Changing health behaviors using financial incentives: a review from behavioral economics

Self-management behavior strategy based on behavioral economics in patients with hypertension: a scoping review

Hypertensive patients often do not make the most favorable choices and behaviors for managing disease. Behavioral economics strategies offer new ideas for guiding patients toward health behavior. The scoping review aimed to summarize behavioral economics strategies designed to improve hypertension self-management behaviors. A literature search was conducted in September 2022 using the following electronic databases: Embase, Medline, CINAHL, PsycINFO, Web of Science, Cochrane Library, CNKI, Wan Fang Database for Chinese Periodicals, and CBM-SinoMed. We screened the literature for experimental studies written in Chinese or English reporting on BE strategies designed to improve self-management behavior in hypertension. We searched 17 820 records and included 18 articles in the final scoping review. We performed qualitative synthesis by the categories of choice architecture. The most common BE strategies were those targeting decision information and decision assistance, such as changing the presentation of information, making information visible, and providing reminders for actions. Most strategies targeted BP, diet, medication adherence, and physical activity behavior. Ten out of 18 studies reported statistically significant improvement in self-management behavior. Further research on BE strategies should focus on addressing the challenges, including changing the decision structure, encompassing a more comprehensive range of target behaviors, and examining the long-term effects of BE strategies.

Exploring community needs in combating aedes mosquitoes and dengue fever: a study with urban community in the recurrent hotspot area

BACKGROUND

Aedes mosquitoes are the main vector of dengue infection, a global health threat affecting millions of people annually. Conventional prevention and control methods against dengue outbreaks have only achieved marginal success. Recognizing the complex issue at hand, a multilevel participatory approach is crucial. Thus, alternative strategies that involve community engagement are increasingly being considered and attempted. While community-based vector control programs have been conducted, sustaining behavioral changes among the population remains a challenge. This study aimed to identify the specific community needs in combating Aedes mosquitoes and dengue fever as a basis to guide the development of community-driven initiatives and foster a deeper sense of ownership in the fight against dengue.

METHODS

Between 1 August 2022 and 30 November 2022, we conducted a study in Hulu Langat district, Selangor, using a mixed-method design. All participants consented to the study, which comprised 27 participants (FGDs) and 15 participants (IDIs). The IDIs included two participants with a history of dengue fever, one community leader, one faith leader, seven local authorities, and four district health officers. Semi-structured interviews and discussions were performed among stakeholders and community members recruited via purposive and snowball sampling techniques. All interviews were audio-recorded before being analyzed using reflexive thematic analysis.

RESULTS

These results derived from qualitative data explored the perspectives and needs of communities in combating Aedes mosquitoes and dengue fever. Interviews were conducted with various stakeholders, including community members, leaders, and health officers. The study identified the necessity of decisive actions by authorities to address the impact of the dengue epidemic, the importance of community engagement through partnerships and participatory approaches, the potential benefits of incentives and rewards to enhance community participation, and the need for sustained community engagement and education, especially via the involvement of young people in prevention efforts. These findings provide valuable insights into the design of effective strategies against Aedes mosquitoes and dengue fever.

CONCLUSIONS

In short, there is an urgent need for a comprehensive approach involving multiple stakeholders in the fight against Aedes mosquitoes and dengue fever. The approach should incorporate efforts to raise awareness, provide practical resources, and foster community responsibility. The active involvement of teenagers as volunteers can contribute to long-term prevention efforts. Collaboration, resource allocation, and community engagement are crucial for effective dengue control and a healthier environment.

Financial incentives to motivate treatment for hepatitis C with direct acting antivirals among Australian adults (The Methodical evaluation and Optimisation of Targeted IncentiVes for Accessing Treatment of Early-stage hepatitis C: MOTIVATE-C): protocol for a dose-response randomised controlled study

BACKGROUND

Untreated hepatitis C virus (HCV) infection can result in cirrhosis and hepatocellular cancer. Direct-acting antiviral (DAA) therapies are highly effective and have few side effects compared to older interferon-based therapy. Despite the Australian government providing subsidised and unrestricted access to DAA therapy for chronic HCV infection, uptake has not been sufficient to meet the global target of eliminating HCV as a public health threat by 2030. This study will offer people with HCV financial incentives of varying values in order to evaluate its effect on initiation of DAA therapy in primary care.

METHODS

Australian adults (18 years or older) who self-report as having current untreated HCV infection can register to participate via an automated SMS-based system. Following self-screening for eligibility, registrants are offered a financial incentive of randomised value (AUD 0 to 1000) to initiate DAA therapy. Study treatment navigators contact registrants who have consented to be contacted, to complete eligibility assessment, outline the study procedures (including the requirement for participants to consult a primary care provider), obtain consent, and finalise enrolment. Enrolled participants receive their offered incentive on provision of evidence of DAA therapy initiation within 12 weeks of registration (primary endpoint). Balanced randomisation is used across the incentive range until the first analysis, after which response-adaptive randomisation will be used to update the assignment probabilities. For the primary analysis, a Bayesian 4-parameter EMAX model will be used to estimate the dose-response curve and contrast treatment initiation at each incentive value against the control arm (AUD 0). Specified secondary statistical and economic analyses will evaluate the effect of incentives on adherence to DAA therapy, virological response, and cost-effectiveness.

DISCUSSION

This project seeks to gain an understanding of the dose-response relationship between incentive value and DAA treatment initiation, while maximising the number of people treated for HCV within fixed budget and time constraints. In doing so, we hope to offer policy-relevant recommendation(s) for the use of financial incentives as a pragmatic, efficient, and cost-effective approach to achieving elimination of HCV from Australia.

TRIAL REGISTRATION

ANZCTR (anzctr.org.au), Identifier ACTRN12623000024640, Registered 11 January 2023 ( https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384923&isReview=true ).

A 5-Year Review of the Impact of Lottery Incentives on HIV-Related Services

PURPOSE OF REVIEW

Lottery incentives are an innovative approach to encouraging HIV prevention, treatment initiation, and adherence behaviours. This paper reviews the latest research on lottery incentives' impact on HIV-related services, and their effectiveness for motivating behaviours to improve HIV service engagement and HIV health outcomes.

RECENT FINDINGS

Our review of ten articles, related to lottery incentives, published between 2018 and 2023 (inclusive) shows that lottery incentives have promise for promoting HIV-related target behaviours. The review highlights that lottery incentives may be better for affecting simpler behaviours, rather than more complex ones, such as voluntary medical male circumcision. This review recommends tailoring lottery incentives, ensuring contextual-relevance, to improve the impact on HIV-related services. Lottery incentives offer tools for improving uptake of HIV-related services. The success of lottery incentives appears to be mediated by context, the value and nature of the incentives, and the complexity of the target behaviour.

Contingency Management for Drug Use Disorders: Meta-Analysis and Application of Tolin's Criteria

Several professional organizations and federal agencies recommend contingency management (CM) as an empirically supported treatment for drug use disorder. However, the release of the "Tolin criteria" warrants an updated recommendation. Using this methodology, five meta-analyses (84 studies, 11,000 participants) were reviewed. Two meta-analyses were rated moderate quality, and three were rated low or critically low quality. Comparator conditions included active treatment, placebo, treatment as usual, and no treatment. The primary outcome was abstinence. Considering only the moderate quality meta-analyses, the effect of CM versus control on posttreatment abstinence was d = 0.54 [0.43, 0.64] and follow-up abstinence was d=0.08 [0.00, 0.16]. A "strong" recommendation was provided for CM as an empirically supported treatment for drug use disorder.

Cost-effectiveness of incentives for physical activity in coronary heart disease in Germany: pre-trial health economic model of a complex intervention following the new MRC framework

Objectives

The German Incentives for Physical Activity in Cardiac Patients trial is a three-arm, randomised controlled trial for secondary prevention of coronary heart disease (CHD). Guidance for developing complex interventions recommends pre-trial health economic modelling. The aim of this study is to model the long-term cost-effectiveness of the incentive-based physical activity interventions in a population with CHD.

Methods

A decision-analytical Markov model was developed from a health services provider perspective, following a cohort aged 65 years with a previous myocardial infarction for 25 years. Monetary and social incentives were compared relative to no incentive. Intervention effects associated with physical activity were used to determine the costs, quality-adjusted life-years (QALYs) gained, incremental cost-effectiveness and cost-utility ratios. The probability of cost-effectiveness was calculated through sensitivity analyses.

Results

The incremental QALYs gained from the monetary and social incentives, relative to control, were respectively estimated at 0.01 (95% CI 0.00 to 0.01) and 0.04 (95% CI 0.02 to 0.05). Implementation of the monetary and social incentive interventions increased the costs by €874 (95% CI €744 to €1047) and €909 (95% CI €537 to €1625). Incremental cost-utility ratios were €25 912 (95% CI €15 056 to €50 210) and €118 958 (95% CI €82 930 to €196 121) per QALY gained for the social and monetary incentive intervention, respectively. With a willingness-to-pay threshold set at €43 000/QALY, equivalent to the per-capita gross domestic product in Germany, the probability that the social and monetary incentive intervention would be seen as cost-effective was 95% and 0%, respectively.

Conclusions

Exercise-based secondary prevention using inventive schemes may offer a cost-effective strategy to reduce the burden of CHD.

What Happens When Payments End? Fostering Long-Term Behavior Change With Financial Incentives

Financial incentives are widely used to get people to adopt desirable behaviors. Many small landholders in developing countries, for example, receive multiyear payments to engage in conservation behaviors, and the hope is that they will continue to engage in these behaviors after the program ends. Although effective in the short term, financial incentives rarely lead to long-term behavior change because program participants tend to revert to their initial behaviors soon after the payments stop. In this article, we propose that four psychological constructs can be leveraged to increase the long-term effectiveness of financial-incentive programs: motivation, habit formation, social norms, and recursive processes. We review successful and unsuccessful behavior-change initiatives involving financial incentives in several domains: public health, education, sustainability, and conservation. We make concrete recommendations on how to implement the four above-mentioned constructs in field settings. Finally, we identify unresolved issues that future research might want to address to advance knowledge, promote theory development, and understand the psychological mechanisms that can be used to improve the effectiveness of incentive programs in the real world.

Investigating the role of the built environment, socio-economic status, and lifestyle factors in the prevalence of chronic diseases in Mashhad: PLS-SEM model

Background

Chronic diseases remain a significant contributor to both mortality and disability in our modern world. Physical inactivity and an unhealthy diet are recognized as significant behavioral risk factors for chronic diseases, which can be influenced by the built environment and socio-economic status (SES). This study aims to investigate the relationship between the built environment, SES, and lifestyle factors with chronic diseases.

Methods

The current study was conducted in Mashhad's Persian cohort, which included employees from Mashhad University of Medical Sciences (MUMS). In the study, 5,357 participants from the cohort were included. To assess the state of the built environment in Mashhad, a Geographic Information System (GIS) map was created for the city and participants in the Persian Mashhad study. Food intake and physical exercise were used to assess lifestyle. A food frequency questionnaire (FFQ) was used to assess food intake. To assess food intake, the diet quality index was computed. To assess the link between variables, the structural model was created in accordance with the study's objectives, and partial least square structural equation modeling (PLS-SEM) was utilized.

Results

The chronic diseases were positively associated with male sex (p < 0.001), married (p < 0.001), and higher age (p < 0.001). The chronic diseases were negatively associated with larger family size (p < 0.05), higher SES (p < 0.001), and higher diet quality index (DQI) (p < 0.001). No significant relationship was found between chronic disease and physical activity.

Conclusion

Food intake and socioeconomic status have a direct impact on the prevalence of chronic diseases. It seems that in order to reduce the prevalence of chronic diseases, increasing economic access, reducing the class gap and increasing literacy and awareness should be emphasized, and in the next step, emphasis should be placed on the built environment.

Low-Income Participants' Preference Between Financial Incentives for Behavioral Goals vs Weight Loss Targets and Associations With Behavioral Goal Adherence

PURPOSE

Examine associations between whether participants' were matched to their preferred financial incentive design and behavioral goal adherence in a weight management intervention.

DESIGN

Secondary quantitative analysis incorporating qualitative survey data.

SETTING

Primary care clinics in socioeconomically disadvantaged communities in New York City and Los Angeles.

SUBJECTS

668 participants (mean age 47.7 years, 81.0% female, 72.6% Hispanic) with obesity were enrolled in the Financial Incentives foR Weight Reduction (FIReWoRk) intervention.

MEASURES

We explored qualitatively participant's reasons for hypothetically choosing a behavioral goal-directed vs a weight loss outcome-based financial incentive program. Additionally, behavioral adherence to different goals was collected at the 6-month timepoint, categorized by match to preferred financial incentive design.

ANALYSIS

Logistic regression was used to examine if participants with certain demographic and higher psychosocial factors were more likely to choose goal-directed over outcome-based incentives. Additionally, logistic regression was used to test for associations between preference and behavioral adherence, using incentive type as an interaction term.

RESULTS

60.2% of participants preferred the goal-directed incentive, with the majority stating that it was more structured. Married participants were more likely to prefer goal-directed incentives (OR = 1.57, CI = 1.06-2.33, P = .025). Moderation analysis revealed that participants who preferred goal-directed and were matched to goal-directed had greater rates of behavioral adherence for program attendance and self-weighing, but not dietary tracking and physical activity tracking, compared to those who preferred outcome-based and were matched to outcome-based.

CONCLUSION

Receiving one's preferred incentive design may not play a strong role in behavioral goal adherence during financially incentivized weight loss interventions.

The Effect of Financial Incentives on Adherence to Glucose Self-Monitoring during Pregnancy among Patients with Insulin-Requiring Diabetes: A Randomized Clinical Trial

OBJECTIVE

 Glucose self-monitoring is critical for the management of diabetes in pregnancy, and increased adherence to testing is associated with improved obstetrical outcomes. Incentives have been shown to improve adherence to diabetes self-management. We hypothesized that use of financial incentives in pregnancies complicated by diabetes would improve adherence to glucose self-monitoring.

STUDY DESIGN

 We conducted a single center, randomized clinical trial from May 2016 to July 2019. In total, 130 pregnant patients, <29 weeks with insulin requiring diabetes, were recruited. Participants were randomized in a 1:1:1 ratio to one of three payment groups: control, positive incentive, and loss aversion. The control group received $25 upon enrollment. The positive incentive group received 10 cents/test, and the loss aversion group received $100 for >95% adherence and "lost" payment for decreasing adherence. The primary outcome was percent adherence to recommended glucose self-monitoring where adherence was reliably quantified using a cellular-enabled glucometer. Adherence, calculated as the number of tests per day divided by the number of recommended tests per day×100%, was averaged from time of enrollment until admission for delivery.

RESULTS

 We enrolled 130 participants and the 117 participants included in the final analysis had similar baseline characteristics across the three groups. Average adherence rates in the loss aversion, control and positive incentive groups were 69% (SE=5.12), 57% (SE = 4.60), and 58% (SE=3.75), respectively (p=0.099). The loss aversion group received an average of $50 compared with $38 (positive incentive) and $25 (control).

CONCLUSION

 In this randomized clinical trial, loss aversion incentives tended toward higher adherence to glucose self-monitoring among patients whose pregnancies were complicated by diabetes, though did not reach statistical significance. Further studies are needed to determine whether use of incentives improve maternal and neonatal outcomes.

KEY POINTS

· Self-glucose monitoring is a critical part of diabetes management in pregnancy.. · Loss aversion financial incentives may increase adherence to glucose self-monitoring in pregnancy.. · The impact of testing incentives on maternal and neonatal outcomes requires further investigation..

Financial incentive interventions for smoking cessation among Chinese smokers: study protocol for a cluster randomised controlled trial

INTRODUCTION

There is an urgent issue to relieve the burdens caused by tobacco use through feasible and effective smoking cessation interventions, particularly in a middle-income country with less accessible smoking cessation services and high demand for quitting smoking. Financial incentives have shown effective in changing health behaviours, thus needing to test its portability to a wider implementation and effectiveness of increasing smoking cessation rates.

METHODS AND ANALYSIS

This is a three-arm cluster randomised controlled trial. 462 eligible participants will be assigned to 2 financial incentive groups-rewards or deposits, or the control group. All participants including those in the control group will receive text messages to help quitting smoking developed by the US National Cancer Institute over a 3-month intervention period. In addition to text messages, reward group participants will be rewarded with CNY200 and CNY400 (CNY100 approximately US$15) for sustained smoking abstinence at 1 month and 3 months follow-up assessments; participants in the deposit group will accumulate CNY200 and CNY600 in the deposit accounts after verified smoking abstinence at 1 month and 3 months follow-up assessments, and all the deposits will be given at once right after the 3-month follow-up visit. The primary outcome is biochemically verified smoking abstinence rate sustained for 6 months after enrolment.

ETHICS AND DISSEMINATION

This trial protocol has been approved by the Ethics Committee of Peking University Health Science Centre (date: 23 February 2023; ethical approval number: IRB00001052-22172). Results and findings of this trial will be disseminated in peer-reviewed journals and professional conferences.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-2300069631.

The Impact of Monetary Incentives on Delay Discounting Within a Year-Long Physical Activity Intervention

BACKGROUND

Delay discounting is the depreciation in a reward's perceived value as a function of the time until receipt. Monetary incentive programs that provide rewards contingent on meeting daily physical activity (PA) goals may change participants' delay discounting preferences.

PURPOSE

Determine if monetary incentives provided in close temporal proximity to meeting PA goals changed delay discounting, and if such changes mediated intervention effects.

METHODS

Inactive adults (n = 512) wore accelerometers during a 12-month intervention where they received proximal monetary incentives for meeting daily moderate-to-vigorous PA (MVPA) goals or delayed incentives for study participation. Delay discount rate and average MVPA were assessed at baseline, end of intervention, and a 24-month follow-up. Using structural equation modeling, we tested effects of proximal versus delayed rewards on delay discounting and whether any changes mediated intervention effects on MVPA. PA self-efficacy was also evaluated as a potential mediator, and both self-efficacy and delay discounting were assessed as potential moderators of intervention effects.

RESULTS

Proximal rewards significantly increased participants' delay discounting (β = 0.238, confidence interval [CI]: -0.078, 0.380), indicating greater sensitivity to reinforcement timing. This change did not mediate incentive-associated increases in MVPA at the end of the 12-month intervention (β = -0.016, CI: -0.053, 0.019) or at a 24-month follow-up (β = -0.020, CI: -0.059, 0.018). Moderation effects were not found.

CONCLUSIONS

Incentive-induced increases in delay discounting did not deleteriously impact MVPA. This finding may help assuage concerns about using monetary incentives for PA promotion, but further research regarding the consequences of changes in delay discounting is warranted.

3 Months without the car in Bielefeld, Germany- a mixed-method study exploring individual motivation to participate in a municipal intervention

BACKGROUND

Climate change is a major public health issue worldwide. To achieve climate targets and reduce morbidity, a paradigm shift in individual behavior e.g., in mobility, is needed. Municipal interventions can motivate individuals to engage in climate-friendly behavior through different psychological mechanisms. In order for successful interventions, it is necessary to gain better insight from study participants and their reasons for participating in mobility projects (e.g., motivational aspects).

MATERIALS AND METHODS

A mixed-methods design was used to evaluate reasons and characteristics of people for participating in an municipal mobility intervention. The quantitative sub-study assesses socioeconomic characteristics, environmental awareness and perceived stress. The qualitative sub-study explores motivation for participation and change, perspectives on car replacement and reasons for car use.

RESULTS

Results show that participants (n = 42) are rather high educated and show medium environmental awareness. Participants of the qualitative study part (n = 15) were motiviated to reduce car use already before the intervention and used the intervention as starting point or trial phase.

CONCLUSIONS

Urban intervention projects with fitted recruitment strategies and better insights from study participants with the aim to motivate individuals to engage in climate-friendly behavior can help to strengthen sustainability and public health.

Exercise behaviours and motivation after a first psychotic episode: A digital intervention

AIM

Research has demonstrated that participation in aerobic exercise can have significant beneficial effects across both physical and mental health domains for individuals who are in the early phase of schizophrenia. Despite these notable benefits of exercise, deficits in motivation and a lack of methods to increase engagement are significant barriers for exercise participation, limiting these potentially positive effects. Fortunately, digital health tools have the potential to improve adherence to an exercise program. The present study examined the role of motivation for exercise and the effects of an automated digital text messaging program on participation in an aerobic exercise program.

METHODS

A total of 46 first-episode psychosis participants from an ongoing 12-month randomized clinical trial (Enhancing Cognitive Training through Exercise Following a First Schizophrenia Episode (CT&E-RCT)) were included in an analysis to examine the efficacy of motivational text messaging. Personalized motivational text message reminders were sent to participants with the aim of increasing engagement in the exercise program.

RESULTS

We found that participants with higher levels of intrinsic motivation to participate in a text messaging program and in an exercise intervention completed a higher proportion of individual, at-home exercise sessions. In a between groups analysis, participants who received motivational text messages, compared to those who did not, completed a higher proportion of at-home exercise sessions.

CONCLUSION

These results indicate the importance of considering a person's level of motivation for exercise and the potential utility of using individualized and interactive mobile text messaging reminders to increase engagement in aerobic exercise in the early phase of psychosis. We emphasize the need for understanding how individualized patient preferences and needs interplay between intrinsic motivation and digital health interventions for young adults.

Interventions to promote household waste segregation: A systematic review

Waste segregation at source, particularly at the household level, is an integral component of sustainable solid waste management, which is a critical public health issue. Although multiple interventions have been published, often with contradictory findings, few authors have conducted a comprehensive systematic synthesis of the published literature. Therefore, we undertook a systematic review to synthesize all published interventions conducted in any country in the world which targeted household-level waste segregation with or without additional focus on recycling or composting. Following PRISMA guidelines, Web of Science, Medline, Global Health, and Google Scholar were searched using a search strategy created by combining the keywords 'Waste', 'Segregation', and 'Household'. Two-stage blinded screening and consensus-based conflict resolution were done, followed by quality assessment, data extraction, and narrative synthesis. 8555 articles were identified through the database searches and an additional 196 through grey literature and citation searching. After excluding 2229 duplicates and screening title abstracts of 6522 articles, 283 full texts were reviewed, and 78 publications reporting 82 intervention studies were included in the data synthesis. High methodological heterogeneity was seen, excluding the possibility of a meta-analysis. Most (n = 60) of the interventions were conducted in high-income countries. Interventions mainly focused on information provision. However, differences in the content of information communicated and mode of delivery have not been extensively studied. Finally, our review showed that the comparison of informational interventions with provision of incentives and infrastructural modifications needs to be explored in-depth. Future studies should address these gaps and, after conducting sufficient formative research, should aim to design their interventions following the principles of behaviour change.

Looking inside the lab: a systematic literature review of economic experiments in health service provision

Experimental economics is, nowadays, a well-established approach to investigate agents' behavior under economic incentives. In the last decade, a fast-growing number of studies have focused on the application of experimental methodology to health policy issues. The results of that stream of literature have been intriguing and strongly policy oriented. However, those findings are scattered between different health-related topics, making it difficult to grasp the overall state-of-the-art. Hence, to make the main contributions understandable at a glance, we conduct a systematic literature review of laboratory experiments on the supply of health services. Of the 1248 articles retrieved from 2011, 56 articles published in peer-review journals have met our inclusion criteria. Thus, we have described the experimental designs of each of the selected papers and we have classified them according to their main area of interest.

The illness trap: The impact of disability benefits on willingness to receive HCV treatment

Health care is assumed to be a primary good, implying that patients should always demand or accept treatments that may enhance their life expectancy and quality of life, especially if the risks associated with the treatment are low. We argue that, especially in countries with a well-developed welfare state, treating an invalidating condition may lead to opportunity costs in terms of reduced disability allowances that may represent a barrier to treatment for low-income individuals. We test this hypothesis by applying a recursive bivariate probit approach to population data from an ad hoc administrative database for Liguria (an Italian administrative region). The dataset includes data for more than 8 thousand people affected by hepatitis C Virus (HCV) infection between 2013 and 2020. After the discovery of new direct-acting antivirals (DAAs) in 2014, HCV eradication may now be possible. However, despite the national and international efforts, several patients diagnosed with HCV choose not to undergo drug therapy despite the adverse consequences for their personal health and relevant costs to the national health system. We show that five years after the implementation of the new drugs, approximately 41 % of the diagnosed population in Liguria remains untreated. This percentage increases to 64 % within the subgroup entitled to disability benefits and characterized by lower income levels. The "illness trap" effect is more substantial for older people but also low-income patients. Moreover, we find that this effect is higher in patients with an intermediate range of comorbidities; indeed, these patients are at a higher risk of losing economic benefits if they recover from HCV. These results suggest the need for healthcare policies addressing this distorting effect when designing benefit programs and granting financial benefits to patients.

Using ERIC to Assess Implementation Science in Drowning Prevention Interventions in High-Income Countries: A Systematic Review

This systematic review identifies and describes the use of the Expert Recommendation for Implementing Change (ERIC) concepts and strategies using public health approaches to drowning prevention interventions as a case study. International calls for action have identified the need to better understand the implementation of drowning prevention interventions so that intervention design and implementation is improved. In high-income countries (HICs), interventions are sophisticated but still little is known or written about their implementation. The review was registered on PROSPERO (number CRD42022347789) and followed the PRISMA guidelines. Eight databases were searched. Articles were assessed using the Public Health Ontario Meta-tool for quality appraisal of public health evidence. Forty-nine articles were included. Where ERIC strategies were reported, the focus was on evaluative and iterative strategies, developing partnerships and engaging the target group. The review identified few articles that discussed intervention development and implementation sufficiently for strategies to be replicated. Findings will inform further research into the use and measurement of implementation strategies by practitioners and researchers undertaking work in drowning prevention in HICs and supports a call to action for better documentation of implementation in public health interventions.

A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa

Despite widespread availability of life-saving antiretroviral therapy (ART) in sub-Saharan Africa, AIDS remains one of the leading causes of death among adolescents living with HIV (ALHIV) in sub-Saharan Africa. The purpose of this article was to review the state of the science regarding interventions to improve ART adherence and/or HIV care retention among ALHIV throughout sub-Saharan Africa. The primary aim of this review was to describe the impact of peer support interventions in improving treatment outcomes (i.e., ART adherence and retention in HIV care) among ALHIV in sub-Saharan Africa. The secondary aim of this review was to determine whether these interventions may be efficacious at improving mental health outcomes. We identified 27 articles that met the eligibility criteria for our review, and categorized each article based on the type of peer support provided to ALHIV-individualized peer support, group-based support, and individualized plus group-based support. Results regarding the efficacy of these interventions are mixed and most of the studies included were deemed moderate in methodological quality. Although studies evaluating group-based peer support interventions were the most common, most of these studies were not associated with retention, adherence, or mental health outcomes. More robust, fully powered studies are needed to strengthen our knowledge base regarding peer support for ALHIV.

Behavioural economic interventions to reduce health care appointment non-attendance: a systematic review and meta-analysis

BACKGROUND

Appointment non-attendance - often referred to as "missed appointments", "patient no-show", or "did not attend (DNA)" - causes volatility in health systems around the world. Of the different approaches that can be adopted to reduce patient non-attendance, behavioural economics-oriented mechanisms (i.e., psychological, cognitive, emotional, and social factors that may impact individual decisions) are reasoned to be better suited in such contexts - where the need is to persuade, nudge, and/ or incentivize patients to honour their scheduled appointment. The aim of this systematic literature review is to identify and summarize the published evidence on the use and effectiveness of behavioural economic interventions to reduce no-shows for health care appointments.

METHODS

We systematically searched four databases (PubMed/Medline, Embase, Scopus, and Web of Science) for published and grey literature on behavioural economic strategies to reduce no-shows for health care appointments. Eligible studies met four criteria for inclusion; they were (1) available in English, Spanish, or French, (2) assessed behavioural economics interventions, (3) objectively measured a behavioural outcome (as opposed to attitudes or preferences), and (4) used a randomized and controlled or quasi-experimental study design.

RESULTS

Our initial search of the five databases identified 1,225 articles. After screening studies for inclusion criteria and assessing risk of bias, 61 studies were included in our final analysis. Data was extracted using a predefined 19-item extraction matrix. All studies assessed ambulatory or outpatient care services, although a variety of hospital departments or appointment types. The most common behaviour change intervention assessed was the use of reminders (n = 56). Results were mixed regarding the most effective methods of delivering reminders. There is significant evidence supporting the effectiveness of reminders (either by SMS, telephone, or mail) across various settings. However, there is a lack of evidence regarding alternative interventions and efforts to address other heuristics, leaving a majority of behavioural economic approaches unused and unassessed.

CONCLUSION

The studies in our review reflect a lack of diversity in intervention approaches but point to the effectiveness of reminder systems in reducing no-show rates across a variety of medical departments. We recommend future studies to test alternative behavioural economic interventions that have not been used, tested, and/or published before.

FEEDBACK trial - A randomised control trial to investigate the effect of personalised feedback and financial incentives on reducing the incidence of road crashes

BACKGROUND

Road crashes continue to pose a significant threat to global health. Young drivers aged between 18 and 25 are over-represented in road injury and fatality statistics, especially the first six months after obtaining their license. This study is the first multi-centre two-arm parallel-group individually randomised controlled trial (the FEEDBACK Trial) that will examine whether the delivery of personalised driver feedback plus financial incentives is superior to no feedback and no financial incentives in reducing motor vehicle crashes among young drivers (18 to 20 years) during the first year of provisional licensing.

METHODS

A total of 3,610 young drivers on their provisional licence (P1, the first-year provisional licensing) will participate in the trial over 28 weeks, including a 4-week baseline, 20-week intervention and 4-week post-intervention period. The primary outcome of the study will be police-reported crashes over the 20-week intervention period and the 4-week post-intervention period. Secondary outcomes include driving behaviours such as speeding and harsh braking that contribute to road crashes, which will be attained weekly from mobile telematics delivered to a smartphone app.

DISCUSSION

Assuming a positive finding associated with personalised driver feedback and financial incentives in reducing road crashes among young drivers, the study will provide important evidence to support policymakers in introducing the intervention(s) as a key strategy to mitigate the risks associated with the burden of road injury among this vulnerable population.

TRIAL REGISTRATION

Registered under the Australian New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12623000387628p on April 17, 2023.

Efficacy of Time-Restricted Eating and Behavioral Economic Intervention in Reducing Fasting Plasma Glucose, HbA1c, and Cardiometabolic Risk Factors in Patients with Impaired Fasting Glucose: A Randomized Controlled Trial

This randomized controlled trial is aimed at assessing the efficacy of combining time-restricted eating (TRE) with behavioral economic (BE) interventions and comparing it to TRE alone and to the usual care for reducing fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), and other cardiometabolic risk factors among patients with impaired fasting glucose (IFG). Seventy-two IFG patients aged 18-65 years were randomly allocated for TRE with BE interventions (26 patients), TRE alone (24 patients), or usual care (22 patients). Mean FPG, HbA1c, and other cardiometabolic risk factors among the three groups were compared using a mixed-effect linear regression analysis. Mean body weight, FPG, HbA1c, fasting insulin, and lipid profiles did not significantly differ among the three groups. When considering only patients who were able to comply with the TRE protocol, the TRE group showed significantly lower mean FPG, HbA1c, and fasting insulin levels compared to the usual care group. Our results did not show significant differences in body weight, blood sugar, fasting insulin, or lipid profiles between TRE plus BE interventions, TRE alone, and usual care groups. However, TRE might be an effective intervention in lowering blood sugar levels for IFG patients who were able to adhere to the TRE protocol.

Non-pharmaceutical interventions to optimize cancer immunotherapy

The traditional picture of cancer patients as weak individuals requiring maximum rest and protection is beginning to dissolve. Too much focus on the medical side and one's own vulnerability and mortality might be counterproductive and not doing justice to the complexity of human nature. Unlike cytotoxic and lympho-depleting treatments, immune-engaging therapies strengthen the immune system and are typically less harmful for patients. Thus, cancer patients receiving checkpoint inhibitors are not viewed as being vulnerable per se, at least not in immunological and physical terms. This perspective article advocates a holistic approach to cancer immunotherapy, with an empowered patient in the center, focusing on personal resources and receiving domain-specific support from healthcare professionals. It summarizes recent evidence on non-pharmaceutical interventions to enhance the efficacy of immune checkpoint blockade and improve quality of life. These interventions target behavioral factors such as diet, physical activity, stress management, circadian timing of checkpoint inhibitor infusion, and waiving unnecessary co-medication curtailing immunotherapy efficacy. Non-pharmaceutical interventions are universally accessible, broadly applicable, instantly actionable, scalable, and economically sustainable, creating value for all stakeholders involved. Most importantly, this holistic framework re-emphasizes the patient as a whole and harnesses the full potential of anticancer immunity and checkpoint blockade, potentially leading to survival benefits. Digital therapeutics are proposed to accompany the patients on their mission toward change in lifestyle-related behaviors for creating optimal conditions for treatment efficacy and personal growth.

Reporting of 3Rs Approaches in Preclinical Animal Experimental Studies-A Nationwide Study

The 3Rs aim to refine animal welfare, reduce animal numbers, and replace animal experiments. Investigations disclose that researchers are positive towards 3Rs recommendations from peers. Communication of 3Rs approaches via primary preclinical animal experimental literature may become a fast-forward extension to learn relevant 3Rs approaches if such are reported. This study investigates 3Rs-reporting in peer-reviewed preclinical animal research with at least one author affiliated to a Danish university. Using a systematic search and random sampling, we included 500 studies from 2009 and 2018. Reporting was low and improvement over time limited. A word search for 3R retrieved zero results in 2009 and 3.2% in 2018. Reporting on 3Rs-related sentences increased from 6.4% in 2009 to 18.4% in 2018, "reduction" increased from 2.4% to 8.0%, and "refinement" from 5.2% to 14.4%. Replacement was not reported. Reporting of the methodology was missing. For "reduction", methodology was mentioned in one study in 2009 and 11 studies in 2018, and for "refinement" in 9 and 21, respectively. Twenty-one studies stated compliance with ARRIVE-guidelines or similar without disclosure of details. Reporting of 3Rs approaches in preclinical publications is currently insufficient to guide researchers. Other strategies, e.g., education, interdisciplinary collaboration, and 3Rs funding initiatives, are needed.

Impact of soda tax on beverage price, sale, purchase, and consumption in the US: a systematic review and meta-analysis of natural experiments

Background

As a primary source of added sugars in the US diet, sugar-sweetened beverage (SSB) consumption is presumed to contribute to obesity prevalence and poor oral health. We systematically synthesized and quantified evidence from US-based natural experiments concerning the impact of SSB taxes on beverage prices, sales, purchases, and consumption.

Methods

A keyword and reference search was performed in PubMed, Web of Science, Cochrane Library, Scopus, and EconLit from the inception of an electronic bibliographic database to Oct 31, 2022. Meta-analysis was conducted to estimate the pooled effect of soda taxes on SSB consumption, prices, passthrough rate, and purchases.

Results

Twenty-six natural experiments, all adopting a difference-in-differences approach, were included. Studies assessed soda taxes in Berkeley, Oakland, and San Francisco in California, Philadelphia in Pennsylvania, Boulder in Colorado, Seattle in Washington, and Cook County in Illinois. Tax rates ranged from 1 to 2 ¢/oz. The imposition of the soda tax was associated with a 1.06 ¢/oz. (95% confidence interval [CI] = 0.90, 1.22) increase in SSB prices and a 27.3% (95% CI = 19.3, 35.4%) decrease in SSB purchases. The soda tax passthrough rate was 79.7% (95% CI = 65.8, 93.6%). A 1 ¢/oz. increase in soda tax rate was associated with increased prices of SSBs by 0.84 ¢/oz (95% CI = 0.33, 1.35).

Conclusion

Soda taxes could be effective policy leverage to nudge people toward purchasing and consuming fewer SSBs. Future research should examine evidence-based classifications of SSBs, targeted use of revenues generated by taxes to reduce health and income disparities, and the feasibility of redesigning the soda tax to improve efficiency.

Sentiment Analysis of Tweets on Soda Taxes

CONTEXT

As a primary source of added sugars, sugar-sweetened beverage (SSB) consumption may contribute to the obesity epidemic. A soda tax is an excise tax charged on selling SSBs to reduce consumption. Currently, 8 cities/counties in the United States have imposed soda taxes.

OBJECTIVE

This study assessed people's sentiments toward soda taxes in the United States based on social media posts on Twitter.

DESIGN

We designed a search algorithm to systematically identify and collect soda tax-related tweets posted on Twitter. We built deep neural network models to classify tweets by sentiments.

SETTING

Computer modeling.

PARTICIPANTS

Approximately 370 000 soda tax-related tweets posted on Twitter from January 1, 2015, to April 16, 2022.

MAIN OUTCOME MEASURE

Sentiment associated with a tweet.

RESULTS

Public attention paid to soda taxes, indicated by the number of tweets posted annually, peaked in 2016, but has declined considerably ever since. The decreasing prevalence of tweets quoting soda tax-related news without revealing sentiments coincided with the rapid increase in tweets expressing a neutral sentiment toward soda taxes. The prevalence of tweets expressing a negative sentiment rose steadily from 2015 to 2019 and then slightly leveled off, whereas that of tweets expressing a positive sentiment remained unchanged. Excluding news-quoting tweets, tweets with neutral, negative, and positive sentiments occupied roughly 56%, 29%, and 15%, respectively, during 2015-2022. The authors' total number of tweets posted, followers, and retweets predicted tweet sentiment. The finalized neural network model achieved an accuracy of 88% and an F1 score of 0.87 in predicting tweet sentiments in the test set.

CONCLUSIONS

Despite its potential to shape public opinion and catalyze social changes, social media remains an underutilized source of information to inform government decision making. Social media sentiment analysis may inform the design, implementation, and modification of soda tax policies to gain social support while minimizing confusion and misinterpretation.

Goals for Adherence with Low-cost Incentives (GOALS): a protocol for a randomized controlled trial evaluating the impact of small airtime incentives on ART adherence among young people living with HIV in Kampala, Uganda

BACKGROUND

Treatment outcomes of HIV-positive individuals are threatened by low antiretroviral therapy (ART) adherence, a problem that is particularly acute among youth. Incentives are a promising tool to support ART adherence, but traditional incentive designs rewarding uniformly high levels of the desired health behavior may demotivate those with low levels of the behavior. In this study, we investigate the effectiveness of alternative approaches to target-setting for incentive eligibility using subgoals (i.e., individual-specific, interim targets leading up to the optimal target).

METHODS / DESIGN

We will enroll 628 HIV-positive youth between ages 15 and 30 into a 3-year randomized controlled trial. Participants will be randomized 1:1:1:1 to a control arm or one of three intervention arms (n = 157 each) that allow them to enter a prize drawing for small incentives if their ART adherence meets the given goal. In the first arm (T1, assigned subgoal), goals will be externally assigned and adapted to their initial adherence level. In the second arm (T2, participatory subgoal), participants can set their own interim goals. In the third arm (T3, fixed goal), all participants must reach the same target goal of 90% adherence. T1 and T2 participants are required to reach 90% adherence by month 12 to participate in a larger prize drawing. The control group receives the usual standard of care. All four groups will receive weekly motivational messages; the three treatment groups will additionally receive reminders of their upcoming prize drawing. Adherence will be measured continuously throughout the intervention period using electronic devices and for 12 months post-intervention. Surveys will be conducted at baseline and every 6 months. Viral loads will be measured annually. The primary outcome is Wisepill-measured adherence and a binary measure for whether the person took at least 90% of their pills. The secondary outcome is the log-transformed viral load as a continuous measure.

DISCUSSION

Our study is one of the first to apply insights about the psychology and behavioral economics of goal-setting to the design of incentives, by testing whether conditioning the eligibility threshold for incentives on subgoals (interim goals leading up to the ultimate, high goal) improves motivation and adherence more than setting a uniformly highly goal, and a comparison group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05378607. Date of registration: May 18, 2022.

Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial

BACKGROUND

Missed appointments ("no-shows") are a persistent and costly problem in healthcare. Appointment reminders are widely used but usually do not include messages specifically designed to nudge patients to attend appointments.

OBJECTIVE

To determine the effect of incorporating nudges into appointment reminder letters on measures of appointment attendance.

DESIGN

Cluster randomized controlled pragmatic trial.

PATIENTS

There were 27,540 patients with 49,598 primary care appointments, and 9420 patients with 38,945 mental health appointments, between October 15, 2020, and October 14, 2021, at one VA medical center and its satellite clinics that were eligible for analysis.

INTERVENTIONS

Primary care (n = 231) and mental health (n = 215) providers were randomized to one of five study arms (four nudge arms and usual care as a control) using equal allocation. The nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms, specific behavioral instructions, and consequences of missing appointments.

MAIN MEASURES

Primary and secondary outcomes were missed appointments and canceled appointments, respectively.

STATISTICAL ANALYSIS

Results are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients.

KEY RESULTS

Missed appointment rates in study arms ranged from 10.5 to 12.1% in primary care clinics and 18.0 to 21.9% in mental health clinics. There was no effect of nudges on missed appointment rate in primary care (OR = 1.14, 95%CI = 0.96-1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90-1.60, p = 0.21) clinics, when comparing the nudge arms to the control arm. When comparing individual nudge arms, no differences in missed appointment rates nor cancellation rates were observed.

CONCLUSIONS

Appointment reminder letters incorporating brief behavioral nudges were ineffective in improving appointment attendance in VA primary care or mental health clinics. More complex or intensive interventions may be necessary to significantly reduce missed appointments below their current rates.

TRIAL NUMBER

ClinicalTrials.gov, Trial number NCT03850431.

A virtual pilot optimization trial for African American/Black and Latino persons with non-suppressed HIV viral load grounded in motivational interviewing and behavioral economics

Introduction

Virtual and low-touch behavioral interventions are needed for African American/Black and Latino persons living with HIV (PLWH) with barriers to HIV viral suppression, particularly during COVID-19. Guided by the multiphase optimization strategy, we explored three components for PLWH without viral suppression, grounded in motivational interviewing and behavioral economics: (1) motivational interviewing counseling, (2) 21-weeks of automated text messages and quiz questions about HIV management, and (3) financial rewards for viral suppression (lottery prize vs. fixed compensation).

Methods

This pilot optimization trial used sequential explanatory mixed methods to explore the components' feasibility, acceptability, and preliminary evidence of effects using an efficient factorial design. The primary outcome was viral suppression. Participants engaged in baseline and two structured follow-up assessments over an 8-month period, and provided laboratory reports to document HIV viral load. A subset engaged in qualitative interviews. We carried out descriptive quantitative analyses. Then, qualitative data were analyzed using directed content analysis. Data integration used the joint display method.

Results

Participants (N = 80) were 49 years old, on average (SD = 9), and 75% were assigned male sex at birth. Most (79%) were African American/Black, and the remainder were Latino. Participants were diagnosed with HIV 20 years previously on average (SD = 9). Overall, components were feasible (>80% attended) and acceptability was satisfactory. A total of 39% (26/66) who provided laboratory reports at follow-up evidenced viral suppression. Findings suggested no components were entirely unsuccessful. The lottery prize compared to fixed compensation was the most promising component level. In qualitative analyses, all components were seen as beneficial to individual wellbeing. The lottery prize appeared more interesting and engaging than fixed compensation. However, structural barriers including financial hardship interfered with abilities to reach viral suppression. The integrated analyses yielded areas of convergence and discrepancy and qualitative findings added depth and context to the quantitative results.

Conclusions

The virtual and/or low-touch behavioral intervention components tested are acceptable and feasible and show enough potential to warrant refinement and testing in future research, particularly the lottery prize. Results must be interpreted in the context of the COVID-19 pandemic.

Trial registration

NCT04518241 (https://clinicaltrials.gov/ct2/show/NCT04518241).

Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Background

Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.

Materials and Methods

A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.

Results

Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.

Conclusions

The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.

Alleviating Financial Hardships Associated with High-Deductible Health Plans for Adults with Chronic Conditions Through Health Savings Accounts

BACKGROUND

High-deductible health plans (HDHPs) are becoming increasingly common, but their financial implications for enrollees with and without chronic conditions and the mitigating effects of health savings accounts (HSAs) are relatively unknown.

OBJECTIVE

Our aim was to compare financial hardship between non-HDHPs and HDHPs with and without HSAs, stratified by enrollees' number of chronic conditions.

DESIGN

We used data from 2015 to 2018 Medical Expenditure Panels Surveys (MEPS) to compare rates of financial hardship across individuals with HDHPs and non-HDHPs using linear and logistic regression models.

PARTICIPANTS

A nationally representative sample of 30,981 adults aged 18-64 enrolled in HDHPs and non-HDHPs.

MAIN MEASURES

We examined several measures of financial hardship, including total yearly out-of-pocket medical spending as well as rates of delaying medical care or prescriptions in the past year due to cost, forgoing medical care or prescriptions in the past year due to cost, paying medical bills over time, or having problems paying medical bills. We compared rates using the non-HDHP as the control.

KEY RESULTS

On most measures, HDHPs are associated with greater financial hardship compared to non-HDHPs, including average annual out-of-pocket spending of $637 for non-HDHPs, $939 for HDHPs with HSAs, and $825 for HDHPs without HSAs (p < 0.01). However, for HDHP enrollees with multiple chronic conditions, having an HSA was associated with less financial hardship (p < 0.05).

CONCLUSIONS

Our findings suggest that HSAs may be most beneficial for those with chronic conditions, in part due to the tax benefits they offer as well as the fact that those with chronic conditions are more likely to take advantage of their HSAs than their younger, healthier counterparts. However, as HDHPs are more likely to be correlated with worse financial outcomes regardless of health status, recent trends of increasing participation may be a reason for concern.

Impact of a financial incentive scheme on purchase of fruits and vegetables from unorganised retailers in rural India: a cluster-randomised controlled trial

Background

Inadequate intake of fruits and vegetables is prevalent in rural areas of India, where around 65% of the population reside. Financial incentives have been shown to increase the purchase of fruits and vegetables in urban supermarkets, but their feasibility and effectiveness with unorganised retailers in rural India is unclear.

Methods

A cluster-randomised controlled trial of a financial incentive scheme involving ∼20% cashback on purchase of fruits and vegetables from local retailers was conducted in six villages (3535 households). All households in three intervention villages were invited to participate in the scheme which ran for three months (February-April 2021), while no intervention was offered in control villages. Self-reported (pre-intervention and post-intervention) data on purchase of fruits and vegetables were collected from a random sub-sample of households in control and intervention villages.

Findings

A total of 1109 households (88% of those invited) provided data. After the intervention, the weekly quantity of self-reported fruits and vegetables purchased were (i) 18.6 kg (intervention) and 14.2 kg (control), baseline-adjusted mean difference 4 kg (95% CI: -6.4 to 14.4) from any retailer (primary outcome); and (ii) 13.1 kg (intervention) and 7.1 kg (control), baseline-adjusted mean difference 7.4 kg (95% CI: 3.8-10.9) from local retailers participating in the scheme (secondary outcome). There was no evidence of differential effects of the intervention by household food security or by socioeconomic position, and no unintended adverse consequences were noted.

Interpretation

Financial incentive schemes are feasible in unorganised food retail environments. Effectiveness in improving diet quality of the household likely hinges on the percentage of retailers willing to participate in such a scheme.

Funding

This research has been funded by the Drivers of Food Choice (DFC) Competitive Grants Program, which is funded by the UK Government's Department for International Development and the Bill & Melinda Gates Foundation, and managed by the University of South Carolina, Arnold School of Public Health, USA; however, the views expressed do not necessarily reflect the UK Government's official policies.

Exploring the potential of mobile health interventions to address behavioural risk factors for the prevention of non-communicable diseases in Asian populations: a qualitative study

BACKGROUND

Changing lifestyle patterns over the last decades have seen growing numbers of people in Asia affected by non-communicable diseases and common mental health disorders, including diabetes, cancer, and/or depression. Interventions targeting healthy lifestyle behaviours through mobile technologies, including new approaches such as chatbots, may be an effective, low-cost approach to prevent these conditions. To ensure uptake and engagement with mobile health interventions, however, it is essential to understand the end-users' perspectives on using such interventions. The aim of this study was to explore perceptions, barriers, and facilitators to the use of mobile health interventions for lifestyle behaviour change in Singapore.

METHODS

Six virtual focus group discussions were conducted with a total of 34 participants (mean ± SD; aged 45 ± 3.6 years; 64.7% females). Focus group recordings were transcribed verbatim and analysed using an inductive thematic analysis approach, followed by deductive mapping according to perceptions, barriers, facilitators, mixed factors, or strategies.

RESULTS

Five themes were identified: (i) holistic wellbeing is central to healthy living (i.e., the importance of both physical and mental health); (ii) encouraging uptake of a mobile health intervention is influenced by factors such as incentives and government backing; (iii) trying out a mobile health intervention is one thing, sticking to it long term is another and there are key factors, such as personalisation and ease of use that influence sustained engagement with mobile health interventions; (iv) perceptions of chatbots as a tool to support healthy lifestyle behaviour are influenced by previous negative experiences with chatbots, which might hamper uptake; and (v) sharing health-related data is OK, but with conditions such as clarity on who will have access to the data, how it will be stored, and for what purpose it will be used.

CONCLUSIONS

Findings highlight several factors that are relevant for the development and implementation of mobile health interventions in Singapore and other Asian countries. Recommendations include: (i) targeting holistic wellbeing, (ii) tailoring content to address environment-specific barriers, (iii) partnering with government and/or local (non-profit) institutions in the development and/or promotion of mobile health interventions, (iv) managing expectations regarding the use of incentives, and (iv) identifying potential alternatives or complementary approaches to the use of chatbots, particularly for mental health.

Household- Versus Incentive-Based Contact Investigation for Tuberculosis in Rural South Africa: A Cluster-Randomized Trial

BACKGROUND

Household contact investigation for people newly diagnosed with tuberculosis (TB) is poorly implemented, particularly in low- and middle-income countries. Conditional cash incentives may improve uptake.

METHODS

We conducted a pragmatic, cluster-randomized, crossover trial of 2 TB contact investigation approaches (household-based and incentive-based) in 28 public primary care clinics in South Africa. Each clinic used 1 approach for 18 months, followed by a 6-month washout period, after which the opposite approach was used. Fourteen clinics were randomized to each approach. In the household-based arm, we conducted TB screening and testing of contacts at the household. In the incentive-based arm, both index patients and ≤10 of their close contacts (either within or outside the household) were given small cash incentives for presenting to study clinics for TB screening. The primary outcome was the number of people with incident TB who were diagnosed and started on treatment at study clinics.

RESULTS

From July 2016 to January 2020, we randomized 28 clinics to each study arm, and enrolled 782 index TB patients and 1882 contacts in the household-based arm and 780 index patients and 1940 contacts in the incentive-based arm. A total of 1413 individuals started on TB treatment in the household-based arm and 1510 in the incentive-based arm. The adjusted incidence rate ratio of TB treatment initiation in the incentive- versus household-based arms was 1.05 (95% confidence interval: .97-1.13).

CONCLUSIONS

Incentive-based contact investigation for TB has similar effectiveness to traditional household-based approaches and may be a viable alternative or complementary approach to household-based investigation.

Women and health professionals' perspectives on a conditional cash transfer programme to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomised controlled study

OBJECTIVES

Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns.

DESIGN

Prospective qualitative research.

SETTING

We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial.

PARTICIPANTS

26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs.

INTERVENTIONS

We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth.

RESULTS

Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT.

CONCLUSIONS

In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby's birth.

TRIAL REGISTRATION NUMBER

NCT02402855.

Stroke survivors' preferences for post-stroke self-management programs: A discrete choice experiment

BACKGROUND AND PURPOSE

Self-management programs enhance survival in stroke patients. However, they require patient-centered designs to be effective. The aim of this study was therefore to investigate the type of post-stroke self-management programs that appeal to stroke survivors, and to estimate their willingness to participate in such programs.

METHODS

A Discrete Choice Experiment was administered to patients who had either a transient ischemic attack (TIA) or stroke within the past 3 years and were cognitively intact (i.e., stroke survivors). Stroke survivors were presented with eight choice tasks and asked to choose between 'No Program' and two hypothetical post-stroke management programs that varied by six attributes: Topics covered by the program; schedule of the program; frequency and duration of the sessions; number of participants; out-of-pocket registration fee for the whole program; and rewards for completing the program.

RESULTS

The analysis involved 146 stroke survivors. Based on the mixed logit model, the predicted willingness to participate ranged from 53% to 76%. The most popular characteristics in a program were topics on health education and risk management, being scheduled during weekends as four sessions that are each 2 hours long and involve four participants, a registration fee of SGD50 (∼USD36), and SGD500 (∼USD359) reward for program completion.

CONCLUSIONS

Interest in post-stroke self-management programs was high, with at least half of the sample showing interest in participating in these programs. Program features such as focusing on health education and risk management, charging a low registration fee, and offering incentives helped to increase the demand.

"It Goes Hand in Hand with Us Trying to Get More Kids to Play" Stakeholder Experiences in a Sport and Active Recreation Voucher Program

Vouchers that reduce the cost of sport and active recreation participation have been shown to increase children's and adolescent's physical activity levels. Yet, the influence of government-led voucher programs on the capacity of sport and active recreation organisations is unclear. This qualitative study explored the experiences of stakeholders in the sport and recreation sector that were engaged in implementing the New South Wales (NSW) Government's Active Kids voucher program in Australia. Semi-structured interviews were conducted with 29 sport and active recreation providers. Interview transcriptions were analysed by a multidisciplinary team using the Framework method. Overall, participants reported that the Active Kids voucher program was an acceptable intervention to address the cost barrier to participation for children and adolescents. Three main steps influenced the capacity of organisations to deliver their sport and recreation programs and the voucher program: (1) Implementation priming-alignment of the intervention aims with stakeholder priorities and early information sharing, (2) Administrative ease-enhanced technology use and establishment of simple procedures, and (3) Innovation impacts-enablement of staff and volunteers to address barriers to participation for their participants. Future voucher programs should include strategies to enhance the capacity of sport and active recreation organisations to meet program guidelines and increase innovation.

Take patients seriously when they say financial incentives help with adherence

Small financial incentives have been proven effective at promoting healthy behaviours across medicine, including in psychiatry. There are a range of philosophical and practical objections to financial incentives. Drawing on the existing literature, specifically attempts to use financial incentives to promote antipsychotic adherence, we propose a 'patient-centred' view of evaluating financial incentive regimes. We argue that there is evidence that mental health patients like financial incentives, considering them fair and respectful. The enthusiasm of mental health patients for financial incentives lends support to their use, although it does not invalidate all objections against them.

How do financial incentives in parenting skills programs effect engagement and outcomes? A systematic review and meta-analysis protocol

OBJECTIVE

This systematic review will investigate the effects of financial incentives on engagement with and outcomes of evidence-based parenting skills programs to prevent and treat disruptive behavior disorders.

INTRODUCTION

Evidence-based parenting skills programs are a first-line treatment in disruptive behavior disorders (ie, oppositional defiant disorder, conduct disorder, and attention-deficit/hyperactivity disorder), but fewer than half of referred parents complete these programs. When untreated, children affected by disruptive behavior disorders are at elevated risk for incarceration, drug misuse, and education under-performance. Financial incentives can improve parents' engagement with parenting skills programs and are increasingly popular strategies in public health policy to increase rates of compliance with health interventions. However, no previous systematic review or meta-analysis of financial incentives in parenting skills programs has been conducted.

INCLUSION CRITERIA

Randomized controlled trials or quasi-experimental studies (ie, studies with a control group allocated through a non-random process) testing the effects of financial incentives on engagement will be included. Study participants must be in a guardian role to a person under 18 years of age. There will be no restrictions on country setting. Only English-language publications will be included.

METHODS

We will search PubMed, CINAHL, Sociological Abstracts, Cochrane Trials, and PsycINFO databases for relevant articles. Two independent reviewers will screen abstracts for eligibility. Data will be extracted from eligible articles by 2 researchers and results will be presented in tabular and narrative format, along with a meta-analysis using a random effects model and assessment of heterogeneity.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022336210.

Commitment devices: beyond the medical ethics of nudges

Commitment devices (CDs) can help people overcome self-control problems to act on their plans and preferences. In these arrangements, people willingly make one of their options worse in order to change their own future behaviour, often by setting aside a sum of money that they will forfeit it if they fail to complete the planned action. Such applications of behavioural science have been used to help people stick to healthier lifestyle choices, overcome addictions and adhere to medication; they are acceptable to many patients and even relatively small sums can be effective. Some authors have objected to the use of nudges in healthcare. Engelen has listed nine potential objections to nudges in relation to means (why nudge rather than persuade?), ends (what action is being promoted?) and agents (who is nudging whom?). These objections are shown to lack force in the context of CDs. Instead, an analysis specific to the ethical issues in CDs is employed. CDs exclude certain groups including so-called 'naifs' and risk increasing health inequality. CDs may promote the wrong behaviour and people might legitimately change their minds. Intermediaries might encounter perverse incentives. Approaches to overcoming these problems are described and eight key ethical considerations for those considering implementing CDs in the future are described. Altogether this paper illustrates the advantages of appraising the ethics of behavioural science in medicine on a case-by-case basis.

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.

Lottery incentives for smoking cessation at the workplace: design and protocol of the smoke-free lottery - a cluster randomized trial

BACKGROUND

Smoking is the leading behavioral risk factor for the loss of healthy life years. Many smokers want to quit, but have trouble doing so. Financial incentives in workplace settings have shown promising results in supporting smokers and their design influences their impact. Lotteries that leverage behavioral economic insights might improve the effectiveness of workplace cessation support.

METHODS AND DESIGN

We examine in a cluster randomized trial if a workplace cessation group training paired with lottery deadlines will increase continuous abstinence rates over and above the cessation training alone. Organizations are randomized to either the control arm or lottery arm. The lotteries capitalize regret aversion by always informing winners at the deadline, but withholding prizes if they smoked. In the lottery-arm, winners are drawn out of all participants within a training group, regardless of their smoking status. In weeks 1-13 there are weekly lotteries. Winners are informed about their prize (€50), but can only claim it if they did not smoke that week, validated biochemically. After 26 weeks, there is a long-term lottery where the winners are informed about their prize (vacation voucher worth €400), but can only claim it if they were abstinent between weeks 13 and 26. The primary outcome is continuous abstinence 52 weeks after the quit date.

DISCUSSION

There is a quest for incentives to support smoking cessation that are considered fair, affordable and effective across different socioeconomic groups. Previous use of behavioral economics in the design of lotteries have shown promising results in changing health behavior. This cluster randomized trial aims to demonstrate if these lotteries are also effective for supporting smoking cessation. Therefore the study design and protocol are described in detail in this paper. Findings might contribute to the application and development of effective cessation support at the workplace.

TRIAL REGISTRATION

Netherlands Trial Register Identifier: NL8463 . Date of registration: 17-03-2020.

Promoting participation in remote digital health studies: An expert interview study

Background

Remote digital health studies are on the rise and promise to reduce the operational inefficiencies of in-person research. However, they encounter specific challenges in maintaining participation (enrollment and retention) due to their exclusive reliance on technology across all study phases.

Objective

The goal of this study was to collect experts' opinions on how to facilitate participation in remote digital health studies.

Method

We conducted 13 semi-structured interviews with principal investigators, researchers, and software developers who had recent experiences with remote digital health studies. Informed by the Unified Theory of Acceptance and Use of Technology (UTAUT) framework, we performed a thematic analysis and mapped various approaches to successful study participation.

Results

Our analyses revealed four themes: (1) study planning to increase participation, where experts suggest that remote digital health studies should be planned based on adequate knowledge of what motivates, engages, and disengages a target population; (2) participant enrollment, highlighting that enrollment strategies should be selected carefully, attached to adequate support, and focused on inclusivity; (3) participant retention, with strategies that minimize the effort and complexity of study tasks and ensure that technology is adapted and responsive to participant needs, and (4) requirements for study planning focused on the development of relevant guidelines to foster participation in future studies.

Conclusions

Our findings highlight the significant requirements for seamless technology and researcher involvement in enabling high remote digital health study participation. Future studies can benefit from collected experiences and the development of guidelines to inform planning that balances participant and scientific requirements.

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.

Designing financial incentives for health behaviour change: a mixed-methods case study of weight loss in men with obesity

Aim

Designing financial incentives for health behaviour change requires choices across several domains, including value (the size of the incentive), frequency of incentives, and direction (gain or loss). However, the rationale underlying complex incentive design is infrequently reported. Transparent reporting is important if we want to understand and improve the incentive development process. This paper describes a mixed methods approach for designing financial incentives for health behaviour change which involves stakeholders throughout the design process.

Subject and methods

The mixed methods approach focuses on incentives for weight loss for men with obesity living in areas with high levels of disadvantage. The approach involves: (a) using an existing framework to identify all domains of a financial incentive scheme for which choices need to be made, deciding what criteria are relevant (such as effectiveness, acceptability and uptake) and making choices on each domain on the basis of the criteria; (b) conducting a survey of target population preferences to inform choices for domains and to design the incentive scheme; and (c) making final decisions at a stakeholder consensus workshop.

Results

The approach was implemented and an incentive scheme for weight loss for men living with obesity was developed. Qualitative interview data from men receiving the incentives in a feasibility trial endorses our approach.

Conclusion

This paper demonstrates that a mixed methods approach with stakeholder involvement can be used to design financial incentives for health behaviour change such as weight loss.

Trial registration number

NCT03040518. Date: 2 February 2017.

Patient Willingness to Dispose of Leftover Opioids After Surgery: A Mixed Methods Study

We examined how convenience and financial incentives influence patient willingness to dispose of leftover prescription opioids after surgery. We also identified additional barriers and facilitators to disposal.

Background

In the United States, up to 70% of surgical patients are prescribed opioids and up to 92% will have leftover tablets. Most do not dispose of leftover opioids, increasing the risk for opioid-related harm. Current interventions promoting opioid disposal have shown mixed success.

Methods

We conducted a mixed methods study using a standard gamble survey and semi-structured interviews. Participants estimated willingness to dispose in 16 scenarios with varying convenience (time requirements of <5, 15, 30, and 60 minutes) and financial incentives ($0, $5, $25, $50). We estimated the likelihood of disposal using a multivariable mixed effects modified Poisson regression model. Semi-structured interviews explored how convenience, financial incentives, and other barriers and facilitators influenced decisions to dispose.

Results

Fifty-five participants were surveyed and 42 were interviewed. Most were willing to dispose when the time required was <15 minutes. Few were willing to dispose if the process required 60 minutes, although a $50 financial incentive increased rates from 9% to 36%. Anxiety about future pain, opioid scarcity, recreational use, family safety, moral beliefs, addiction, theft, and environmental harm also influenced decision-making.

Conclusions

Interventions promoting opioid disposal should focus on convenience, but the selective use of financial incentives can be effective. Tailoring interventions to individual barriers and facilitators could also increase disposal rates.

Evaluation of the Effectiveness of Behavioral Economic Incentive Programs for Goal Achievement on Healthy Diet, Weight Control and Physical Activity: A Systematic Review and Network Meta-analysis

Background

Healthy diet, weight control and physical activity to reduce obesity can be motivated by financial incentives (FI). Behavioral-economic approaches may improve the incentivization effectiveness. This study compares and ranks the effectiveness of standard and behavioral incentivization for healthy diet, weight control, and physical activity promotion.

Purpose

To investigate whether behavioral-economic insights improve incentivization effectiveness.

Methods

A systematic search of Medline and Scopus was performed from database inception to December 2020. Study characteristics, program designs, and risk ratio (RR) were extracted. A two-stage network meta-analysis pooled and ranked intervention effects.

Results

There were 35 eligible RCTs. For diet-weight control, standard FI, deposit contract (deposit), lottery-based incentive (lottery), and standard-FI + lottery increased goal achievement compared to no-FI but only deposit was statistically significant with pooled RRs and 95% confidence intervals (CI) of 1.21 (0.94, 1.56), 1.79 (1.04, 3.05), 1.45 (0.99, 2.13), and 1.73 (0.83, 3.63). For physical activity, standard-FI, deposit, and lottery significantly increased goal achievement compared to no-FI, with pooled RRs of 1.38 (1.13, 1.68), 1.63 (1.24, 2.14) and 1.43 (1.14, 1.80), respectively. In a follow-up period for physical activity, only deposit significantly increased goal achievement compared to no-FI, with pooled RRs of 1.39 (1.11, 1.73).

Conclusion

Deposit, followed by lottery, were best for motivating healthy diet, weight control and physical activity at program end. Post-intervention, deposit then standard-FI were best for motivating physical activity. Behavioral insights can improve incentivization effectiveness, although lottery-based approaches may offer only short-term benefit regarding physical activity. However, the imprecise intervention effects were major concerns.

Preliminary analysis of self-reported quality health indicators of patients on opioid agonist therapy at specialty and primary care clinics in Ukraine: A randomized control trial

International agencies recommend integrating addiction treatment into primary care for people who inject drugs (PWID) with opioid use disorder (OUD). Empirical data supporting integration that incorporates comprehensive health outcomes, however, are not known. For this randomized controlled trial in Ukraine, adult PWID with OUD were randomized to receive opioid agonist therapy (OAT) in specialty addiction treatment clinics (SATC) or to primary care clinics (PCCs). For those randomized to PCC, they were subsequently allocated to PCCs where clinicians received pay-for-performance (P4P) incentives (PCC with P4P) or not (PCC without P4P). Participating cities had one of each of the three intervention sites to control for geographic variation. Ongoing tele-education specialty training (OAT, HIV, tuberculosis) was provided to all PCCs. While the primary outcome for the parent trial focuses on patient medical record data, this preliminary analysis focuses on assessment of self-reported achievement of nationally recommended quality health indicators (QHIs) which is summed as a composite QHI score. Secondary outcomes included specialty and primary care QHI subscores. This study occurred from 01/20/2018-11/1/2020 with 818 of 990 randomized participants having complete self-reported data for analysis. Relative to SATC (treatment as usual), the mean composite QHI score was 12.7 (95% CI: 10.1-15.3; p<0.001) percentage points higher at PCCs; similar and significantly higher scores were observed in PCCs compared to SATCs for both primary care (PCC vs SATC: 18.4 [95% CI: 14.8-22.0; p<0.001] and specialty (PCC vs SATC: 5.9 [95% CI: 2.6-9.2; p<0.001] QHI scores. Additionally, the mean composite QHI score was 4.6 (95% CI: 2.0-7.2; p<0.001) points higher in participants with long term (>3 months) experience with OAT compared to participants newly initiating OAT. In summary, PWID with OUD receive greater primary care and specialty healthcare services when receiving OAT at PCCs supported by tele-education relative to treatment as usual provided in SATCs. Clinical trial registration: This trial was registered at clinicaltrials.gov and can be found using the following registration number: NCT04927091.

Applications of Behavioral Economics to Pharmaceutical Policymaking: A Scoping Review with Implications for Best-Value Biological Medicines

BACKGROUND AND OBJECTIVE

Pharmaceutical policies are generally based on the assumption that involved stakeholders make rational decisions. However, behavioral economics has taught us that this is not always the case as people deviate from rational behavior in rather predictable patterns. This scoping review examined to what extent behavioral concepts have already been applied in the pharmaceutical domain and what evidence exists about their effectiveness, with the aim of formulating future applications and research hypotheses on policymaking for best-value biologicals.

METHODS

A scoping literature review was conducted on the evidence of behavioral applications to pharmaceuticals. Scientific databases (Embase, MEDLINE, APA PsycArticles, and Scopus) were searched up to 20 October, 2021.

RESULTS

Forty-four full-text scientific articles were identified and narratively described in this article. Pharmaceutical domains where behavioral concepts have been investigated relate to influencing prescribing behavior, improving medication adherence, and increasing vaccination uptake. Multiple behavioral concepts were examined in the identified studies, such as social norms, defaults, framing, loss aversion, availability, and present bias. The effectiveness of the applied interventions was generally positive, but depended on the context. Some of the examined interventions can easily be translated into effective policy interventions for best-value biological medicines. However, some applications require further investigation in a research context.

CONCLUSIONS

Applications of behavioral economics to pharmaceutical policymaking are promising. However, further research is required to investigate the effect of behavioral applications on policy interventions for a more sustainable market environment for best-value biological medicines.