socioeconomically disadvantaged individuals (ie, those with low socioeconomic status [SES]) have difficulty quitting smoking and may benefit from incentive-based cessation interventions. To evaluate the impact of incentivizing smoking abstinence on smoking cessation among adults with low SES. This study used a 2-group randomized clinical trial design. Data collection occurred between January 30, 2017, and February 7, 2022. Participants included adults with low SES who were willing to undergo smoking cessation treatment. Data were analyzed from April 18, 2023, to April 19, 2024. Participants were randomized to usual care (UC) for smoking cessation (counseling plus pharmacotherapy) or UC plus abstinence-contingent financial incentives (UC plus FI). The primary outcome was biochemically verified 7-day point prevalence smoking abstinence (PPA) at 26 weeks after the quit date. Secondary outcomes included biochemically verified 7-day PPA at earlier follow-ups, 30-day PPA at 12 and 26 weeks, repeated 7-day PPA, and continuous abstinence. Multiple approaches were employed to handle missing outcomes at follow-up, including categorizing missing data as smoking (primary), complete case analysis, and multiple imputation. The 320 participants had a mean (SD) age of 48.9 (11.6) and were predominantly female (202 [63.1%]); 82 (25.6%) were Black, 15 (4.7%) were Hispanic, and 200 (62.5%) were White; and 146 (45.6%) participated during the COVID-19 pandemic. Overall, 161 were randomized to UC and 159 were randomized to UC plus FI. After covariate adjustment with missing data treated as smoking, assignment to UC plus FI was associated with a greater likelihood of 7-day PPA at the 4-week (adjusted odds ratio [AOR], 3.11 [95% CI, 1.81-5.34]), 8-week (AOR, 2.93 [95% CI, 1.62-5.31]), and 12-week (AOR, 3.18 [95% CI, 1.70-5.95]) follow-ups, but not at the 26-week follow-up (22 [13.8%] vs 14 [8.7%] abstinent; AOR, 1.79 [95% CI, 0.85-3.80]). However, the association of group assignment with smoking cessation reached statistical significance at all follow-ups, including 26 weeks, with multiple imputation (37.37 [23.5%] in the UC plus FI group vs 19.48 [12.1%] in the UC group were abstinent; AOR, 2.29 [95% CI, 1.14-4.63]). Repeated-measures analyses indicated that participants in the UC plus FI group were significantly more likely to achieve PPA across assessments through 26 weeks with all missing data estimation methods. Other secondary cessation outcomes also showed comparable patterns across estimation methods. Participants earned a mean (SD) of $72 ($90) (of $250 possible) in abstinence-contingent incentives. Participation during the COVID-19 pandemic reduced the likelihood of cessation across assessments. In this randomized clinical trial, incentivizing smoking cessation did not increase cessation at 26 weeks when missing data were treated as smoking; however, the UC plus FI group had greater odds of quitting at follow-ups through 12 weeks. Cessation rates were higher for the UC plus FI group at all follow-ups through 26 weeks when multiple imputation was used to estimate missing outcomes. ClinicalTrials.gov Identifier: NCT02737566.

Cost-effectiveness of incentives for physical activity in coronary heart disease in Germany: pre-trial health economic model of a complex intervention following the new MRC framework

ObjectivesThe German Incentives for Physical Activity in Cardiac Patients trial is a three-arm, randomised controlled trial for secondary prevention of coronary heart disease (CHD). Guidance for developing complex interventions recommends...

Participant perspectives on incentives for TB preventative therapy adherence and reduced alcohol use: A qualitative study.

Economic incentives to promote health behavior change are highly efficacious for substance use disorders as well as increased medication adherence. Knowledge about participants' experiences with and perceptions of incentives is needed to understand their mechanisms of action and optimize future incentive-based interventions. The Drinkers' Intervention to Prevent Tuberculosis (DIPT) trial enrolled people with HIV (PWH) in Uganda with latent tuberculosis and unhealthy alcohol use in a 2x2 factorial trial that incentivized recent alcohol abstinence and isoniazid (INH) adherence on monthly urine testing while on INH preventive therapy. We interviewed 32 DIPT study participants across trial arms to explore their perspectives on this intervention. Participants described 1) satisfaction with incentives of sufficient size that allowed them to purchase items that improved their quality of life, 2) multiple ways in which incentives were motivating, from gamification of "winning" through support of pre-existing desire to improve health to suggesting variable effects of extrinsic and intrinsic motivation, and 3) finding value in learning results of increased clinical monitoring. To build effective incentive programs to support both reduced substance use and increased antimicrobial adherence, we recommend carefully selecting incentive magnitude as well as harnessing both intrinsic motivation to improve health and extrinsic reward of target behavior. In addition to these participant-described strengths, incorporating results of clinical monitoring related to the incentive program that provide participants more information about their health may also contribute to health-related empowerment.

Education, incentive, and engineering-based interventions to promote the use of seat belts.

Education, incentive, and engineering-based interventions to promote the use of seat belts.

Participation, anticipation effects and impact perceptions of two collective incentive-based conservation interventions in Ucayali, Peru

This study contributes to the relatively scarce literature evaluating household-level outcomes of collective agreements. We examine participation in and anticipation effects of two collective, incentive-based initiatives in Ucayali, Peru. The first initiative is a local REDD+ project, the second is Peru's National Forest Conservation Program (NFCP). Both initiatives were evaluated at an early stage of implementation, thus any effects are characterized as anticipation effects. We first examine the determinants of participation in the initiatives and find that household participation is negatively associated with agricultural income and positively associated with market access and previous experiences with external initiatives. Next, we use quasi-experimental methods and self-reflexive evaluations to examine impacts on land use and livelihoods. The results show no evidence of anticipation effects on income or land use. Self-reflexive evaluations indicate, however, that a total of 82% of the NFCP participating households perceive a positive effect on wellbeing, while only 39% of participants in REDD+ perceive a positive effect. The differences in perceptions of the two initiatives is attributed to design and implementation factors, including delayed payments, lack of transparency, and limited local input. The study demonstrates the value of self-reflexive evaluations for identifying intangible effects on wellbeing of conservation initiatives.

National Institute on Drug Abuse (NIDA) research priorities to support the development of incentive-based treatments for substance use disorders

The purpose of this commentary is to highlight current research priorities of National Institute on Drug Abuse (NIDA) Division of Therapeutics and Medical Consequences (DTMC) regarding the development and testing of incentive-based interventions for the treatment of substance use disorders (SUDs). This manuscript summarizes the NIH Stage Model for behavioral intervention development, briefly reviews existing research on incentive-based treatments for SUDs that falls within the scope of DTMC at NIDA and highlights the development of digital therapeutics-based incentive interventions as an exemplar and high priority area. We briefly review how digital therapeutics approaches may address some common limitations to dissemination of incentive-based interventions and highlight opportunities for integrating incentive-based approaches into pharmacotherapy efficacy trials. Finally, we mention several related funding opportunities for researchers interested in developing incentive-based approaches for SUD treatment. The overall goal of this commentary is to inform the research community of current NIDA priority areas for intervention development and funding.

Loss-Framed Adaptive Microcontingency Management for Preventing Prolonged Sedentariness: Development and Feasibility Study.

A growing body of evidence shows that financial incentives can effectively reinforce individuals' positive behavior change and improve compliance with health intervention programs. A critical factor in the design of incentive-based interventions is to set a proper incentive magnitude. However, it is highly challenging to determine such magnitudes as the effects of incentive magnitude depend on personal attitudes and contexts. This study aimed to illustrate loss-framed adaptive microcontingency management (L-AMCM) and the lessons learned from a feasibility study. L-AMCM discourages an individual's adverse health behaviors by deducting particular expenses from a regularly assigned budget, where expenses are adaptively estimated based on the individual's previous responses to varying expenses and contexts. We developed a mobile health intervention app for preventing prolonged sedentary lifestyles. This app delivered a behavioral mission (ie, suggesting taking an active break for a while) with an incentive bid when 50 minutes of uninterrupted sedentary behavior happened. Participants were assigned to either the fixed (ie, deducting the monotonous expense for each mission failure) or adaptive (ie, deducting varying expenses estimated by the L-AMCM for each mission failure) incentive group. The intervention lasted 3 weeks. We recruited 41 participants (n=15, 37% women; fixed incentive group: n=20, 49% of participants; adaptive incentive group: n=21, 51% of participants) whose mean age was 24.0 (SD 3.8; range 19-34) years. Mission success rates did not show statistically significant differences by group (P=.54; fixed incentive group mean 0.66, SD 0.24; adaptive incentive group mean 0.61, SD 0.22). The follow-up analysis of the adaptive incentive group revealed that the influence of incentive magnitudes on mission success was not statistically significant (P=.18; odds ratio 0.98, 95% CI 0.95-1.01). On the basis of the qualitative interviews, such results were possibly because the participants had sufficient intrinsic motivation and less sensitivity to incentive magnitudes. Although our L-AMCM did not significantly affect users' mission success rate, this study configures a pioneering work toward adaptively estimating incentives by considering user behaviors and contexts through leveraging mobile sensing and machine learning. We hope that this study inspires researchers to develop incentive-based interventions.

Reminders Work, but for Whom? Evidence from New York City Parking Ticket Recipients

We investigate heterogeneity in responsiveness to reminder letters among New York City parking ticket recipients. Using variation in the timing of letters, we find a strong aggregate response. But we find large differences across individuals: those with a low baseline propensity to respond to tickets—a natural nudge target—react least to letters. These low-response types, who incur significant late penalties, disproportionately come from already disadvantaged groups. They do react strongly to traditional, incentive-based interventions. We discuss how accounting for response heterogeneity might change one’s approach to policy and how one might use our analysis to target interventions at low-response types. (JEL D04, D12, D91, H71)

The feasibility, acceptability, and initial efficacy of a remotely delivered, financial-incentive intervention to initiate vaping abstinence in young adults.

Electronic cigarette use (i.e., vaping) has become increasingly popular, especially among youth. Although vaping nicotine is thought to be safer than smoking combustible cigarettes, vaping cessation has become a topic of interest because of health concerns and the potential risk of electronic cigarette use leading to the use of other substances. The current study is the first to explore the feasibility, acceptability, and preliminary efficacy of a remotely delivered intervention using financial incentives to reinforce vaping abstinence among young adults. A secondary purpose of the study was to compare two cotinine measures, NicAlert and Alere iScreen, for remotely monitoring vaping abstinence. Using a single-case design, college students (N = 8) were given NicAlert and iScreen saliva cotinine tests to verify vaping abstinence. During a baseline condition, financial incentives were delivered contingent on submitting cotinine samples during live telemedicine calls (across varying baseline durations, consistent with multiple-baseline designs), whereas during an abstinence condition, escalating financial bonuses were delivered contingent on negative cotinine samples only. All participants attended 100% of their scheduled telemedicine calls and all participants quit vaping nicotine during the 2-week intervention, following the introduction of abstinence-contingent bonuses. Participants also rated the intervention favorably on a number of dimensions. Participants liked the iScreen cotinine tests, and found them easier to use, than NicAlert. Future research should focus on exploring strategies for promoting long-term sustainability of incentive-based interventions for vaping abstinence. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Improving COVID-19 Vaccine Uptake among Black Populations: A Systematic Review of Strategies.

Given the growing body of evidence on COVID-19 vaccine hesitancy among Black populations, the aim of this systematic review was to identify the interventions and strategies used to improve COVID-19 vaccine confidence and uptake among Black populations globally. To identify relevant studies, we conducted a systematic review of the literature based on a systematic search of 10 electronic databases: MEDLINE, Embase, PsycINFO, CINAHL, Scopus, Cochrane Library, Web of Science, Sociological s, Dissertations and Theses Global, and SocINDEX. We screened a total of 1728 records and included 14 peer-reviewed interventional studies that were conducted to address COVID-19 vaccine hesitancy among Black populations. A critical appraisal of the included studies was performed using the Newcastle-Ottawa Quality Assessment Scale. The intervention strategies for increasing COVID-19 vaccine uptake were synthesized into three major categories: communication and information-based interventions, mandate-based interventions, and incentive-based interventions. Interventions that incorporated communication, community engagement, and culturally inclusive resources significantly improved vaccine uptake among Black populations, while incentive- and mandate-based interventions had less impact. Overall, this systematic review revealed that consideration of the sociocultural, historical, and political contexts of Black populations is important, but tailored interventions that integrate culture-affirming strategies are more likely to decrease COVID-19 vaccine hesitancy and increase uptake among Black populations.

Determinants of Intention to Consume Dibiterie Meat towards the Risks of Non-Communicable Diseases in the Dakar Region, Senegal

The general opinion and current scientific evidence highlight the link between red meat consumption and the development of non-communicable diseases (NCDs). We explored the determinants of the intention to consume red meat in relation to the risks of developing NCDs in Senegal with a special focus on popular “dibiterie” meat (braised meat) consumed in Dakar, Senegal. Building on the theory of planned behaviour as a theoretical framework, we used a structured questionnaire to collect data on the knowledge of consumers regarding the risk of NCDs from consuming meat. The survey involved 478 people randomly selected from households in the Dakar region. Data collected was analysed by performing the calculation of the dibiterie meat quantities consumed and frequencies of consumption, analyses of the principal components, binary logistic regression, and multiple hierarchical regression. Results show that dibiterie meat is mainly a dietary supplement for the population. The convenience, the social pressure, and quality indicators such as producer expertise and health perceived a link between meat consumption and NCDs; gender and age predicted the intention to consume dibiterie meat in the households of the Dakar region. This study provides a theoretical basis for the development of incentive-based interventions aiming to promote a balanced diet and healthy eating habits. Nutrition education and the use of social media have been raised as important in risky meat consumption behaviour change.

Investigating the cost-effectiveness of three cessation interventions on a national scale using the Economics of Smoking in Pregnancy (ESIP) decision analytical model.

To measure the cost-effectiveness of adding text message (TMB), exercise (EB) and abstinent-contingent financial incentive-based (CFIB) stop smoking interventions to standard smoking cessation support for pregnant women in England. Modelling cost-effectiveness outcomes by separately adding three cessation interventions to standard cessation care offered to pregnant women in England. English National Health Service Stop Smoking Services (NHS SSS) statistics from 2019 to 2020 were used for estimating the base quit rate. Intervention effectiveness and cost data for interventions were taken from trial reports. Cost-effectiveness was derived using the economics of smoking in pregnancy (ESIP) model from a health service and personal social services perspective. Interventions were compared with each other as well as against standard cessation care. English NHS SSS. A total of 13 799 pregnant women who accessed NHS SSS. Interventions and comparator; comparator: standard stop smoking support comprising behavioural intervention and an offer of nicotine replacement therapy (NRT). Three additive interventions were TMB, EB and CFIB. Incremental cost-effectiveness ratios per quality-adjusted life-years gained for both mothers and offspring over their life-times; return on investment (ROI); and cost-effectiveness acceptability curves (CEACs). The addition of any of the interventions compared with standard care alone was preferred, but only significant for the addition of CFIB, with the CEAC suggesting an at least 90% chance of being favoured to standard care alone. When compared against each other CFIB appeared to yield the largest returns, but this was not significant. The estimated ROI for CFIB was £2 [95% confidence interval (CI) = £1-3] in health-care savings for every £1 spent by the NHS on the cessation intervention. For a health system which currently provides behavioural support and an offer of nicotine replacement therapy as standard stop smoking support for pregnant women, the greatest economic gains would be provided by operating an abstinent-contingent financial incentives scheme alongside this.

Participation, Anticipation Effects and Impact Perceptions of Two Collective Incentive-Based Conservation Interventions in Ucayali, Peru

Participation, Anticipation Effects and Impact Perceptions of Two Collective Incentive-Based Conservation Interventions in Ucayali, Peru

Increasing the Impact of Interventions Incentivizing Psychiatric Treatment Engagement: Challenges and Opportunities.

Individuals with psychiatric disorders often struggle to initiate and engage in treatment. Financial incentives improve treatment engagement, including treatment attendance, medication adherence, and abstinence from substance use. The U.S. Department of Veterans Affairs (VA) recently made the first large-scale, successful effort to implement incentive-based interventions in substance use disorder treatment. Health care systems, including the VA, can increase the impact of these interventions by extending them to target a range of psychiatric disorders, adapting them for specific clinical contexts, using insights from behavioral economics, and partnering with corporations to fund incentives and implement interventions.

Individuals’ preference for financial over social incentives for medication adherence

BackgroundPatients with chronic conditions continue to face financial and system-related barriers to medication adherence. Pharmacy, provider, and payer-based financial and social incentive-based interventions may reduce these barriers and improve adherence. However, it is unclear how patient demographics and clinical characteristics influence the type of incentives preferred by patients. ObjectivesTo examine individuals’ preference for financial versus social incentives and to explore the association between patient demographic and clinical characteristics with preferences for financial or social incentives. MethodsA cross-sectional survey of a nationally representative sample of patients was conducted with Qualtrics panelists (N = 909). U.S. adults taking at least 1 prescription medication for a chronic condition were included. Survey items elicited participants’ demographic characteristics, preference for financial or social incentives, self-reported medication adherence, number of prescribed medications, and number of chronic conditions. Bivariate associations between patient characteristics and incentive preferences were tested using t and chi-square tests. Logistic regression was performed to determine patient characteristics associated with participants’ preference for incentives. ResultsWhen compared with those who were adherent to medications, individuals who were nonadherent were less likely to prefer financial incentives over social incentives (adjusted odds ratio [OR] 0.55 [95% CI 0.31–0.98]). Patient income, sex, and ethnicity were also associated with preferences for financial incentives. Those earning less than $50,000 per year were less likely to prefer financial incentives compared with social incentives (adjusted OR 0.44 [0.24–0.79]). Females were more likely to prefer financial incentives (adjusted OR 1.98 [1.16–3.37]). Hispanic/Latinos were less likely to prefer financial incentives compared to non-Hispanics/non-Latinos (adjusted OR 0.51 [0.29–0.89]). ConclusionPreferences for medication adherence incentives differed on the basis of adherence status and patients’ demographic characteristics. Findings have implications for how incentive-based interventions can be structured to target certain patient groups.

A Randomized Controlled Trial Evaluating the FIT Game's Efficacy in Increasing Fruit and Vegetable Consumption.

Few children eat the recommended amounts of fruits and vegetables (FV). Although incentive-based interventions can increase FV consumption, this approach is costly and may be viewed as controversial due to the possible negative effects on intrinsic motivation. The FIT Game was designed to address these challenges. Four elementary schools were randomly assigned to either cooperatively play the FIT Game (n = 881) for ~8 weeks or to a no-game Control condition (n = 978). The FIT Game was presented daily as comic-book formatted episodes projected onto a large screen in the school cafeteria throughout lunchtime. All children could see the episodes which communicated daily whole-school vegetable-eating goals and illustrated the progress of the game’s heroes when these goals were collectively met. Photo estimates of FV consumption and skin carotenoid concentrations (biomarker of carotenoid consumption) were collected at baseline, during the last 5 days of the FIT Game, and 3 months after the intervention concluded. Control schools followed the same FV consumption-monitoring procedures for the same duration. At the conclusion of the intervention phase, children attending the FIT Game schools consumed more vegetables (d = 0.41), more fruit (d = 0.39), and had higher skin carotenoids (d = 0.66) than at baseline. These statistically significant increases were maintained at a 3-month follow-up for vegetables (d = 0.21, the food targeted for change) and carotenoids (d = 0.53). Thus, the no-cost virtual incentives of the FIT Game increased FV consumption in the short- and long-run, without negatively impacting intrinsic motivation.

Three accounts of intrinsic motivation in economics: a pragmatic choice?

ABSTRACT This paper argues that the concept of intrinsic motivation has been used by economists in inconsistent ways because the underlying theories of intrinsic motivation, imported into economics from psychology, are competing and mutually exclusive despite employing the same terminology. I first identify and analyze three distinct economic accounts where intrinsic motivation refers to different things due to different underlying psychological theories employed. I then discuss implications these differences have for empirical work and incentive-based policy interventions. Finally, I use this discussion as a case study to demonstrate the shortcomings of the recently proposed pragmatic synthesis between neoclassical and behavioral economics. If there are multiple and fundamentally different psychological theories of the same phenomenon, using their insights in economic analysis is hardly just a matter of a straightforward pragmatic choice among the various tools in the economist’s toolbox.

"The Money, It's OK but It's not OK": Patients' and Providers' Perceptions of the Acceptability of Cash Incentives for HIV Treatment Initiation in Cape Town, South Africa.

Incentive-based interventions are used to encourage HIV testing, linkage to HIV care, and antiretroviral therapy (ART) adherence. Studies assessing efficacy of cash incentives have raised questions about the perceived ethicality of and attitudes towards incentives. Here we explore patients' and health providers' perspectives of the acceptability of a conditional cash transfer for ART initiation after receiving a positive HIV test through community-based services in resource-poor communities in Cape Town, South Africa. Drawing on in-depth interviews with patients and health care workers (HCWs), we find that, despite the perception that cash incentives are effective in promoting ART initiation, significant ambivalence surrounds the acceptability of such incentives. The receipt of a financial incentive was highly moralized, and fraught with challenges. Increasing the acceptability of cash incentives through careful design and delivery of interventions is central to the potential of this type of intervention for improving outcomes along the HIV care continuum.

Beliefs related to health care incentives: Comparison of substance use disorder treatment providers, medical treatment providers, and a public sample

This study surveyed substance use disorder (SUD) treatment providers, medical treatment providers, and a public sample about beliefs regarding health care incentives to explore differences among the groups and across health disorders for which research has demonstrated incentives improve outcomes. Six hundred participants (n = 200/group) completed the Provider Survey of Incentives. The study found between group differences for positive and negative beliefs. The public sample was highest on the positive beliefs subscale (M = 3.81), followed by SUD (M = 3.63) and medical treatment providers (M = 3.48; F(2, 597) = 20.09, p < .001). The medical treatment providers were highest on the negative beliefs subscale (M = 2.91), compared to the public sample (M = 2.77) and SUD treatment providers (M = 2.65; F(2, 597) = 7.521, p < .001). Endorsement of incentives to treat medical disorders was similar across the groups, with obesity the most endorsed disorder. In contrast, endorsement of incentives to treat SUDs differed across groups, except for smoking. The SUD treatment providers were almost twice as likely as the public sample (OR = 1.81, 95% CI = 1.27–2.59) and the public sample almost twice as likely as the medical treatment providers (OR = 1.74, 95% CI = 1.24–2.47) to endorse the use of incentives to treat more SUDs. Medical treatment providers were also the least likely to endorse incentives to treat both legal and illicit substance use. These findings suggest that incentive programs have good acceptability among SUD treatment providers and the public, but medical treatment providers are less accepting of incentive programs. This study provides evidence that incentive-based interventions are acceptable to the public and is the first to document specific objections that individuals disseminating incentive interventions will most likely face when introducing them in medical settings.

Uncovering a behavioral strategy for establishing new habits: Evidence from incentives for medication adherence in Uganda

Incentives are used to improve many health-related behaviors, but evidence is mixed for their effectiveness both during the incentivization period and, even more so, on the persistence of the behavior after incentives are withdrawn. In this paper, we present the results of a randomized controlled trial that successfully uses incentives to improve medication adherence among HIV-infected patients in Uganda over 20 months, and follows the sample for another 6 months to measure the persistence of these behavioral improvements. Our study contributes to the literature on habit formation by identifying a behavioral strategy that is associated with persistently high medication adherence after controlling for observable individual-level characteristics and the receipt of incentives. We find evidence supporting a psychological theory of habits as reflexive context-behavior associations, which suggests new ways of designing incentive-based interventions for better promoting persistent, healthier behaviors.