Modest Incentives Research Articles

Increasing a Quitline's Reach to Low-Income Tobacco Users Through 211 Agencies.

Low-income individuals bear a disproportionate share of the burden of tobacco use. This study tested the feasibility of increasing a quitline's reach to low-income tobacco users by collaborating with 211 information and referral agencies, which primarily serve people experiencing economic hardship. Study participants (N = 114888) were adult tobacco users referred to the California quitline by 211 agencies, referred by healthcare clinics, or self-referred from April 17, 2021 to December 31, 2023. All were offered telephone counseling. Those referred by 211 received $20 for completing one counseling session. A subset (n = 2021) was followed up at 7 months. Referral outcomes, baseline characteristics, counseling and quitting aid utilization, and quitting outcomes were analyzed by referral source in 2024. Over a 2.7-year period, 211 agencies referred 55151 clients to the quitline. Participants referred by 211 were more than twice as likely as healthcare-referred participants to enroll in quitline services (34.0% vs. 15.9%, p < .0001). They were more likely than healthcare- and self-referred participants to be female, lesbian, gay, bisexual, transgender, orqueer/questioning, Black or multiracial, younger, less educated, and Medicaid-insured; more likely to complete a first counseling session (64.2% vs. 59.7% and 55.7%; both ps < .0001); and completed a similar number of sessions, 2.4. They were less likely to use quitting aids. Quit rates (ie, 30-day point prevalence abstinence) at 7-month follow-up were similar for all three groups. A collaboration between a quitline and 211 agencies connected large numbers of underserved, low-income tobacco users to evidence-based cessation treatment. The study shows that quitlines and 211 agencies can collaborate effectively to help low-income tobacco users quit. It shows that when offered a modest incentive, 211-referred participants engage in counseling as much as healthcare- and self-referred participants and are as likely to quit. If 211 agencies across the US referred at the same rate as agencies in this study, an estimated 65000 additional tobacco users annually would receive treatment. Total reach at full implementation would likely be much higher. Quitline and 211 funders and other supporters should find ways to sustain these gains and expand their reach.

Incentivizing adherence to pre-exposure prophylaxis for HIV prevention: a randomized pilot trial among male sex workers in Mexico.

Low adherence to preventative medications against life-long health conditions is a major contributor to global morbidity and mortality. We implemented a pilot randomized controlled trial in Mexico to measure the extent to which conditional economic incentives help male sex workers increase their adherence to pre-exposure prophylaxis (PrEP) for HIV prevention. We followed n = 110 male sex workers over 6 months. At each quarterly visit (at months 0, 3, and 6), all workers received a $10 transport reimbursement, a free 3-month PrEP supply, and completed socio-behavioral surveys. The primary outcome was an objective biomarker of medication adherence based on tenofovir (TFV) drug concentration levels in hair collected at each visit. Individuals randomized to the intervention received incentives based on a grading system as a function of PrEP adherence: those with high (> 0.043 ng/mg TFV concentration), medium (0.011 to 0.042 ng/mg), or low (< 0.011 ng/mg) adherence received $20, $10, or $0, respectively. Six-month pooled effects of incentives on PrEP adherence were analyzed using population-averaged gamma generalized estimating equation models. We estimated heterogeneous treatment effects by sex worker characteristics. The incentive intervention led to a 28.7% increase in hair antiretroviral concentration levels over 6 months consistent with increased PrEP adherence (p = 0.05). The effect of incentives on PrEP adherence was greater for male sex workers who were street-based (vs. internet) workers (p < 0.10). These pilot findings suggest that modest conditional economic incentives could be effective, at scale, for improving PrEP adherence among male sex workers, and should be tested in larger implementation trials. ClinicalTrials.gov Identifier: NCT03674983.

Improving accuracy in predictions about future performance

Within the academic context, students often expect to perform significantly better on an upcoming exam when compared to their actual performance. Unfortunately, students who are least accurate in their performance predictions are also the most at risk of being underprepared compared to their peers. Thus, efforts to enhance accuracy in performance predictions would benefit the student population that is most at risk of academic shortcomings and failure. Two studies examined whether incentives improve accuracy of academic performance predictions. In Study 1, 126 students in a 200-level undergraduate course provided estimates of how well they would perform on an upcoming exam. Two weeks later, the same students were randomly assigned to receive a reward incentive, punishment incentive, or no incentive for accuracy in performance predictions and their exam performance estimates were reassessed then compared to their actual scores on an exam completed one week later. In Study 2, 144 students from multiple 300-level courses provided performance predictions for an upcoming exam that were then compared to their actual exam scores for accuracy. For a subsequent exam, the same students were randomly assigned to varying levels of reward incentives (no incentive, modest incentive, large incentive) for prediction accuracy and their performance estimates were examined and compared to actual performance on a second exam. Findings from both studies indicated performance estimates are malleable and with the appropriate incentives, accuracy in predictions may be improved and contribute to better actual performance.

Design and Implementation of the Surveys of Women: Protocol for an Address-Based Sampling Multimodal Study

Studies conducted in the United States such as the National Survey of Family Growth (NSFG) and the Pregnancy Risk Assessment Monitoring System (PRAMS) collect data on pregnancy intentions to aid in improving health education, services, and programs. PRAMS collects data from specific sites, and NSFG is a national household-based survey. Like NSFG, the Surveys of Women was designed to survey participants residing in households using an address-based sample and a multimode data collection approach. The Surveys of Women collects data from eligible participants in 9 states within the United States on contraception use, reproductive health, and pregnancy intentions. In this paper, we focus on the baseline data collection protocol, including sample design, data collection procedures, and data processing. We also include a brief discussion on the follow-up and endline survey methodologies. Our goal is to inform other researchers on methods to consider when fielding a household-level reproductive health survey. The Surveys of Women was developed to support state-specific research and evaluation projects, with an overall goal of understanding contraceptive health practices among women aged 18-44 years. The project collects data from respondents in 9 different states (Arizona, Alabama, Delaware, Iowa, Maryland, New Jersey, Ohio, South Carolina, and Wisconsin) over multiple rounds. Households were selected at random using address-based sampling methods. This project includes a cross-sectional baseline survey, 2 or 3 follow-up surveys with an opt-in panel of respondents, and a cross-sectional endline survey. Each round of data collection uses a multimode design through the use of a programmed web survey and a formatted hard copy questionnaire. Participants from the randomly selected households access their personalized surveys through a web survey or mail in a hard copy questionnaire. To maximize responses, these surveys follow a rigorous schedule of various prompts bolstering the survey implementation design, and the participants received a modest monetary incentive. This is an ongoing project with results published separately by the evaluation teams involved with data analysis. The methods used in the first baseline survey informed modifications to the methods used in subsequent statewide surveys. Data collected from this project will provide insight into women's reproductive health, contraceptive use, and abortion attitudes in the 9 selected states. The long-term goal of the project is to use a data collection methodology that collects data from a representative sample of participants to assess changes in reproductive health behaviors over time. DERR1-10.2196/40675.

Risks of Intimate Partner Violence for Women Living with HIV Receiving Cash Transfers: A Qualitative Study in Shinyanga, Tanzania

Cash transfers are increasingly used to motivate adherence to HIV care. However, evidence on cash transfers and intimate partner violence (IPV) is mixed and little is known about their safety for women living with HIV. We conducted in-depth interviews with women living with HIV who participated in a randomized trial providing 6 months of cash transfers (~$4.5 or $11 USD) conditional on HIV clinic attendance in Shinyanga, Tanzania to assess how receiving cash affects IPV and relationship dynamics. Eligible participants were 18–49 years, received cash transfers, and in a partnership at baseline. Data were analyzed in Dedoose using a combined inductive-deductive coding approach. 25 interviews were conducted between November 2019-February 2020. Women’s employment was found to be a source of household tension and violence. None of the participants reported physical or sexual IPV in relation to cash transfers, however, some women experienced controlling behaviors or emotional violence including accusations and withholding of money, particularly those who were unemployed. Cash transfers were predominantly used for small household expenses and were not viewed as being substantial enough to shift the financial dynamic or balance of power within relationships. Our findings suggest that small, short-term cash transfers do not increase physical or sexual IPV for women living with HIV however can exacerbate controlling behaviors or emotional violence. Modest incentives used as a behavioral nudge to improve health outcomes may affect women differently than employment or larger cash transfers. Nonetheless, consultations with beneficiaries should be prioritized to protect women from potential IPV risks.

How a compensated kidney donation program facilitates the sale of human organs in a regulated market: the implications of Islam on organ donation and sale

BackgroundAdvocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales.MethodsThis study reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation.Results and discussionAccording to Islamic law, organ donation is an act of sadaqatul jariyah, and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim eethaar, undermining donors of ‘selfless’ or ‘altruistic’ motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran’s unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran’s unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of ‘buyer and seller’, ensuring the philosophy of ‘donor and recipient’ is maintained.ConclusionsOffering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors’ health and reducing human suffering without legalizing the human organ trade.

Financial incentives to increase stool collection rates for microbiome studies in adult bone marrow transplant patients.

In order to study the role of the microbiome in hematopoietic stem cell transplantation (HCT), researchers collect stool samples from patients at various time points throughout HCT. However, stool collection requires active subject participation and may be limited by patient reluctance to handling stool. We performed a prospective study on the impact of financial incentives on stool collection rates. The intervention group consisted of allogeneic HCT patients from 05/2017-05/2018 who were compensated with a $10 gas gift card for each stool sample. The intervention group was compared to a historical control group of allogeneic HCT patients from 11/2016-05/2017 who provided stool samples before the incentive was implemented. To control for possible changes in collections over time, we also compared a contemporaneous control group of autologous HCT patients from 05/2017-05/2018 with a historical control group of autologous HCT patients from 11/2016-05/2017; neither autologous HCT group was compensated. The collection rate was defined as the number of samples provided divided by the number of time points we attempted to obtain stool. There were 35 allogeneic HCT patients in the intervention group, 19 allogeneic HCT patients in the historical control group, 142 autologous HCT patients in the contemporaneous control group (that did not receive a financial incentive), and 75 autologous HCT patients in the historical control group. Allogeneic HCT patients in the intervention group had significantly higher average overall collection rates when compared to the historical control group allogeneic HCT patients (80% vs 37%, p<0.0001). There were no significant differences in overall average collection rates between the autologous HCT patients in the contemporaneous control and historical control groups (36% vs 32%, p = 0.2760). Our results demonstrate that a modest incentive can significantly increase collection rates. These results may help to inform the design of future studies involving stool collection.

Incentives to Eat Healthily: Evidence from a Grocery Store Field Experiment

We use a field experiment with over 200 participants to investigate the effect of incentives on grocery store purchases. We randomize participants to treatments where we incentivize produce purchases, provide tips for produce preparation, or both, and follow shopping behaviour for 6 months. Our informational treatment has a weak effect. However, we find an important price effect: modest incentives quadruple produce purchasing at our grocery store relative to the control group. After incentives are removed, the treatment group continues to purchase more produce at our grocery store. These long‐term results are consonant with a habit‐formation model, in contrast to standard price models or behavioural ‘crowd out‘ models.

Monetary incentives increase COVID-19 vaccinations.

The stalling of COVID-19 vaccination rates threatens public health. To increase vaccination rates, governments across the world are considering the use of monetary incentives. Here we present evidence about the effect of guaranteed payments on COVID-19 vaccination uptake. We ran a large preregistered randomized controlled trial (with 8286 participants) in Sweden and linked the data to population-wide administrative vaccination records. We found that modest monetary payments of 24 US dollars (200 Swedish kronor) increased vaccination rates by 4.2 percentage points (P = 0.005), from a baseline rate of 71.6%. By contrast, behavioral nudges increased stated intentions to become vaccinated but had only small and not statistically significant impacts on vaccination rates. The results highlight the potential of modest monetary incentives to raise vaccination rates.

Money and my mind: Maternal cash transfers and mental health.

This paper documents important mental health spillovers in the context of a program that offered pregnant women modest cash incentives to use pre‐ and perinatal health care services. Program participation was randomized and the payments were made after the birth of the child (and after the completion of an endline mental health assessment). I present causal evidence that the program led to improvements in mothers' mental health. The effect size ranges from a 1–3 percentage point reduction in postpartum depression measured using the Edinburgh Postnatal Depression Scale. I present suggestive evidence that these beneficial effects on mental health may be related to program‐induced improvements in child health. These results provide novel evidence that programs designed to improve birth outcomes may generate unanticipated spillover effects on mental health.

Modest and incomplete incentives may work: Pricing plastic bags in Uruguay

We study the impact of voluntary prices on the demand for plastic bags, using two years of administrative data from a national supermarket chain in Uruguay. We find that prices of US$ 0.07 and US$ 0.10 per unit decreased the number of bags used by its customers in the range of 70%–85%. We also find that in anticipation of the price, customers increased the use of bags by up to 38% in some branches before its implementation. This result has strong implications for future studies, regarding the need to use long pre-periods. According to our data, short pre periods could bias upward the estimation of the effect of the prices by up to 41%. Finally, we do not find evidence consistent with the supermarket suffering a loss of sales, due to clients moving to stores not pricing the bags. The fact that the supermarket is a discount chain (clients are more price sensitive) and that it seems to have chosen the cities and towns in which it had more market share to rollout the prices, may inform policy makers about the conditions under which incomplete and moderate incentives may work.

Check It: A Community-Based Chlamydia Seek, Test, and Treat Program for Young Black Men Who Have Sex With Women in New Orleans, Louisiana.

Check It is a novel, bundled, community-based seek, test, and treat Chlamydia trachomatis (Ct) screening program for 15- to 24-year-old Black men in New Orleans who have sex with women. The program design addressed barriers and facilitators to Ct screening/treatment by enlisting trusted community partners, incorporating participant input, providing free index/partner expedited treatment, developing relatable marketing materials and an educational Web site, encouraging peer referral, and providing a modest monetary incentive. Areas of high poverty were identified using census data; ethnographic/key informant interviews identified sites in those areas where the target population congregated. Black youth informed Web site design and social marketing. Content was inspirational/educational/amusing and endorsed recruitment and brand awareness. A community advisory board, participant interviews, community partner feedback, and recruitment staff involvement in the process evaluation helped refine the program in an ongoing manner. During formative stages, 41 key informant/community advisory board members informed program refinement. Community partners provided venue locations (n = 65) and participant referrals. Between May 22, 2017, and February 28, 2020, 1890 men were enrolled (acceptance rate, 96.0%) with Ct infection rate of 10.2%. Overall study treatment was provided to 86.1% (71.4%-90.9%) of participants who tested positive and 28.5% (14.5%-41.5%) of their partners. Findings from in-depth interviews with participants (n = 43) led to increased treatment uptake. C. trachomatis community screening of young Black men was successful through collaboration with trusted community partners, by tailoring implements/marketing with participant input, reducing barriers to treatment, and providing modest monetary incentives. The Check It program can serve as a roadmap for reducing health disparities in this population.

MANAJEMEN PENINGKATAN MUTU SARANA DAN PRASARANA PENDIDIKAN DI MADRASAH TSANAWIYAH WAHID HASYIM BADEGAN PONOROGO

According to Permendiknas No. 13 of 2007 concerning the competencies of principals, it was stated that a principal/madrasah must have five competencies namely personality competence, managerial competence, entrepreneurial competence, supervision competency and social competence. A madrasah head as a manager is required to be able to have managerial readiness in managing eight national education standards, one of which is the standard of educational infrastructure. Based on the survey, the condition of educational infrastructure in Madrasah Tsanawiyah Wahid Hasyim Badegan Ponorogo has decreased even in the last ten years which has decreased the number of students and student achievement. But since the 2017/2018 school year with the existence of a new madrasah head, the quality of infrastructure has improved. The madrasah head develops more managerial competencies in improving the quality of infrastructure in his madrasah. So that it succeeded in increasing student achievement such as the champion of the drumb band competition in Ponorogo Regency, had a computer laboratory that could be used for the Computer Based National Examination (UNBK) for 9th grade students, had a two storey building for teacher's room, madrasah head room, and classrooms.&#x0D; His study aims to explain the managerial competence of madrasa principals in improving the quality of educational infrastructure in Madrasah Tsanawiyah Wahid Hasyim Badegan Ponorogo in terms of management functions which include planning, organizing, implementing and controlling. &#x0D; Data collected through interviews, observations, and documentation. The validity of the data is measured by lengthening observations, perseverance of observations, triangulation, discussions with peers and checking. Data analysis through data collection, data reduction, data presentation and drawing conclusions. &#x0D; The results showed the headmaster of madrasa did four things for the management of improving the quality of educational infrastructure. First, planning to carry out the program (1) madrasa head with the foundation and the committee set the goal of improving the quality and quantity of madrasas by improving the quality of educational infrastructure (2) meetings involving foundations, committees, teachers, employees to determine the priority scale of Sarpras in the form of procurement of complete drumband equipment, the addition of music band instruments, the addition of habsyi equipment, the creation of computer laboratories and the construction of buildings for the teacher's room, madrasah headroom, and classrooms, (3) recruiting new teachers who are willing to not work in other institutions. Second, organizing (1) division of labor according to ability based on the meeting of leaders with all deputy head of madrasa, (2) grouping work into three divisions: procurement of computers, building construction, computer laboratories, (3) determination of relations between parts of the organization, through hierarchy authority restrictions. Division members to the division coordinator, then to wakasarpras then to the headmaster of the madrasa, (4) coordination of all divisions. Through regular meetings every Saturday, communication is immediately interrupted by teaching, and communication with mobile phones. Third, implementation by (1) moving all personnel to carry out the task according to the target, using motivational techniques in the form of reward and punishment, (2) calling the problematic teacher or employee to the madrasah headroom to be directed, (3) providing a modest incentive to the task implementer. Fourth, control by conducting (1) setting building standards based on Ministry of Education Regulation No. 33 of 2008, set a two-semester Sarpras realization tarjet, (2) performance appraisal through matching reality with the standards according to standards such as achievements and achievements, two-story building being built, computer laboratories materialized so that UNBK class IX can be used, (3) making corrections and find a way out by increasing fundraising for building improvements.

Farmland Rental Rates: Does Organic Certification Matter?

We estimate U.S. organic farmers’ marginal willingness to pay to rent an acre of certified organic land relative to conventional farmland. Using a selection-on-observables design and farm-level data on farmland rental rates, organic status, and many conditioning variables, we address the role of profitability in mediating the effect of organic status. We find a 26% rental rate premium for organic farmland not driven by higher profits on organic farms. This premium is a modest incentive for landowners but a barrier for tenants to convert to organic farming practices, which may explain limited growth in U.S. organic acreage.

Adding team-based financial incentives to the Carrot Rewards physical activity app increases daily step count on a population scale: a 24-week matched case control study

BackgroundMobile health applications (mHealth apps) targeting physical inactivity have increased in popularity yet are usually limited by low engagement. This study examined the impact of adding team-based incentives (Step Together Challenges, STCs) to an existing mHealth app (Carrot Rewards) that rewarded individual physical activity achievements.MethodsA 24-week quasi-experimental study (retrospective matched pairs design) was conducted in three Canadian provinces (pre-intervention: weeks 1–12; intervention: weeks 13–24). Participants who used Carrot Rewards and STCs (experimental group) were matched with those who used Carrot Rewards only (controls) on age, gender, province and baseline mean daily step count (±500 steps/d). Carrot Rewards users earned individual-level incentives (worth $0.04 CAD) each day they reached a personalized daily step goal. With a single partner, STC users could earn team incentives ($0.40 CAD) for collaboratively reaching individual daily step goals 10 times in seven days (e.g., Partner A completes four goals and Partner B completes six goals in a week).ResultsThe main analysis included 61,170 users (mean age = 32 yrs.; % female = 64). Controlling for pre-intervention mean daily step count, a significant difference in intervention mean daily step count favoured the experimental group (p < 0.0001; ηp2 = 0.024). The estimated marginal mean group difference was 537 steps per day, or 3759 steps per week (about 40 walking min/wk). Linear regression suggested a dose-response relationship between the number of STCs completed (app engagement) and intervention mean daily step count (adjusted R2 = 0.699) with each new STC corresponding to approximately 200 more steps per day.ConclusionDespite an explosion of physical activity app interest, low engagement leading to small or no effects remains an industry hallmark. In this paper, we found that adding modest team-based incentives to the Carrot Rewards app increased mean daily step count, and importantly, app engagement moderated this effect. Others should consider novel small-teams based approaches to boost engagement and effects.

Securing the future of kidney transplantation by addressing the challenges of transplant nephrology.

Kidney transplant is a life-changing procedure, and transplant nephrologists, as part of a larger transplant team, play an important role in the field by managing the complex medical needs of transplant patients. The subspecialty of transplant nephrology, however, faces structural challenges related to its workforce, reporting structures, compensation, research and innovation, and health care information technology. The position of transplant nephrology at the academic and operational intersection of medicine and surgery may limit its access to critical resources, hinder academic promotion, and contribute to physician burnout. The authors provide an overview of the subspecialty transplant nephrology and propose solutions. Collaborative efforts that fortify the subspecialty of transplant nephrology will ultimately improve the lives of patients suffering from kidney disease.

Sustaining the reach of a scalable weight loss intervention through financial incentives- a pragmatic, feasibility, online randomized trial protocol

BackgroundHigh attrition following initial enrollment in evidence-based weight loss programs is a common, challenging, and under-studied issue. A behavioral economics approach consisting of modest monetary incentives may help to engage participants beyond enrollment to close the initial attrition gap. PurposeTo describe the methods and design of a pragmatic, online randomized controlled trial (RCT) of an incentivized, technology-facilitated weight loss program through an innovative research-practice partnership involving primary care, health promotion researchers, and a small business. MethodsThis study is a four-arm (1:1:1:1) RCT that compares the efficacy of outcome-based (weight loss), process-based (weighing in), a combination of outcome- and process-based, or choice-based incentives on sustaining program reach after initial enrollment for an evidence-based weight loss program. The multicomponent weight loss program includes a website, social cognitive theory-based daily health coaching, tailored messaging delivered via email and text messaging, access to online health coaches, and objective weight assessment through a community kiosk. The study will enroll 400 individuals aged 19 and older who have a body mass index ≥25 kg/m2, and have reliable access to the Internet or a smart phone. Participants will be followed for 3, 6, 9, and 12 months to assess program reach and representativeness, and continued participation after enrollment. The secondary outcomes include weight loss and program implementation costs. We will conduct participant focus groups to understand the barriers and facilitators of participation and key informant interviews focusing on clinic managers and care providers to explore the potential for future adoption and implementation of the evidence-based program. DiscussionThis study possesses the potential to close the attrition gap after initial enrollment in a web-based digital weight loss intervention in the primary care and community settings. Clinicaltrials.gov registration: NCT04225234.

Hormonal contraceptive use and competitive persistence

To investigate the effects of two monetary incentives on response rates to postal questionnaires from primary care physicians (PCPs).The PCPs were randomized into three arms (n = 550 per arm), namely (1) €5 sent with the questionnaire (cash); (2) entry into a draw on return of completed questionnaire (prize); or (3) no incentive. Effects of incentives on response rates and item nonresponse were examined, as was cost-effectiveness.Response rates were significantly higher in the cash (66.1%; 95% confidence interval [CI]: 61.9, 70.4%) and prize arms (44.8%; 95% CI: 40.1, 49.3%) compared with the no-incentive arm (39.9%; 95% CI: 35.4, 44.3%). Adjusted relative risk of response was 1.17 (95% CI: 1.02, 1.35) and 1.68 (95% CI: 1.48, 1.91) in the prize and cash arms, respectively, compared with the no-incentive group. Costs per completed questionnaire were €9.85, €11.15, and €6.31 for the cash, prize, and no-incentive arms, respectively. Compared with the no-incentive arm, costs per additional questionnaire returned in the cash and prize arms were €14.72 and €37.20, respectively.Both a modest cash incentive and entry into a prize draw were effective in increasing response rates. The cash incentive was most effective and the most cost-effective. Where it is important to maximize response, a modest cash incentive may be cost-effective.

Designing effective incentives for living shorelines as a habitat conservation strategy along residential coasts

AbstractShoreline armoring is a pervasive driver of habitat loss and ecosystem decline along coastlines. Nature‐based strategies for coastal protection, such as “living shorelines,” offer potential alternatives to armoring and are rapidly gaining traction among conservation scientists and practitioners. However, along residential coasts where armoring has often occurred at high rates, transitioning away from armoring has been generally slow. We studied the attitudes, beliefs, and decisions of waterfront homeowners with a goal of identifying effective incentives for living shorelines as a conservation tool for reversing coastal habitat loss. We show that while only 18% of homeowners with armored shorelines would willingly transition to living shorelines during a key window of opportunity, a modest economic incentive could increase the likelihood among 43% of all respondents and up to 61% of recent homeowners. Our study demonstrates potential pathways for navigating social, economic, and environmental influences on landowner decisions for coastal habitat conservation.

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.