Modest Financial Incentives Research Articles

Effect of a Lifestyle Intervention on Cardiometabolic Health Among Emerging Adults

The prevalence of obesity has increased substantially among emerging adults, yet no previous large-scale behavioral weight loss trials have been conducted among this age group. To test the effect of 2 theory-based motivational enhancements on weight loss within a primarily digital lifestyle intervention designed for emerging adults. In this randomized clinical trial conducted at an academic medical research center, 382 participants aged 18 to 25 years with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 25 to 45 were enrolled between February 2, 2016, and February 6, 2019. Data collection was completed February 8, 2020. Analysis was performed on an intention-to-treat basis. Participants were randomized to 1 of 3 groups: developmentally adapted behavioral weight loss (aBWL), aBWL plus behavioral economics (aBWL + BE), or aBWL plus self-determination theory (aBWL + SDT). All groups received a 6-month intervention with 1 group session, 1 individual session, and a digital platform (digital tools for self-monitoring, weekly lessons, tailored feedback, text messages, and optional social media). The aBWL + BE group received modest financial incentives for self-monitoring and weight loss; the aBWL + SDT group received optional experiential classes. Coaching and message framing varied by group. The primary outcome was mean (SE) weight change (in kilograms) at 6 months. Secondary outcomes included proportion of participants achieving weight loss of 5% or more, percentage weight change, waist circumference, body composition, and blood pressure. Among the 382 participants (mean [SD] age, 21.9 [2.2] years), 316 (82.7%) were female, mean (SD) BMI was 33.5 (4.9), 222 (58.1%) were of underrepresented race and/or ethnicity, and 320 (83.8%) were retained at the primary end point. There was a significant time effect for mean (SE) weight loss (-3.22 [0.55] kg in the aBWL group; -3.47 [0.55] kg in the aBWL + BE group; and -3.40 [0.53] kg in the aBWL + SDT group; all P < .001), but no between-group differences were observed (aBWL vs aBWL + BE: difference, -0.25 kg [95% CI, -1.79 to 1.29 kg]; P = .75; aBWL vs aBWL + SDT: difference, -0.18 kg [95% CI, -1.67 to 1.31 kg]; P = .81; and aBWL + SDT vs aBWL + BE: difference, 0.07 kg [95% CI, -1.45 to 1.59 kg]; P = .93). The proportion of participants achieving a weight loss of 5% or more was 40.0% in the aBWL group (50 of 125), 39.8% in the aBWL + BE group (51 of 128), and 44.2% in the aBWL + SDT group (57 of 129), which was not statistically different across groups (aBWL vs aBWL + BE, P = .89; aBWL vs aBWL + SDT, P = .45; aBWL + SDT vs aBWL + BE, P = .54). Parallel findings were observed for all secondary outcomes-clinically and statistically significant improvements with no differences between groups. In this randomized clinical trial, all interventions produced clinically significant benefit, but neither of the motivational enhancements promoted greater reductions in adiposity compared with the developmentally adapted standard group. Continued efforts are needed to optimize lifestyle interventions for this high-risk population and determine which intervention works best for specific individuals based on sociodemographic and/or psychosocial characteristics. ClinicalTrials.gov Identifier: NCT02736981.

Examining Ways to Improve Weight Control Programs' Population Reach and Representativeness: A Discrete Choice Experiment of Financial Incentives.

BackgroundBoth theoretical and empirical evidence supports the potential of modest financial incentives to increase the reach of evidence-based weight control programs. However, few studies exist that examine the best incentive design for achieving the highest reach and representativeness at the lowest cost and whether or not incentive designs may be valued differentially by subgroups that experience obesity-related health disparities.MethodsA discrete choice experiment was conducted (n = 1232 participants; over 90% of them were overweight/obese) to collect stated preference towards different financial incentive attributes, including reward amount, program location, reward contingency, and payment form and frequency. Mixed logit and conditional logit models were used to determine overall and subgroup preference ranking of attributes. Using the National Health and Nutrition Examination Survey data sample weights and the estimated models, we predicted US nationally representative participation rates by subgroups and examined the effect of offering more than one incentive design. External validity was checked by using a completed cluster randomized control trial.ResultsThere were significant subgroup differences in preference toward incentive attributes. There was also a sizable negative response to larger incentive amounts among African Americans, suggesting that higher amounts would reduce participation from this population. We also find that offering participants a menu of incentive designs to choose from would increase reach more than offering higher reward amounts.ConclusionsWe confirmed the existence of preference heterogeneity and the importance of subgroup-targeted incentive designs in any evidence-based weight control program to maximize population reach and reduce health disparities.

Using a pragmatically adapted, low-cost contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial

IntroductionMost individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence...

Impacts of the Million Hearts® Cardiovascular Disease Risk Reduction Model on Provider‐Reported Preventive Care: A Pragmatic Randomized Trial

Research ObjectiveThe Million Hearts ® Cardiovascular Disease (CVD) Risk Reduction Model aims to reduce first‐time incidence of heart attacks and strokes among Medicare beneficiaries through improvements in CVD preventive care. The model pays providers (1) to assess each of their Medicare beneficiary’s risk of having a CVD event in 10 years and (2) to reduce risk among their high‐risk cohort. As risk stratification is central to clinical guidelines for CVD prevention, it is unclear whether the model’s modest incentives would change care beyond what practices would already provide. We assess whether the model has improved providers’ delivery of CVD preventive care.Study DesignA survey of providers from organizations in a randomized trial. CMS enrolled 516 organizations (primary care and specialty practices, health centers, and hospitals) throughout the country and randomly assigned half to the intervention group. We surveyed randomly selected providers within each of 283 organizations participating after one and a half years of model implementation (45% of organizations from both groups either withdrew or did not enroll any beneficiaries, mainly due to burdensome reporting requirements). We estimated impacts as regression‐adjust differences in intervention and control providers’ responses to survey questions about CVD preventive care provided to their patients (survey response rate: 72%).Population Studied261 providers in 245 organizations who enrolled beneficiaries and responded to the survey. Most respondents (77%) were physicians, 17% were nurse practitioners, and 6% were physician assistants. Despite high attrition rates, respondents in the intervention (N = 138) and control groups (N = 123) were well balanced on specialty and organization type.Principal FindingsRelative to the control group, the model increased by 31% percentage points the share of providers reporting they risk stratify at least half of their Medicare beneficiaries (71% in the intervention group versus 39% in the control, P &lt; .001). Both intervention and control providers reported increasing their use of risk scores since the model began in 2017, but intervention providers reported substantially greater gains (25 to 71%) than control providers (31 to 39%). Most intervention group providers (73%) said that risk stratification helped them identify beneficiaries at risk of CVD events, and most (71%) reported that the model prompted them to more systematically apply the current standard of CVD care to their Medicare beneficiaries.ConclusionsThe Million Hearts® Model appears to have substantially improved CVD preventive care including enhanced identification and provider awareness of beneficiaries at risk for CVD events.Implications for Policy or PracticeWhile clinical guidelines recommend using CVD risk stratification in primary CVD prevention, many of the participating organizations—which are likely a self‐selected group of higher performers—were not routinely risk stratifying patients at baseline. This trial shows that, among organizations that remained in the model 1.5 years after it started, commitment to the Million Hearts CVD preventive care model and modest financial incentives focused provider attention on CVD risk, leading to more routine use risk assessment, better detection of CVD risks in patient panels, and greater adherence to current standards of CVD preventive care. Together, these impacts have the potential to eventually reduce the risk of heart attacks and strokes.Primary Funding SourceCenters for Medicare and Medicaid Services.

Can Financial Incentives Promote Exercise Adherence Amongst Cardiac Rehabilitation Graduates? A 24-week Pilot Randomized Controlled Trial

The health benefits of cardiac rehabilitation (CR) and sustained physical activity (PA) post-CR are well known; yet, CR graduates often fail to adhere to their exercise prescriptions post-program. Financial incentives have shown promise in increasing PA in adults but have been rarely evaluated in a CR context. PURPOSE: To examine the impact of adding financial incentives to a multi-component eHealth (MCE) intervention on moderate-vigorous physical activity (MVPA) amongst CR graduates. Second, to determine whether financial incentives increased eHealth platform engagement compared to non-incentive controls. METHODS: In this 24-week pilot randomized controlled trial participants were recruited from a large outpatient CR program and randomized to control (CT) or intervention (FI) conditions. CTs were instructed to track their exercise daily using a MCE website that included self-monitoring, individual and group-level feedback, and virtual (non-monetary) rewards for exercise session completion. Only FIs could earn $1.00 CAD per day when exercise was tracked and completed. Group differences in MVPA minutes per day (min/d) during the final intervention month were made using a one-way ANOVA. Participants with five or more ‘valid’ days during the final month (days with objectively measured step counts between 500 and 40000) were included in the analysis. RESULTS: Seventy-four CR graduates (63% male; mean age 69±11 years) were randomized to CT (n=38) or FI (n=36) groups, and 34 participants (15/38 CT, 19/36 FI) had at least five valid days (mean 19.7±6.4 days). No significant group difference in mean MVPA min/d in the final intervention month was observed (CT: 21.90±18.56; FI: 27.18±15.52; p=0.41), nor between the mean number of eHealth website logins over the six month intervention (CT: 101.2±129.5; FI: 109.7±91.5; p=0.75). CONCLUSION: While this pilot trial was not powered to detect group differences, our initial results suggest that adding modest financial incentives ($1 per day) to a MCE intervention may not boost engagement (a main driver of eHealth program effectiveness), nor MVPA in a sample of Canadian CR graduates. However, higher study retention, mean MVPA min/d, and total logins in the FI compared to the CT shows intervention promise. These data will inform the design of a fully powered trial.

Randomized Trial of an Intervention to Improve Blood Pressure Control in Stroke Survivors.

We conducted the first-of-its kind randomized stroke trial in Africa to test whether a THRIVES (Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke) intervention improved blood pressure (BP) control among patients with stroke. Intervention comprised a patient global risk factor control report card, personalized phone text-messaging, and educational video. Four hundred patients recruited from 4 distinct medical facilities in Nigeria, aged ≥18 years with stroke-onset within one-year, were randomized to THRIVES intervention and control group. The control group also received text messages, and both groups received modest financial incentives. The primary outcome was mean change in systolic BP (SBP) at 12 months. There were 36.5% females, 72.3% with ischemic stroke; mean age was 57.2±11.7 years; 93.5% had hypertension and mean SBP was 138.33 (23.64) mm Hg. At 12 months, there was no significant difference in SBP reduction from baseline in the THRIVES versus control group (2.32 versus 2.01 mm Hg, P=0.82). In an exploratory analysis of subjects with baseline BP >140/90 mm Hg (n=168), THRIVES showed a significant mean SBP (diastolic BP) decrease of 11.7 (7.0) mm Hg while control group showed a significant mean SBP (diastolic BP) decrease of 11.2 (7.9) mm Hg at 12 months. THRIVES intervention did not significantly reduce SBP compared with controls. However, there was similar significant decrease in mean BP in both treatment arms in the subgroup with baseline hypertension. As text-messaging and a modest financial incentive were the common elements between both treatment arms, further research is required to establish whether these measures alone can improve BP control among stroke survivors. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01900756.

Enhancing the Social and Natural Capital of Canadian Agro-Ecosystems through Incentive-Based “Alternative Land Use Services” (ALUS) Programs: Recurring Themes and Emerging Lessons

Alternative Land Use Services (ALUS) is an incentive-based program established in Canada to pay farmers for their voluntary delivery of ecosystem services (ES). All seven ALUS programs across the country were examined using a standardized case-study approach based on site visits, reading internal documents, attending program meetings, and engaging in semi-structured interviews with program administrators, participating farmers, and advisory board members. Direct content analysis was used to highlight recurrent themes and emerging lessons in relation to the salient particulars of program physical location, administration framework, delivery of ES, and development and receipt by communities. Our three major findings are: 1) Overall, ALUS has been judged by participants to be a very successful program, whose strength is that it is completely voluntary, non-permanent, and readily adaptable to each location’s environmental conditions, economic funding base, and cultural milieu. 2) One serious shortcoming of all ALUS programs is a general lack of quantifiable data on their ability to increase ES. Instead, environmental benefits are either assumed or based on the idea that the areal extent of enrolled land is the sole measure of its environmental worth. 3) It may be that the social impact of ALUS is its greatest success. In this regard, for farmers, it is the process of engaging in land-use decision making and the recognition of their role as environmental stewards that is a bigger motivation for participating in an ALUS program than the modest financial incentives which they receive.

Racial/Ethnic Differences in the Response to Incentives for Quitline Engagement

Certain racial and ethnic minorities have lower utilization of tobacco cessation services, such as Helpline counseling and cessation medications. The goal of the California Medicaid (Medi-Cal) Incentives to Quit Smoking Program was to facilitate successful cessation by promoting modest financial and cessation medication-related incentives to increase engagement with the California Smokers' Helpline counseling services. Differences in the response to incentives and outreach on engagement with Helpline services among racial/ethnic groups within the Medi-Cal population were examined. Analysis of Helpline caller data. African American (n=18,656); English-speaking Latinx (n=12,792); Spanish-speaking Latinx (n=3,254); and white (n=45,907) Medi-Cal callers. The Medi-Cal Incentives to Quit Smoking team conducted statewide and community-based outreach and facilitated direct-to-member all-household mailings about the Medi-Cal Incentives to Quit Smoking program to engage with Medi-Cal callers and promote Helpline services between March 2012 and July 2015 (analyzed 2017/2018). Medi-Cal callers could ask for a $20 gift card incentive after having completed a counseling session; in September 2013, callers were offered free nicotine replacement therapy. Three behavioral outcomes are reported that reflect activated callers and callers who engaged in treatment that is proven to improve chances of quitting smoking: receipt of the $20 incentive, receipt of nicotine replacement therapy, and receipt of counseling. African Americans and English-speaking Latinx had higher engagement with the financial incentive than whites (African American APR=1.66, 95% CI=1.59, 1.73, English-speaking Latinx APR=1.29, 95% CI=1.22, 1.36). Spanish-speaking Latinx had lower initial engagement with the financial incentive (APR=0.75, 95% CI=0.66, 0.85), but higher engagement with Medi-Cal's all-household mailing (Spanish-speaking Latinx 30.6% vs whites 18.2%, p<0.001). Although African Americans and English-speaking Latinx had similar rates of completing counseling and receiving nicotine replacement therapy as whites, Spanish-speaking Latinx had higher rates than whites. The promotion of modest financial and cessation medication incentives through multiple outreach channels increased callers' engagement with the Helpline and appeared to promote ethnic and linguistic equity with respect to the receipt of counseling and nicotine replacement therapy. Targeted community-based outreach may resonate particularly for African Americans, and language-concordant Medi-Cal insurance plan mailings may have reached newly covered Spanish-speaking Latinx. This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Economic Impact of Financial Incentives and Mailing Nicotine Patches to Help Medicaid Smokers Quit Smoking: A Cost–Benefit Analysis

An RCT designed to increase Medicaid smokers' quitting success was conducted in California during 2012-2013. In the trial, alternative cessation treatment strategies were embedded in the state's ongoing quitline services. It found that modest financial incentives of up to $60 per participant and sending nicotine patches induced significantly higher cessation rates compared with usual care alone and usual care plus nicotine patches. Building upon that study, this study assessed potential population-level costs and benefits of integrating financial incentives and nicotine patches in a quitline setting for Medicaid smokers. A cost-benefit analysis was undertaken from the Medicaid program's perspective. The Cardiovascular Disease Policy Model was used to simulate future healthcare expenditures over a 10-year horizon for each treatment strategy for a study cohort of California Medicaid enrollees who were aged 35-64 years in 2014 (n=2,452,000). To simulate potential population-level benefits under each treatment strategy, each treatment was applied to all active smokers in the study cohort (n=478,300). Sensitivity analyses were conducted by varying key parameters, such as cessation costs, discount rate, relapse rates, and time horizon. Adding both financial incentives and nicotine patches to usual quitline care would result in $15 million net savings over 10 years, with a benefit-cost ratio of 1.30 compared with the usual care plus nicotine patches strategy. It would yield $44 million net savings, with a benefit-cost ratio of 1.90 compared with usual care alone. The strategy of providing financial incentives and mailing nicotine patches directly to Medicaid smokers who call the quitline is cost saving. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

A Quasi-Experiment to Assess the Impact of a Scalable, Community-Based Weight Loss Program: Combining Reach, Effectiveness, and Cost.

Primary care addresses obesity through physician oversight of intensive lifestyle interventions or referral to external programs with demonstrated efficacy. However, limited information exists on community program reach, effectiveness, and costs across different groups of participants. To evaluate a scalable, community weight loss program using reach, effectiveness, and cost metrics. Longitudinal pre-post quasi-experiment without control. Enrolled participants in Weigh and Win (WAW), a community-based weight loss program. A 12-month program with daily social cognitive theory-based email and/or text support, online access to health coaches, objective weight assessment through 83 community-based kiosks, and modest financial incentives to increase program reach. Number of participants, representativeness, weight loss achievement (3%, 5% of initial weight lost), and cost of implementation. A total of 40,308 adults (79% women; 73% white; BMI = 32.3 ± 7.44, age = 43.9 ± 13.1 years) enrolled in WAW. Women were more likely than men to enroll in the program and continue engagement beyond an initial weigh-in (57% vs. 53%). Based on census data, African Americans were over-represented in the sample. Among participants who engaged in the program beyond an initial weigh-in (n = 19,029), 47% and 34% of participants lost 3% and 5% of their initial body weight, respectively. The average duration for those who achieved 5% weight loss was 1.7 ± 1.3years. African American participants were more likely to achieve 5% weight loss and remain enrolled in the program longer compared to non-African American participants (2.0 ± 1.3 vs. 1.6 ± 1.2years). Implementation costs were $2,822,698. Cost per clinically meaningful weight loss for African Americans ($257.97/3% loss; $335.96/5% loss) was lower than that for Hispanics ($318.62; $431.10) and Caucasians ($313.65; $441.87), due to the higher success rate of that subgroup of participants. Weigh and Win is a scalable technology-supported and community-based weight loss program that reaches a large number of participants and may contribute to reducing health disparities.

Secondary data analysis from a randomized trial examining the effects of small financial incentives on intrinsic and extrinsic motivation for weight loss

ABSTRACTThe purpose of this study was to examine whether (a) an obesity treatment involving financial incentives yields higher levels of extrinsic motivation for weight management compared to an identical intervention without incentives, (b) extrinsic motivation for weight management mediates, or accounts for, the difference in weight loss outcomes between the two interventions, and (c) there is any evidence that financial incentives and associated extrinsic motivation “crowd out” intrinsic motivation for weight control. Participants (N = 153, 80.4% female; body mass index [BMI] = 33.2 ± 5.9) were randomly assigned to a 3-month Web-based behavioral weight loss program (WBWL) or the same program plus small financial incentives delivered consistent with behavioral economics and behavior change theories (WBWL + $). Weight was objectively assessed at baseline, post-treatment (month 3), and after a 9-month no-treatment follow-up phase (month 12). Intrinsic and extrinsic motivation for weight management were assessed at months 3 and 12 using a modified version of the Treatment Self-Regulation Questionnaire (TSRQ), with questions added to specifically target extrinsic motivation related to incentives. Compared to WBWL alone, WBWL + $ had better weight loss and higher levels of both extrinsic and intrinsic motivation for weight management (p-values ≤ .02). Moreover, during the no-treatment follow-up phase, the trajectories of weight regain did not significantly differ between WBWL and WBWL + $ (p = .58). Extrinsic motivation was not a significant mediator of treatment outcomes. These results suggest that modest financial incentives delivered consistent with behavioral economics and behavior change theories do not undermine intrinsic motivation for weight management during obesity treatment; in fact, they yield higher levels of both extrinsic and intrinsic motivation. Additional research is needed to better understand the mechanisms by which incentives improve outcomes in health behavior change interventions. Clinicaltrials.gov number: NCT01560130.

Trade-offs in water and carbon ecosystem services with land-use changes in grasslands.

Increasing pressures for food, fiber, and fuel continue to drive global land-use changes. Efforts to optimize ecosystem services under alternative land uses are often hampered by the complex interactions and trade-offs among them. We examined the effects of land-use changes on ecosystem carbon storage and groundwater recharge in grasslands of Argentina and the United States to (1) understand the relationships between both services, (2) predict their responses to vegetation shifts across environmental gradients, and (3) explore how market or policy incentives for ecosystem services could affect land-use changes. A trade-off of ecosystem services was evident in most cases, with woody encroachment increasing carbon storage (+29 MgC/ha) but decreasing groundwater recharge (-7.3mm/yr) and conversions to rain-fed cultivation driving opposite changes (-32MgC/ha vs. +13mm/yr). In contrast, crops irrigated with ground water tended to reduce both services compared to the natural grasslands they replaced. Combining economic values of the agricultural products together with the services, we highlight potentials for relatively modest financial incentives for ecosystem services to abate land-use changes and for incentives for carbon to drive land-use decisions over those of water. Our findings also identify key opportunities and caveats for some win-win and lose-lose land-use changes for more integrative and sustainable strategies for land management.

Healthy Foods, Healthy Families: combining incentives and exposure interventions at urban farmers' markets to improve nutrition among recipients of US federal food assistance.

Background: Healthy Foods, Healthy Families (HFHF) is a fruit and vegetable (F&V) exposure/incentive program implemented at farmers’ markets in low-income neighborhoods, targeting families receiving US federal food assistance. We examined program effects on participants’ diet and associations between attendance, demographics and dietary change. Methods: Exposure activities included F&V tastings and cooking demonstrations. Incentives included 40% F&V bonus for electronic benefit transfer (EBT) card users and $20 for use purchasing F&V at every third market visit. Self-report surveys measuring nutritional behaviors/literacy were administered to participants upon enrollment (n = 425, 46.2% Hispanic, 94.8%female). Participants were sampled for follow-up at markets during mid-season (n = 186) and at season end (n = 146). Attendance was tracked over 16 weeks. Results: Participants post-intervention reported significantly higher vegetable consumption(P = 0.005) and lower soda consumption (P = 0.005). Participants reporting largest F&V increases attended the market 6-8 times and received $40 in incentives. No change in food assistance spent on F&V (P = 0.94); 70% reported significant increases in family consumption of F&V,indicating subsidies increased overall F&V purchasing. Participants reported exposure activities and incentives similarly affected program attendance. Conclusion: Interventions combining exposure activities and modest financial incentives at farmers’ markets in low-income neighborhoods show strong potential to improve diet quality of families receiving federal food assistance.

Development of immunity following financial incentives for hepatitis B vaccination among people who inject drugs: A randomized controlled trial

BackgroundPeople who inject drugs (PWID) are at risk of hepatitis B virus (HBV) but have low rates of vaccination completion. The provision of modest financial incentives increases vaccination schedule completion, but their association with serological protection has yet to be determined. ObjectiveTo investigate factors associated with vaccine-induced immunity among a sample of PWID randomly allocated to receive AUD$30 cash following receipt of doses two and three (‘incentive condition’) or standard care (‘control condition’) using an accelerated 3-dose (0,7,21 days) HBV vaccination schedule. Study designA randomised controlled trial among PWID attending two inner-city health services and a field site in Sydney, Australia, assessing vaccine-induced immunity measured by hepatitis B surface antibodies (HBsAb≥10mIU/ml) at 12 weeks. The cost of the financial incentives and the provision of the vaccine program are also reported. ResultsJust over three-quarters of participants – 107/139 (77%) – completed the vaccination schedule and 79/139 (57%) were HBsAb≥10mIU/ml at 12 weeks. Vaccine series completion was the only variable significantly associated with vaccine-induced immunity in univariate analysis (62% vs 41%, p<0.035) but was not significant in multivariate analysis. There was no statistically discernible association between group allocation and series completion (62% vs 53%). The mean costs were AUD$150.5, (95% confidence interval [CI]: 142.7–158.3) and AUD$76.9 (95% CI: 72.6–81.3) for the intervention and control groups respectively. ConclusionDespite increasing HBV vaccination completion, provision of financial incentives was not associated with enhanced serological protection. Further research into factors which affect response rates and the optimal vaccination regimen and incentive schemes for this population are needed.

A behavioral economics intervention to encourage epinephrine-carrying among food-allergic adults: a randomized controlled trial

BackgroundAdolescents and young adults with food allergies are at increased risk of adverse events, including death from anaphylaxis. Epinephrine is the cornerstone of emergency response, yet few individuals with serious food allergies consistently carry their emergency medication. Behavioral economics offers promising, previously untapped opportunities for behavior change in this arena. ObjectiveTo test the effectiveness of modest financial incentives in promoting the carrying of epinephrine and to evaluate the acceptability of text messaging for delivering reminders and key health messages to young adults with food allergies. MethodsA mixed-methods randomized controlled trial in young adults with food allergies investigated the carrying of epinephrine auto-injectors using financial incentives plus text message reminders vs text message reminders alone. Epinephrine carriage was assessed 10 times during the 49-day intervention using rapid-reply cell phone photographs plus daily code words. ResultsThe intervention (financial incentive) group had their epinephrine auto-injectors at 54% of check-ins vs 27% of check-ins in the control (text-only) group (P = .023). Participants in the 2 groups consistently reported favorable impressions of text messaging as a desirable, unobtrusive way to receive information and support for food allergy management. ConclusionAlthough the intervention and control groups reported favorable impressions of text message-based reminder systems, the intervention group performed significantly better than the control group on a photograph-based measurement of epinephrine carriage. There remained ample room for improvement in the 2 groups given the goal of consistent, uninterrupted epinephrine carriage by people with potentially life-threatening food allergies. Trial Registrationhttps://clinicaltrials.gov; NCT02354729.

Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial

Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy. In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493. Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12·1, 95% CI 3·7-39·9; p<0·0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14·0, 4·2-46·2; p<0·0001). These differences remained significant with sensitivity analyses. Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown. National Institute for Health Research (RP-PG-0707-10149).

Effectiveness of financial incentives to improve adherence to maintenance treatment with antipsychotics: cluster randomised controlled trial

Objective To test whether offering financial incentives to patients with psychotic disorders is effective in improving adherence to maintenance treatment with antipsychotics. Design Cluster randomised controlled trial. Setting Community mental...

A randomised controlled trial of financial incentives to increase hepatitis B vaccination completion among people who inject drugs in Australia

ObjectiveThis study aimed to investigate the efficacy of modest financial incentives in increasing completion of an accelerated 3-dose hepatitis B virus (HBV) vaccination schedule (0, 7, 21days) among people who inject drugs (PWID). MethodsRandomised controlled trial. Participants were randomly allocated to receive $30 Australian Dollars cash following receipt of vaccine doses two and three (‘incentive condition’), or standard care (‘control condition’). Serologically confirmed HBV-susceptible PWID. Two inner-city health services and a field study site in Sydney, Australia. The primary outcome was completion of the vaccination series. Additional assessments included self-reported demographic, drug use and treatment, and risk-taking histories. ResultsCompared to the control condition, significantly more participants in the incentive condition received all three vaccine doses, under intention-to-treat analyses (n=139; 87% versus 66%; p=.004); and within the specified window periods under per protocol analyses (n=107 received three vaccine doses; 92% versus 67%; p=.001). Multivariate analysis indicated that the incentive condition and longer injecting histories significantly increased the likelihood of series completion. Aboriginal/Torres Strait Islanders were significantly less likely to complete the series. ConclusionsModest financial incentives, per-dose, increased adherence to the accelerated HBV vaccination schedule among PWID. Results have implications for increasing HBV and, potentially, other vaccine-preventable infections, among PWID.

Predictors of Successful Telephone Contact After Emergency Department-based Recruitment into a Multicenter Smoking Cessation Cohort Study.

IntroductionEmergency department (ED) studies often require follow-up with subjects to assess outcomes and adverse events. Our objective was to identify baseline subject characteristics associated with successful contact at 3 time points after the index ED visit within a sample of cigarette smokers.MethodsThis study is a secondary analysis of a prospective cohort. We recruited current adult smokers at 10 U.S. EDs and collected baseline demographics, smoking profile, substance abuse, health conditions, and contact information. Site investigators attempted contact at 2 weeks, 3 months, and 6 months to assess smoking prevalence and quit attempts. Subjects were paid $20 for successful follow-up at each time point. We analyzed data using logistic and Poisson regressions.ResultsOf 375 recruited subjects, 270 (72%) were contacted at 2 weeks, 245 (65%) at 3 months, and 217 (58%) at 6 months. Overall, 175 (47%) were contacted at 3 of 3, 71 (19%) at 2 of 3, 62 (17%) at 1 of 3, and 66 (18%) at 0 of 3 time points. At 6 months, predictors of successful contact were: older age (adjusted odds ratio [AOR] 1.2 [95%CI, 0.99–1.5] per ↑10 years); female sex (AOR 1.7 [95%CI, 1.04–2.8]); non-Hispanic black (AOR 2.3 [95%CI, 1.2–4.5]) vs Hispanic; private insurance (AOR 2.0 [95%CI, 1.03–3.8]) and Medicare (AOR 5.7 [95%CI, 1.5–22]) vs no insurance; and no recreational drug use (AOR 3.2 [95%CI; 1.6–6.3]). The characteristics independently predictive of the total number of successful contacts were: age (incidence rate ratio [IRR] 1.06 [95%CI, 1.00–1.13] per ↑10 years); female sex (IRR 1.18 [95%CI, 1.01–1.40]); and no recreational drug use (IRR 1.37 [95%CI, 1.07–1.74]). Variables related to smoking cessation (e.g., cigarette packs-years, readiness to quit smoking) and amount of contact information provided were not associated with successful contact.ConclusionSuccessful contact 2 weeks after the ED visit was 72% but decreased to 58% by 6 months, despite modest financial incentives. Older, female, and non-drug abusing participants were the most likely to be contacted. Strategies to optimize longitudinal follow-up rates, with limited sacrifice of generalizability, remain an important challenge for ED-based research. This is particularly true for studies on substance abusers and other difficult-to-reach populations.

Feasibility, effectiveness, and perceptions of an Internet-and incentive-based behavioral weight loss intervention for overweight and obese college freshmen: A mixed methods approach

Challenges inherent with the transition to college are often accompanied by weight gain among college freshmen. Weight gain and duration of obesity increase metabolic syndrome and cardiovascular disease risk in young adulthood, which supports the need for weight loss interventions tailored to college students. The purpose of this investigation was to conduct a mixed methods pilot trial to determine the efficacy and acceptability of a semester long Internet-and incentive-based weight loss intervention for overweight/obese college freshmen. Participants (n = 27, aged >18 yrs, BMI >25) were randomly assigned to a 12-week social cognitive theory (SCT)-based intervention (Fit Freshmen [FF]) or a health information control group. The FF intervention also included modest financial incentives for weight loss. Primary outcomes included body weight/composition, dietary and physical activity (PA) behaviors, and psychosocial measures (i.e. self-efficacy, self-regulation) associated with diet, PA, and weight loss. Students in the FF intervention participated in focus groups to provide qualitative feedback on program structure and design. FF participants demonstrated significant reductions (all group differences p