Interpersonal Communication and Smoking Cessation in the Context of an Incentive-Based Program: Survey Evidence From a Telehealth Intervention in a Low-Income Population

How and why do financial incentives contribute to helping people stop smoking? A realist review

BACKGROUND

Tobacco smoking remains a key cause of preventable illness and death globally. In response, many countries provide extensive services to help people to stop smoking by offering a variety of effective behavioural and pharmacological therapies. However, many people who wish to stop smoking do not have access to or use stop smoking supports, and new modes of support, including the use of financial incentives, are needed to address this issue. A realist review of published international literature was undertaken to understand how, why, for whom, and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women.

METHODS

Systematic searches were undertaken from inception to February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Study selection was inclusive of all study designs. Twenty-two studies were included. Using Pawson and Tilley's iterative realist review approach, data collected were screened, selected, coded, analysed, and synthesised into a set of explanatory theoretical findings.

RESULTS

Data were synthesised into six Context-Mechanism-Outcome Configurations and one overarching programme theory after iterative rounds of analysis, team discussion, and expert panel feedback. Our programme theory shows that financial incentives are particularly useful to help people stop smoking if they have a financial need, are pregnant or recently post-partum, have a high threshold for behaviour change, and/or respond well to external rewards. The incentives work through a number of mechanisms including the role their direct monetary value can play in a person's life and through a process of reinforcement where they can help build confidence and self-esteem.

CONCLUSION

This is the first realist review to synthesise how, why, and for whom financial incentives work among those attempting to stop smoking, adding to the existing evidence demonstrating their efficacy. The findings will support the implementation of current knowledge into effective programmes which can enhance the impact of stop smoking care.

PROSPERO REGISTRATION NUMBER

CRD42022298941.

From Health Campaign to Interpersonal Communication: Does Traditional Diet Culture Hinder the Communication of the Chinese Gongkuai Campaign?

Interpersonal communication is beneficial in promoting individuals' tendency to accept health-campaign-targeted behavior. Based on the protective action decision model, this study investigated the key factors underlying individual's interpersonal communication on the Gongkuai campaign, which was carried out during Coronavirus disease 2019 (COVID-19). The main goal of the Gongkuai campaign was to change traditional communal eating habits and reduce public health risks. An online questionnaire survey involving 618 respondents was conducted in China after the 2020 Gongkuai campaign propagated, and the data were analyzed by using the structural equation modeling technique. The results indicated that health campaign exposure is a critical determinant of perceived campaign-related knowledge and health risk perception, which are significant predictors of interpersonal communication. Meanwhile, campaign-related knowledge can elicit risk perception. Furthermore, campaign exposure influenced interpersonal communication in ways that traditional diet culture did not predict. Risk perception was also unaffected by traditional diet culture. It is worth noting that individuals' agreement with traditional diet culture does not hinder health campaign-generated interpersonal communication in the context of public health crisis. Based on the findings, theoretical and policy implications for motivating interpersonal communication were discussed, and research limitations were pointed out.

A National Communications Campaign to decrease childhood stunting in Tanzania: an analysis of the factors associated with exposure

Background

Childhood stunting is a major problem in Tanzania, affecting an estimated 2.7 million children under 5 years of age. The purpose of this study was to examine the factors associated with exposure to mass media (radio and television) and IPC (interpersonal communication) components integrated in a national communications campaign aiming to decrease stunting in Tanzania.

Methods

A cross-sectional survey was conducted among 3082 men and 4996 women dyads after the campaign. The average age of men was 34.7 years (SD = 8.9) and 28.1 years (SD = 6.9) for women. Several factors affecting exposure to the campaign were studied. Comparisons were made between radio, TV, and IPC exposure.

Results

Mothers who reported i) higher wealth, ii) being the primary decision-makers in the home, iii) receiving support from their husbands, iv) frequent access to radio and TV and, v) ownership of a cell phone, were more likely to report exposure to the mass media component of the communications campaign. Contrarily, the same factors were not predictors of exposure to the IPC component. Fathers who reported: i) higher wealth and education, ii) ownership of a cell phone, iii) recently listened to the radio, iv) that the mother made the decisions in the home and v) helping at home, were more likely to be exposed to the mass media component.

Conclusion

Significant factors affecting exposure to the communications campaign were varied but not consistent between mass media and IPC. Because of the high frequency of exposure to the campaign overall, both media and IPC components are important in a large-scale, health-related communications campaign.

Perceived Change in Tobacco Use and Its Associated Factors among Older Adults Residing in Rohingya Refugee Camps during the COVID-19 Pandemic in Bangladesh

This study explored the perceived change in tobacco use during the COVID-19 pandemic and its associated factors among older adults residing in Rohingya refugee camps, also referred to as Forcibly Displaced Myanmar Nationals in Bangladesh. The study followed a cross-sectional design and was conducted in October 2020 among 416 older adults aged 60 years and above. A purposive sampling technique was applied to identify eligible participants, and face-to-face interviews were conducted using a pre-tested semi-structured questionnaire to collect the data. Participants were asked if they noted any change in their tobacco use patterns (smoking or smokeless tobacco) during the COVID-19 pandemic compared to pre-pandemic. Binary logistic regression models determined the factors associated with the perceived change in tobacco use. More than one in five participants (22.4%) were current tobacco users, of whom 40.8% reported a perceived increase in tobacco use during the COVID-19 pandemic. Adjusted analysis revealed that participants who were concerned about COVID-19 had significantly (p < 0.05) lower odds of perceived increase in tobacco use (aOR = 0.22, 95% CI: 0.06–0.73), while older adults who were overwhelmed by COVID-19 (aOR = 0.26, 95% CI: 0.06–1.18) and communicated less frequently with others during the pandemic than before (aOR = 0.19, 95% CI: 0.03–1.20) had marginally significantly (p < 0.1) lower odds of perceived increase in tobacco use during this pandemic. Relevant stakeholders, policymakers, and practitioners need to focus on strengthening awareness-raising initiatives as part of an emergency preparedness plan to control tobacco use during such a crisis period.

National Nutrition Communication Campaign in Indonesia: a cross-sectional study of factors associated with exposure

Background

Reducing childhood stunting continues to be a priority in Indonesia. In 2015, the National Nutrition Communication Campaign (NNCC) implemented mass media and interpersonal communication (IPC) interventions to disseminate stunting-related information. Whereas other studies of the NNCC’s impact on attitudes and behaviors are currently underway, the purpose of this study was to better understand the factors associated with exposure to the media and IPC components of the NNCC.

Methods

A cross-sectional survey was conducted following the NNCC media and IPC campaigns in rural Indonesia. The final study sample included 1734 mothers. Survey data was collected from each participant by trained interviewers using an electronic tablet. Responses relating to demographic and socioeconomic factors, use of social media and WhatsApp, and electronic device ownership were analyzed. Logistic regression analyses, using SAS version 9.4, were conducted to evaluate the relationship between technology-related items and exposure to both the media and the IPC interventions.

Results

Owning an internet device (OR = 1.643, CI = 1.237–2.183, p < 0.001), accessing social media (OR = 1.81, CI = 1.32–2.49, p < 0.001), using a device to access health information (OR = 2.068, CI = 1.469–2.911, p < 0.0001), and accessing WhatsApp (OR = 1.663, CI = 1.175–2.355, p < 0.05) were positively related to exposure to NNCC messages meant to change behavior to decrease stunting. In separate analyses, owning an internet device (OR = 0.609, CI = 0.459–0.81, p < 0.001) accessing social media (OR = 0.626, CI = 0.459–0.854, p < 0.05), using a device to access health information (OR = 0.528, CI = 0.377–0.740, p < 0.001), and accessing WhatsApp (OR = 0.688, CI = 0.489–0.968, p < 0.05) were negatively related to IPC exposure. Mothers with access to internet-accessible devices were more likely to be exposed to the media campaign component to decrease stunting while mothers without access to internet-accessible devices were more likely to be exposed through IPC.

Conclusions

Mothers who owned devices that could access the internet were more likely to have been exposed to the media campaign component to decrease stunting by behavior change but were less likely to participate in IPC activities. The opposite was true for mothers who did not have access to internet-accessible devices. These findings may be used to inform future community health efforts in rural Indonesia and similar regions that may be considering the use of both mass media and interpersonal interventions to influence health behaviors in order to decrease stunting.

Determinants of the behavioral intention to use a mobile nursing application by nurses in China

BACKGROUND

Although a mobile nursing application has began to adopt in nursing, few studies have focused on nurses' behavioral intention of it. The objective of this study is to gain insight into the behavioral intention of nurses, i.e. chinese nurses of the future, to use a mobile nursing application. This study adopted an extension of the Unified Theory of Acceptance and Use of Technology to examine Chinese nurses' acceptance of a mobile nursing application.

METHODS

A total of 1207 nurses participated in the cross-sectional survey. The majority of nurses were female (96.2%). The mean age of the participants was 34.18 (SD 7.39). The hypothesized relationships were tested using AMOS structural equation model.

RESULTS

All constructs exhibited an acceptable level of reliability and validity with Cα and CR > 0.7 and AVE > 0.5. An extension of the Unified Theory of Acceptance and Use of Technology Model had good explanatory power for nurses' behavioral intention of a mobile nursing application. Although effort expectancy and perceived risks had a surprisingly insignificant effect on nurses' behavioral intention to use a mobile nursing application, performance expectancy, social influence, facilitating conditions, self-efficacy, and perceived incentives demonstrated significant influence with β = .259, p < .001, β = .296, p < .001, β = .063, p = .037, β = .344, p < .001, β = .091, p = .001, respectively.

CONCLUSION

With 70.2% of the variance in behavioral intention to use a mobile nursing app explained by this model, it could be helpful for potential adopters, and further investigation should test the actual usage behavior for a mobile nursing app and investigate the related factors.

An interpersonal nutrition campaign and maternal knowledge and childhood feeding practices: a case study from mothers in rural Indonesia

Background

The purpose of this study was to examine the extent to which a national nutrition communication campaign (NNCC) intervention providing interpersonal communication (IPC) was associated with improved knowledge and behaviors related to feeding practices among mothers with children under two years of age in rural Indonesia.

Methods

Data came from a follow-up, cross-sectional survey of 1734 mothers. Key outcomes of interest were minimum meal frequency, minimum dietary diversity and minimum acceptable diet, as defined by the World Health Organization. Associations between exposure to the NNCC intervention and infant and young child feeding (IYCF) knowledge and behaviors were analyzed using adjusted linear and logistic regression, controlling for age, education, and income.

Results

A total of 525 mothers reported exposure to IPC interventions (30.3%). Participation in IPC was associated with increased knowledge of feeding practices (p < .0001). Separately, knowledge of feeding practices was related to achieving recommended behavioral practices of minimum meal frequency (p = 0.019), dietary diversity (p = 0.013), adequate diet (p < .001).

Conclusion

These findings underscore the value of increasing maternal knowledge of IYCF practices through IPC interventions as a way to improve behavioral practices and address stunting in rural Indonesia.

Financial incentives and proactive calling for reducing barriers to tobacco treatment among socioeconomically disadvantaged women: A factorial randomized trial

Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. We tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017; the trial was designed to last 3 months (July through October). Participants were female smokers who were 250% below the federal poverty level (randomized N = 3723; analyzed N = 3365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services ($0 vs $10 vs $20). Simple randomization was conducted using Stata v.13. All individuals received direct mail. Participants and staff were blinded to allocation. The outcome was connection via phone to QUITPLAN Services®, Minnesota's population-based cessation services. Groups that received $10 or $20 incentives had higher odds of treatment engagement compared to the no incentive group [respectively, OR = 1.94; 95% CI (1.19-3.14); OR = 2.18; 95% CI (1.36-3.51)]. Individuals that received proactive calls had higher odds of treatment engagement compared to individuals not called [OR = 1.59; 95% CI (1.11-2.29)]. Economic evaluation revealed that the $10 incentive, no call group had the best cost-benefit ratio compared to the no incentive, no call group. Direct mail with moderate incentives or proactive calling can successfully encourage connections to population-based tobacco treatment services among low-SES smokers. The intervention could be disseminated to similar programs serving low-SES populations. This trial is registered at ClinicalTrials.gov (NCT03760107).

The Medi-Cal Incentives to Quit Smoking Project: Impact of Statewide Outreach Through Health Channels

INTRODUCTION

Little is known about how incentives may encourage low income smokers to call for quitline services. This study evaluates the impact of outreach through health channels on California Medicaid (Medi-Cal) quitline caller characteristics, trends, and reach.

STUDY DESIGN

Longitudinal study.

SETTING/PARTICIPANTS

Medi-Cal quitline callers.

INTERVENTION

Statewide outreach was conducted with health providers, Medi-Cal plans (all-household mailings with tracking codes), and public health organizations (March 2012-July 2015). For incentives, Medi-Cal callers could ask for a $20 gift card; in September 2013, callers were offered free nicotine patches.

MAIN OUTCOME MEASURES

Caller characteristics were compared with chi-square analyses, joinpoint analysis of call trends was performed accounting for Medi-Cal population growth, referral source among Medi-Cal and non-Medi-Cal callers was documented, and the annual percentage of the population reached who called the Helpline was calculated. Analyses were conducted 2016-2018.

RESULTS

Total Medi-Cal callers were 92,900, a 70% increase from prior annual averages: 12.4% asked for the financial incentive, 17.3% reported the mailing code, and 73.3% received nicotine patches while offered. Among the two thirds of callers who completed counseling, 15.5% asked for the financial incentive, and 13.6% reported the mailing code. A joinpoint analysis showed call trends increased 23% above expected for the Medi-Cal population growth after mailings to providers and members began, and decreased after outreach ended. Annual reach increased from 2.3% (95% CI=2.1, 2.6) in 2011 to peak at 4.5% (95% CI=3.6, 5.3) in 2014. Among subgroups with higher reach rates, some also had higher rates of asking for the financial incentive (African Americans, American Indian), reporting the tracking code (whites), or both (aged 45-64 years). Medi-Cal callers were more likely than non-Medi-Cal callers to report providers (32.3% vs 23.8%) and plans (19.7% vs 1.4%) as their referral source, and less likely to cite media (20.2% vs 44.4%, p<0.001).

CONCLUSIONS

Statewide outreach through health channels incentivizing Medi-Cal members increased the utilization and reach of quitline services.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

The ethics of uninsured participants accessing healthcare in biomedical research: A literature review

Background/aims Sparse literature exists on the challenges and ethical considerations of including people with limited access to healthcare, such as the uninsured and low-income, in clinical research in high-income countries. However, many ethical issues should be considered with respect to working with uninsured and low-income participants in clinical research, including enrollment and retention, ancillary care, and post-trial responsibilities. Attention to the uninsured and low-income is particularly salient in the United States due to the high rates of uninsurance and underinsurance. Thus, we conducted a scoping review on the ethical considerations of biomedical clinical research with uninsured and low-income participants in high-income countries in order to describe what is known and to pinpoint areas of needed research on this issue. Methods MEDLINE/PubMed, Embase, and Scopus databases were searched using terms that described main concepts of interest (e.g., uninsured, underinsured, access to healthcare, poverty, ethics, compensation, clinical research). Articles were included if they met four inclusion criteria: (1) English, (2) high-income countries context, (3) about research participants who are uninsured or low-income, which limits their access to healthcare, and in biomedical clinical research that either had a prospect of direct medical benefit or was offered to them on the basis of their ill health, and (4) recognizes and/or addresses challenges or ethical considerations of uninsured or low-income participants in biomedical clinical research. Results The searches generated a total of 974 results. Ultimately, 23 papers were included in the scoping review. Of 23 articles, the majority (n = 19) discussed enrollment and retention of uninsured or low-income participants. Several barriers to enrolling uninsured and low-income groups were identified, including limited access to primary or preventive care; lack of access to institutions conducting trials or physicians with enough time or knowledge about trials; overall lack of trust in the government, research, or medical system; and logistical issues. Considerably fewer articles discussed treatment of these participants during the course of research (n = 5) or post-trial responsibilities owed to them (n = 4). Thus, we propose a research agenda that builds upon the existing literature by addressing three broad questions: (1) What is the current status of uninsured research participants in biomedical clinical research in high-income countries? (2) How should uninsured research participants be treated during and after clinical research? (3) How, if at all, should additional protections for uninsured research participants affect their enrollment? Conclusions This review reveals significant gaps in both data and thoughtful analysis on how to ethically involve uninsured research participants. To address these gaps, we propose a research agenda to gather needed data and theoretical analysis that addresses three broad research questions.

Project reach: Piloting a risk-tailored smoking cessation intervention for lung screening

The purpose of this study was to explore the feasibility, acceptability, and efficacy of a telephone-based smoking cessation intervention for lung screening patients. Participants (N = 39) were enrolled in a single-arm pilot study of a four-session telephone-based intervention. Self-report measures were completed at baseline, post-intervention, and 3-month follow-up. Participants were long-term smokers; 62 percent were not motivated to quit. Twenty-three percent attempted quitting, 29 percent decreased their smoking, and 11 percent reported abstinence. Confidence increased (p < .001) and there were trends toward increased importance (p = .09) and comparative disease risk (p = .02). This intervention was acceptable and associated with improvements in smoking-related beliefs and behaviors.

Interpersonal Communication in Response to an Intervention and Its Impact on Smoking Cessation Within a Low-Income Population

BACKGROUND

It is a priority to develop population-based strategies for reducing barriers to smoking cessation among low-income populations. Harnessing secondary transmission such as interpersonal communication (IC) has helped to reduce tobacco use, but there is a dearth of quasi-experimental research that examines IC and the full spectrum of smoking cessation behaviors, particularly in the context of population-level programs.

AIMS

Using quasi-experimental methods, we examined IC in response to a population-level intervention and its impact on the full spectrum of smoking cessation outcomes among low-income smokers.

METHOD

We used propensity score matching; three different propensity score matching procedures were used to estimate and approximate experimental effects. We assessed four cessation outcomes: utilization of a free tobacco quitline (QL), making a quit attempt, and being smoke-free for 7 and 30 days at follow-up. We also examined predictors of IC.

RESULTS

IC was significantly related to QL utilization (effect sizes ranging from 0.135 to 0.166), making a quit attempt (effect sizes ranging from 0.115 to 0.147), being smoke-free for 7 days (effect sizes ranging from 0.080 to 0.121), and being smoke-free for 30 days at follow-up (effect sizes ranging from 0.058 to 0.082). Program-related and participant characteristics predicted IC, such as receiving emotional direct mail materials and living with a fellow smoker.

DISCUSSION

IC in response to a population-based program affected the cessation process, and IC had a marked impact on sustained cessation.

CONCLUSION

Population-based programs should aim to harness psychosocial dynamics such as IC to promote sustained cessation among low-income populations.

Behavioral change in response to a statewide tobacco tax increase and differences across socioeconomic status

BACKGROUND

Tobacco use is a leading behavioral risk factor for morbidity and mortality, and the tobacco epidemic disproportionately affects low-socioeconomic status (SES) populations. Taxation is effective for reducing cigarette use, and it is an effective population-based policy for reducing SES-related tobacco disparities. However, progress in implementing cigarette excise taxes has stalled across the United States, and there is a dearth of research on the full spectrum of behavioral shifts that result from taxes, particularly among low-SES populations. This project documents the impact of Minnesota's $1.75 cigarette tax increase implemented in 2013.

METHODS

Data come from the 2014 Minnesota Adult Tobacco Survey. Descriptive analyses and Latent Class Analysis (LCA) were used to provide a typology of the tax impact.

RESULTS

From the LCA, six classes were identified, and 42% of respondents were classified as reporting action-oriented behavioral change related to the tax-8% reported sustained smoking abstinence. We found differential behavior change across levels of SES. Low-SES and medium/high-SES individuals were equally likely to report complete tobacco cessation, but the prevalence of daily smokers who reported action-oriented behavior without sustained cessation was nearly double for low-SES individuals.

CONCLUSIONS

Smokers report a range of behavioral changes in response to cigarette taxes, with differences across SES. The majority of smokers, and particularly low-SES smokers, report behavioral steps toward quitting or achieving sustained tobacco cessation in response to cigarette taxes. Complementary population-based programs geared toward assisting individuals, especially low-SES individuals, to achieve continuous tobacco cessation could increase the reach and effectiveness of cigarette taxes.

Treatment of Lung Cancer in Medically Compromised Patients

Outcomes for patients with lung cancer have been improved substantially through the integration of surgery, radiation, and systemic therapy for patients with early-stage disease. Meanwhile, advances in our understanding of molecular mechanisms have substantially advanced our treatment of patients with advanced lung cancer through the introduction of targeted therapies, immune approaches, improvements in chemotherapy, and better supportive care. However, the majority of these advances have occurred among patients with good functional status, normal organ function, and with the social and economic support systems to be able to benefit most from these treatments. The aim of this article is to bring greater attention to management of lung cancer in patients who are medically compromised, which remains a major barrier to care delivery. Impaired performance status is associated with poor outcomes and correlates with the high prevalence of cachexia among patients with advanced lung cancer. CT imaging is emerging as a research tool to quantify muscle loss in patients with cancer, and new therapeutics are on the horizon that may provide important adjunctive therapy in the future. The benefits of cancer therapy for patients with organ failure are poorly understood because of their exclusion from clinical trials. The availability of targeted therapy and immunotherapy may provide alternatives that may be easier to deliver in this population, but clinical trials of these new agents in this population are vital. Patients with lower socioeconomic status are disproportionately affected by lung cancer because of higher rates of tobacco addiction and the impact of socioeconomic status on delay in diagnosis, treatment, and outcomes. For all patients who are medically compromised with lung cancer, multidisciplinary approaches are particularly needed to evaluate these patients and to incorporate rapidly changing therapeutics to improve outcomes.

Coupling Financial Incentives With Direct Mail in Population-Based Practice

Financial incentives are being used increasingly to encourage a wide array of health behaviors because of their well-established efficacy. However, little is known about how to translate incentive-based strategies to public health practice geared toward improving population-level health, and a dearth of research exists on how individuals respond to incentives through public health communication strategies such as direct mail. This study reports results of a population-based randomized controlled trial testing a direct mail, incentive-based intervention for promoting mammography uptake. The study population was composed of a random sample of Minnesota women enrolled in Medicare fee-for-service and overdue for breast cancer screening. Participants ( N = 18,939) were randomized into three groups: (1) Direct Mail only, (2) Direct Mail plus Incentive, and (3) Control. Both direct mail groups received two mailers with a message about the importance of mammography; however, Mail plus Incentive mailers also offered a $25 incentive for getting a mammogram. Logistic regression analyses measured intervention effects. Results showed the odds for receiving mammography were significantly higher for the Direct Mail plus Incentive group compared with both Direct Mail only and Control groups. The use of incentives also proved to be cost-effective. Additionally, the Direct Mail only group was more likely to receive mammography than the Control group. Findings offer experimental evidence on how the population-based strategy of direct mail coupled with a financial incentive can encourage healthy behavior, as well as how incentive-based programs can be translated into health promotion practice aimed at achieving population-level impact.