Incentives, health promotion and equality

Improving oral health in people with severe mental illness (SMI): A systematic review

BACKGROUND

Those with severe mental illness (SMI) are at greater risk of having poor oral health, which can have an impact on daily activities such as eating, socialising and working. There is currently a lack of evidence to suggest which oral health interventions are effective for improving oral health outcomes for people with SMI.

AIMS

This systematic review aims to examine the effectiveness of oral health interventions in improving oral health outcomes for those with SMI.

METHODS

The review protocol was registered with PROSPERO (ID CRD42020187663). Medline, EMBASE, PsycINFO, AMED, HMIC, CINAHL, Scopus and the Cochrane Library were searched for studies, along with conference proceedings and grey literature sources. Titles and abstracts were dual screened by two reviewers. Two reviewers also independently performed full text screening, data extraction and risk of bias assessments. Due to heterogeneity between studies, a narrative synthesis was undertaken.

RESULTS

In total, 1462 abstracts from the database search and three abstracts from grey literature sources were identified. Following screening, 12 studies were included in the review. Five broad categories of intervention were identified: dental education, motivational interviewing, dental checklist, dietary change and incentives. Despite statistically significant changes in plaque indices and oral health behaviours as a result of interventions using dental education, motivational interviewing and incentives, it is unclear if these changes are clinically significant.

CONCLUSION

Although some positive results in this review demonstrate that dental education shows promise as an intervention for those with SMI, the quality of evidence was graded as very low to moderate quality. Further research is in this area is required to provide more conclusive evidence.

Role of financial incentives in family planning services in India: a qualitative study

Background

In an effort to encourage Family Planning (FP) adoption, since 1952, the Government of India has been implementing various centrally sponsored schemes that offer financial incentives (FIs) to acceptors as well as service providers, for services related to certain FP methods. However, understanding of the role of FIs on uptake of FP services, and the quality of FP services provided, is limited and mixed.

Methods

A qualitative descriptive study was conducted in Chatra and Palamu districts of Jharkhand state. A total of 64 interviews involving multiple stakeholders were conducted. The stakeholders included recent FP acceptors or clients, FP service providers of public health facilities including Accredited Social Healthcare Activists (ASHAs), government health officials managing FP programs at the district and state level, and members of development partners supporting FP programs in Jharkhand. Data analysis included both inductive and deductive strategies. It was done using the software Atlas ti version 8.

Results

It has emerged that there is a strong felt need for FP among majority of the clients, and FIs may be a motivator for uptake of FP methods only among those belonging to the lower socio economic strata. For ASHAs, FI is the primary motivator for providing FP related services. There may be a tendency among them and the nurses to promote methods which have more financial incentives linked with them. There are mixed opinions on discontinuing FIs for clients or replacing them with non-financial incentives. Delays in payment of FIs to both clients and the ASHAs is a common issue and adversely effects the program.

Conclusion

FIs for clients have limited influence on their decision to take up a FP method while different amounts of FIs for ASHAs and nurses, linked with different FP methods, may be influencing their service provision. More research is needed to determine the effect of discontinuing FI for FP services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06799-1.

Mitigating Nonattendance Using Clinic-Resourced Incentives Can Be Mutually Beneficial: A Contingency Management-Inspired Partially Observable Markov Decision Process Model

OBJECTIVES

Nonattendance of appointments in outpatient clinics results in many adverse effects including inefficient use of valuable resources, wasted capacity, increased delays, and gaps in patient care. This research presents a modeling framework for designing positive incentives aimed at decreasing patient nonattendance.

METHODS

We develop a partially observable Markov decision process (POMDP) model to identify optimal adaptive reinforcement schedules with which financial incentives are disbursed. The POMDP model is conceptually motivated based on contingency management evidence and practices. We compare the expected net profit and trade-offs for a clinic using data from the literature for a base case and the optimal positive incentive design resulting from the POMDP model. To accommodate a less technical audience, we summarize guidelines for reinforcement schedules from a simplified Markov decision process model.

RESULTS

The results of the POMDP model show that a clinic can increase its net profit per recurrent patient while simultaneously increasing patient attendance. An increase in net profit of 6.10% was observed compared with a policy with no positive incentive implemented. Underlying this net profit increase is a favorable trade-off for a clinic in investing in a targeted contingency management-based positive incentive structure and an increase in patient attendance rates.

CONCLUSIONS

Through a strategic positive incentive design, the POMDP model results show that principles from contingency management can support decreasing nonattendance rates and improving outpatient clinic efficiency of its appointment capacity, and improved clinic efficiency can offset the costs of contingency management.

A critical examination of empowerment discourse in medical tourism: the case of the dental tourism industry in Los Algodones, Mexico

BACKGROUND

Medical tourism is a term used to describe the phenomenon of individuals intentionally traveling across national borders to privately purchase medical care. The medical tourism industry has been portrayed in the media as an "escape valve" providing alternative care options as a result of vast economic asymmetries between the global north and global south and the flexible regulatory environment in which care is provided to medical tourists. Discourse suggesting the medical tourism industry necessarily enhances access to medical care has been employed by industry stakeholders to promote continued expansion of the industry; however, it remains unknown how this discourse informs industry practices on the ground. Using case study methodology, this research examines the perspectives and experiences of industry stakeholders working and living in a dental tourism industry site in northern Mexico to develop a better understanding of the ways in which common discourses of the industry are taken up or resisted by various industry stakeholders and the possible implications of these practices on health equity.

RESULTS

Interview discussions with a range of industry stakeholders suggest that care provision in this particular location enables international patients to access high quality dental care at more affordable prices than typically available in their home countries. However, interview participants also raised concerns about the quality of care provided to medical tourists and poor access to needed care amongst local populations. These concerns disrupt discourses about the positive health impacts of the industry commonly circulated by industry stakeholders positioned to profit from these unjust industry practices.

CONCLUSIONS

We argue in this paper that elite industry stakeholders in our case site took up discourses of medical tourism as enhancing access to care in ways that mask health equity concerns for the industry and justify particular industry activities despite health equity concerns for these practices. This research provides new insight into the ways in which the medical tourism industry raises ethical concern and the structures of power informing unethical practices.

Unmet healthcare needs of elderly people in Korea

BACKGROUND

Elderly people often have more complicated healthcare needs than younger adults due to additional functional decline, physical illness, and psychosocial needs. Unmet healthcare needs increase illness severity, complications, and mortality. Despite this, research on the unmet healthcare needs of elderly people is limited in Korea. This study analysed the effect of functional deterioration related to aging on unmet healthcare needs based on the Korea Health Panel Study.

METHODS

This cross-sectional study used data from the 2011-2013 survey of 8666 baseline participants aged 65 years and older. Unmet healthcare needs were calculated using a complex weighted sample design. Group differences in categorical variables were analysed using the Rao-Scott Chi-square test. Using logistic regression analysis, the association between unmet healthcare needs and aging factors was analysed.

RESULTS

The prevalence of unmet healthcare needs in Korean elderly was 17.4%. Among them, the leading reason was economic hardship (9.2%). Adjusting for sex, age, socioeconomic characteristics, and health-related characteristics, the group with depression syndrome was 1.45 times more likely to have unmet healthcare needs than that without depression syndrome (95% CI = 1.13-1.88). The group with visual impairment was 1.48 times more likely to have unmet healthcare needs than that without it (95% CI = 1.22-1.79). The group with hearing impairment was 1.40 times more likely to have unmet healthcare needs than that without it (95% CI = 1.15-1.72). The group with memory impairment was 1.74 times more likely to have unmet healthcare needs than that without it (95% CI = 1.28-2.36).

CONCLUSIONS

The unmet medical needs of the elderly are more diverse than those of younger adults. This is because not only socioeconomic and health-related factors but also aging factors that are important to the health of the elderly are included. All factors were linked organically; therefore, integrated care is needed to improve healthcare among the elderly. To resolve these unmet healthcare needs, it is necessary to reorganize the healthcare system in Korea to include preventive and rehabilitative services that address chronic diseases in an aged society and promote life-long health promotion.

Intrapartum obstetric care in the United States military: Comparison of military and civilian care systems within TRICARE

BACKGROUND

Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE.

METHODS

TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care.

RESULTS

A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care.

CONCLUSION

Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States.

Incentives, equity and the Able Chooser Problem

Health incentive schemes aim to produce healthier behaviours in target populations. They may do so both by making incentivised options more salient and by making them less costly. Changes in costs only result in healthier behaviour if the individual rationally assesses the cost change and acts accordingly. Not all people do this well. Those who fail to respond rationally to incentives will typically include those who are least able to make prudent choices more generally. This group will typically include the least advantaged more generally, since disadvantage inhibits one's effective ability to choose well and since poor choices tend to cause or aggravate disadvantage. Therefore, within the target population, health benefits to the better off may come at the cost of aggravated inequity. This is one instance of a problem I name the Able Chooser Problem, previously emphasised by Richard Arneson in relation to coercive paternalism. I describe and discuss this problem by distinguishing between policy options and their effects on the choice situation of individuals. Both positive and negative incentives, as well as mandates that are less than perfectly effective, require some sort of rational deliberation and action and so face the Able Chooser Problem. In contrast, effective restriction of what options are physically available, as well as choice context design that makes some options more salient or appealing, does not demand rational agency. These considerations provide an equity-based argument for preferring smart design of our choice and living environment to incentives and mandates.

Solidarity, justice and unconditional access to healthcare

Luck egalitarianism provides a reason to object to conditionality in health incentive programmes in some cases when conditionality undermines political values such as solidarity or inclusiveness. This is the case with incentive programmes that aim to restrict access to essential healthcare services. Such programmes undermine solidarity. Yet, most people's lives are objectively worse, in one respect, in non-solidary societies, because solidarity contributes both instrumentally and directly to individuals' well-being. Because solidarity is non-excludable, undermining it will deprive both the prudent and the imprudent citizens of its goods. Thereby, undermining solidarity can make prudent citizens worse off than they would have otherwise been, out of no fault or choice of their own, but rather as a result of somebody else's imprudent choice. This goes against the spirit of luck egalitarianism. Therefore (luck egalitarian) justice can require us to save the imprudent and avoid conditionality in access to essential healthcare services.

Health incentive research and social justice: does the risk of long term harms to systematically disadvantaged groups bear consideration?

The ethics of health incentive research-a form of public health research-are not well developed, and concerns of justice have been least examined. In this paper, we explore what potential long term harms in relation to justice may occur as a result of such research and whether they should be considered as part of its ethical evaluation. 'Long term harms' are defined as harms that contribute to existing systematic patterns of disadvantage for groups. Their effects are experienced on a long term basis, persisting even once an incentive research project ends. We will first establish that three categories of such harms potentially arise as a result of health incentive interventions. We then argue that the risk of these harms also constitutes a morally relevant consideration for health incentive research and suggest who may be responsible for assessing and mitigating these risks. We propose that responsibility should be assigned on the basis of who initiates health incentive research projects. Finally, we briefly describe possible strategies to prevent or mitigate the risk of long term harms to members of disadvantaged groups, which can be employed during the design, conduct and dissemination of research projects.

Too poor to say no? Health incentives for disadvantaged populations

Incentive schemes, which offer recipients benefits if they meet particular requirements, are being used across the world to encourage healthier behaviours. From the perspective of equality, an important concern about such schemes is that since people often do not have equal opportunity to fulfil the stipulated conditions, incentives create opportunity for further unfair advantage. Are incentive schemes that are available only to disadvantaged groups less susceptible to such egalitarian concerns? While targeted schemes may at first glance seem well placed to help improve outcomes among disadvantaged groups and thus reduce inequalities, I argue in this paper that they are susceptible to significant problems. At the same time, incentive schemes may be less problematic when they operate in ways that differ from the 'standard' incentive mechanism; I discuss three such mechanisms.

Framing preventive care messaging and cervical cancer screening in a health-insured population in South Africa: Implications for population-based communication?

The impact of health message framing on cervical cancer screening uptake is poorly understood. In a prospective randomized control study with 748 females, aged 21–65 years with no Pap smear in the previous 3 years, they randomly received a loss-framed, gain-framed, or neutral health message (control) regarding cervical cancer screening by email. Screening rate in the control group was 9.58 percent (CI: 9.29%–9.87%), 5.71 percent (CI: 5.48%–6.98%) in the gain-framed group, and 8.53 percent (CI: 8.24%–8.81%) in the loss-framed group. Statistically there was no difference between the three screening rates. Framing of health messages may not be a significant consideration when communicating through emails.

Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods

OBJECTIVE

Financial incentives are effective in encouraging healthy behaviours, yet concerns about acceptability remain. We conducted a systematic review exploring acceptability of financial incentives for encouraging healthy behaviours.

METHODS

Database, reference, and citation searches were conducted from the earliest available date to October 2014, to identify empirical studies and scholarly writing that: had an English language title, were published in a peer-reviewed journal, and explored acceptability of financial incentives for healthy behaviours in members of the public, potential recipients, potential practitioners or policy makers. Data was analysed using thematic analysis.

RESULTS

Eighty one papers were included: 59 pieces of scholarly writing and 22 empirical studies, primarily exploring acceptability to the public. Five themes were identified: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Although there was consensus that if financial incentives are effective and cost effective they are likely to be considered acceptable, a number of other factors also influenced acceptability.

CONCLUSIONS

Financial incentives tend to be acceptable to the public when they are effective and cost-effective. Programmes that benefit recipients and wider society; are considered fair; and are delivered to individuals deemed appropriate are likely to be considered more acceptable.

Access disparity and health inequality of the elderly: unmet needs and delayed healthcare

The purpose of this study is to investigate healthcare access disparity that will cause delayed and unmet healthcare needs for the elderly, and to examine health inequality and healthcare cost burden for the elderly. To produce clear policy applications, this study adapts a modified PRECEDE-PROCEED model for framing theoretical and experimental approaches. Data were collected from a large collection of the Community Tracking Study Household Survey 2003-2004 of the USA. Reliability and construct validity are examined for internal consistency and estimation of disparity and inequality are analyzed by using probit/ols regressions. The results show that predisposing factors (e.g., attitude, beliefs, and perception by socio-demographic differences) are negatively associated with delayed healthcare. A 10% increase in enabling factors (e.g., availability of health insurance coverage, and usual sources of healthcare providers) are significantly associated with a 1% increase in healthcare financing factors. In addition, information through a socio-economic network and support system has a 5% impact on an access disparity. Income, health status, and health inequality are exogenously determined. Designing and implementing easy healthcare accessibility (healthcare system) and healthcare financing methods, and developing a socio-economic support network (including public health information) are essential in reducing delayed healthcare and health inequality.

Predictors of adherence to screening guidelines for chronic diseases of lifestyle, cancers, and HIV in a health-insured population in South Africa

BACKGROUND

Adherence to screening guidelines has been widely accepted to reduce morbidity, mortality, and cost outcomes. The aim of this study was to identify predictors of adherence to screening guidelines for chronic diseases of lifestyle (CDL), cancers, and HIV in a health-insured population in South Africa, some of whom voluntarily opt into a wellness program that incentivizes screening.

METHOD

A cross-sectional study for the period 2007-2011 was conducted using a random sample of 170,471 health insurance members from a single insurer. Adherence to screening guidelines was calculated from medical claims data.

RESULTS

Adherence to screening guidelines ranged from 1.1% for colorectal cancer to 40.9% for cholesterol screening. Members of the wellness program were up to three times more likely to screen for diseases (odds ratio [OR] = 3.2 for HIV screening, confidence interval [CI] = 2.75-3.73). Plan type (full comprehensive plan) was most strongly associated with cholesterol screening (OR = 3.53, CI = 3.27-3.80), and most negatively associated (hospital-only core plan) with cervical cancer screening (OR = 0.44, CI = 0.28-0.70). Gender was a negative predictor for glucose screening (OR = 0.88, CI = 0.82-0.96). Provincial residence was most strongly associated with cervical cancer screening (OR = 1.89, CI = 0.65-5.54).

CONCLUSION

Adherence to screening recommendations was <50%. Plan type, gender, provincial residence, and belonging to an incentivized wellness program were associated with disproportionate utilization of screening services, even with equal payment access.

Willingness to participate in a lifestyle intervention program of patients with type 2 diabetes mellitus: a conjoint analysis

BACKGROUND

Several studies suggest that lifestyle interventions can be effective for people with, or at risk for, diabetes. The participation in lifestyle interventions is generally low. Financial incentives may encourage participation in lifestyle intervention programs.

OBJECTIVE

The main aim of this exploratory analysis is to study empirically potential effects of financial incentives on diabetes patients' willingness to participate in lifestyle interventions. One financial incentive is negative ("copayment") and the other incentive is positive ("bonus"). The key part of this research is to contrast both incentives. The second aim is to investigate the factors that influence participation in a lifestyle intervention program.

METHODS

Conjoint analysis techniques were used to empirically identify factors that influence willingness to participate in a lifestyle intervention. For this purpose diabetic patients received a questionnaire with descriptions of various forms of hypothetical lifestyle interventions. They were asked if they would be willing to participate in these hypothetical programs.

RESULTS

In total, 174 observations were rated by 46 respondents. Analysis showed that money was an important factor independently associated with respondents' willingness to participate. Receiving a bonus seemed to be associated with a higher willingness to participate, but having to pay was negatively associated with participation in the lifestyle intervention.

CONCLUSION

Conjoint analysis results suggest that financial considerations may influence willingness to participate in lifestyle intervention programs. Financial disincentives in the form of copayments might discourage participation. Although the positive impact of bonuses is smaller than the negative impact of copayments, bonuses could still be used to encourage willingness to participate.