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Bardou M, Meunier-Beillard N, Godard-Marceau A, Deruelle P, Virtos C, Eckman-Lacroix A, Debras E, Schmitz T. 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. BMJ Open 2023; 13:e067066. [PMID: 36990483 PMCID: PMC10069550 DOI: 10.1136/bmjopen-2022-067066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
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.
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Affiliation(s)
- Marc Bardou
- CIC-P INSERM 1432, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | | | - Aurélie Godard-Marceau
- Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive EA 481, Université Bourgogne Franche-Comté, Besancon, Franche-Comté, France
| | - Philippe Deruelle
- Department of Obstetrics and Gynaecology, Strasbourg University Hospital, Starsbourg, France
| | - Claude Virtos
- Service de Gynécologie et Obstétruique, Centre Hospitalier de Dreux, Dreux, France
| | - Astrid Eckman-Lacroix
- Département de Gynécologie et d'Obstétrioque, Centre Hospitalier et Universitaire de Besançon, Besançon, France
| | - Elodie Debras
- Service de Gynécologie et obstrétrique, CHU de Bicêtre DAR, Le Kremlin-Bicetre, Île-de-France, France
| | - Thomas Schmitz
- Obstetrical Perinatal and Pediatric Epidemiology Research Team, Université de Paris, Paris, France
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Inghels M, Kim HY, Mathenjwa T, Shahmanesh M, Seeley J, Wyke S, McGrath N, Sartorius B, Yapa HM, Dobra A, Bärnighausen T, Tanser F. Can a conditional financial incentive (CFI) reduce socio-demographic inequalities in home-based HIV testing uptake? A secondary analysis of the HITS clinical trial intervention in rural South Africa. Soc Sci Med 2022; 311:115305. [PMID: 36084520 DOI: 10.1016/j.socscimed.2022.115305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 07/04/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
In sub-Saharan Africa, home-based HIV testing interventions are designed to reach sub-populations with low access to HIV testing such as men, younger or less educated people. Combining these interventions with conditional financial incentives (CFI) has been shown to be effective to increase testing uptake. CFI are effective for one-off health behaviour change but whether they operate differentially on different socio-demographic groups is less clear. Using data from the HITS trial in South Africa, we investigated whether a CFI was able to reduce existing home-based HIV testing uptake inequalities observed by socio-demographic groups. Residents aged ≥15 years in the study area were assigned to an intervention arm (16 clusters) or a control arm (29 clusters). In the intervention arm, individuals received a food voucher (∼3.5 US dollars) if they accepted to take a home-based HIV test. Testing uptake differences were considered for socio-demographic (sex, age, education, employment status, marital status, household asset index) and geographical (urban/rural living area, distance from clinic) characteristics. Among the 37,028 residents, 24,793 (9290 men, 15,503 women) were included in the analysis. CFI increased significantly testing uptake among men (39.2% vs 25.2%, p < 0.001) and women (45.9% vs 32.0%, p < 0.001) with similar absolute increase between men and women. Uptake was higher amongst the youngest or least educated individuals, and amongst single (vs in union) or unemployed men. Absolute uptake increase was also significantly higher amongst these groups resulting in increasing socio-demographic differentials for home-based HIV testing uptake. However, because these groups are known to have less access to other public HIV testing services, CFI could reduce inequalities for HIV testing access in our specific context. Although CFI significantly increased home-based HIV testing uptake, it did not do so differentially by socio-demographic group. Future interventions using CFI should make sure that the intervention alone does not increase existing health inequities.
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Affiliation(s)
- Maxime Inghels
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK; Centre Population et Développement (UMR 196 Paris Descartes - IRD), SageSud (ERL INSERM 1244), Institut de Recherche pour le Développement, Paris, France.
| | - Hae-Young Kim
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Department of Population Health, New York University School of Medicine, New York, NY, USA; KwaZulu-Natal Innovation and Sequencing Platform, KwaZulu-Natal, South Africa.
| | | | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Institute for Global Health, University College London, London, United Kingdom.
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
| | - Sally Wyke
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
| | - Nuala McGrath
- Africa Health Research Institute, KwaZulu-Natal, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Department of Social Statistics and Demography, Faculty of Social Sciences, University of Southampton, Southampton, United Kingdom.
| | - Benn Sartorius
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | - H Manisha Yapa
- Africa Health Research Institute, KwaZulu-Natal, South Africa; The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.
| | | | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa; Heidelberg Institute of Global Health (HIGH), Heidelberg University, 69120 Heidelberg, Germany.
| | - Frank Tanser
- Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa; School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.
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3
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Gagnon M, Payne A, Guta A. What are the ethical implications of using prize-based contingency management in substance use? A scoping review. Harm Reduct J 2021; 18:82. [PMID: 34348710 PMCID: PMC8335458 DOI: 10.1186/s12954-021-00529-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 07/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The area of substance use is notable for its early uptake of incentives and wealth of research on the topic. This is particularly true for prize-based contingency management (PB-CM), a particular type of incentive that uses a fishbowl prize-draw design. Given that PB-CM interventions are gaining momentum to address the dual public health crises of opiate and stimulant use in North America and beyond, it is imperative that we better understand and critically analyze their implications. PURPOSE The purpose of this scoping review paper is to identify the characteristics of PB-CM interventions for people who use substances and explore ethical implications documented in the literature as well as emerging ethical implications that merit further consideration. METHODS The PRISMA-ScR checklist was used in conjunction with Arksey and O'Malley's methodological framework to guide this scoping review. We completed a two-pronged analysis of 52 research articles retrieved through a comprehensive search across three key scholarly databases. After extracting descriptive data from each article, we used 9 key domains to identify characteristics of the interventions followed by an analysis of ethical implications. RESULTS We analyzed the characteristics of PB-CM interventions which were predominantly quantitative studies aimed at studying the efficacy of PB-CM interventions. All of the interventions used a prize-draw format with a classic magnitude of 50%. Most of the interventions combined both negative and positive direction to reward processes, behaviors, and/or outcomes. One ethical implication was identified in the literature: the risk of gambling relapse. We also found three emerging ethical implications by further analyzing participant characteristics, intervention designs, and potential impact on the patient-provider relationship. These implications include the potential deceptive nature of PB-CM, the emphasis placed on the individual behaviors to the detriment of social and structural determinants of health, and failures to address vulnerability and power dynamics. CONCLUSIONS This scoping review offers important insights into the ethics on PB-CM and its implications for research ethics, clinical ethics, and public health ethics. Additionally, it raises important questions that can inform future research and dialogues to further tease out the ethical issues associated with PB-CM.
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Affiliation(s)
- Marilou Gagnon
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada.
- School of Nursing, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada.
| | - Alayna Payne
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, 167 Ferry Street, Windsor, ON, N9A 0C5, Canada
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Scheel IB, Scheel AE, Fretheim A. The moral perils of conditional cash transfer programmes and their significance for policy: a meta-ethnography of the ethical debate. Health Policy Plan 2021; 35:718-734. [PMID: 32538436 DOI: 10.1093/heapol/czaa014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2020] [Indexed: 11/13/2022] Open
Abstract
Conditional cash transfer (CCT) is a compelling policy alternative for reducing poverty and improving health, and its effectiveness is promising. CCT programmes have been widely deployed across geographical, economic and political contexts, but not without contestation. Critics argue that CCTs may result in infringements on freedom and dignity, gender discrimination and disempowerment and power imbalances between programme providers and beneficiaries. In this analysis, we aim to identify the ethical concepts applicable to CCTs and to contextualize these by mapping the tensions of the debate, allowing us to understand the separate contributions as parts of a larger whole. We searched a range of databases for records on public health CCT. Strategies were last run in January 2017. We included 31 dialectical articles deliberating the ethics of CCTs and applied a meta-ethnographic approach. We identified 22 distinct ethical concepts. By analysing and mapping the tensions in the discourse, the following four strands of debate emerged: (1) responsibility for poverty and health: personal vs public duty, (2) power balance: autonomy vs paternalism, (3) social justice: empowerment vs oppression and (4) marketization of human behaviour and health: 'fair trade' vs moral corruption. The debate shed light on the ethical ideals, principles and doctrines underpinning CCT. These were consistent with a market-oriented liberal welfare regime ideal: privatization of public responsibilities; a selective rather than a universal approach; empowerment by individual entrepreneurship; marketization of health with a conception of human beings as utility maximizing creatures; and limited acknowledgement of the role of structural injustices in poverty and health. Identification of key tensions in the public health ethics debate may expose underpinning ideological logics of health and social programmes that may be at odds with public values and contemporary political priorities. Decisions about CCTs should therefore not be considered a technical exercise, but a context-dependent process requiring transparent, informed and deliberative decision-making.
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Affiliation(s)
- Inger B Scheel
- Department of Global Health, Norwegian Institute of Public Health, PO Box 4404, Nydalen, N-0403 Oslo, Norway
| | - Andrea E Scheel
- Department of Global Health, Norwegian Institute of Public Health, PO Box 4404, Nydalen, N-0403 Oslo, Norway
| | - Atle Fretheim
- Division for Health Services, Norwegian Institute of Public Health, PO Box 4404, Nydalen, N-0403 Oslo, Norway
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Gagnon M, Guta A, Upshur R, Murray SJ, Bungay V. "It gets people through the door": a qualitative case study of the use of incentives in the care of people at risk or living with HIV in British Columbia, Canada. BMC Med Ethics 2020; 21:105. [PMID: 33109165 PMCID: PMC7590593 DOI: 10.1186/s12910-020-00548-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/16/2020] [Indexed: 11/22/2022] Open
Abstract
Background There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care—each one representing an interconnecting step in the "HIV Cascade." Methods The main objective of this qualitative case study was to document the experiences of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes. Results Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve (and sustain) viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional—thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional. Conclusions We identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care—an area of life previously not subject to monetary exchanges.
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Affiliation(s)
- Marilou Gagnon
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC, V8N 5M8, Canada.
| | - Adrian Guta
- School of Social Work, University of Windsor, 167 Ferry Street, Windsor, ON, N9A 0C5, Canada
| | - Ross Upshur
- Dalla Lana Chair in Clinical Public Health, Dalla Lana School of Public Health, 678-155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Stuart J Murray
- Canada Research Chair in Rhetoric and Ethics, Department of English Language and Literature, Carleton University, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6, Canada
| | - Vicky Bungay
- Canada Research Chair in Gender, Equity and Community Engagement, School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T2B5, Canada
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6
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Corepal R, Tully MA, Kee F, Miller SJ, Hunter RF. Behavioural incentive interventions for health behaviour change in young people (5-18 years old): A systematic review and meta-analysis. Prev Med 2018; 110:55-66. [PMID: 29432789 DOI: 10.1016/j.ypmed.2018.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 02/01/2018] [Accepted: 02/05/2018] [Indexed: 10/18/2022]
Abstract
Physical inactivity, an unhealthy diet, smoking, and alcohol consumption are key determinants of morbidity and mortality. These health behaviours often begin at a young age and track into adulthood, emphasising a need for interventions in children and young people. Previous research has demonstrated the potential effectiveness of behavioural incentive (BI) interventions in adults. However, little is known about their effectiveness in children and adolescents. Eight bibliographic databases were searched. Eligibility criteria included controlled trials using behavioural incentives (rewards provided contingent on successful performance of the target behaviour) as an intervention component for health behaviour change in children and adolescents. Intervention effects (standardised mean differences or odds ratios) were calculated and pooled by health behaviour, using a random effects model. Twenty-two studies were included (of n = 8392 identified), 19 of which were eligible for meta-analysis: physical activity (n = 8); healthier eating (n = 3); and smoking (n = 8). There was strong evidence that behavioural incentives may encourage healthier eating behaviours, some evidence that behavioural incentives were effective for encouraging physical activity behaviour, and limited evidence to support the use of behavioural incentives for smoking cessation and prevention in adolescents. Findings suggest that behavioural incentives may encourage uptake and initiation of healthy eating and physical activity in young people. However, this is a limited evidence base and a wide range of incentive designs have yet to be explored. Future research should further investigate the acceptability of these intervention approaches for young people.
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Affiliation(s)
- Rekesh Corepal
- Centre for Public Health, Queen's University Belfast, Northern Ireland, UK; UKCRC Centre of Excellence for Public Health Research (NI), Queen's University Belfast, Northern Ireland, UK.
| | - Mark A Tully
- Centre for Public Health, Queen's University Belfast, Northern Ireland, UK; UKCRC Centre of Excellence for Public Health Research (NI), Queen's University Belfast, Northern Ireland, UK
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Northern Ireland, UK; UKCRC Centre of Excellence for Public Health Research (NI), Queen's University Belfast, Northern Ireland, UK
| | - Sarah J Miller
- UKCRC Centre of Excellence for Public Health Research (NI), Queen's University Belfast, Northern Ireland, UK; School of Social Sciences, Education and Social Work, Queen's University Belfast, Northern Ireland, UK
| | - Ruth F Hunter
- Centre for Public Health, Queen's University Belfast, Northern Ireland, UK; UKCRC Centre of Excellence for Public Health Research (NI), Queen's University Belfast, Northern Ireland, UK.
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Paldan K, Sauer H, Wagner NF. Promoting inequality? Self-monitoring applications and the problem of social justice. AI & SOCIETY 2018. [DOI: 10.1007/s00146-018-0835-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Shelus V, Taylor J, Greene E, Stanton J, Pack A, Tolley EE, Branson BM, El-Sadr WM, Pollydore J, Gamble T. It's all in the timing: Acceptability of a financial incentive intervention for linkage to HIV care in the HPTN 065 (TLC-Plus) study. PLoS One 2018; 13:e0191638. [PMID: 29394259 PMCID: PMC5796687 DOI: 10.1371/journal.pone.0191638] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 01/05/2018] [Indexed: 01/01/2023] Open
Abstract
The HPTN 065 (TLC-Plus) study tested the feasibility and effectiveness of using financial incentives (FIs) to increase linkage to care (L2C) among individuals with newly diagnosed HIV and those out of care in the Bronx, NY and Washington, DC. Qualitative data collection with a subset of participating patients and staff focused on experiences with and attitudes about the FI intervention. Semi-structured interviews were conducted with 15 patients and 14 site investigators. Four focus group discussions were conducted with a total of 15 staff members. The use of FIs for L2C was generally viewed favorably. Patients were grateful and benefited financially, but sites had some challenges implementing the program. Challenges included the timing and sensitive introduction of the intervention immediately after an HIV diagnosis, negative attitudes towards paying people for health behaviors, and the existence and strength of existing linkage programs. Future programs should consider optimal timing and presentation of FIs.
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Affiliation(s)
- Victoria Shelus
- Science Facilitation, HPTN Leadership and Operations Center, FHI 360, Durham, NC, United States of America
| | - Jamilah Taylor
- Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, NC, United States of America
| | - Elizabeth Greene
- Science Facilitation, HPTN Leadership and Operations Center, FHI 360, Durham, NC, United States of America
| | - Jill Stanton
- Science Facilitation, HPTN Leadership and Operations Center, FHI 360, Durham, NC, United States of America
| | - Allison Pack
- Science Facilitation, HPTN Leadership and Operations Center, FHI 360, Durham, NC, United States of America
| | - Elizabeth E. Tolley
- Behavioral, Epidemiological and Clinical Sciences, FHI 360, Durham, NC, United States of America
| | | | - Wafaa M. El-Sadr
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, United States of America
| | - June Pollydore
- The Women’s Collective, Washington, D.C., United States of America
| | - Theresa Gamble
- Science Facilitation, HPTN Leadership and Operations Center, FHI 360, Durham, NC, United States of America
- * E-mail:
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Balderrama F, Longo CJ. Design of effective interventions for smoking cessation through financial and non-financial incentives. Healthc Manage Forum 2017; 30:289-292. [PMID: 29061074 DOI: 10.1177/0840470417714490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Smoking has a tremendous negative impact on the Canadian economy and contributes to growing costs in the healthcare system. Efforts to reduce smoking rates may therefore reduce strain on the healthcare system and free up scarce resources. Academic literature on economic smoking cessation incentives presents a countless variety of interventions that have met with varying degrees of success. This study reviews six different variables used in the design of incentives in smoking cessation interventions: direction, form, magnitude, certainty, recipient grouping, and target demographic. The purpose of this study is to provide analysis and recommendations about the contribution of each variable into the overall effectiveness of smoking cessation programs and help health leaders design better interventions according to their specific needs.
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Affiliation(s)
- Fanor Balderrama
- 1 Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Christopher J Longo
- 2 Health Policy and Management, DeGroote School of Business, McMaster University, Hamilton, Ontario, Canada
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Greene E, Pack A, Stanton J, Shelus V, Tolley EE, Taylor J, El Sadr WM, Branson BM, Leider J, Rakhmanina N, Gamble T. "It Makes You Feel Like Someone Cares" acceptability of a financial incentive intervention for HIV viral suppression in the HPTN 065 (TLC-Plus) study. PLoS One 2017; 12:e0170686. [PMID: 28182706 PMCID: PMC5300168 DOI: 10.1371/journal.pone.0170686] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 01/09/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND HPTN 065 (TLC-Plus) evaluated the feasibility and effectiveness of providing quarterly $70 gift card financial incentives to HIV-infected patients on antiretroviral therapy (ART) to encourage ART adherence and viral suppression, and represents the largest study to-date of a financial incentive intervention for HIV viral suppression. A post-trial qualitative substudy was undertaken to examine acceptability of the financial incentives among those receiving and implementing the intervention. METHODS Between July and October 2013, semi-structured interviews were conducted with 72 patients and 12 investigators from 14 sites; three focus groups were conducted with 12 staff from 10 sites. Qualitative data collection elicited experiences with and attitudes about the intervention, including philosophical viewpoints and implementation experiences. Transcripts were analyzed in NVivo 10. Memos and matrices were developed to explore themes from different participant group perspectives. RESULTS Patients, investigators, and staff found the intervention highly acceptable, primarily due to the emotional benefits gained through giving or receiving the incentive. Feeling rewarded or cared for was a main value perceived by patients; this was closely tied to the financial benefit for some. Other factors influencing acceptability for all included perceived effectiveness and health-related benefits, philosophical concerns about the use of incentives for health behavior change, and implementation issues. The termination of the incentive at the end of the study was disappointing to participants and unexpected by some, but generally accepted. CONCLUSION Positive experiences with the financial incentive intervention and strategies used to facilitate implementation led to high acceptability of the intervention, despite some reluctance in principle to the use of incentives. The findings of this analysis provide encouraging evidence in support of the acceptability of a large-scale financial incentive intervention for HIV viral suppression in a clinical setting, and offer valuable lessons for future applications of similar interventions.
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Affiliation(s)
- Elizabeth Greene
- Science Facilitation Department, FHI 360, Durham, North Carolina, United States of America
- * E-mail:
| | - Allison Pack
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Jill Stanton
- Science Facilitation Department, FHI 360, Durham, North Carolina, United States of America
| | - Victoria Shelus
- Institute for Reproductive Health, Georgetown University, Washington DC, United States of America
| | - Elizabeth E. Tolley
- Social and Behavioral Health Sciences, FHI 360, Durham, North Carolina, United States of America
| | - Jamilah Taylor
- Social and Behavioral Health Sciences, FHI 360, Durham, North Carolina, United States of America
| | - Wafaa M. El Sadr
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, United States of America
| | | | - Jason Leider
- Jacobi Medical Center, New York, New York, United States of America
| | - Natella Rakhmanina
- Children’s National Health System, Washington DC, United States of America
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, United States of America
| | - Theresa Gamble
- Science Facilitation Department, FHI 360, Durham, North Carolina, United States of America
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Chen TT, Tung TH, Hsueh YSA, Tsai MH, Liang HM, Li KL, Chung KP, Tang CH. Measuring Preferences for a Diabetes Pay-for-Performance for Patient (P4P4P) Program using a Discrete Choice Experiment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:578-586. [PMID: 26297085 DOI: 10.1016/j.jval.2015.03.1793] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 01/30/2015] [Accepted: 03/22/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To elicit a patient's willingness to participate in a diabetes pay-for-performance for patient (P4P4P) program using a discrete choice experiment method. METHODS The survey was conducted in March 2013. Our sample was drawn from patients with diabetes at five hospitals in Taiwan (International Classification of Diseases, Ninth Revision, Clinical Modification code 250). The sample size was 838 patients. The discrete choice experiment questionnaire included the attributes monthly cash rewards, exercise time, diet control, and program duration. We estimated a bivariate probit model to derive willingness-to-accept levels after accounting for the characteristics (e.g., severity and comorbidity) of patients with diabetes. RESULTS The preferred program was a 3-year program involving 30 minutes of exercise per day and flexible diet control. Offering an incentive of approximately US $67 in cash per month appears to increase the likelihood that patients with diabetes will participate in the preferred P4P4P program by approximately 50%. CONCLUSIONS Patients with more disadvantageous characteristics (e.g., elderly, low income, greater comorbidity, and severity) could have less to gain from participating in the program and thus require a higher monetary incentive to compensate for the disutility caused by participating in the program's activities. Our result demonstrates that a modest financial incentive could increase the likelihood of program participation after accounting for the attributes of the P4P4P program and patients' characteristics.
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Affiliation(s)
- Tsung-Tai Chen
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan.
| | - Tao-Hsin Tung
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan; Medical Research and Education, Cheng Hsin General Hospital, Taipei City, Taiwan
| | - Ya-Seng Arthur Hsueh
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Ming-Han Tsai
- Division of Endocrinology Metabolism, Min-Sheng General Hospital, Taoyuan City, Taiwan
| | - Hsiu-Mei Liang
- Division of Endocrinology Metabolism, Min-Sheng General Hospital, Taoyuan City, Taiwan
| | - Kay-Lun Li
- Division of Metabolism and Endocrinology, Chang Gung Memorial Hospital, Linkou Branch, Linkou, Taiwan
| | - Kuo-Piao Chung
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Chao-Hsiun Tang
- School of Health Care Administration, Taipei Medical University, Taipei City, Taiwan
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Giles EL, Holmes M, McColl E, Sniehotta FF, Adams JM. Acceptability of financial incentives for breastfeeding: thematic analysis of readers' comments to UK online news reports. BMC Pregnancy Childbirth 2015; 15:116. [PMID: 25982305 PMCID: PMC4475305 DOI: 10.1186/s12884-015-0549-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 05/05/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Whilst it is recommended that babies are breastfed exclusively for the first six months, many mothers do not maintain breastfeeding for this length of time. Previous research confirms that women and midwives value financial incentives for breastfeeding, but limited research has explored the wider acceptability of these interventions to the general public. This paper examines opinion towards financial incentives for breastfeeding using reader responses to UK on-line media coverage of a study undertaken in this area. METHODS This study used netnography to undertake a thematic analysis of 3,373 reader comments posted in response to thirteen articles, published in November 2013, which reported findings from a feasibility study of financial incentives for breastfeeding. All articles were published on one of six UK news websites that achieved a monthly audience of at least five million viewers across laptop and desktop computers and mobile devices during April-May 2013. RESULTS Nine analytical themes were identified, with a majority view that financial incentives for breastfeeding are unacceptable. These themes cover a range of opinions: from negligent parents unable to take responsibility for their own actions; through to psychologically vulnerable members of society who should be protected from coercion and manipulation; to capable and responsible women who can, and should be allowed to, make their own decisions. Many views focused on the immediate costs of the intervention, concluding that this was something that was currently unaffordable to fund (e.g. by the NHS). Others contrasted the value of the incentive against other 'costs' of breastfeeding. There was some consideration of the issue of cost-effectiveness and cost-saving, where the potential future benefit from initial investment was identified. Many commenters identified that financial incentives do not address the many structural and cultural barriers to breastfeeding. CONCLUSIONS Overall, those commenting on the on-line UK news articles viewed financial incentives for breastfeeding as unacceptable and that alternative, structural, interventions were likely to be more effective. Further consideration of how best to conduct internet-based qualitative research to elicit opinion towards public health issues is required.
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Affiliation(s)
- Emma L Giles
- Health and Social Care Institute, Teesside University, Middlesbrough, North Yorkshire, TS1 3BA, UK.
| | - Matthew Holmes
- The Medical School, Newcastle University, Framlington Place, NE2 4HH, Newcastle upon Tyne, Tyne and Wear, UK.
| | - Elaine McColl
- Institute of Health & Society, Newcastle Clinical Trials Unit, The Medical School, Newcastle University, 4th Floor, William Leech Building, Framlington Place, NE2 4HH, Newcastle upon Tyne, Tyne and Wear, UK.
| | - Falko F Sniehotta
- Health and Social Care Institute, Teesside University, Middlesbrough, North Yorkshire, TS1 3BA, UK.
| | - Jean M Adams
- Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Level 3 Institute of Metabolic Science, Addenbrooke's Treatment Centre, Cambridge Biomedical Campus, Cambridge, CB2 0SL, UK.
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13
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Giles EL, Robalino S, Sniehotta FF, Adams J, McColl E. Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods. Prev Med 2015; 73:145-58. [PMID: 25600881 DOI: 10.1016/j.ypmed.2014.12.029] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 11/28/2014] [Accepted: 12/26/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Financial incentives are effective in encouraging healthy behaviours, yet concerns about acceptability remain. We conducted a systematic review exploring acceptability of financial incentives for encouraging healthy behaviours. METHODS Database, reference, and citation searches were conducted from the earliest available date to October 2014, to identify empirical studies and scholarly writing that: had an English language title, were published in a peer-reviewed journal, and explored acceptability of financial incentives for healthy behaviours in members of the public, potential recipients, potential practitioners or policy makers. Data was analysed using thematic analysis. RESULTS Eighty one papers were included: 59 pieces of scholarly writing and 22 empirical studies, primarily exploring acceptability to the public. Five themes were identified: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Although there was consensus that if financial incentives are effective and cost effective they are likely to be considered acceptable, a number of other factors also influenced acceptability. CONCLUSIONS Financial incentives tend to be acceptable to the public when they are effective and cost-effective. Programmes that benefit recipients and wider society; are considered fair; and are delivered to individuals deemed appropriate are likely to be considered more acceptable.
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Affiliation(s)
- Emma L Giles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK.
| | - Shannon Robalino
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK.
| | - Falko F Sniehotta
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK.
| | - Jean Adams
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK.
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, 4th Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, Tyne and Wear NE2 4HH, UK.
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14
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Giles EL, Sniehotta FF, McColl E, Adams J. Acceptability of financial incentives and penalties for encouraging uptake of healthy behaviours: focus groups. BMC Public Health 2015; 15:58. [PMID: 25636330 PMCID: PMC4318173 DOI: 10.1186/s12889-015-1409-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 01/13/2015] [Indexed: 11/21/2022] Open
Abstract
Background There is evidence that financial incentive interventions, which include both financial rewards and also penalties, are effective in encouraging healthy behaviours. However, concerns about the acceptability of such interventions remain. We report on focus groups with a cross-section of adults from North East England exploring their acceptance of financial incentive interventions for encouraging healthy behaviours amongst adults. Such information should help guide the design and development of acceptable, and effective, financial incentive interventions. Methods Eight focus groups with a total of 74 adults were conducted between November 2013 and January 2014 in Newcastle upon Tyne, UK. Focus groups lasted approximately 60 minutes and explored factors that made financial incentives acceptable and unacceptable to participants, together with discussions on preferred formats for financial incentives. Verbatim transcripts were thematically coded and analysed in Nvivo 10. Results Participants largely distrusted health promoting financial incentives, with a concern that individuals may abuse such schemes. There was, however, evidence that health promoting financial incentives may be more acceptable if they are fair to all recipients and members of the public; if they are closely monitored and evaluated; if they are shown to be effective and cost-effective; and if clear health education is provided alongside health promoting financial incentives. There was also a preference for positive rewards rather than negative penalties, and for shopping vouchers rather than cash incentives. Conclusions This qualitative empirical research has highlighted clear suggestions on how to design health promoting financial incentives to maximise acceptability to the general public. It will also be important to determine the acceptability of health promoting financial incentives in a range of stakeholders, and in particular, those who fund such schemes, and policy-makers who are likely to be involved with the design, implementation and evaluation of health promoting financial incentive schemes. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1409-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emma L Giles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK.
| | - Falko F Sniehotta
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK.
| | - Elaine McColl
- Newcastle Clinical Trials Unit, 4th Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
| | - Jean Adams
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear, NE2 4AX, UK. .,Centre for Diet & Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285 Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
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15
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Gorin M, Schmidt H. 'I Did it For the Money': Incentives, Rationalizations and Health. Public Health Ethics 2014. [DOI: 10.1093/phe/phu034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
AbstractOver recent years, nudge policies have become increasingly popular (if somewhat confused) internationally. This article attempts to clarify what a nudge entails, and critically summarises some of the nudge policies that have been proposed to motivate weight loss in the United Kingdom and the United States. Despite the fact that most of the evidence on nudge-related policy has so far been produced in the United States, and that the leading nudge champions are American, the United Kingdom, at least with respect to considering policy interventions of this kind at the national level, appears to be relatively advanced. That said, nudge interventions remain of marginal practical import everywhere, and are never going to solve completely the obesity problem. Nonetheless, even a marginal effect may extend and improve many lives, a result that would satisfy most behavioural economists.
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Dolan P, Rudisill C. The effect of financial incentives on chlamydia testing rates: evidence from a randomized experiment. Soc Sci Med 2013; 105:140-8. [PMID: 24373390 PMCID: PMC3969100 DOI: 10.1016/j.socscimed.2013.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 10/31/2013] [Accepted: 11/11/2013] [Indexed: 11/28/2022]
Abstract
Financial incentives have been used in a variety of settings to motivate behaviors that might not otherwise be undertaken. They have been highlighted as particularly useful in settings that require a single behavior, such as appointment attendance or vaccination. They also have differential effects based on socioeconomic status in some applications (e.g. smoking). To further investigate these claims, we tested the effect of providing different types of non-cash financial incentives on the return rates of chlamydia specimen samples amongst 16–24 year-olds in England. In 2011 and 2012, we ran a two-stage randomized experiment involving 2988 young people (1489 in Round 1 and 1499 in Round 2) who requested a chlamydia screening kit from Freetest.me, an online and text screening service run by Preventx Limited. Participants were randomized to control, or one of five types of financial incentives in Round 1 or one of four financial incentives in Round 2. We tested the effect of five types of incentives on specimen sample return; reward vouchers of differing values, charity donation, participation in a lottery, choices between a lottery and a voucher and including vouchers of differing values in the test kit prior to specimen return. Financial incentives of any type, did not make a significant difference in the likelihood of specimen return. The more deprived individuals were, as calculated using Index of Multiple Deprivation (IMD), the less likely they were to return a sample. The extent to which incentive structures influenced sample return was not moderated by IMD score. Non-cash financial incentives for chlamydia testing do not seem to affect the specimen return rate in a chlamydia screening program where test kits are requested online, mailed to requestors and returned by mail. They also do not appear more or less effective in influencing test return depending on deprivation level. This chlamydia testing study is one of the largest, most thorough incentives trials. Non-cash financial incentives had no impact on chlamydia testing for young adults. Incentives were no more or less effective depending on socioeconomic status. The results are surprising given the theoretical underpinnings of the incentives' designs. Context is important in the success of any policies designed to change behavior.
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Affiliation(s)
- Paul Dolan
- Department of Social Policy, London School of Economics & Political Science, Houghton St., London WC2A 2AE, UK
| | - Caroline Rudisill
- Department of Social Policy, London School of Economics & Political Science, Houghton St., London WC2A 2AE, UK.
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18
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Forget EL. Paying people to be healthy. Int J Health Policy Manag 2013; 1:245-6. [PMID: 24596879 DOI: 10.15171/ijhpm.2013.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 11/12/2013] [Indexed: 11/09/2022] Open
Abstract
User Financial Incentives (UFIs) have emerged as a powerful tool for health promotion. Strong evidence suggests that large enough incentives paid to individuals conditional on behaviour they can control encourages more of the desired behaviour. However, such interventions can have unintended consequences for non-targeted behaviours. Implementation difficulties that result in individuals not understanding the nature of the incentive, unintended opportunities to "game" the system and inefficient roll-outs, can dampen results. Moreover, the legitimacy of paternalistic interventions by health planners requires careful consideration if we accept that the families involved will almost certainly be better judges of their own best interests than outsiders.
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Affiliation(s)
- Evelyn L Forget
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Bassani DG, Arora P, Wazny K, Gaffey MF, Lenters L, Bhutta ZA. Financial incentives and coverage of child health interventions: a systematic review and meta-analysis. BMC Public Health 2013; 13 Suppl 3:S30. [PMID: 24564520 PMCID: PMC3847540 DOI: 10.1186/1471-2458-13-s3-s30] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Financial incentives are widely used strategies to alleviate poverty, foster development, and improve health. Cash transfer programs, microcredit, user fee removal policies and voucher schemes that provide direct or indirect monetary incentives to households have been used for decades in Latin America, Sub-Saharan Africa, and more recently in Southeast Asia. Until now, no systematic review of the impact of financial incentives on coverage and uptake of health interventions targeting children under 5 years of age has been conducted. The objective of this review is to provide estimates on the effect of six types of financial incentive programs: (i) Unconditional cash transfers (CT), (ii) Conditional cash transfers (CCT), (iii) Microcredit (MC), (iv) Conditional Microcredit (CMC), (v) Voucher schemes (VS) and (vi) User fee removal (UFR) on the uptake and coverage of health interventions targeting children under the age of five years. Methods We conducted systematic searches of a series of databases until September 1st, 2012, to identify relevant studies reporting on the impact of financial incentives on coverage of health interventions and behaviors targeting children under 5 years of age. The quality of the studies was assessed using the CHERG criteria. Meta-analyses were undertaken to estimate the effect when multiple studies meeting our inclusion criteria were available. Results Our searches resulted in 1671 titles identified 25 studies reporting on the impact of financial incentive programs on 5 groups of coverage indicators: breastfeeding practices (breastfeeding incidence, proportion of children receiving colostrum and early initiation of breastfeeding, exclusive breastfeeding for six months and duration of breastfeeding); vaccination (coverage of full immunization, partial immunization and specific antigens); health care use (seeking healthcare when child was ill, visits to health facilities for preventive reasons, visits to health facilities for any reason, visits for health check-up including growth control); management of diarrhoeal disease (ORS use during diarrhea episode, continued feeding during diarrhea, healthcare during diarrhea episode) and other preventive health interventions (iron supplementation, vitamin A, zinc supplementation, preventive deworming). The quality of evidence on the effect of financial incentives on breastfeeding practices was low but seems to indicate a potential positive impact on receiving colostrum, early initiation of breastfeeding, exclusive breastfeeding and mean duration of exclusive breastfeeding. There is no effect of financial incentives on immunization coverage although there was moderate quality evidence of conditional cash transfers leading to a small but non-significant increase in coverage of age-appropriate immunization. There was low quality evidence of impact of CCT on healthcare use by children under age 5 (Risk difference: 0.14 [95%CI: 0.03; 0.26]) as well as low quality evidence of an effect of user fee removal on use of curative health services (RD=0.62 [0.41; 0.82]). Conclusions Financial incentives may have potential to promote increased coverage of several important child health interventions, but the quality of evidence available is low. The more pronounced effects seem to be achieved by programs that directly removed user fees for access to health services. Some indication of effect were also observed for programs that conditioned financial incentives on participation in health education and attendance to health care visits. This finding suggest that the measured effect may be less a consequence of the financial incentive and more due to conditionalities addressing important informational barriers.
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20
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Miller PSJ, Biddle EA, van Dongen JM, van Tulder MW, Tompa E, Shemilt I. Economic incentives to enhance safety behaviour in workers for preventing occupational injuries. Hippokratia 2013. [DOI: 10.1002/14651858.cd010474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Paul SJ Miller
- University of Nottingham; School of Community Health Sciences; Nottingham UK
| | - Elyce A Biddle
- National Institute of Occupational Safety and Health; Division of Safety Research; 1095 Willowdale Road Morgantown West Virginia USA 26505
| | - Johanna Maria van Dongen
- VU University; Department of Health Sciences, Faculty of Earth and Life Sciences; De Boelelaan 1085 Amsterdam Netherlands 1081HV
| | - Maurits W van Tulder
- VU University; Department of Health Sciences, Faculty of Earth and Life Sciences; De Boelelaan 1085 Amsterdam Netherlands 1081HV
| | - Emile Tompa
- Institute for Work and Health; 481 University Avenue, Suite 800 Toronto Ontario Canada M5G 2E9
| | - Ian Shemilt
- University of Cambridge; The Primary Care Unit; Institute of Public Health Forvie Site, Robinson Way Cambridge Cambridgeshire UK CB2 0SR
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Horwitz JR, Kelly BD, DiNardo JE. Wellness Incentives In The Workplace: Cost Savings Through Cost Shifting To Unhealthy Workers. Health Aff (Millwood) 2013; 32:468-76. [DOI: 10.1377/hlthaff.2012.0683] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jill R. Horwitz
- Jill R. Horwitz is a professor of law at the University of California, Los Angeles, School of Law
| | - Brenna D. Kelly
- Brenna D. Kelly is an associate in the New York office of the law firm Ropes and Gray
| | - John E. DiNardo
- John E. DiNardo is a professor of economics and public policy at the University of Michigan, in Ann Arbor
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Schmidt H, Asch DA, Halpern SD. Fairness and wellness incentives: what is the relevance of the process-outcome distinction? Prev Med 2012; 55 Suppl:S118-23. [PMID: 22449482 DOI: 10.1016/j.ypmed.2012.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 02/18/2012] [Accepted: 03/08/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To determine whether the commonly drawn distinction between the fairness of incentives targeting behavioral processes (or effort) and those targeting outcomes (or achievement) provide suitable grounds for favoring either approach in healthcare research, policy and practice. METHODS Conceptual analysis, literature review. RESULTS A categorical distinction between process- and outcome-based incentives is less crisp than it seems. Both processes and outcomes involve targets, and both are subject to differences - across and within socio-economic groups - in circumstance and perspective. Thus, a spectrum view is more appropriate, in which the fairness of incentive programs increases with the extent of control that people have. The effectiveness of incentives is a further relevant consideration, and some available evidence suggests that incentives closer to the outcome-end of the spectrum can be more effective. CONCLUSIONS Simple distinctions between processes and outcomes by themselves provide little assurance that programs are effective or fair. Effectiveness can and should be assessed empirically. Assessments of fairness should focus on the extent to which an activity or outcome might be feasible and under an individual's control, not on whether it targets a process or outcome. Rigid uniform targets for all are generally less desirable than those that reward person-specific improvement.
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Affiliation(s)
- Harald Schmidt
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA.
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