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Using financial incentives to achieve healthy behaviour
Abstract
Personal financial incentives are increasingly being used to motivate patients and general populations to change their behaviour, most often as part of schemes aimed at reducing rates of obesity, smoking, and other addictive behaviours (table⇓). Opinion on their use varies, with incentives being described both as “key to reducing smoking, alcohol and obesity rates” and as “a form of bribery” and “rewarding people for unhealthy behaviour.” We review evidence on the effectiveness of financial incentives in achieving health related behaviour change and examine the basis for moral and other concerns about their use.
... Upon accessing the incentives, participants were still required to complete a sequence of actions to engage in the target behaviour. For example, to use the bus voucher participants have to activate the voucher, be aware of the bus timetable and travel to the bus stop and more sophisticated rewards systems may be required for complex behaviours such as these (Marteau et al., 2009;Sutherland et al., 2008). Furthermore, theory suggests that the ability to execute complex sequences of action is associated with sociodemographic position, thus potentially increasing sociodemographic inequalities in health. ...
... Our findings suggest that non-contingent financial incentives operate through a sequence of cognitive and behavioural steps, dependent on environmental and individual context. Previous literature has described the importance of the conditions surrounding incentives on their success (Marteau et al., 2009), citing extraneous circumstances such as public transport availability, frequency and routes (Bamberg, 2006;Thøgersen, 2009). Therefore, it is vital that financial incentives and the environment operate in synergy to achieve their potential. ...
... Financial incentives may address deficiencies in psychological capability (awareness), physical environment (cost) or reflective motivation (prompt), however it is feasible that deficiencies remain within other parts of the COM-B model that prevent behaviour change. These differences in environmental and individual contexts in which financial incentive studies are implemented may affect their acceptability and effectiveness (Martin et al., 2012;Marteau et al., 2009) and should be described to identify contextual factors that explain intervention effectiveness (Marteau et al., 2009). ...
Introduction: Alternatives to the car, such as walking, cycling and public transport can integrate physical activity into everyday life. Interventions promoting alternatives to the car targeting individual behaviour have shown modest effects, and supportive environments appear important. Methods: This mixed-method study assesses the scientific and operational feasibility of conducting a randomised controlled trial (RCT) of individual financial incentives within a supportive physical environment. We invited residents of Northstowe, Cambridgeshire, UK who had not previously claimed financial incentives to complete a baseline questionnaire assessing socio-demographic characteristics and travel behaviour. On completion, households were randomly assigned to (1) control-claimed incentives online; (2) intervention-received incentives via email; and (3) intervention plus-received greater value incentives via email. We assessed incentive use via questionnaires at three and six months. Longitudinal qualitative interviews at baseline, three months and six months elicited views of incentives and factors influencing use. Results: 99 residents from 88 households (household response rate: 88/475 (19%)) completed the baseline questionnaire and were randomised at household level. The local authority delivered all incentives. Compared to the control group, incentive use was higher in the intervention and intervention plus groups at six months, but there was little difference between intervention and intervention plus group. Qualitative data suggests that incentives worked by prompting existing intentions, raising awareness of alternative travel modes and to a lesser degree by reducing travel cost. This resulted in some new leisure travel behaviour, but most often to subsidise existing travel. Qualitative data suggests that existing travel preferences and environmental conditions influenced incentive use. Conclusion: It is feasible to deliver an RCT in collaboration with a local authority and future trials should account for recruitment challenges. Reducing the effort required to obtain incentives increased their use, but future research should investigate the surrounding enabling environmental contexts.
... Financial incentives operate by providing an immediate reward for a behavior that will lead to long term health Abbreviations: CCT, conditional cash transfer; MCH, maternal and child health; CU5, children under-five; SURE-P, Subsidy Reinvestment and Empowerment Programme; SURE-P/MCH Subsidy Reinvestment and Empowerment Programme, Maternal and Child health; CHEW, Community health extension worker; PHC, Primary health centre; VHW, village health worker; WDC, ward development committee; ANC, ante-natal care; HMIS, health management information system. improvements (11). The incentives also influence health system actors on the demand side (to access the right services at the right time) and on the supply side (to provide the right services, of high quality, to all those who need them) (12). ...
... CCT in healthcare programmes functions by providing financial incentives to its users (specific population) to promote health-seeking behavior and create a positive impact on their health (11). CCTs have been suggested to potentially tackle financial barriers and motivational barriers to care-seeking and service utilization among beneficiaries (19,20). ...
... CCTs seems to be particularly beneficial to poorer households, on the condition that those households will meet certain criteria such as periodic growth monitoring, up-to-date vaccinations, focused ANC, facility delivery, etc. to a health facility (18,21,22). While acknowledging the positive outcome of CCTs on health, of which has been the focus of most studies in recent times, scholars have called for greater attention to studying unintended consequences and moral concerns related to CCTs arising in a variety of local contexts (11,(23)(24)(25). The designs of CCT can be broadly similar but the specific designs are very different with regards to incentive size, time, duration etc. and these factors can make a difference (26). ...
Background: Increasing access to maternal and child health (MCH) services is crucial to achieving universal health coverage (UHC) among pregnant women and children under-five (CU5). The Nigerian government between 2012 and 2015 implemented an innovative MCH programme to reduce maternal and CU5 mortality by reducing financial barriers of access to essential health services. The study explores how the implementation of a financial incentive through conditional cash transfer (CCT) influenced the uptake of MCH services in the programme.
Methods: The study used a descriptive exploratory approach in Anambra state, southeast Nigeria. Data was collected through qualitative [in-depth interviews (IDIs), focus group discussions (FGDs)] and quantitative (service utilization data pre- and post-programme) methods. Twenty-six IDIs were conducted with respondents who were purposively selected to include frontline health workers (n = 13), National and State policymakers and programme managers (n = 13). A total of sixteen FGDs were conducted with service users and their family members, village health workers, and ward development committee members from four rural communities. We drew majorly upon Skinner's reinforcement theory which focuses on human behavior in our interpretation of the influence of CCT in the uptake of MCH services. Manual content analysis was used in data analysis to pull together core themes running through the entire data set.
Results: The CCTs contributed to increasing facility attendance and utilization of MCH services by reducing the financial barrier to accessing healthcare among pregnant women. However, there were unintended consequences of CCT which included a reduction in birth spacing intervals, and a reduction of trust in the health system when the CCT was suddenly withdrawn by the government.
Conclusion: CCT improved the utilization of MCH, but the sudden withdrawal of the CCT led to the opposite effect because people were discouraged due to lack of trust in government to keep using the MCH services. Understanding the intended and unintended outcomes of CCT will help to build sustainable structures in policy designs to mitigate sudden programme withdrawal and its subsequent effects on target beneficiaries and the health system at large.
... However, opinion on the use of financial incentive interventions varies widely; while some believe such incentives play an important role in the promotion of health behaviours, they can be viewed as a form of bribery or coercion, and are perceived by some to undermine individual autonomy [16,17]. Financial incentives have been found to be less acceptable than other methods of behaviour change, such as education or peer support [18], although acceptability has been shown to increase with reported effectiveness [19]. ...
... The findings support previous research which has found that financial incentives may be viewed as a bribe or form of coercion [16,17], a concern that a number of participants expressed. However, this concern was often based on the misconception that the incentive was dependent on vaccination receipt, rather than consent form return. ...
... As previously discussed, incentivising vaccination receipt has ethical implications that mean it is not likely to be an acceptable option for improving HPV vaccination rates [16][17][18]. Our findings demonstrate that incentivising consent form return instead of vaccine receipt, is a moderately acceptable form of intervention for those receiving and delivering the incentive, which may have implications for the types of interventions used, not only within the HPV vaccination context, but potentially within the context of other school-based vaccinations. ...
Background
Uptake of human papillomavirus (HPV) vaccination is high overall but there are disparities in uptake, particularly by ethnicity. Incentivising vaccination consent form return is a promising approach to increase vaccination uptake. As part of a randomised feasibility trial we qualitatively assessed the acceptability of increasing uptake of HPV vaccination by incentivising consent form return.
Methods
In the context of a two-arm, cluster randomised feasibility trial, qualitative free-text questionnaire responses were collected from adolescent girls (n = 181) and their parents (n = 61), assessing the acceptability of an incentive intervention to increase HPV vaccination consent form return. In the incentive intervention arm, girls who returned a signed consent form (regardless of whether consent was given or refused), had a 1-in-10 chance of winning a £50 shopping voucher. Telephone interviews were also conducted with members of staff from participating schools (n = 6), assessing the acceptability of the incentive. Data were analysed thematically.
Results
Girls and parents provided a mix of positive, negative and ambivalent responses about the use of the incentive to encourage HPV vaccination consent form return. Both girls and parents held misconceptions about the nature of the incentive, wrongly believing that the incentive was dependent on vaccination receipt rather than consent form return. School staff members also expressed a mix of opinions on the acceptability of the incentive, including perceptions of effectiveness and ethics.
Conclusions
The use of an incentive intervention to encourage the return of HPV vaccination consent forms was found to be moderately acceptable to those receiving and delivering the intervention, although a number of changes are required to improve this. In particular, improving communication about the nature of the incentive to reduce misconceptions is vital. These findings suggest that incentivising consent form return may be an acceptable means of improving HPV vaccination rates, should improvements be made.
Trial registration
ISRCTN Registry; ISRCTN72136061, 26 September 2016, retrospectively registered.
... It uses regulatory approaches to address the broader, structural environment or mandates the implementation of behaviorally informed interventions (Smith & Toprakkiran, 2019). Examples of nudge-type policies include: modifying the built environment to encourage physical activity; utilizing pre-commitment strategies to commit to more healthy decisions; using payment mechanisms such as prepaid cards and vouchers to make the purchase of healthy options easier (UK Cabinet Office Behavioral Insights Team, 2010); or capitalizing on present-biased preferences by using financial incentives to provide more immediate rewards for healthy behavior (Marteau et al., 2009). For the individual who discounts future costs of obesity-related health problems, payment to engage in physical activity modifies the present costs and benefits of exercising today rather than putting it off to tomorrow. ...
... T A B L E 1 Attributes and levels and harder to make unhealthy food choices (Just et al., 2008). Paying individuals to engage in healthy behavior is increasingly being considered (Marteau et al., 2009) including in the context of nutrition and physical exercise (Paul-Ebhohimhen & Avenell, 2008;Promberger et al., 2012). The policy of improvements to the built environment had a wider set of potential impacts, with benefits beyond obesity. ...
The obesity epidemic is a significant public policy issue facing the international community, resulting in substantial costs to individuals and society. Various policies have been suggested to reduce and prevent obesity, including those informed by standard economics (a key feature of which is the assumption that individuals are rational) and behavioral economics (which identifies and harness deviations from rationality). It is not known which policy interventions taxpayers find acceptable and would prefer to fund via taxation. We provide evidence from a discrete choice experiment on an Australian sample of 996 individuals to investigate social acceptability of eight policies: mass media campaign; traffic light nutritional labeling; taxing sugar sweetened beverages; prepaid cards to purchase healthy food; financial incentives to exercise; improved built environment for physical activity; bans on advertising unhealthy food and drink to children; and improved nutritional quality of food sold in public institutions. Latent class analysis revealed three classes differing in preferences and key respondent characteristics including capacity to benefit. Social acceptability of the eight policies at realistic levels of tax increases was explored using post-estimation analysis. Overall, 78% of the sample were predicted to choose a new policy, varying from 99% in those most likely to benefit from obesity interventions to 19% of those least likely to benefit. A policy informed by standard economics, traffic light labeling was the most popular policy, followed by policies involving regulation: bans on junk food advertising to children and improvement of food quality in public institutions. The least popular policies were behaviorally informed: prepaid cards for the purchase of only healthy foods, and financial incentives to exercise.
... In the present study, participants suggested that subsidizing or eliminating entrance fees to venues where football games are televised would potentially increase attendance of the televised games and may also result in increased use of HIV testing services. The role of incentives in positively influencing health behavior has been highlighted in previous studies [38][39][40][41]. With respect to HIV testing, incentivized programs demonstrated a positive effect in increasing use of HIV testing services in both adult men [42][43][44] and in children and older adolescents [45]. ...
... This might address some of the limitations plaguing community-based HIV screening services. However, the design of such a study would still need to take into consideration concerns of equity in regard to gender and socioeconomic status, coercion, and other ethical challenges which arise in relation to using incentives to modify health behavior [41,46]. A non-monetary incentivized HTC service approach at these venues coupled with the rapidly growing concept of HIV selftesting [44], holds promise in optimizing HIV testing among men. ...
Background:
Worldwide, HIV remains a major public health challenge, especially in Sub-Saharan Africa. Literature indicates that men's involvement in HIV testing, care, and treatment services is lower compared to women, therefore novel approaches are required to engage men in the cascade of HIV care. This study aimed to explore men's perception on the provision of HIV testing services in venues where English Premier League football games are televised.
Methods:
An exploratory qualitative study was conducted between February and May 2018. Six focus group discussions were conducted with 50 conveniently selected men aged 18 years and older using a pre-tested discussion guide. All focus group discussions were audio recorded, transcribed verbatim, and analyzed thematically.
Results:
Overall, HIV testing at venues telecasting English Premier League football games was acceptable to men. There was a very strong preference for health workers providing testing and counseling services be external or unknown in the local community. Possible motivators for testing services provided in these settings include subsidizing or eliminating entrance fee to venues telecasting games, integrating testing and counseling with health promotion or screening for other diseases, use of local football games as mobilization tools and use of expert clients as role models.
Conclusions:
This study suggests that HIV testing services at venues where EPL football games are televised is generally acceptable to men. In implementing such services, consideration should be given to preferences for external or unknown health workers and the motivating factors contributing to the use of these services. Given that HIV testing is currently not conducted in these settings, further research should be conducted to evaluate the feasibility of this approach as a means of enhancing HIV testing among Ugandan men.
... But widespread concerns do exist and tend to center on the potentially coercive impact of using incentives and the 'unfairness' of rewarding people for doing things that are already in their own interest [9,10]. We share some of those reservations, but rather than adding further to this normative debate, we will focus herein on positive ways in which we might give incentives the best opportunity to work if and when they are considered appropriate. ...
... Marteau et al. [9] suggest a psychological perspective that can help us think about the appropriateness of using incentives for encouraging participation screening tests. It is known that individuals do not always act according to their long-term goals and interests. ...
Background:
Incentives are central to economics and are used across the public and private sectors to influence behavior. Recent interest has been shown in using financial incentives to promote desirable health behaviors and discourage unhealthy ones.
Main text:
If we are going to use incentive schemes to influence health behaviors, then it is important that we give them the best chance of working. Behavioral economics integrates insights from psychology with the laws of economics and provides a number of robust psychological phenomena that help to better explain human behavior. Individuals' decisions in relation to incentives may be shaped by more subtle features - such as loss aversion, overweighting of small probabilities, hyperbolic discounting, increasing payoffs, reference points - many of which have been identified through research in behavioral economics. If incentives are shown to be a useful strategy to influence health behavior, a wider discussion will need to be had about the ethical dimensions of incentives before their wider implementation in different health programmes.
Conclusions:
Policy makers across the world are increasingly taking note of lessons from behavioral economics and this paper explores how key principles could help public health practitioners design effective interventions both in relation to incentive designs and more widely.
... Financial incentives operate by providing an immediate reward for a behaviour that will lead to long term health improvements (Marteau, Ashcroft, & Oliver, 2009). Such programmes have become increasingly popular across low and middle-income countries (LMICs)particularly conditional cash transfers (CCTs), which maintain strong support from international funding institutions, such as the World Bank and the International Monetary Fund (IMF). ...
... A lack of ethnographic studies that would be able to adequately assess empowerment effects and a deeper understanding of the lived experiences of women may have distorted the picture that we have of CCTs (Cookson, 2018;Handl & Spronk, 2015). While acknowledging the positive role that CCTs can have on health, scholars have called for greater attention to studying unintended consequences of and moral concerns related to CCTs arising in a variety of contexts (Cookson, 2018;Marteau et al., 2009;Powell-Jackson, Mazumdar, & Mills, 2015). ...
The use of financial incentives is a common instrument to advance women’s health across low and middle-income countries. Since the 1990s, the conditional cash transfer (CCT) for health has been generally lauded by researchers, policy makers and international financial institutions due to demonstrated improvements in access to health services and a range of health outcomes. Some scholars, however, have cautioned that CCTs should be further scrutinised to assess potential unintended consequences and moral concerns in a variety of contexts. In this article, I re-examine Janani Suraksha Yojana (JSY), a cash incentive programme that aims to promote institutional deliveries in order to reduce high levels of home deliveries and maternal deaths in India. I adopt a critical perspective, focusing on the specific instrument of dowry through the lens of capitalist patriarchy (Mies, M. (1986). Patriarchy and accumulation on a world scale. London: Zed Books). Global and national health policy experts and policy makers require a greater awareness of the dowry system, since this system may hamper the use of financial incentives by reinforcing the commodification of women.
... For example, an offer of incentives for vaccinating one's children represents an unwelcome offer for parents who are opposed to vaccination. Now, provision of CCTs for healthy behaviours, including behaviours that promote public health, raise ethical issues on many levels (Lunze and Paasche-Orlow 2013;Marteau et al. 2009), including the design of CCTs schemes, their implementation, and their possible unintended consequences. Carleigh Krubiner and Maria Merritt have argued that in designing CCT interventions, policymakers should attend five types of considerations. ...
... Moreover, once implemented, CCT programs raise distinctive ethical issues. These include, among others, the potential of incentives for bribery (paying people to act against their wishes), coercion, paternalism, unfairness (it might be argued that people should not be paid to do what they ought to do anyway), and poor use of scarce financial resources (Marteau et al. 2009). Finally, other concerns arise with regard to the possible unintended consequences of CCTs, such as the "crowding out" of intrinsic motivation (Krubiner and Merritt 2017, p. 170). ...
This open access book discusses individual, collective, and institutional responsibilities with regard to vaccination from the perspective of philosophy and public health ethics. It addresses the issue of what it means for a collective to be morally responsible for the realisation of herd immunity and what the implications of collective responsibility are for individual and institutional responsibilities.
The first chapter introduces some key concepts in the vaccination debate, such as ‘herd immunity’, ‘public goods’, and ‘vaccine refusal’; and explains why failure to vaccinate raises certain ethical issues. The second chapter analyses, from a philosophical perspective, the relationship between individual, collective, and institutional responsibilities with regard to the realisation of herd immunity. The third chapter is about the principle of least restrictive alternative in public health ethics and its implications for vaccination policies. Finally, the fourth chapter presents an ethical argument for unqualified compulsory vaccination, i.e. for compulsory vaccination that does not allow for any conscientious objection.
The book would appeal both philosophers interested in public health ethics and the general public interested in the philosophical underpinning of different arguments about our moral obligations with regard to vaccination.
... For example, an offer of incentives for vaccinating one's children represents an unwelcome offer for parents who are opposed to vaccination. Now, provision of CCTs for healthy behaviours, including behaviours that promote public health, raise ethical issues on many levels (Lunze and Paasche-Orlow 2013;Marteau et al. 2009), including the design of CCTs schemes, their implementation, and their possible unintended consequences. Carleigh Krubiner and Maria Merritt have argued that in designing CCT interventions, policymakers should attend five types of considerations. ...
... Moreover, once implemented, CCT programs raise distinctive ethical issues. These include, among others, the potential of incentives for bribery (paying people to act against their wishes), coercion, paternalism, unfairness (it might be argued that people should not be paid to do what they ought to do anyway), and poor use of scarce financial resources (Marteau et al. 2009). Finally, other concerns arise with regard to the possible unintended consequences of CCTs, such as the "crowding out" of intrinsic motivation (Krubiner and Merritt 2017, p. 170). ...
This first chapter introduces some ethically relevant concepts that illustrate why we need an “ethics of vaccination”, such as “herd immunity”, “public good”, and “vaccine refusal”. It argues that the choice whether to vaccinate oneself or one’s children is by its own nature an “ethical” choice: it requires individuals to act not only or even not primarily to promote their self-interest but also or even primarily to contribute to an important public good like herd immunity. Besides, since herd immunity is an important public good, ethical questions arise also at the level of state action with regard to the obligations to implement vaccination policies, if necessary coercive ones, that allow to realize herd immunity.
... For example, an offer of incentives for vaccinating one's children represents an unwelcome offer for parents who are opposed to vaccination. Now, provision of CCTs for healthy behaviours, including behaviours that promote public health, raise ethical issues on many levels (Lunze and Paasche-Orlow 2013;Marteau et al. 2009), including the design of CCTs schemes, their implementation, and their possible unintended consequences. Carleigh Krubiner and Maria Merritt have argued that in designing CCT interventions, policymakers should attend five types of considerations. ...
... Moreover, once implemented, CCT programs raise distinctive ethical issues. These include, among others, the potential of incentives for bribery (paying people to act against their wishes), coercion, paternalism, unfairness (it might be argued that people should not be paid to do what they ought to do anyway), and poor use of scarce financial resources (Marteau et al. 2009). Finally, other concerns arise with regard to the possible unintended consequences of CCTs, such as the "crowding out" of intrinsic motivation (Krubiner and Merritt 2017, p. 170). ...
This chapter presents an argument for compulsory vaccination and against allowing non-medical vaccine exemptions. The argument is based on the idea that the proper aim of vaccination policies should be not only herd immunity but also a fair distribution of the burdens entailed by its realization. I argue that a fairness requirement need not and should not be constrained by a principle of liberty and a principle of least restrictive alternative. Indeed, I argue how compulsory vaccination is more successful than other types of vaccination policies at satisfying the principles of fairness, least restrictive alternative, and maximizing expected utility, once these principles have been properly understood.
... For example, an offer of incentives for vaccinating one's children represents an unwelcome offer for parents who are opposed to vaccination. Now, provision of CCTs for healthy behaviours, including behaviours that promote public health, raise ethical issues on many levels (Lunze and Paasche-Orlow 2013;Marteau et al. 2009), including the design of CCTs schemes, their implementation, and their possible unintended consequences. Carleigh Krubiner and Maria Merritt have argued that in designing CCT interventions, policymakers should attend five types of considerations. ...
... Moreover, once implemented, CCT programs raise distinctive ethical issues. These include, among others, the potential of incentives for bribery (paying people to act against their wishes), coercion, paternalism, unfairness (it might be argued that people should not be paid to do what they ought to do anyway), and poor use of scarce financial resources (Marteau et al. 2009). Finally, other concerns arise with regard to the possible unintended consequences of CCTs, such as the "crowding out" of intrinsic motivation (Krubiner and Merritt 2017, p. 170). ...
This chapter discusses the relation between collective, individual, and institutional responsibilities with regard to the realization of herd immunity from certain infectious diseases. The argument is put forth that there is a form of collective moral obligation to realize herd immunity, that there is a principle of fairness in the distribution of the burdens of collective obligations, and that such principle entails that each of us has the individual moral responsibility to make their fair contribution to herd immunity through vaccination. These individual moral obligations, in turn, entail a further individual obligation to support policies aimed at realizing herd immunity. The chapter concludes with a suggestion that the individual moral obligations to support such policies generate an institutional responsibility to implement them.
... For example, an offer of incentives for vaccinating one's children represents an unwelcome offer for parents who are opposed to vaccination. Now, provision of CCTs for healthy behaviours, including behaviours that promote public health, raise ethical issues on many levels (Lunze and Paasche-Orlow 2013;Marteau et al. 2009), including the design of CCTs schemes, their implementation, and their possible unintended consequences. Carleigh Krubiner and Maria Merritt have argued that in designing CCT interventions, policymakers should attend five types of considerations. ...
... Moreover, once implemented, CCT programs raise distinctive ethical issues. These include, among others, the potential of incentives for bribery (paying people to act against their wishes), coercion, paternalism, unfairness (it might be argued that people should not be paid to do what they ought to do anyway), and poor use of scarce financial resources (Marteau et al. 2009). Finally, other concerns arise with regard to the possible unintended consequences of CCTs, such as the "crowding out" of intrinsic motivation (Krubiner and Merritt 2017, p. 170). ...
The principle of least restrictive alternative (PLRA) states that policymakers have significant reason to implement the policy that is effective in achieving a certain result and that is least restrictive of individual liberty or autonomy. This chapter provides a ranking of vaccination policies, or an intervention ladder, on the basis of the PLRA, assessing the level of coercion of each type of policy. The ranking of vaccination policies I suggest, in order of increasing restrictiveness or coerciveness, is as follows: persuasion, nudging, financial incentives, disincentives (including withholding of financial benefits, taxation, and mandatory vaccination), and outright compulsion. Each type of policy suggestion is presented with a discussion of the level of restrictiveness or coerciveness involved and the potential effectiveness.
... One possible scenario could be establishing premium systems that reward or penalize individuals based on their health behavior. Such systems could lead to increased insurance costs or reduced benefits for those categorized as leading unhealthy lifestyles or reward individuals that achieve healthy behavior [23]. Permanent surveillance reminds us of the characteristics of a state of surveillance, potentially resulting in different psychological and social effects. ...
This Paper explores how emergent technologies such as 6G and tactile Internet can potentially enhance cognitive, personal informatics (CPI) in participatory healthcare, promoting patient-centered healthcare models through high-speed, reliable communication networks. It highlights the transition to improved patient engagement and better health outcomes facilitated by these technologies, underscoring the importance of ultra-reliable, low-latency communications (URLLC) and realizing the tactile Internet’s potential in healthcare. This innovation could dramatically transform telemedicine and mobile health (mHealth) by enabling remote healthcare delivery while providing a better understanding of the inner workings of the patient. While generating many advantages, these developments have disadvantages and risks. Therefore, this study addresses the critical security and privacy concerns related to the digital transformation of healthcare. Our work focuses on the challenges of managing and understanding cognitive data within the CPI and the potential threats from analyzing such data. It proposed a comprehensive analysis of potential vulnerabilities and cyber threats, emphasizing the need for robust security frameworks designed with resilience in mind to protect sensitive cognitive data. We present scenarios for reward and punishment systems and their impacts on users. In conclusion, we outline a vision for the future of secure, resilient, and patient-centric digital healthcare systems that leverage 6G and the tactile Internet to enhance the CPI. We offer policy recommendations and strategic directions for stakeholders to create a secure, empowering environment for patients to manage their cognitive health information.
... The offer of financial incentives may be criticised as a subtle form of coercion, or as having the potential to undermine intrinsic motivation for positive health behaviour. In some cases, the offer of a financial incentive may affect a person's judgement about the risk of potential harm, undermining a person's autonomy [17]. However, people do not always act how they would like to, so an alternative perspective is that financial incentives enhance rather than restrict autonomy as they can help people align their actions with their preferences. ...
Background
Untreated hepatitis C virus (HCV) infection can result in cirrhosis and hepatocellular cancer. Direct-acting antiviral (DAA) therapies are highly effective and have few side effects compared to older interferon-based therapy. Despite the Australian government providing subsidised and unrestricted access to DAA therapy for chronic HCV infection, uptake has not been sufficient to meet the global target of eliminating HCV as a public health threat by 2030. This study will offer people with HCV financial incentives of varying values in order to evaluate its effect on initiation of DAA therapy in primary care.
Methods
Australian adults (18 years or older) who self-report as having current untreated HCV infection can register to participate via an automated SMS-based system. Following self-screening for eligibility, registrants are offered a financial incentive of randomised value (AUD 0 to 1000) to initiate DAA therapy. Study treatment navigators contact registrants who have consented to be contacted, to complete eligibility assessment, outline the study procedures (including the requirement for participants to consult a primary care provider), obtain consent, and finalise enrolment. Enrolled participants receive their offered incentive on provision of evidence of DAA therapy initiation within 12 weeks of registration (primary endpoint). Balanced randomisation is used across the incentive range until the first analysis, after which response-adaptive randomisation will be used to update the assignment probabilities. For the primary analysis, a Bayesian 4-parameter EMAX model will be used to estimate the dose–response curve and contrast treatment initiation at each incentive value against the control arm (AUD 0). Specified secondary statistical and economic analyses will evaluate the effect of incentives on adherence to DAA therapy, virological response, and cost-effectiveness.
Discussion
This project seeks to gain an understanding of the dose–response relationship between incentive value and DAA treatment initiation, while maximising the number of people treated for HCV within fixed budget and time constraints. In doing so, we hope to offer policy-relevant recommendation(s) for the use of financial incentives as a pragmatic, efficient, and cost-effective approach to achieving elimination of HCV from Australia.
Trial registration
ANZCTR (anzctr.org.au), Identifier ACTRN12623000024640, Registered 11 January 2023 (https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384923&isReview=true).
... The debate between penalty and incentive has been long in behavioral economics in the realm of addiction, education (Fryer et al., 2012;Marteau et al., 2009). While the comparative analysis of penalty and incentive in TDM is still limited. ...
Incentive-based travel demand management (IBTDM) programs endow monetary
incentives to encourage travel demand redistribution across space and time. They are more appealing than alternatives such as congestion charging because commuters do not need to pay out of pocket. However, such congestion-alleviation solutions are usually managed by small private companies with constrained incentive budgets. Thus, the incentive should be wisely determined so that a limited incentive budget can be effectively used to fulfill maximum social welfare while maintaining the financial health of the IBTDM program. It is essential to know whether IBTDM is financially sound—that is, whether financial investment in IBTDM will lead to more than the equivalent value in total system travel time reduction. However, optimizing the link-based endowment scheme in a large-scale network is challenging because 1) the objective function and the budget constraint are both characterized by expensive-to-evaluate functions without closed form, and 2) it is a large-scale optimization problem that contains massive amount of decision variables. In this study, a computationally efficient surrogate-based optimization framework that is suitable for high-dimensional problems is proposed. A simulation-based dynamic traffic assignment model is used to evaluate the performance of transportation systems, and a Kriging model with partial least squares acts as the surrogate to approximate the simulation model. The results show that the optimal network-wide link-based incentive scheme improves the performance of the system. The higher the incentive budget, the more effective the incentive and the
lower the marginal utility of the incentive. Furthermore, in a well-designed incentive
scheme, a 1M in total system travel time reduction, which proves the economic viability of IBTDM and provides support for its promotion. IBTDM implemented within smaller regions and tighter incentive budgets produces higher utility ratios.
... Each week, participants were notified by email whether they met their trip target, the smartcard credit they have received (if any), and their trip target for the following week. To assist in the achievement of weekly targets, and support the retention of public transportuse following the cessation of the intervention [20], additional behaviour change support was delivered to intervention group participants in weekly text messages informing participants of the consequences of transportrelated physical activity behaviours, goal setting, and providing social support [21]. These text messages were developed using the Behaviour Change Technique Taxonomy, informed by previous research assessing transport behaviour and physical activity [22] and a prior incentive-based study designed to increase weekly leisure-time physical activity [23]. ...
Background
Public transport users tend to accumulate more physical activity than non-users; however, whether physical activity is increased by financially incentivising public transport use is unknown. The trips4health study aimed to determine the impact of an incentive-based public transport intervention on physical activity.
Methods
A single-blinded randomised control trial of a 16-week incentive-based intervention involved Australian adults who were infrequent bus users (≥ 18 years; used bus ≤ 2 times/week) split equally into intervention and control groups. The intervention group were sent weekly motivational text messages and awarded smartcard bus credit when targets were met. The intervention group and control group received physical activity guidelines. Accelerometer-measured steps/day (primary outcome), self-reported transport-related physical activity (walking and cycling for transport) and total physical activity (min/week and MET-min/week) outcomes were assessed at baseline and follow-up.
Results
Due to the COVID pandemic, the trial was abandoned prior to target sample size achievement and completion of all assessments (N = 110). Steps/day declined in both groups, but by less in the intervention group [-557.9 steps (-7.9%) vs.-1018.3 steps/week (-13.8%)]. In the intervention group, transport-related physical activity increased [80.0 min/week (133.3%); 264.0 MET-min/week (133.3%)] while total physical activity levels saw little change [35.0 min/week (5.5%); 25.5 MET-min/week (1.0%)]. Control group transport-related physical activity decreased [-20.0 min/week (-27.6%); -41.3 MET-min/week (-17.3%)], but total physical activity increased [260.0 min/week (54.5%); 734.3 MET-min/week (37.4%)].
Conclusion
This study found evidence that financial incentive-based intervention to increase public transport use is effective in increasing transport-related physical activity These results warrant future examination of physical activity incentives programs in a fully powered study with longer-term follow-up.
Trial registration
This trial was registered with the Australian and New Zealand Clinical Trials Registry August 14th, 2019: ACTRN12619001136190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377914&isReview=true
... Also, in bioethics we may be subject to present bias, e.g., when we show a stronger preference for addressing more immediate issues, outcomes, or solutions compared to more long-term problems, outcomes, or solutions. When we face with topical cases in the clinic or in the media and are expected to suggest solutions, more long-term and principled issues may be overshadowed [51,52]. ...
Given that biases can distort bioethics work, it has received surprisingly little and fragmented attention compared to in other fields of research. This article provides an overview of potentially relevant biases in bioethics, such as cognitive biases, affective biases, imperatives, and moral biases. Special attention is given to moral biases, which are discussed in terms of (1) Framings, (2) Moral theory bias, (3) Analysis bias, (4) Argumentation bias, and (5) Decision bias. While the overview is not exhaustive and the taxonomy by no means is absolute, it provides initial guidance with respect to assessing the relevance of various biases for specific kinds of bioethics work. One reason why we should identify and address biases in bioethics is that it can help us assess and improve the quality of bioethics work.
... 15 Incentives have been shown to increase other health behaviors such as smoking cessation and immunization. 16 A systematic review published in 2014 found that incentivizing STBBI screening may be a useful tool to increase screening rates, but recommended further research in this area. 17 Given continuing increases in STBBI and evaluation of incentivized STBBI screening programs, an updated review of the efficacy of these interventions was warranted. ...
Background:
Despite increasing access to treatment and screening, rates of sexually transmitted and blood-borne infections (STBBI) continue to rise in high-income countries. The high cost of undiagnosed and untreated STBBI negatively affects individuals, health care systems, and societies. The use of monetary and non-monetary incentives may increase STBBI screening uptake in high-income countries. Incentivized screening programs are most effective when developed specific to context and target population.
Methods:
Our review was performed according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the Cochrane Handbook for Systematic Reviews of Interventions. Inclusion criteria were: English language, high-income countries, primary research studies, and age > 16 years. Study quality was assessed using Joanna Briggs Institute quality assessment tools.
Results:
The search yielded 6219 abstracts. 13 articles met the inclusion criteria. Studies took place in the United States, the United Kingdom, and Australia. Populations screened included: post-secondary and tertiary students, parolees or probationers, youth, and inner-city emergency department patients. Incentivized STBBI screened were human immunodeficiency virus (HIV) (n = 5), chlamydia (n = 7), and multiple infections (n = 1). Incentives offered were monetary (cash/gift cards/not specified) (n = 10), non-monetary (n = 1), and mixed (n = 2). Both monetary and non-monetary incentives enhance STBBI screening in high-income countries.
Conclusion:
Incentivized screening programs are most effective when developed specific to context and target population. Further research is needed to analyze incentivized screening across similar study designs and to evaluate long-term effectiveness.
... Although FI are effective, there are concerns that FI may have unintended consequences when offered in a programmatic setting, such as raising expectations and creating dependency, leading to decreased willingness to continue in care if FI are not provided. In addition to concerns about unintended consequences, ethical issues, such as decreased voluntariness and concerns about equity, underlie potential acceptability of the use of FI to motivate health behavior [18,19]. ...
Children living with HIV experience gaps in HIV testing globally; scaling up evidence-based testing strategies is critical for preventing HIV-related mortality. Financial incentives (FI) were recently demonstrated to increase uptake of pediatric HIV testing. As part of this qualitative follow-up study to the FIT trial (NCT03049917) conducted in Kenya, 54 caregivers participated in individual interviews. Interview transcripts were analyzed to identify considerations for scaling up FI for pediatric testing. Caregivers reported that FI function by directly offsetting costs or nudging caregivers to take action sooner. Caregivers found FI to be feasible and acceptable for broader programmatic implementation, and supported use for a variety of populations. Some concerns were raised about unintended consequences of FI, including caregivers bringing ineligible children to collect incentives and fears about the impact on linkage to care and retention if caregivers become dependent on FI.
... Expectation/reward systems have powerful effects on learning and performance of desired scheduled emptying behaviour because it could provide incentives that change perceptions of the target community (Bresciani et al., 2016;Grant, 2002). Reward and expectation management can take many forms and need to be carefully thought-out (Marteau et al., 2009;Vlaev et al., 2019;DiClemente et al., 2001); IV. Using reference/preference groups to influence perceptions could create attitudes and intentions to perform the desired emptying behaviour (Tom et al., 1987). ...
This paper explores the influence of perception on behaviours associated with emptying of faecal sludge from non-sewered sanitation systems using findings from a study on the emptying behaviour of residents of Khulna city, Bangladesh. The purpose of the study was to highlight perception as a behaviour determinants as well as develop perception management strategies for the design, plan and implementation of effective behaviour change intervention programmes with a focus on ‘scheduled emptying’. The study uses a mixed-method cross-sectional approach to collect data through structured household questionnaire surveys, face-to-face key informant interviews, group interviews, and structured observations. The study revealed that the emptying behaviour of the community was reactive, untimely and unsafe and over half of the systems had never been emptied, which was traced to emptying perceptions that encouraged a laissez-faire attitude within households and the community. The study concluded by proposing a perception management model to achieve behaviour change towards scheduled emptying via perception change.
... They may be politically unpopular as they are intrusive and involve the loss of liberty (although the restriction of environmental harm may benefit the liberty of people in society more widely [Science and Technology Select Committee, 2011]). Pecuniary interventions also require consistent funding in the long term to be sustainable and raise questions around autonomy and power, especially in socioeconomically disadvantaged groups (Marteau et al., 2009). Noncoercive approaches to behavior change have received increasing interest because people retain the freedom to make the choices they wish without concern for legal or financial repercussions, and reliance on political will is lessened (Greenfield & Veríssimo, 2018;Schubert, 2017). ...
Conservationists are increasingly interested in interventions which aim to encourage voluntary behaviour change in environmentally-beneficial ways. We conducted a systematic review to assess the strength of evidence that these interventions will result in desired behaviour change. We started with more than 300 000 records and after critical appraisal of quality identified 128 individual studies that merited inclusion in the review. We classified interventions by thematic area, type of intervention, the number of times audiences were exposed to interventions, and the length of time for which interventions ran. We found strong evidence that education, prompts and feedback interventions will result in positive behaviour change, but the strongest evidence comes from combining multiple interventions in one programme. Neither exposure duration nor frequency had an effect on the likelihood of desired behaviour change. There is a clear need to both improve the quality of impact evaluation conducted, and the reporting standards for intervention results.
... A focus on individual choices generally relies on transferring knowledge, raising awareness and using economic (dis)incentives (see e.g. Ajzen 1991; Godin and Kok 1995; Armitage and Conner 2001; Kollmuss and Agyeman 2002;Marteau et al. 2009). This approach is described as the 'ABC model' (Attitude, Behaviour and Choice, see Shove 2009). ...
... Providing free or subsidised exercise sessions incentivised the participation in the project. It has been suggested that targeting financial incentives to high-risk population may result in greater behaviour change success [24]. However, physical activity is a habitual behaviour and the use of financial incentives may assist in initiating the behaviour but may not necessarily result in long term behaviour change. ...
Background
Engaging in physical activity is essential for maintaining mental and physical health but a high proportion of adults are inactive, especially in areas of socioeconomic deprivation. We evaluated a novel exercise referral scheme funded by Sport England and run by a social enterprise in an area of socioeconomic deprivation in inner London. This study aimed to examine the experiences of participants and staff and to identify barriers and facilitators of implementation and participation in this and potentially similar projects.
Methods
Thirty-five semi-structured interviews with project participants (N = 25) and staff members involved with the project (N = 10) were conducted based at one centre in London in 2017/2018. The interview schedule was informed by the Theoretical Domains Framework. Data was analysed using the Framework method and NVivo software.
Results
Three themes emerged from the data: ‘Not like your regular gym’, Individual journeys and Practical aspects of the scheme. Study participants regarded the environment of the project centre as friendly and sociable. The project differed from a commercial gym by offering free or subsidised membership and the participation of people of all sizes and abilities. Classes were provided free of charge and this, together with mentor support, facilitated participation and continuation in the project. Participants reported changes not only in their physical activity level, but also in their physical and mental health. Additionally, their families’ lifestyle changes were reported. Difficulties of accessing the project included lack of awareness of the project and lack of engagement from key referring groups.
Conclusions
Providing free or subsidised classes incorporating individualised assessment, follow-up and support appeared to facilitate engagement in physical activity among socioeconomically deprived populations. The supportive social context of the centre was a major facilitator. Differing levels of abilities and health status among participants call for special attention. Increasing community and referrer awareness of available exercise referral schemes and enhancing communication between sources of referrals and project staff may help to address access issues.
... The incentive mechanisms can range from providing information that is meant to resonate with basic values, such as using this technology will save lives to material and non-material incentives in the form of (i) paying people for their personal data (e.g., providing tax-rebates, etc.) or (ii) providing priority access to some services (e.g., medical services, etc.). For example, in the past, people successfully adopted healthy behaviours when they received financial incentives [30]. From this, it follows that if incentives are offered people (a) adopt a certain behavior or (b) engage in a behavioral change. ...
UNSTRUCTURED
COVID-19 has shown a relatively low case fatality rate in young healthy individuals, with the majority of this group being asymptomatic or having mild symptoms. However, the severity of the disease among the elderly as well as in individuals with underlying health conditions has caused significant mortality rates worldwide. Understanding this variance amongst different sectors of society and modelling this will enable the different levels of risk to be determined to enable strategies to be applied to different groups. Long established compartmental epidemiological models like SIR and SEIR do not account for the variability encountered in the severity of the SARS-CoV-2 disease across different population groups. To overcome this limitation, it is proposed that a modified model, namely SEIR-v, through which the population is separated into two groups regarding their vulnerability to SARS-CoV2 is applied. This enables the analysis of the spread of the epidemic when different contention measures are applied to different groups in society regarding their vulnerability to the disease. A Monte Carlo simulation adopting the proposed SEIR-v model indicates a large number of deaths could be avoided by slightly decreasing the exposure of vulnerable groups to the disease. From this modelling a number of mechanisms are proposed to limit the exposure of vulnerable individuals to the disease in order to reduce the mortality rate among this group. One option could be the provision of a wristband to vulnerable people and those without a smartphone and contact-tracing app, filling the gap created by systems relying on smartphone apps only.
... The incentive mechanisms can range from providing information that is meant to resonate with basic values, such as using this technology will save lives to material and non-material incentives in the form of (i) paying people for their personal data (e.g., providing tax-rebates, etc.) or (ii) providing priority access to some services (e.g., medical services, etc.). For example, in the past, people successfully adopted healthy behaviours when they received financial incentives [30]. From this, it follows that if incentives are offered people (a) adopt a certain behavior or (b) engage in a behavioral change. ...
COVID-19 has shown a relatively low mortality rate in young healthy individuals, with the majority of this group being asymptomatic or having mild symptoms, while the severity of the disease among individuals with underlying health conditions has caused signiffcant mortality rates worldwide. Understanding these differences in mortality amongst different sectors of society and modelling this will enable the different levels of risk and vulnerabilities to be determined to enable strategies exit the lockdown. However, epidemiological models do not account for the variability encountered in the severity of the SARS-CoV-2 disease across different population groups. To overcome this limitation, it is proposed that a modiffed SEIR model, namely SEIR-v, through which the population is separated into two groups regarding their vulnerability to SARS-CoV-2 is applied. This enables the analysis of the spread of the epidemic when different contention measures are applied to different groups in society regarding their vulnerability to the disease. A Monte Carlo simulation indicates a large number of deaths could be avoided by slightly decreasing the exposure of vulnerable groups to the disease. From this modelling a number of mechanisms can be proposed to limit the exposure of vulnerable individuals to the disease in order to reduce the mortality rate among this group. One option could be the provision of a wristband to vulnerable people and those without a contact-tracing app. By combining very dense contact tracing data from smartphone apps and wristband signals with information about infection status and symptoms, vulnerable people can be protected and kept safer. Widespread utilisation would extend the protection further beyond these high risk groups.
... An alternative option is to use financial incentives to aid with recruitment and retention, as used in other exercise trials to improve health-related behaviours [75][76][77][78]. However, a financial incentive is a confound that may go beyond the confines of what is available in routine practice. ...
Background:
Physical activity and exercise interventions to improve health frequently bring about intended effects under ideal circumstances but often fail to demonstrate benefits in real-world contexts. The aim of this study was to describe the feasibility of an exercise intervention (reduced-exertion, high-intensity interval training) in non-diabetic hyperglycaemia patients delivered in a National Health Service setting to assess whether it would be appropriate to progress to a future large-scale study.
Methods:
The intention was to recruit 40 participants from a single centre (specialist diabesity centre). Patients were eligible to take part if they were diagnostically defined as non-diabetic hyperglycaemic based on a glycated haemoglobin (HbA1c) value of 42-46 mmol mol. Study procedures including recruitment, occurrence of adverse events, intervention acceptability, and intervention adherence were used to assess feasibility.
Results:
Key criteria for progression to a larger study were not met. The study revealed several issues including patient eligibility, challenges to recruitment, patient consent, and poor clinician engagement. Furthermore, despite the simplicity and convenience of using HbA1c to screen for diabetes risk, the process of accurately screening and case finding eligible patients was problematic. The small sample recruited for this trial (n = 6) also limits the interpretation of data, thus it is not possible to estimate the variability of intended outcomes to use in a formal sample size calculation for a full-scale trial. Some aspects of the intervention worked well. The acceptability of the exercise intervention and outcome measures met progression criteria thresholds and adherence was very high, with 97% of exercise sessions completed for participants that finished the study.
Conclusions:
Given the issues, the trial is not feasible in its current form. Yet, this preparatory stage of trial design pre-empted problems with the intervention that could be changed to optimise the design and conduct of future studies. Solutions to the issues identified in this study revolve around using a dedicated local recruiter with a strong relationship among the healthcare team and patients, using participant incentives to take part, and allowing for a longer recruitment period.
Trial registration:
ClinicalTrials.gov, NCT04011397. Registered 07 July 2019-retrospectively registered.
... However, the success of incentive programs depends on other factors related to the type of behavior desired and how the incentive programs are designed. The completion of a survey is a simple behavior compared to quitting smoking or sustaining weight-loss which are complex behaviors and harder for such incentive programs to change ( Jenkins et al., 2018;Johnston and Sniehotta, 2010;Kane et al., 2004;Mantzari et al., 2015;Marteau et al., 2009). Factors that characterize an incentive program are many and include the size of the financial incentive (a larger incentive is generally argued to have a bigger impact), the type of incentive (e.g. ...
Purpose
Many companies in the USA have corporate wellness programs but are having trouble encouraging employees to take part in these programs. Even with monetary incentives, many employees do not join. The purpose of this paper is to consider whether timely reminders combined with monetary incentives improve participation in health benefit programs.
Design/methodology/approach
Employees of a large manufacturing company across multiple facilities were encouraged to enroll in a messaging service. Once a week, members received an SMS or e-mail reminder to complete a Health Risk Assessment (HRA) and Health Action Plan (HAP). The authors segmented employees based on prior year health insurance plan choice and HRA participation to analyze current HRA and HAP completion, with and without intervention.
Findings
The intervention increased completion rates 6 percent for subgroups that completed the HRA in the prior year and 34–37 percent for those that did not.
Practical implications
Corporate wellness programs should develop good communication channels with employees. The effectiveness of such programs will depend also on employee engagement.
Originality/value
With better communication, companies could raise participation in corporate wellness programmes and potentially reduce some of the monetary incentives that they currently offer.
... Sensors were operational during working hours (ie, 7 am-7 pm, Monday-Friday). Other behavior change techniques included regular tailored motivational emails (ie, prompts), tailored feedback, and links to other resources (eg, physical activity and healthy eating advice) [23]. Discussion forums on the website provided a platform for participants to contact researchers and other participants (ie, social support). ...
Background:
Investigating participant engagement and nonusage attrition can help identify the likely active ingredients of electronic health interventions. Research on engagement can identify which intervention components predict health outcomes. Research on nonusage attrition is important to make recommendations for retaining participants in future studies.
Objective:
This study aimed to investigate engagement and nonusage attrition in the Physical Activity Loyalty (PAL) scheme, a 6-month complex physical activity intervention in workplaces in Northern Ireland. The intervention included financial incentives with reward redemption and self-regulation techniques. Specific objectives were (1) to determine whether engagement in specific intervention components predicted physical activity at 6 months, (2) to determine whether engagement in specific intervention components predicted targeted mediators at 6 months, and (3) to investigate predictors of nonusage attrition for participants recording daily activity via the PAL scheme physical activity monitoring system and logging onto the website.
Methods:
Physical activity was assessed at baseline and 6 months using pedometers (Yamax Digiwalker CW-701, Japan). Markers of engagement and website use, monitoring system use, and reward redemption were collected throughout the scheme. Random-effects generalized least-squares regressions determined whether engagement with specific intervention components predicted 6-month physical activity and mediators. Cox proportional hazards regressions were used to investigate predictors of nonusage attrition (days until first 2-week lapse).
Results:
A multivariable generalized least-squares regression model (n=230) showed that the frequency of hits on the website's monitoring and feedback component (regression coefficient [b]=50.2; SE=24.5; P=.04) and the percentage of earned points redeemed for financial incentives (b=9.1; SE=3.3; P=.005) were positively related to 6-month pedometer steps per day. The frequency of hits on the discussion forum (b=-69.3; SE=26.6; P=.009) was negatively related to 6-month pedometer steps per day. Reward redemption was not related to levels of more internal forms of motivation. Multivariable Cox proportional hazards regression models identified several baseline predictors associated with nonusage attrition. These included identified regulation (hazard ratio [HR] 0.88, 95% CI 0.81-0.97), recovery self-efficacy (HR 0.88, 95% CI 0.80-0.98), and perceived workplace environment safety (HR 1.07, 95% CI 1.02-1.11) for using the physical activity monitoring system. The EuroQoL health index (HR 0.33, 95% CI 0.12-0.91), financial motivation (HR 0.93, 95% CI 0.87-0.99), and perceived availability of physical activity opportunities in the workplace environment (HR 0.96, 95% CI 0.93-0.99) were associated with website nonusage attrition.
Conclusions:
Our results provide evidence opposing one of the main hypotheses of self-determination theory by showing that financial rewards are not necessarily associated with decreases in more internal forms of motivation when offered as part of a complex multicomponent intervention. Identifying baseline predictors of nonusage attrition can help researchers to develop strategies to ensure maximum intervention adherence.
Trial registration:
ISRCTN Registry ISRCTN17975376; http://www.isrctn.com/ISRCTN17975376 (Archived by WebCite at http://www.webcitation.org/76VGZsZug).
... People usually feel obliged to remain consistent with prior commitments (Freedman & Fraser, 1966;Howard, 1990) Incentives Incentivising a behaviour is will encourage people to engage in the behaviour (Marteau, Ashcroft, & Oliver, 2009;Volpp et al., 2009) Creating Negative Affect Experiencing negative emotion can make people act to reduce it by doing something for others (R. Cialdini et al., 1973;Piliavin, 1981) Creating Positive Affect Experiencing negative emotion can make people easier to persuade (R. B. Cialdini, 2009;Guéguen & De Gail, 2003). ...
Organisations increasingly use websites to promote prosocial behaviour such as volunteering, philanthropy, and activism. However, these websites often fail to encourage prosocial behaviours effectively. To address the lack of relevant research, we develop, then refine, a design model that identifies the user experience factors that create intention to engage in prosocial behaviour on websites. We test an initial model developed from the literature, by interviewing forty participants, each of whom visited and compared six volunteering websites. Our analysis of the participants’ user experience reveals eighteen elements that interplay to create intention to engage in prosocial behaviour. Our refined design model comprises ten website features (interaction, factual, anecdata, external recognition, organisational expression, value suggestion, explanatory content, visual media, written media and, website design), seven perceptions (ease of use, aesthetics, information quality, trust, negative affect, positive affect, and argument strength), and one motivation (egoism). These findings provide novel insights into how to design Information and Communications Technology (ICT) to encourage prosocial behaviour.
... Commitment devices aim to assist people who are initially motivated to exercise on a regular basis, but believe they will probably fail to do so without proper commitment. In contrast, a financial incentive in its most traditional (neoclassical economic) sense is aimed at encouraging the unmotivated to become motivated due to the payment (Gneezy & Rustichini, 2000;Mantzari et al., 2015;Marteau, 2009). An incentive is thus a conditional cash transfer in order to increase the attractiveness of a certain behavior. ...
Commitment Lotteries: Overcoming procrastination of lifestyle improvement with regret aversion
... The decision-making errors or behavioral "biases" highlighted by behavioral economics (BE) are particularly important for health. For example, they may cause individuals to overeat or smoke even when they realize that these activities are unhealthy and are, in fact, highly motivated to avoid them [1,2]. Such biases may also act as barriers for people attempting to remain HIV-negative and may be stronger for key populations [3]. ...
In this short communication, we discuss some key behavioral economic (BE) biases that likely minimize HIV prevention efforts, explore why certain key populations such as men who have sex with men or transgender women-may be more likely to succumb to these biases, and suggest how incentives informed by BE can support these populations in their effort to remain HIV-negative. Based on our formative work in an ongoing study, we discuss two important insights regarding the use of incentives to inform future HIV prevention efforts. First, participants often expressed more excitement for prizes that were viewed as fun (e.g., movie gift cards) or luxurious (e.g., cosmetics gift cards) rather than necessities (e.g., grocery store gift cards) of the same financial value and suggests that including an element of fun can be a powerful tool for incentivizing safe HIV-related behavior. Second, participants preferred not to be “paid” to display health behaviors, indicating the way incentives are given out (and perceived) is central to their success. Going forward, a BE perspective can help improve the impact of incentives - and increase their cost-effectiveness by carefully adapting them to the preferences of their recipients.
... 2 Paradigmatic in this class of interventions are patient financial incentives. 3 Incentives have been portrayed by some as a panacea to influence health behavior, 4 but their effectiveness has received mixed support. ...
Promoting healthy behavior is a challenge for public health officials, especially in the context of asking patients to participate in preventive cancer screenings. Small financial incentives are sometimes used, but there is a little scientific basis to support a compelling description of the best‐practice implementation of such incentives. We present a simple behavioral strategy based on mental accounting from prospect theory that maximizes the impact of incentives with no additional cost. We show how the partition of one incentive into two smaller incentives of equivalent total amount produces substantial behavioral changes, demonstrated in the context of colorectal cancer screening. In a randomized controlled trial, eligible patients aged 50−74 (n = 1652 patients) were allocated to receive either one €10 incentive (upon completion of screening) or two €5 incentives (at the beginning and at the end of screening). We show that cancer screening rates were dramatically increased by partitioning the financial incentive (61.1%), compared with a single installment at the end (41.4%). These results support the hedonic editing hypothesis from prospect theory, and underline the importance of implementing theoretically grounded healthcare interventions. Our results suggest that, when patient incentives are feasible, healthcare procedures should be framed as multistage events with smaller incentives offered at multiple points in time.
... prompts), tailored feedback and links to other resources (e.g. PA and healthy eating advice) [22]. Discussion forums on the website provided a platform for participants to contact researchers and other participants (i.e. ...
BACKGROUND
Investigating participant engagement and nonusage attrition can help identify the likely active ingredients of electronic health interventions. Research on engagement can identify which intervention components predict health outcomes. Research on nonusage attrition is important to make recommendations for retaining participants in future studies.
OBJECTIVE
This study aimed to investigate engagement and nonusage attrition in the Physical Activity Loyalty (PAL) scheme, a 6-month complex physical activity intervention in workplaces in Northern Ireland. The intervention included financial incentives with reward redemption and self-regulation techniques. Specific objectives were (1) to determine whether engagement in specific intervention components predicted physical activity at 6 months, (2) to determine whether engagement in specific intervention components predicted targeted mediators at 6 months, and (3) to investigate predictors of nonusage attrition for participants recording daily activity via the PAL scheme physical activity monitoring system and logging onto the website.
METHODS
Physical activity was assessed at baseline and 6 months using pedometers (Yamax Digiwalker CW-701, Japan). Markers of engagement and website use, monitoring system use, and reward redemption were collected throughout the scheme. Random-effects generalized least-squares regressions determined whether engagement with specific intervention components predicted 6-month physical activity and mediators. Cox proportional hazards regressions were used to investigate predictors of nonusage attrition (days until first 2-week lapse).
RESULTS
A multivariable generalized least-squares regression model (n=230) showed that the frequency of hits on the website’s monitoring and feedback component (regression coefficient [b]=50.2; SE=24.5; P=.04) and the percentage of earned points redeemed for financial incentives (b=9.1; SE=3.3; P=.005) were positively related to 6-month pedometer steps per day. The frequency of hits on the discussion forum (b=−69.3; SE=26.6; P=.009) was negatively related to 6-month pedometer steps per day. Reward redemption was not related to levels of more internal forms of motivation. Multivariable Cox proportional hazards regression models identified several baseline predictors associated with nonusage attrition. These included identified regulation (hazard ratio [HR] 0.88, 95% CI 0.81-0.97), recovery self-efficacy (HR 0.88, 95% CI 0.80-0.98), and perceived workplace environment safety (HR 1.07, 95% CI 1.02-1.11) for using the physical activity monitoring system. The EuroQoL health index (HR 0.33, 95% CI 0.12-0.91), financial motivation (HR 0.93, 95% CI 0.87-0.99), and perceived availability of physical activity opportunities in the workplace environment (HR 0.96, 95% CI 0.93-0.99) were associated with website nonusage attrition.
CONCLUSIONS
Our results provide evidence opposing one of the main hypotheses of self-determination theory by showing that financial rewards are not necessarily associated with decreases in more internal forms of motivation when offered as part of a complex multicomponent intervention. Identifying baseline predictors of nonusage attrition can help researchers to develop strategies to ensure maximum intervention adherence.
CLINICALTRIAL
ISRCTN Registry ISRCTN17975376; http://www.isrctn.com/ISRCTN17975376 (Archived by WebCite at http://www.webcitation.org/76VGZsZug)
... The use of incentives may therefore be a particularly good approach to employ when recruiting "hard-to-reach" groups, and is an approach which should be factored into the budgeting of a study from the outset. However, the ethical implications of using such an approach must be considered, as incentives can be viewed as a form of bribery or coercion (Marteau, Ashcroft, & Oliver, 2009). ...
In this article, we discuss the challenges faced in recruiting “hard-to-reach” groups for interview studies, specifically those who do not access preventative healthcare services. We do this by reflecting on the varying success of different recruitment methods we have used in two recent studies; one investigating ethnic disparities in human papillomavirus vaccination uptake and another exploring difference in cervical screening non-participation. Engaging new community groups to help with recruitment proved particularly difficult, as did recruiting online. Our most successful recruitment methods included recruiting through community groups with whom we had previously established relationships, recruiting through schools and re-contacting participants who previously completed a related survey. We conclude that successful recruitment is dependent on study awareness and engagement. We urge others to be transparent in reporting recruitment methods in order to benefit the qualitative research community and suggest that details are published as supplementary material alongside qualitative articles in future.
... A first distinction that can be made regarding environmental change is between individual and collective approaches to behaviour change. Policies that target individuals usually focus either on changing knowledge and attitudes (Azjen 1991; Godin and Kok 1995;Armitage and Conner 2001) or on mak-ing wanted behaviour cheaper/easier and unwanted behaviour more expensive/difficult (Marteau et al. 2009;Kollmuss and Agyeman 2002). Such an individual approach is exemplified in Case 1. ...
Environmental behaviour change is one of the keys to address global warming. This paper presents ten Danish case studies which attempt to promote environmentally friendly behaviour. They were implemented in four different municipalities and studied within the Citizen Driven Environmental Action (CIDEA) research project. The paper discusses how these cases target individuals or groups, play on monetary or environmental incentives, balance private and collective environmental costs and benefits, adopt a top-down or bottom-up approach, and address daily or one-time behaviour. Given the complexity of environmental behaviour, it is argued that a larger combination of the different options can help promoting behaviour change, and that projects that rely on a larger combination of options are usually locally-anchored projects driven by a few enthusiasts.
... A focus on individual choices generally relies on transferring knowledge, raising awareness and using economic (dis)incentives (see e.g. Ajzen 1991; Godin and Kok 1995;Armitage and Conner 2001;Kollmuss and Agyeman 2002;Marteau et al. 2009). This approach is described as the 'ABC model' (Attitude, Behaviour and Choice, see Shove 2009). ...
Background: Certain causes of death can be avoided with access to timely prevention and treatment. We quantified trends in avoidable deaths from cardiovascular diseases for European Union (EU) countries from 1995 to 2020 and examined variations by demographics, disease characteristics, and geography.
Methods: Retrospective secondary data analysis of avoidable cardiovascular mortality using the WHO Mortality Database. Avoidable causes of death were identified from the OECD and Eurostat list (which uses an age threshold of 75 years). Regression models were used to identify changes in the trends of age-standardized mortality rates and potential years of life lost.
Findings: From 1995 to 2020, 11.4 million deaths from cardiovascular diseases in Europe were avoidable, resulting in 213.1 million potential life years lost. Avoidable deaths were highest among males (7.5 million), adults 65–74 years (6.8 million), and with the leading cause of death being ischemic heart disease (6.1 million). From its peak in 1995 until 2020, avoidable mortality from cardiovascular diseases has decreased by 57% across the EU. The difference in avoidable cardiovascular diseases mortality between females and males, and between Eastern and Western Europe has reduced greatly, however gaps continue to persist.
Interpretation: Avoidable mortality from cardiovascular diseases has decreased substantially among EU countries, although improvement has not been uniform across diseases, demographic groups or regions. These trends suggest additional policy interventions are needed to ensure that improvements in mortality are continued.
Background:
Financial incentives enhance long-term smoking cessation rates, but their effects on motivation to quit in those who fail to quit are not well documented.
Aim:
To test the effects of large financial incentives on motivation to quit smoking and on cigarette dependence in smokers who failed to quit despite receiving incentives.
Participants:
Low-income smokers in the general population in Geneva, Switzerland, in 2011-2013.
Methods:
A randomised controlled trial with follow-up after three, six and 18 months. Participants were assigned to receive either booklets plus access to a smoking cessation website (control group, n = 404), or the same intervention plus financial incentives (intervention group, n = 401). Incremental financial rewards, to a maximum of CHF 1500 (USD 1650, GBP 1000), were offered for biochemically verified smoking abstinence. No in-person counselling, telephone counselling, or medications were provided.
Measurements:
Intrinsic and extrinsic motivation to quit, intention to quit, cigarette dependence.
Findings:
In smokers at 6-month follow-up, intrinsic motivation decreased in the control group (-0.24 SD units, p < 0.001), extrinsic motivation increased in the intervention group (+0.35 SD units, p = 0.001), and twice as many participants in the intervention group (35 %) than in the control group (17 %, p < 0.001) said they intended to quit smoking in the next 30 days. Quit attempts were more frequent and their duration was longer in the intervention group than in the control group. The intervention had no impact on cigarette dependence scores.
Conclusions:
Large financial incentives increased motivation to quit smoking in smokers who failed to quit smoking despite receiving incentives.
Understanding human behavior is vital to developing interventions that effectively lead to proenvironmental behavior change, whether the focus is at the individual or societal level. However, interventions in many fields have historically lacked robust forms of evaluation, which makes it hard to be confident that these conservation interventions have successfully helped protect the environment. We conducted a systematic review to assess how effective nonpecuniary and nonregulatory interventions have been in changing environmental behavior. We applied the Office of Health Assessment and Translation systematic review methodology. We started with more than 300,000 papers and reports returned by our search terms and after critical appraisal of quality identified 128 individual studies that merited inclusion in the review. We classified interventions by thematic area, type of intervention, the number of times audiences were exposed to interventions, and the length of time interventions ran. Most studies reported a positive effect (n = 96). The next most common outcome was no effect (n = 28). Few studies reported negative (n = 1) or mixed (n = 3) effects. Education, prompts, and feedback interventions resulted in positive behavior change. Combining multiple interventions was the most effective. Neither exposure duration nor frequency affected the likelihood of desired behavioral change. Comparatively few studies tested the effects of voluntary interventions on non‐Western populations (n = 17) or measured actual ecological outcome behavior (n = 1). Similarly, few studies examined conservation devices (e.g., energy‐efficient stoves) (n = 9) and demonstrations (e.g., modeling the desired behavior) (n = 5). There is a clear need to both improve the quality of the impact evaluation conducted and the reporting standards for intervention results.
Background
Poor adherence to anti-hypertensive medications leads to poorly controlled blood pressure which is associated with worse cardiovascular outcomes. Emerging technologies may be utilised advantageously in interventions to improve adherence and reduce morbidity and mortality from poorly controlled hypertension.
Objective
To determine the efficacy of technology-based interventions in improving adherence to antihypertensive medications.
Methods
PubMed and EMBASE databases were searched using keywords and MeSH terms. Included studies met the following criteria: randomized controlled trial (RCT); adults ≥ 18 years old taking anti-hypertensives; intervention delivered by or accessed using a technological device or process; intervention designed to improve adherence.
Results
12 papers met inclusion criteria for the current review: 5 studies significantly improved adherence when compared to usual care; of these 5 studies, 2 had corresponding significant improvement in blood pressure. Successful interventions were: electronic medication bottle cap with audio-visual reminder; short message service (SMS) containing educational information (2 studies); reporting of self-measured blood pressure to a telephone-linked computer system; sending a video of every drug ingestion to obtain monetary rewards.
Conclusion
RCTs on technological interventions to improve adherence and those showing significant effect are rare. Some of the interventions show potential to be applied to other populations, especially if targeted at patients with poor adherence at baseline.
Introduction
Cocooning, the vaccination of close contacts of a newborn, is a strategy to limit the risk of pertussis and influenza infection among vulnerable infants.
Methods
Pregnant women in Colorado and Georgia referred close contacts to an app that provided tailored educational videos about vaccines along with a small pharmacy-based financial incentive for vaccine receipt. The primary objective of this study was to determine the feasibility of implementing this app-based cocooning intervention.
Results
Two hundred seventy seven contacts were enrolled in this study. Of those who received the educational videos, 96% found them interesting, 100% found them clear to understand, 97% found them helpful, and 99% trusted them. Completion of the videos led to significant increases in influenza vaccine knowledge (p = 0.025), Tdap vaccine knowledge (p < 0.001), and intention to receive these vaccines (p = 0.046). Of the 136 participants who reported receiving influenza vaccine, 41 (30%) reported receiving it at a pharmacy, and of the 66 who reported receiving Tdap vaccine, 15 (23%) reported receiving it at a pharmacy. Of all participants, 80% reported being comfortable receiving vaccines at a pharmacy instead of a doctor’s office. The provision of small pharmacy-based financial incentives combined with individually-tailored educational videos about vaccines led to 6.97 (95%CI: 2.25–21.64) times higher odds of self-reported receipt of influenza vaccine than providing small pharmacy-based financial incentives without these videos. No significant difference was found for Tdap vaccine.
Conclusions
Tailored vaccine education can positively impact vaccine knowledge and intentions among adults. An app-based referral program providing education and financial incentives for cocooning vaccination at pharmacies is feasible.
Interventions involving groups of laywomen, men and adolescents to promote health are increasingly popular, but past research has rarely distinguished between different types of intervention with groups. We introduce a simple typology that distinguishes three ideal types: classrooms, clubs and collectives. Classrooms treat groups as a platform for reaching a population with didactic behaviour change strategies. Clubs seek to build, strengthen and leverage relationships between group members to promote health. Collectives engage whole communities in assuming ownership over a health problem and taking action to address it. We argue that this distinction goes a long way towards explaining differences in achievable health outcomes using interventions with groups. First, classrooms and clubs are appropriate when policymakers primarily care about improving the health of group members, but collectives are better placed to achieve population-level impact. Second, classroom interventions implicitly assume bottleneck behaviours preventing a health outcome from being achieved can be reliably identified by experts, whereas collectives make use of local knowledge, skill and creativity to tackle complexity. Third, classroom interventions assume individual participants can address health issues largely on their own, while clubs and collectives are required to engender collective action in support of health. We invite public health researchers and policymakers to use our framework to align their own and communities’ ambitions with appropriate group-based interventions to test and implement for their context. We caution that our typology is meant to apply to groups of laypeople rather than professionalised groups such as whole civil society organisations.
Background
Public transport (PT) users typically accumulate more physical activity (PA) than private motor vehicle users yet redressing physical inactivity through transport-related PA (TRPA) interventions has received limited attention. Further, incentive-based strategies can increase leisure-time PA but their impact on TRPA, is unclear. This study's objective is to determine the impact of an incentive-based strategy on TRPA in a regional Australian setting.
Methods
trips4health is a single-blinded randomised controlled trial with a four-month intervention phase and subsequent six-month maintenance phase. Participants will be randomised to: an incentives-based intervention (bus trip credit for reaching bus trip targets, weekly text messages to support greater bus use, written PA guidelines); or an active control (written PA guidelines only). Three hundred and fifty adults (≥18 years) from southern Tasmania will be recruited through convenience methods, provide informed consent and baseline information, then be randomised. The primary outcome is change in accelerometer measured average daily step count at baseline and four- and ten-months later. Secondary outcomes are changes in: measured and self-reported travel behaviour (e.g. PT use), PA, sedentary behaviour; self-reported and measured (blood pressure, waist circumference, height, weight) health; travel behaviour perspectives (e.g. enablers/barriers); quality of life; and transport-related costs. Linear mixed model regression will determine group differences. Participant and PT provider level process evaluations will be conducted and intervention costs to the provider determined.
Discussion
trips4health will determine the effectiveness of an incentive-based strategy to increase TRPA by targeting PT use. The findings will enable evidence-informed decisions about the worthwhileness of such strategies.
Trial registration
ACTRN12619001136190.
Universal trial number
U1111-1233-8050.
Background:
Medicaid recipients with serious mental illness die 25-30 years earlier than people in the general population due to health conditions that are modifiable through lifestyle changes. Cardiovascular diseases from excess weight, smoking, and sedentary lifestyle contribute substantially to this life expectancy disparity. The current study evaluated the impact of incentives on participation in weight management programming (for overweight and obese adults) and smoking cessation treatment (for regular smokers).
Methods:
Participants were Medicaid recipients with disabling mental illness receiving services at any one of 10 community mental health centers across New Hampshire. Using an equipoise stratified randomized design, n = 1348 were enrolled and assigned to one of four weight management programs (Healthy Choices Healthy Changes: HCHC) and n = 661 were enrolled and assigned to one of three smoking cessation interventions (Breathe Well Live Well: BWLW). Following assignment to an intervention, participants were randomized to receive financial incentives (to attend weight management programs, or to achieve abstinence from smoking) or not. Data were collected at baseline and every 3 months for 12 months.
Discussion:
New Hampshire's HCHC and BWLW programs were designed to address serious and preventable health disparities by providing incentivized health promotion programs to overweight/obese and/or tobacco-smoking Medicaid beneficiaries with mental illness. This study was an unprecedented opportunity to evaluate an innovative statewide implementation of incentivized health promotion targeting the most at-risk and costly beneficiaries. If proven effective, this program has the potential to serve as a national model for widespread implementation.
On behalf of all authors and the Clube Humboldt do Brasil, I am very pleased to edit this book, which is one of the greatest results of the Brazilian Humboldt Kolleg 2016 meeting, entitled “Environments: technoscience and its relation to sustainability, ethics, aesthetics, health and the human future”. The theme is broad and interconnected, as it should be to be addressed by us all, collectively. The main objective is to contribute with a work where researchers can understand the Humboldtian spirit, to provide an opportunity for in-depth reflections on educational, scientific and technological challenges that not only Brazil faces nowadays. The book was conceived as an inter-, multi- and transdisciplinary work to bring together those interested to get to know these researchers, to learn about where they are from, what they do, how they work and how the Humboldt experience has had an impact on their lives and careers, especially considering effective academic cooperation and international cultural dialogue.
http://www.edufscar.com.br/farol/edufscar/ebook/environments-technoscience-and-its-relation-to-sustainability-ethics-aesthetics-health-and-the-human-future/830536/
http://www.avh.kollegbr.ufscar.br/
* Any unauthorized use, disclosure, reproduction, copying, distribution, or other form of unauthorized dissemination of the contents without its correct citation is expressly prohibited.
Mobile health (mHealth) technologies have increasingly been used in interventions to promote physical activity (PA), yet, they often have high attrition rates. Integrating social features into mHealth has the potential to engage users; however, little is known about the efficacy and user engagement of such interventions. Thus, the aim of this systematic review was to characterize and evaluate the impact of interventions integrating social features in mHealth interventions to promote PA. During database screening, studies were included if they involved people who were exposed to a mHealth intervention with social features, to promote PA. We conducted a narrative synthesis of included studies and a meta-analysis of randomized controlled trials (RCTs). Nineteen studies were included: 4 RCTs, 10 quasi-experimental, and 5 non-experimental studies. Most experimental studies had retention rates above 80%, except two. Social features were often used to provide social support or comparison. The meta-analysis found a non-significant effect on PA outcomes [standardized difference in means = 0.957, 95% confidence interval −1.09 to 3.00]. Users’ preferences of social features were mixed: some felt more motivated by social support and competition, while others expressed concerns about comparison, indicating that a one-size-fits-all approach is insufficient. In summary, this is an emerging area of research, with limited evidence suggesting that social features may increase user engagement. However, due to the quasi-experimental and multi-component nature of most studies, it is difficult to determine the specific impact of social features, suggesting the need for more robust studies to assess the impact of different intervention components.
Objectives:
Young children in resource-poor settings remain inadequately immunized. We evaluated the role of compliance-linked incentives versus mobile phone messaging to improve childhood immunizations.
Methods:
Children aged ≤24 months from a rural community in India were randomly assigned to either a control group or 1 of 2 study groups. A cloud-based, biometric-linked software platform was used for positive identification, record keeping for all groups, and delivery of automated mobile phone reminders with or without compliance-linked incentives (Indian rupee Rs30 or US dollar $0.50 of phone talk time) for the study groups. Immunization coverage was analyzed by using multivariable Poisson regression.
Results:
Between July 11, 2016, and July 20, 2017, 608 children were randomly assigned to the study groups. Five hundred and forty-nine (90.3%) children fulfilled eligibility criteria, with a median age of 5 months; 51.4% were girls, 83.6% of their mothers had no schooling, and they were in the study for a median duration of 292 days. Median immunization coverage at enrollment was 33% in all groups and increased to 41.7% (interquartile range [IQR]: 23.1%-69.2%), 40.1% (IQR: 30.8%-69.2%), and 50.0% (IQR: 30.8%-76.9%) by the end of the study in the control group, the group with mobile phone reminders, and the compliance-linked incentives group, respectively. The administration of compliance-linked incentives was independently associated with improvement in immunization coverage and a modest increase in timeliness of immunizations.
Conclusions:
Compliance-linked incentives are an important intervention for improving the coverage and timeliness of immunizations in young children in resource-poor settings.
