A legal assessment of private land conservation in South America

Privately protected areas (PPAs) are a potentially innovative conservation tool. Legal recognition is necessary for their success, especially where there are institutional challenges to nature conservation, such as in South America. Although PPAs have increased in South America since the early 2000s, there is a critical information gap pertaining to their legal frameworks. We analyzed the level of landowner commitment to and governmental support for PPAs across countries in South America that officially recognize PPAs. We analyzed the legal framework governing PPAs and reviewed literature on them. This process was done in English and Spanish. The information we gathered was validated by 16 conservation experts from 10 South American countries. Because Peru is 1 of only 2 South American countries where local communities create and manage PPAs, we studied Peruvian PPAs in more detail by examining official creation documents and interviewing 13 local conservation professionals. We found inadequate minimum duration of PPAs and vague guidelines for conducting economic activities within them and a lack of governmental support (e.g., financial and technical support) for PPAs. Support was limited to the exemption from rural property taxes, which are relatively low compared with countries outside South America. In Peru, PPAs run by individuals and communities needed different legal frameworks because they were created with different objectives and had different sizes and duration of commitments. The prompt improvement of legal frameworks across South America is necessary for PPAs to achieve their aim of being places for enduring nature conservation in the region.

The Effect of Business Operating Systems on Nursing Home Termination

Objectives: Nursing home terminations have increased worldwide due to rising costs, staffing shortages, and the coronavirus disease pandemic. However, little is known about the impact that business operating systems have on nursing home termination. Methods: This study used the National Long-term Care database, which comprised 7,842 operating nursing homes in January 2018. Nursing home termination was identified when nursing homes discontinued provision of long-term care services to all residents between January 2018 and December 2020. Business operating systems that were reimbursed by the LTC insurance system were the exposure of interest. The logistic regression model for nursing home termination included a series of organizational, internal, and external factors as covariates. Results: From 2018 to 2020, 83 (1.1%) nursing homes were terminated. The proportion of reimbursed nursing homes varied greatly depending on the type of business operating systems. Implementing physical function training and improving working conditions were significantly associated with a lower risk of nursing home termination. Conclusion: Financial incentives to several business operating systems are an effective way to build a sustainable environment for nursing homes to continue to exist.

Evaluation of the NHS England evidence-based interventions programme: a difference-in-difference analysis

BACKGROUND

The NHS England evidence-based interventions programme (EBI), launched in April 2019, is a novel nationally led initiative to encourage disinvestment in low value care.

METHOD

We sought to evaluate the effectiveness of this policy by using a difference-in-difference approach to compare changes in volume between January 2016 and February 2020 in a treatment group of low value procedures against a control group unaffected by the EBI programme during our period of analysis but subsequently identified as candidates for disinvestment.

RESULTS

We found only small differences between the treatment and control group after implementation, with reductions in volumes in the treatment group 0.10% (95% CI 0.09% to 0.11%) smaller than in the control group (equivalent to 16 low value procedures per month). During the month of implementation, reductions in volumes in the treatment group were 0.05% (95% CI 0.03% to 0.06%) smaller than in the control group (equivalent to 7 low value procedures). Using triple difference estimators, we found that reductions in volumes were 0.35% (95% CI 0.26% to 0.44%) larger in NHS hospitals than independent sector providers (equivalent to 47 low value procedures per month). We found no significant differences between clinical commissioning groups that did or did not volunteer to be part of a demonstrator community to trial EBI guidance, but found reductions in volume were 0.06% (95% CI 0.04% to 0.08%) larger in clinical commissioning groups that posted a deficit in the financial year 2018/19 before implementation (equivalent to 4 low value procedures per month).

CONCLUSIONS

Our analysis shows that the EBI programme did not accelerate disinvestment for procedures under its remit during our period of analysis. However, we find that financial and organisational factors may have had some influence on the degree of responsiveness to the EBI programme.

Interest in and perceived effectiveness of contingency management among alcohol drinkers using behavioral economic purchase tasks

Contingency management (CM), in which financial incentives are provided upon verification of abstinence from alcohol, cigarettes, and/or illicit substances, is one of the most highly effective and empirically supported treatments for substance use disorders. However, the financial cost of implementation has been identified as a major barrier to implementation of this treatment. The purpose of this study was to develop behavioral economic purchase tasks to assess interest in CM as a function of treatment cost and perceived effectiveness of CM as a function of abstinence incentive size in alcohol drinkers. Alcohol drinkers recruited from Amazon Mechanical Turk (MTurk) completed behavioral economic purchase tasks measuring demand for CM based on targeted abstinence intervals and treatment effectiveness and alcohol use disorder severity assessments. Nonlinear mixed-effects modeling was used to fit demand curves and assess the relationship between individual characteristics and demand metrics for CM. Results reveal that participants reported higher probability of remaining abstinent from drinking when offered larger incentives and required larger incentives when duration of abstinence required to earn the incentive was increased. Additionally, willingness to pay for treatment increased as effectiveness of treatment increased. Abstinence interval and treatment effectiveness are important features to consider when developing effective CM for widespread use, as these variables affected participants' likelihood of being abstinent and their interest in treatment. Future work will validate these assessments with actual treatment outcomes and determine predictors of CM treatment effectiveness. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

E-Bicycle as a Green and Physically Active Mode of Transport from the Aspect of Students: TPB and Financial Incentives

The positive effects of e-bikes on physical activity, health, and the environment have been confirmed in many studies. Their choice, as well as of cycling in general, was previously considered from, among others, the socio-psychological aspect (often by use of the theory of planned behavior (TPB)) or the financial aspect (in the context of financial incentives). In addition, the question of physical activity can be especially relevant for the student population, since their level of physical activity usually declines. Starting from the previous framework, the aim of this research was to consider the intention to use e-bikes by the student population in the context of their attitudes, subjective norms, perceived behavioral control, and financial incentives. It is, according to the authors' knowledge, the first research that combines all those variables when studying e-bikes. The research was conducted in 2022 on a convenience sample of 332 students from the University of Novi Sad (Republic of Serbia). The results show that the strongest predictor of the intention to use e-bikes can be attributed to financial incentives, followed by attitudes and subjective norms, while perceived behavioral control is not significant. Besides considerations in the context of previous research, additional recommendations for increasing e-bikes' use were provided.

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

BACKGROUND

A growing body of evidence shows that financial incentives can effectively reinforce individuals' positive behavior change and improve compliance with health intervention programs. A critical factor in the design of incentive-based interventions is to set a proper incentive magnitude. However, it is highly challenging to determine such magnitudes as the effects of incentive magnitude depend on personal attitudes and contexts.

OBJECTIVE

This study aimed to illustrate loss-framed adaptive microcontingency management (L-AMCM) and the lessons learned from a feasibility study. L-AMCM discourages an individual's adverse health behaviors by deducting particular expenses from a regularly assigned budget, where expenses are adaptively estimated based on the individual's previous responses to varying expenses and contexts.

METHODS

We developed a mobile health intervention app for preventing prolonged sedentary lifestyles. This app delivered a behavioral mission (ie, suggesting taking an active break for a while) with an incentive bid when 50 minutes of uninterrupted sedentary behavior happened. Participants were assigned to either the fixed (ie, deducting the monotonous expense for each mission failure) or adaptive (ie, deducting varying expenses estimated by the L-AMCM for each mission failure) incentive group. The intervention lasted 3 weeks.

RESULTS

We recruited 41 participants (n=15, 37% women; fixed incentive group: n=20, 49% of participants; adaptive incentive group: n=21, 51% of participants) whose mean age was 24.0 (SD 3.8; range 19-34) years. Mission success rates did not show statistically significant differences by group (P=.54; fixed incentive group mean 0.66, SD 0.24; adaptive incentive group mean 0.61, SD 0.22). The follow-up analysis of the adaptive incentive group revealed that the influence of incentive magnitudes on mission success was not statistically significant (P=.18; odds ratio 0.98, 95% CI 0.95-1.01). On the basis of the qualitative interviews, such results were possibly because the participants had sufficient intrinsic motivation and less sensitivity to incentive magnitudes.

CONCLUSIONS

Although our L-AMCM did not significantly affect users' mission success rate, this study configures a pioneering work toward adaptively estimating incentives by considering user behaviors and contexts through leveraging mobile sensing and machine learning. We hope that this study inspires researchers to develop incentive-based interventions.

Estimation of Total Cost Required in Controlling COVID-19 Outbreaks by Financial Incentives

In this article, we present a Monte Carlo simulation (MCS) to estimate the total cost required to control the spread of the COVID-19 pandemic by financial incentives. One of the greatest difficulties in controlling the spread of the COVID-19 pandemic is that most infected people are not identified and can transmit the virus to other people. Therefore, there is an urgent need to rapidly identify and isolate the infected people to avoid the further spread of COVID-19. To achieve this, we can consider providing a financial incentive for the people who voluntarily take the COVID-19 test and test positive. To prevent the abuse of the financial incentive policy, several conditions should be satisfied to receive the incentive. For example, an incentive is offered only if the recipients know who infected them. Based on the data obtained from epidemiological investigations, we calculated an estimated total cost of financial incentives for the policy by generating various possible infection routes using the estimated parameters and MCS. These results would help public health policymakers implement the proposed method to prevent the spread of the COVID-19 pandemic. In addition, the incentive policy can support various preparations such as hospital bed preparation, vaccine development, and so forth.

Increasing diabetes testing adherence with incentives in rural Northwestern Ontario

Introduction

The health outcomes of rural Canadians have been described as poor and can in some part be related to diabetes mellitus. Despite the high mortality and morbidity rates associated with the disease, compliance with management remains low. Research has shown that a small financial incentive used to modify patient behaviour, can improve outcomes in cardiac disease and exercise adherence. This study aims to evaluate if a small financial incentive awarded to rural Northwestern Ontario patients with diabetes who complete an haemoglobin A1c (HbA1c) test, would result in greater compliance in test completion.

Methods

Patients were recruited through two Northern rural clinics. Participants were divided into two groups: Group A received a financial incentive, whereas Group B received a letter of reminder. HbA1c tests were recorded every 6 months for 2 years and compliance was analysed using a t-test and Chi-square.

Results

One hundred and forty-six participants were recruited with 30 lost to follow-up. Overall, the incentive group completed a statistically significantly higher number of HbA1c tests compared to those in the control group. In addition, it was noted that there was an increase in test adherence for participants that received reminder letters, although not an initially expected outcome of the study.

Conclusion

The results suggest that either a financial incentive or a reminder directed towards rural Canadians could have a benefit in promoting health behaviours to subsequent medical management of diabetes mellitus.

Money can't buy happiness: A randomized controlled trial of a digital mental health app with versus without financial incentives

Mental health disorders are prevalent among college students and increasing in frequency and severity. However, there is a significant gap between those who need treatment and those who engage in treatment. Given the documented efficacy of financial incentives for promoting health behavior change and engagement in treatment, financial incentives may help, along with nonfinancial behavioral incentives such as motivational messaging, gamification, and loss aversion techniques. We compared brief (28-day) use of two versions of a behavioral economics-inspired digital mental health app, NeuroFlow: (1) the full app including financial incentives and nonfinancial behavioral incentives (treatment group) and (2) a version of the app with nonfinancial behavioral incentives only (control group). In our intent-to-treat analyses, in order to examine the primary outcome of app engagement, a one-way analysis of variance (ANOVA) (treatment vs. control) was conducted, and to examine the secondary outcomes (depression, anxiety, emotion dysregulation, and wellbeing), a two-way repeated measures ANOVAs (treatment vs. control × baseline vs. post-trial) were conducted. We found that there were no differences between treatment groups on app engagement or the change in the mental health/wellness outcome measures. There was a main effect of timepoint on symptoms of anxiety and emotion dysregulation, such that there were significantly lower self-reported symptoms at post-trial relative to baseline. Our results suggest that financial incentives in digital mental health apps over and above nonfinancial behavioral incentives do not have an impact on app engagement or mental health/wellness outcomes.

Randomized Controlled Trial Examining the Efficacy of Adding Financial Incentives to Best practices for Smoking Cessation Among pregnant and Newly postpartum Women

We report results from a single-blinded randomized controlled trial examining financial incentives for smoking cessation among 249 pregnant and newly postpartum women. Participants included 169 women assigned to best practices (BP) or BP plus financial incentives (BP + FI) for smoking cessation available through 12-weeks postpartum. A third condition included 80 never-smokers (NS) sociodemographically-matched to women who smoked. Trial setting was Burlington, Vermont, USA, January, 2014 through January, 2020. Outcomes included 7-day point-prevalence abstinence antepartum and postpartum, and birth and other infant outcomes during 1st year of life. Reliability and external validity of results were assessed using pooled results from the current and four prior controlled trials coupled with data on maternal-smoking status and birth outcomes for all 2019 singleton live births in Vermont. Compared to BP, BP + FI significantly increased abstinence early- (AOR = 9.97; 95%CI, 3.32-29.93) and late-pregnancy (primary outcome, AOR = 5.61; 95%CI, 2.37-13.28) and through 12-weeks postpartum (AOR = 2.46; CI,1.05-5.75) although not 24- (AOR = 1.31; CI,0.54-3.17) or 48-weeks postpartum (AOR = 1.33; CI,0.55-3.25). There was a significant effect of trial condition on small-for-gestational-age (SGA) deliveries (χ2 [2] = 9.01, P = .01), with percent SGA deliveries (+SEM) greatest in BP, intermediate in BP + FI, and lowest in NS (17.65 + 4.13, 10.81 + 3.61, and 2.53 + 1.77, respectively). Reliability analyses supported the efficacy of financial incentives for increasing abstinence antepartum and postpartum and decreasing SGA deliveries; external-validity analyses supported relationships between antepartum cessation and SGA risk. Adding financial incentives to Best Practice increases smoking cessation among antepartum and postpartum women and improves other maternal-infant outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02210832.

Air Pollution Management: A Multivariate Analysis of Citizens' Perspectives and Their Willingness to Use Greener Forms of Transportation

The present research aims to understand how air pollution can be managed by public authorities, both central and local, starting from citizens' perspectives on the issue. Air quality is a real problem, affecting people at multiple levels. Thus, we introduced the following variables to better understand the problem and to be able to formulate theoretical and practical implications for public management: the involvement of authorities in reducing air pollution; the involvement of citizens in reducing air pollution; financial incentives for citizens and companies for adopting behaviors that reduce air pollution; green investments in the city; the impact of air pollution on the community; and the need for independent bodies to monitor air pollution. The research methodology used is partial least squares structural equation modelling (PLS-SEM) and the required data were gathered from issuing a survey to citizens from the most important cities in Romania where pollution poses important challenges for the community and for the authorities. The results are useful to public managers in local and central institutions for creating better strategies meant to reduce air pollution, increase air quality, and improve the quality of the citizens' lives.

Using financial incentives to improve health service engagement and outcomes of adults experiencing homelessness: A scoping review of the literature

People experiencing homelessness (PEH) have high rates of acute and chronic health conditions, complex support needs and often face multiple barriers to accessing health services. Financial incentive (FI) interventions have been found effective in improving service engagement and health outcomes for a range of health conditions, populations and settings, but little is known about their impact on PEH. We conducted a scoping review to explore the impact of FI interventions on treatment retention, adherence and other health outcomes of PEH. We searched seven electronic databases from inception to September 2021 to identify peer-reviewed published English language studies that used FI interventions with adult PEH. A scoping review methodology was used to chart relevant data uniformly. Descriptive statistics and narrative syntheses were used to describe outcomes. Thirty-three quantitative articles related to 29 primary studies were published between 1990 and 2021 and met inclusion criteria. Studies targeted three areas of health behaviour change: decreasing substance use or increasing abstinence rates, preventing or treating infectious diseases or promoting lifestyle/general health goal attainment. A variety of FIs were used (cash/non-cash, escalating/fixed schedule, larger/smaller amounts, some/all behaviours rewarded, certain/uncertain reward) across studies. Twenty-six of the primary studies reported significantly better outcomes for the participants receiving FI compared to controls. There were mixed findings about the efficacy of cash versus non-cash FIs, non-cash FIs versus other interventions and higher versus lower value of incentives. Furthermore, there was limited research about long-term outcomes and impacts. FIs have promise in increasing abstinence from substances, engagement in infectious disease treatment, retention in health services and general lifestyle modifications for PEH. Future research should examine long-term impacts and the contribution of co-interventions and intermediary lifestyle behaviour changes.

A Digital Intervention Using Daily Financial Incentives to Increase Medication Adherence in Severe Mental Illness: Single-Arm Longitudinal Pilot Study

BACKGROUND

Medication nonadherence is prevalent in severe mental illness and is associated with multiple negative outcomes. Mobile technology and financial incentives show promise to improve medication adherence; however, studies in mental health, especially with oral medications, are lacking.

OBJECTIVE

The aim of this paper is to assess the feasibility and effectiveness of offering financial incentives through a mobile app based on behavioral economics principles to improve medication adherence in severe mental illness.

METHODS

A 10-week, single-arm longitudinal pilot study was conducted. Patients earned rewards in the context of app-based adherence incentives. The reward was split into biweekly payments made in increments of US $15, minus any US $2 per day penalties for missed check-ins. Time-varying effect modeling was used to summarize the patients' response during the study.

RESULTS

A total of 25 patients were enrolled in this pilot study, of which 72% (n=18) were female, and 48% (n=12) were of a White racial background. Median age was 24 (Q1-Q3: 20.5-30) years. Participants were more frequently diagnosed with schizophrenia and related disorders (n=9, 36%), followed by major depressive disorder (n=8, 32%). App engagement and medication adherence in the first 2 weeks were higher than in the last 8 weeks of the study. At study endpoint, app engagement remained high (n=24, Z=-3.17; P<.001), but medication adherence was not different from baseline (n=24, Z=-0.59; P=.28).

CONCLUSIONS

Financial incentives were effectively delivered using an app and led to high engagement throughout the study and a significantly increased medication adherence for 2 weeks. Leveraging behavioral economics and mobile health technology can increase medication adherence in the short term.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04191876; https://clinicaltrials.gov/ct2/show/NCT04191876.

Investigating Rewards and Deposit Contract Financial Incentives for Physical Activity Behavior Change Using a Smartphone App: Randomized Controlled Trial

BACKGROUND

Financial incentive interventions for improving physical activity have proven to be effective but costly. Deposit contracts (in which participants pledge their own money) could be an affordable alternative. In addition, deposit contracts may have superior effects by exploiting the power of loss aversion. Previous research has often operationalized deposit contracts through loss framing a financial reward (without requiring a deposit) to mimic the feelings of loss involved in a deposit contract.

OBJECTIVE

This study aimed to disentangle the effects of incurring actual losses (through self-funding a deposit contract) and loss framing. We investigated whether incentive conditions are more effective than a no-incentive control condition, whether deposit contracts have a lower uptake than financial rewards, whether deposit contracts are more effective than financial rewards, and whether loss frames are more effective than gain frames.

METHODS

Healthy participants (N=126) with an average age of 22.7 (SD 2.84) years participated in a 20-day physical activity intervention. They downloaded a smartphone app that provided them with a personalized physical activity goal and either required a €10 (at the time of writing: €1=US $0.98) deposit up front (which could be lost) or provided €10 as a reward, contingent on performance. Daily feedback on incentive earnings was provided and framed as either a loss or gain. We used a 2 (incentive type: deposit or reward) × 2 (feedback frame: gain or loss) between-subjects factorial design with a no-incentive control condition. Our primary outcome was the number of days participants achieved their goals. The uptake of the intervention was a secondary outcome.

RESULTS

Overall, financial incentive conditions (mean 13.10, SD 6.33 days goal achieved) had higher effectiveness than the control condition (mean 8.00, SD 5.65 days goal achieved; P=.002; ηp2=0.147). Deposit contracts had lower uptake (29/47, 62%) than rewards (50/50, 100%; P<.001; Cramer V=0.492). Furthermore, 2-way analysis of covariance showed that deposit contracts (mean 14.88, SD 6.40 days goal achieved) were not significantly more effective than rewards (mean 12.13, SD 6.17 days goal achieved; P=.17). Unexpectedly, loss frames (mean 10.50, SD 6.22 days goal achieved) were significantly less effective than gain frames (mean 14.67, SD 5.95 days goal achieved; P=.007; ηp2=0.155).

CONCLUSIONS

Financial incentives help increase physical activity, but deposit contracts were not more effective than rewards. Although self-funded deposit contracts can be offered at low cost, low uptake is an important obstacle to large-scale implementation. Unexpectedly, loss framing was less effective than gain framing. Therefore, we urge further research on their boundary conditions before using loss-framed incentives in practice. Because of limited statistical power regarding some research questions, the results of this study should be interpreted with caution, and future work should be done to confirm these findings.

TRIAL REGISTRATION

Open Science Framework Registries osf.io/34ygt; https://osf.io/34ygt.

The Influence of Practice Structure on Urologists' Treatment of Men With Low-Risk Prostate Cancer

BACKGROUND

Vertical and horizontal integration among health care providers has transformed the practice arrangements under which many physicians work.

OBJECTIVE

To examine the influence of type of practice structure, and by implication the financial incentives associated with each structure, on treatment received among men newly diagnosed with low-risk prostate cancer.

RESEARCH DESIGN

We compiled a unique database from cancer registry records from 4 large states, Medicare enrollment and claims for the years 2005-2014 and SK & A physician surveys corroborated by extensive internet searches. We estimated a multinomial logit model to examine the influence of urologist practice structure on type of initial treatment received.

RESULTS

The probability of being monitored with active surveillance was 7.4% and 4.2% points higher for men treated by health system and nonhealth system employed urologists ( P <0.01), respectively, in comparison to men treated by single specialty urology practices. Among multispecialty practices, the rate of active surveillance use was 3% points higher compared with single specialty urology practices( P <0.01). Use of intensity modulated radiation therapy among urologists with ownership in intensity modulated radiation therapy was 17.4% points higher compared with urologists working in small single specialty practices.

CONCLUSIONS

Physician practice structure attributes are significantly associated with type of treatment received but few studies control for such factors. Our findings-coupled with the observation that urologist practice structure shifted substantially over this time period due to mergers of small urology groups-provide one explanation for the limited uptake of active surveillance among men with low-risk disease in the US.

Smoking Cessation Programs Are Less Effective in Smokers with Low Socioeconomic Status Even When Financial Incentives for Quitting Smoking Are Offered-A Community-Randomized Smoking Cessation Trial in Denmark

Financial incentives offered to those who quit smoking have been found effective, also in persons with low socioeconomic status (SES), but no previous study has investigated who benefits most: smokers with low or high SES. In this community-randomized trial ("Richer without smoking"), three Danish municipalities were randomized to reward persons who were abstinent when attending the municipal smoking cessation program (FIMs) and three municipalities were randomized to spend the same amount on smoking cessation campaigns recruiting smokers to the smoking cessation program (CAMs). The municipalities each received approximately USD 16,000. An intention-to-treat approach was used in analyses. In regression analyses adjusted for individual- and municipal-level differences, we found that smokers with high SES living in FIMs had significantly higher proportion of validated long-term successful quitters (OR (95% CI): 2.59 (1.6-4.2)) than high-SES smokers living in CAM. Smokers with low SES, however, did not experience the same benefit of financial incentives as smokers with high SES. Neither the FIMs nor the CAMs succeeded in attracting more smokers with low SES during the intervention year 2018 than the year before. Our study showed that smokers with low SES did not experience the same benefit of financial incentives as smokers with high SES.

Examining the Implementation of Conditional Financial Incentives Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to Improve HIV Outcomes among Persons Living with HIV (PLWH) in Louisiana

Economic strengthening interventions are needed to support HIV outcomes among persons living with HIV (PLWH). The Baton Rouge Positive Pathway Study (BRPPS), a mixed method implementation science study, was conducted to assess key RE-AIM components tied to the provision of conditional financial incentives among PLWH in Baton Rouge, Louisiana. Seven hundred and eighty-one (781) PLWH enrolled at four HIV clinic sites were included in the final analyses. Participants completed an initial baseline survey, viral load test, and were contacted at 6 and 12 months (±1 month) post-enrollment for follow-up labs to monitor viral load levels. Participants received up to USD140 in conditional financial incentives. The primary analyses assessed whether participation in the BRPPS was associated with an increase in the proportion of participants who were: (a) engaged in care, (b) retained in care and (c) virally suppressed at baseline to 6 and 12 months post-baseline. We constructed a longitudinal regression model where participant-level outcomes at times t0 (baseline) and t1 (6- or 12-month follow-up) were modeled as a function of time. A secondary analysis was conducted using single-level regression to examine which baseline characteristics were associated with the outcomes of interest at 12-month follow-up. Cost analyses were also conducted with three of the participating clinics. Most participants identified as Black/African American (89%). Fewer than half of participants reported that they were unemployed or made less than USD5000 annually (43%). Over time, the proportion of participants engaged in care and retained in care significantly increased (70% to 93% and 32% to 64%, p < 0.00). However, the proportion of virally suppressed participants decreased over time (59% to 34%, p < 0.00). Implementation costs across the three sites ranged from USD17,198.05 to USD396,910.00 and were associated with between 0.37 and 1.34 HIV transmissions averted at each site. Study findings provide promising evidence to suggest that conditional financial incentives could help support engagement and retention in HIV care for a high need and at risk for falling out of HIV care population.

Motivation and competition in health care

Non-pecuniary sources of motivation are a strong feature of the health care sector and the impact of competitive incentives on behavior may be lower where pecuniary motivation is low. This paper measures the marginal utility of income (MUY) of physicians from a stated-choice experiment, and examines whether this measure influences the association between competition faced by physicians and the prices they charge. We find that physicians are more likely to exploit a lack of competition with higher prices if they have a high MUY.

Do financial incentives increase mental health treatment engagement? A meta-analysis

OBJECTIVE

Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management.

METHOD

We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies.

RESULTS

About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior.

CONCLUSIONS

Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A behavioral economic demand analysis of mothers' decision to exclusively breastfeed in the workplace

The present study determined whether behavioral economic demand analysis could characterize mothers' decision to exclusively breastfeed in the workplace. Females, aged between 18 and 50 who have given birth in the past three years, completed a novel demand task with hypothetical scenarios, in which they returned to work with a 2-month-old baby. Participants rated their likelihood of breastfeeding their baby at a workplace lactation room versus formula-feeding their baby at their desk. The distance to the lactation room ranged from 10 s to 60 min. This assessment was conducted with and without hypothetical financial incentives for 6-month exclusive breastfeeding. Primary dependent measures were demand intensity and change in demand elasticity, which could conceptually represent initiation and continuation of breastfeeding, respectively. Demand for breastfeeding was more intense and less elastic (i.e., more likely to initiate and continue breastfeeding) among mothers with an experience of 6-month exclusive breastfeeding and under the condition with the financial incentives. The novel demand task can potentially provide a useful behavioral marker for quantifying mothers' decision to initiate and continue exclusive breastfeeding in the workplace, informing workplace policy regarding lactation rooms, identifying risk for early cessation, and developing and individualizing an intervention to assist mothers to exclusively breastfeed in the workplace.

The Ethics of Financial Incentivization for Health Research Participation Among Sex Workers in a Canadian Context

Research incentivization with sex workers is common, yet limited guidance exists for ethical incentives practice. We undertook a critical qualitative inquiry into how researchers (n = 17), community services staff (n = 17), and sex workers participating in research (n = 53) perceive incentives in a Canadian context. We employed an interpretive thematic approach informed by critical perspectives of relational autonomy for analysis. Four themes illustrate how (un)ethical use of incentives is situated in transactional micro-economies among groups experiencing severe marginalization: i) transactional research economy, ii) incentive type: assumptions and effects, iii) incentive amount: too much too little?, and iv) resistance, trauma, and research-related harm. Paternalistic assumptions about capacities of sex workers to act in their own best interests conflicted with participants' rights and abilities for self-determination; with researchers maintaining ultimate decision-making authority. Power differentials create conditions of harm. Safe, equitable approaches concerning research incentive use must redress relations of power that perpetuate oppression.

Comparing the Relative Importance of Predictors of Intention to Use Bicycles

The use of bicycles for active commuting is an important target to reach because of the importance of increasing physical activity among the population and improving the air quality in cities. Among the models that have been utilized in previous studies, the Theory of Planned Behavior (TPB) has shown good results in terms of the total variance obtained. However, establishing the relative importance of the TPB variables is difficult. In the present study, which was carried out in the Italian context, the authors sought to establish the weight of the proposed variables based on the dominance analysis approach. Considering the initiatives, which the Italian government carries out, and the particular period in which the study was developed, the authors included two variables in addition to the classical factors: financial incentives and daily commuting habits. A survey was administered to 294 Italians (222 females and 72 males, from 18 to 77 years old) through social networks from July to September 2020. The results have shown how the main predictor of bicycle use was use habits, followed almost at the same level by financial incentives and attitude, while norms and perceived behavioral control (PBC) present low relative importance among the variables considered. Limits of the study have been discussed, and suggestions for future research have been proposed.

Incentivizing Prescription Drug Switching to Reduce Patient and Health Plan Spending: A Microsimulation Model

OBJECTIVES

Most spending for prescription drugs is on branded drugs that do not have direct generic equivalents but many of these drugs do have therapeutic alternatives within class. We estimate the potential savings from providing patients a financial incentive to switch from a higher cost drug to a lower cost, therapeutic alternative drug.

METHODS

We used individual state-transition microsimulations to model medication use and spending with and without financial incentives over a 12-month time horizon with a healthcare sector perspective. Costs and utilization inputs were from individuals on branded insulins or multiple sclerosis drugs enrolled in a regional mixed-model health maintenance organization. Base-case model used a one-time financial incentive of $83 and $250 offered to patients on higher cost insulin and multiple sclerosis treatments, respectively, to switch to lower cost drugs within class.

RESULTS

Savings per individual offered an incentive in the insulin and multiple sclerosis classes were, respectively, $84 (95% CI $46-$122) and $2,127 (95% CI $267-$3,987). Varying the incentive size and switch probability resulted in maximum savings of $712 at elasticity of 0.2 and incentive size $250 for the insulin drug class. For the multiple sclerosis drug class, maximum savings of $5945 was at elasticity of 0.2 and incentive size of $1000. Short time horizon makes our savings estimates conservative.

CONCLUSIONS

If programs such as financial incentives could encourage even a small proportion of patients to switch among drugs within therapeutic class, then substantial savings could be generated.

Promotional Payments to Medical Oncologists and Urologists and Prescriptions for Abiraterone and Enzalutamide

OBJECTIVE

To understand the influence of drug manufacturers on the prescribing patterns of medical oncologists and urologists, we examined the relationship between promotional payments from the manufacturers of abiraterone and enzalutamide and prescriptions for either drug by medical oncologists and urologists.

METHODS

Promotional payments for abiraterone or enzalutamide made to medical oncologists and urologists between January 2014 and December 2017 reported through the Open Payments Program were categorized as $0, $1$999, and $1000 or more. Prescriptions filled between January 2013 and December 2017 were identified in the Medicare Part D File. Associations between promotional payments and prescribing were assessed using generalized linear models.

RESULTS

From 2013 through 2017, the number of medical oncologists and urologists prescribing abiraterone or enzalutamide increased by 38% - 298%, respectively. The odds of prescribing among medical oncologists receiving $1--$999 and those receiving $1,000 or more were 1.69 (95%CI:1.59--1.79) and 2.61 (95% CI: 2.14--3.18) times that of medical oncologists receiving no payments. Among urologists receiving $1--$999 and those receiving $1,000 or more, the odds of prescribing were 4.04 (95%CI: 3.59--4.54) and 13.57 (95%CI: 9.69--19.0) times that of urologists receiving no payments.

CONCLUSION

Increasing promotional payments were associated with prescribing among medical oncologists and urologists, with a stronger relationship evident for urologists. Prescribing patterns for abiraterone and enzalutamide, particularly among urologists, may be influenced by payments from drug manufacturers.

Promoting Healthy Childhood Behaviors With Financial Incentives: A Narrative Review of Key Considerations and Design Features for Future Research

In the last decade, there has been a robust increase in research using financial incentives to promote healthy behaviors as behavioral economics and new monitoring technologies have been applied to health behaviors. Most studies of financial incentives on health behaviors have focused on adults, yet many unhealthy adult behaviors have roots in childhood and adolescence. The use of financial incentives is an attractive but controversial strategy in childhood. In this review, we first propose 5 general considerations in designing and applying incentive interventions to children. These include: 1) the potential impact of incentives on intrinsic motivation, 2) ethical concerns about incentives promoting undue influence, 3) the importance of child neurodevelopmental stage, 4) how incentive interventions may influence health disparities, and 5) how to finance effective programs. We then highlight empirical findings from randomized trials investigating key design features of financial incentive interventions, including framing (loss vs gain), timing (immediate vs delayed), and magnitude (incentive size) effects on a range of childhood behaviors from healthy eating to adherence to glycemic control in type 1 diabetes. Though the current research base on these subjects in children is limited, we found no evidence suggesting that loss-framed incentives perform better than gain-framed incentives in children and isolated studies from healthy food choice experiments support the use of immediate, small incentives versus delayed, larger incentives. Future research on childhood incentives should compare the effectiveness of gain versus loss-framing and focus on which intervention characteristics lead to sustained behavior change and habit formation.