The ABCs of incentive-based treatment in health care: a behavior analytic framework to inform research and practice

Results From a Pilot Study of an Automated Directly Observed Therapy Intervention Using Artificial Intelligence With Conditional Economic Incentives Among Young Adults With HIV

BACKGROUND

Despite improvements in antiretroviral therapy (ART) availability, suboptimal adherence is common among youth with HIV (YWH) and can increase drug resistance and poor clinical outcomes. Our study examined an innovative mobile app-based intervention that used automated directly observed therapy (aDOT) using artificial intelligence, along with conditional economic incentives (CEIs) to improve ART adherence and enhance viral suppression among YWH.

SETTING

We conducted a pilot study of the aDOT-CEI intervention, informed by the operant framework of Key Principles in Contingency Management Implementation, to improve ART adherence among YWH (18-29) in California and Florida who had an unsuppressed HIV viral load.

METHODS

We recruited 28 virally unsuppressed YWH from AIDS Healthcare Foundation clinics, who used the aDOT platform for 3 months. Study outcomes included feasibility and acceptability, self-reported ART adherence, and HIV viral load.

RESULTS

Participants reported high satisfaction with the app (91%), and 82% said that it helped them take their medication. Comfort with the security and privacy of the app was moderate (55%), and 59% indicated the incentives helped improve daily adherence.

CONCLUSIONS

Acceptability and feasibility of the aDOT-CEI intervention were high with potential to improve viral suppression, although some a priori metrics were not met. Pilot results suggest refinements which may improve intervention outcomes, including increased incentive amounts, provision of additional information, and reassurance about app privacy and security. Additional research is recommended to test the efficacy of the aDOT-CEI intervention to improve viral suppression in a larger sample.

Assessing Feasibility and Barriers to Implementing a Family-Based Intervention in Opioid Treatment Programs

Families Facing the Future (FFF) is an intervention designed specifically for families with a parent in methadone treatment. FFF is unique because it addresses prevention for children and recovery for parents in a single intervention. The primary goals of the program are to prevent parents' relapse, help them cope with relapse if it occurs, and teach parenting skills in order to reduce the likelihood of substance use among their children. FFF has been implemented as an adjunct to treatment in several Opioid Treatment Programs, but has not been widely adopted due to various implementation barriers. The aims of this study, therefore, were to (1) assess the perceived feasibility of implementing FFF and (2) identify/describe barriers to implementing FFF. An online survey was used to assess implementation feasibility, while individual qualitative interviews were conducted to explore specific barriers to implementation. Data collection from a total of 40 participants (20 patients and 20 providers) was conducted from August 2022 to October 2022 at two Opioid Treatment Programs in Florida. Analyses revealed high feasibility scores, indicating that FFF was viewed by both patients and providers as a practical intervention to implement. Despite strong perceived feasibility of the intervention, qualitative findings identified several implementation barriers with respect to difficulty attending parent training sessions, aversion to in-home visits, and lack of funding (inability to provide patient incentives/bill insurance). This study provides evidence that while patients and providers view FFF as having high feasibility, significant implementation barriers exist. This paper fills a void in the literature by informing if and which modifications might be necessary to facilitate wider adoption of FFF in real-world Opioid Treatment Program settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION NUMBER

CRD42022298941.

Escalating schedules of incentives increase physical activity with no differences between deposit and no-deposit groups: A systematic replication

Physical inactivity has increasingly affected public health in the United States during the COVID-19 pandemic as it is associated with chronic diseases such as arthritis, cancer, and heart disease. Contingency management has been shown to increase physical activity. Therefore, the present study sought to evaluate the effects of an escalating schedule of monetary reinforcement with a reset contingency on physical activity, as compared between 2 counterbalanced groups in which a monetary deposit of $25 was either required (deposit group) or not (no-deposit group). Twenty-five adults wore Fitbit accelerometers to monitor step counts. An ABA reversal design was used; in the 2 baseline phases, no programmed contingencies were in place for step counts. During intervention, step goals were set using a modified 70^th percentile schedule with a 7-day window: Reaching the first goal would result in $0.25, and incentives increased by $0.25 for each subsequent day in which the goal was met. Failure to reach a goal resulted in a reset of the monetary incentive value to $0.25. Ten out of 12 participants from the deposit group were determined to be responders to intervention, whereas 8 out of 13 participants from the no-deposit group were determined to be responders to intervention. Overall, there were no significant differences between the groups' step counts. However, the deposit group's intervention was cheaper to implement, which suggests that deposit contracts are a viable modification for physical activity interventions.

Dissemination of Contingency Management for the Treatment of Opioid Use Disorder

Contingency management is an intervention for substance use disorders based on operant principles. The evidence base in support of contingency management is massive. It is effective in treating substance use disorder in general and opioid use disorder in particular. Dissemination has remained slow despite the urgency created by the opioid epidemic. Key barriers include a lack of expertise, time, and money. Implementing contingency management with smartphones eliminates the need for special training. It also solves logistical issues and requires little time on the part of clinicians. Thus, remaining barriers relate to cost. Federal anti-kickback regulations complicate solutions to the cost barrier. Other important regulatory challenges related to cost include the lack of billing codes and the difficulty of obtaining FDA approval for digital therapeutics. Even after the cost barrier is overcome, provider adoption is not guaranteed. Incentivizing providers for collaborative care may increase adoption and generate referrals. Recently proposed legislation and governmental policy statements provide optimism regarding the near-term large-scale adoption of contingency management in the treatment of opioid use disorder.

Beliefs related to health care incentives: Comparison of substance use disorder treatment providers, medical treatment providers, and a public sample

This study surveyed substance use disorder (SUD) treatment providers, medical treatment providers, and a public sample about beliefs regarding health care incentives to explore differences among the groups and across health disorders for which research has demonstrated incentives improve outcomes. Six hundred participants (n = 200/group) completed the Provider Survey of Incentives. The study found between group differences for positive and negative beliefs. The public sample was highest on the positive beliefs subscale (M = 3.81), followed by SUD (M = 3.63) and medical treatment providers (M = 3.48; F(2, 597) = 20.09, p < .001). The medical treatment providers were highest on the negative beliefs subscale (M = 2.91), compared to the public sample (M = 2.77) and SUD treatment providers (M = 2.65; F(2, 597) = 7.521, p < .001). Endorsement of incentives to treat medical disorders was similar across the groups, with obesity the most endorsed disorder. In contrast, endorsement of incentives to treat SUDs differed across groups, except for smoking. The SUD treatment providers were almost twice as likely as the public sample (OR = 1.81, 95% CI = 1.27-2.59) and the public sample almost twice as likely as the medical treatment providers (OR = 1.74, 95% CI = 1.24-2.47) to endorse the use of incentives to treat more SUDs. Medical treatment providers were also the least likely to endorse incentives to treat both legal and illicit substance use. These findings suggest that incentive programs have good acceptability among SUD treatment providers and the public, but medical treatment providers are less accepting of incentive programs. This study provides evidence that incentive-based interventions are acceptable to the public and is the first to document specific objections that individuals disseminating incentive interventions will most likely face when introducing them in medical settings.

Individuals' preference for financial over social incentives for medication adherence

BACKGROUND

Patients with chronic conditions continue to face financial and system-related barriers to medication adherence. Pharmacy, provider, and payer-based financial and social incentive-based interventions may reduce these barriers and improve adherence. However, it is unclear how patient demographics and clinical characteristics influence the type of incentives preferred by patients.

OBJECTIVES

To examine individuals' preference for financial versus social incentives and to explore the association between patient demographic and clinical characteristics with preferences for financial or social incentives.

METHODS

A cross-sectional survey of a nationally representative sample of patients was conducted with Qualtrics panelists (N = 909). U.S. adults taking at least 1 prescription medication for a chronic condition were included. Survey items elicited participants' demographic characteristics, preference for financial or social incentives, self-reported medication adherence, number of prescribed medications, and number of chronic conditions. Bivariate associations between patient characteristics and incentive preferences were tested using t and chi-square tests. Logistic regression was performed to determine patient characteristics associated with participants' preference for incentives.

RESULTS

When compared with those who were adherent to medications, individuals who were nonadherent were less likely to prefer financial incentives over social incentives (adjusted odds ratio [OR] 0.55 [95% CI 0.31-0.98]). Patient income, sex, and ethnicity were also associated with preferences for financial incentives. Those earning less than $50,000 per year were less likely to prefer financial incentives compared with social incentives (adjusted OR 0.44 [0.24-0.79]). Females were more likely to prefer financial incentives (adjusted OR 1.98 [1.16-3.37]). Hispanic/Latinos were less likely to prefer financial incentives compared to non-Hispanics/non-Latinos (adjusted OR 0.51 [0.29-0.89]).

CONCLUSION

Preferences for medication adherence incentives differed on the basis of adherence status and patients' demographic characteristics. Findings have implications for how incentive-based interventions can be structured to target certain patient groups.

Water, sanitation and hygiene (WASH) behaviour change research: why an analysis of contingencies of reinforcement is needed

Diarrheal disease associated with poor water, sanitation and hygiene (WASH) kills more than one million people every year. Safe WASH practices have the potential to greatly reduce these statistics but behaviour change interventions in the field have yielded little success to date. Currently, there is an emphasis on addressing cognitive processes to bring about changes in behaviour. In this review, a case is made for the benefits of a contingency-based perspective, focusing on the contextual antecedents and consequences of behaviour. The role of contingencies of reinforcement, not explored in previous WASH literature, is discussed as an explanatory framework for designing behaviour change strategies. A proper use of contrived reinforcers is recommended to counterbalance the natural reinforcers of convenience associated with risk practices. Recognising the role of consequences in the acquisition and maintenance of behaviour is an important step in the search for the answers urgently needed in the WASH field.

Do Community Free-Medication Service Policy Improve Patient Medication Adherence? A Cross-Sectional Study of Patients With Severe Mental Disorders in Beijing Community

Background: Nowadays, mental health problems have become a major concern affecting economic and social development, with severe mental health disorders being the top priority. In 2013, Beijing began to implement the Community Free-Medication Service policy (CFMS). This article aims to evaluate the effect of the policy on medication adherence.

Methods: In this study, multi-stage sampling was used to select representative patients as samples. Some of the baseline data were obtained by consulting the archives, and information about patient medication adherence measured by Brooks Medication Adherence Scale was obtained through face-to-face interviews. Logistic regression was used to examine the impact of the policy.

Results: Policy participation had a significant positive impact on medication adherence (OR = 1.557). The effect of policy participation on medication adherence in the Medication-only mode and Subsidy-only mode were highly significant, but it was not significant in the Mixed mode.

Conclusion: This study found that the CFMS in Beijing as an intervention is effective in improving the medication adherence of community patients. However, the impact of the policy is not consistent among service modes. Reinforcement magnitude and frequency should be considered when designing reinforcement interventions.

Racial and Ethnic Disparities in Laryngeal Cancer Care

There is a long history of racial and ethnic disparities in healthcare and they continue to persist in contemporary society. These disparities have the potential to negatively affect morbidity and mortality in racial and ethnic minorities diagnosed with laryngeal cancer. Diagnosis, medical treatment, and rehabilitation for laryngeal cancer have improved considerably, leading to improvements in overall survival rates and physical, social, and psychological functioning. Yet members of minority and underrepresented groups are at an increased risk for experiencing reduced access to quality care and delays between diagnosis and treatment, and as a result have lower survival rates. Increasing health providers' awareness of racial and ethnic disparities in laryngeal cancer is necessary to facilitate changes in patient and provider education, clinical practice, and health policies. The purpose of this review is to summarize current literature on disparities in laryngeal cancer diagnosis, treatment, and rehabilitation among Black and Hispanic patients. We present recent data from the Surveillance, Epidemiology, and End Results database to examine trends in laryngeal cancer and patient, provider, and health systems factors that may perpetuate these disparities. In addition, we offer interventions to address racism and other racial and ethnic biases in laryngeal cancer care and describe research and legislative actions that are needed to reduce disparities in this area.

Patient preferences for medication adherence financial incentive structures: A discrete choice experiment

BACKGROUND

Medication adherence for chronic conditions continues to be a challenge for patients. Patient incentives for medication adherence may help. Financial incentives delivered at the point of care may act as cues for medication-taking behavior.

OBJECTIVES

The purpose of this study was to investigate patient preferences for specific structures of financial medication adherence incentives that could feasibly be delivered at the point of care.

METHODS

A discrete choice experiment (DCE) was performed using a national online survey. Study participants were adults who self-reported taking at least one prescription medication for one or more chronic conditions. Following an orthogonal design generated in SAS, the DCE included 32 paired-choice tasks. Data were analyzed using mixed logit models and stratified on participants' income level.

RESULTS

In the full cohort (n = 933), form of financial reward (such as gift-card or cash) was 1.02 times as important to participants as the probability of incentive receipt, 1.58 times as important as monetary value, and 1.93 times as important as timing of receipt. Participants were willing to give up $31.04 of an incentive's monetary value (95% CI = $27.11-$34.98) to receive the incentive 5 months sooner (1-month vs. 6-month time-lag); $60.79 (95% CI = $53.19-$68.39) for probability of receipt to increase from a 1 out of 100 chance to a 1 out of 20 chance; and $10.52 (95% CI = $6.46-$14.58) to receive an incentive in the form of a Visa® gift-card instead of grocery store voucher. These patterns of trade-offs between attributes were generally consistent among participants with lower and higher income.

CONCLUSIONS

Regardless of socioeconomic status, patient preferences for financial medication adherence incentives delivered at the point of care may be most heavily influenced by incentive form and probability of receipt. This has implications for designing medication adherence programs in terms of incentive sustainability, patient engagement, plan star ratings, and patient outcomes.

Process- and Outcome-Based Financial Incentives to Improve Self-Management and Glycemic Control in People with Type 2 Diabetes in Singapore: A Randomized Controlled Trial

BACKGROUND

Sub-optimally controlled diabetes increases risks for adverse and costly complications. Self-management including glucose monitoring, medication adherence, and exercise are key for optimal glycemic control, yet, poor self-management remains common.

OBJECTIVE

The main objective of the Trial to Incentivize Adherence for Diabetes (TRIAD) study was to determine the effectiveness of financial incentives in improving glycemic control among type 2 diabetes patients in Singapore, and to test whether process-based incentives tied to glucose monitoring, medication adherence, and physical activity are more effective than outcome-based incentives tied to achieving normal glucose readings.

METHODS

TRIAD is a randomized, controlled, multi-center superiority trial. A total of 240 participants who had at least one recent glycated hemoglobin (HbA1c) being 8.0% or more and on oral diabetes medication were recruited from two polyclinics. They were block-randomized (blocking factor: current vs. new glucometer users) into the usual care plus (UC +) arm, process-based incentive arm, and outcome-based incentive arm in a 2:3:3 ratio. The primary outcome was the mean change in HbA1c at month 6 and was linearly regressed on binary variables indicating the intervention arms, baseline HbA1c levels, a binary variable indicating titration change, and other baseline characteristics.

RESULTS

Our findings show that the combined incentive arms trended toward better HbA1c than UC + , but the difference is estimated with great uncertainty (difference - 0.31; 95% confidence interval [CI] - 0.67 to 0.06). Lending credibility to this result, the proportion of participants who reduced their HbA1c is higher in the combined incentive arms relative to UC + (0.18; 95% CI 0.04, 0.31). We found a small improvement in process- relative to outcome-based incentives, but this was again estimated with great uncertainty (difference - 0.05; 95% CI - 0.42 to 0.31). Consistent with this improvement, process-based incentives were more effective at improving weekly medication adherent days (0.64; 95% CI - 0.04 to 1.32), weekly physically active days (1.37; 95% CI 0.60-2.13), and quality of life (0.04; 95% CI 0.0-0.07) than outcome-based incentives.

CONCLUSION

This study suggests that both incentive types may be part of a successful self-management strategy. Process-based incentives can improve adherence to intermediary outcomes, while outcome-based incentives focus on glycemic control and are simpler to administer.

Behavior-Analytic Approaches to the Management of Diabetes Mellitus: Current Status and Future Directions

Diabetes mellitus is the seventh leading cause of death in the United States, requiring a series of complex behavior changes that must be sustained for a lifetime (e.g., counting carbohydrates, self-monitoring blood glucose, adjusting insulin). Although complex, all of these tasks involve behavior, making them amenable targets for behavior analysts. In this article, the authors describe interventions that have focused on antecedent, consequent, multicomponent, and alternate procedures for the management of diabetes, highlighting ways in which technology has been used to overcome common barriers to the use of these intensive, evidence-based interventions. Additional variables relevant to poorly managed diabetes (e.g., delay discounting) are also discussed. Future research and practice should focus on harnessing continued advances in information technology while also considering underexplored behavioral technologies for the effective treatment of diabetes, with a focus on identifying sustainable, long-term solutions for maintaining proper diabetes management. Practical implementation of these interventions will depend on having qualified behavior analysts working in integrated primary care settings where the interventions are most likely to be used, which will require interdisciplinary training and collaboration.

The Incentives to Quit tobacco in Pregnancy (IQuiP) protocol: piloting a financial incentive-based smoking treatment for women attending substance use in pregnancy antenatal services

INTRODUCTION

While tobacco smoking prevalence is falling in many western societies, it remains elevated among high-priority cohorts. Rates up to 95% have been reported in women whose pregnancy is complicated by other substance use. In this group, the potential for poor pregnancy outcomes and adverse physical and neurobiological fetal development are elevated by tobacco smoking. Unfortunately, few targeted and effective tobacco dependence treatments exist to assist cessation in this population. The study will trial an evidence-based, multicomponent tobacco smoking treatment tailored to pregnant women who use other substances. The intervention comprises financial incentives for biochemically verified abstinence, psychotherapy delivered by drug and alcohol counsellors, and nicotine replacement therapy. It will be piloted at three government-based, primary healthcare facilities in New South Wales (NSW) and Victoria, Australia. The study will assess the feasibility and acceptability of the treatment when integrated into routine antenatal care offered by substance use in pregnancy antenatal services.

METHODS AND ANALYSIS

The study will use a single-arm design with pre-post comparisons. One hundred clients will be recruited from antenatal clinics with a substance use in pregnancy service. Women must be <33 weeks' gestation, ≥16 years old and a current tobacco smoker. The primary outcomes are feasibility, assessed by recruitment and retention and the acceptability of addressing smoking among this population. Secondary outcomes include changes in smoking behaviours, the comparison of adverse maternal outcomes and neonatal characteristics to those of a historical control group, and a cost-consequence analysis of the intervention implementation.

ETHICS AND DISSEMINATION

Protocol approval was granted by Hunter New England Human Research Ethics Committee (Reference 17/04/12/4.05), with additional ethical approval sought from the Aboriginal Health and Medical Research Council of NSW (Reference 1249/17). Findings will be disseminated via academic conferences, peer-reviewed publications and social media.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trial Registry (Ref: ACTRN12618000576224).

Exploring the preferences of a culturally congruent, peer-based HIV prevention intervention for black men who have sex with men

Background HIV testing, treatment initiation and treatment adherence have been emphasised for Black men who have sex with men (BMSM). However, many BMSM do not get tested, obtain HIV treatment or adhere to treatment. It is essential to highlight barriers to HIV testing, treatment adherence and the ideal components for an intervention: peer mentors, socioeconomic resources and participant incentives.

METHODS

Five focus groups (n=24) were conducted among HIV-negative and HIV-positive BMSM aged ≥18 years in Los Angeles, California, USA to explore motivations and barriers to testing and treatment and the components of an ideal, culturally competent HIV testing intervention for BMSM.

RESULTS

Barriers to HIV testing included fear and stigma associated with discovering a HIV-positive status and drug use. Motivations for testing included experiencing symptoms, beginning new relationships, perceptions of risk and peer mentors.

CONCLUSIONS

Future HIV prevention and treatment efforts should consider these components to improve health outcomes among BMSM.

Enhancing Primary Adherence to Prescribed Medications through an Organized Health Status Assessment-Based Extension of Primary Healthcare Services

This study was part of monitoring an intervention aimed at developing a general practitioner cluster (GPC) model of primary healthcare (PHC) and testing its effectiveness in delivering preventive services integrated into the PHC system. The aim was to demonstrate whether GPC operation could increase the percentage of drugs actually dispensed. Using national reference data of the National Health Insurance Fund for each anatomical-therapeutic chemical classification ATC group of drugs, dispensed-to-prescribed ratios standardized (sDPR) for age, sex, and exemption certificate were calculated during the first quarter of 2012 (before-intervention) and the third quarter of 2015 (post-intervention). The after-to-before ratios of the sDPR as the relative dispensing ratio (RDR) were calculated to describe the impact of the intervention program. The general medication adherence increased significantly in the intervention area (RDR = 1.064; 95% confidence interval (CI): 1.054-1.073). The most significant changes were observed for cardiovascular system drugs (RDR = 1.062; 95% CI: 1.048-1.077) and for alimentary tract and metabolism-specific drugs (RDR = 1.072; 95% CI: 1.049-1.097). The integration of preventive services into a PHC without any specific medication adherence-increasing activities is beneficial for medication adherence, especially among patients with cardiovascular, alimentary tract, and metabolic disorders. Monitoring the percentage of drugs actually dispensed is a useful element of PHC-oriented intervention evaluation frames.

Token economy to improve adherence to activities of daily living

BACKGROUND

Participation in key activities of daily living (ADL), including daily bathing, physical activity, and oral hygiene, can decrease the risk of bloodstream infections, oral complications, and deconditioning in pediatric patients undergoing hematopoietic stem cell transplant (HSCT). However, many patients fail to perform ADL during their inpatient stay. To improve inpatient adherence to ADL, we tested a token economy to engage patients, families, and the clinical team in improving adherence to these important health behaviors during this critical time.

METHODS

We used a controlled before-after study design to test our hypothesis. All patients were prescribed three ADL. We used an "all or none" measurement for each component of the ADL 1-2-3 initiative to measure adherence. HSCT patients with poor ADL adherence (<20%) were eligible to receive the intervention, which consisted of rewarding patients through an ADL via a token economy.

RESULTS

Twenty-one patients participated in the study. ADL adherence for the 14 days prior to intervention in study subjects (n = 294 inpatient days) averaged 0.51 ADL per day (95% CI 0.45-0.57). In the 14 days postinitiation of the token economy intervention (n = 294 inpatient days), the average adherence was 2.5 ADL per day (95% CI 2.4-2.5; P = <0.001).

DISCUSSION

Positive reinforcement through a token economy system is associated with improved adherence to ADL in hospitalized pediatric patients who demonstrated poor ADL adherence at baseline. We believe this intervention can positively impact adherence to targeted health behaviors with the ability to correlate with improved health outcomes.

Behavioral Economic Research in Addiction as an Area of Growth for the Experimental Analysis of Behavior

Behavioral economics, a synthesis of the experimental analysis of behavior (EAB) and economics, seeks to determine the relative value of reinforcers as a function of various environmental constraints. Early animal and human studies often focused on drug reinforcement, and this has continued to the present. In particular, behavioral economic analyses of human and animal behavior in relation to nicotine and cigarette smoking have contributed to a greater understanding of this behavior, and to a greater reliance on these methods in the field of smoking cessation treatment, tobacco regulatory science and tobacco control. In this commentary, we briefly describe the history of behavioral economics in the context of EAB methods, the particular contribution of these methods to understanding cigarette smoking and the advance of tobacco regulation, as well as opportunities for growth and remaining challenges in this area. As behavioral economics continues to stimulate research and inform policy, we propose that the underlying elements of a rigorous analytic approach to understanding behavior are key contributors to the fruitfulness of this approach.

Evaluation of patient-focused interventions to promote colorectal cancer screening among new york state medicaid managed care patients

BACKGROUND

The objective of this study was to evaluate an ongoing initiative to improve colorectal cancer (CRC) screening uptake in the New York State (NYS) Medicaid managed care population.

METHODS

Patients aged 50 to 75 years who were not up to date with CRC screening and resided in 2 NYS regions were randomly assigned to 1 of 3 cohorts: no mailed reminder, mailed reminder, and mailed reminder + incentive (in the form of a $25 cash card). Screening prevalence and the costs of the intervention were summarized.

RESULTS

In total, 7123 individuals in the Adirondack Region and 10,943 in the Central Region (including the Syracuse metropolitan area) were included. Screening prevalence in the Adirondack Region was 7.2% in the mailed reminder + incentive cohort, 7.0% in the mailed reminder cohort, and 5.8% in the no mailed reminder cohort. In the Central Region, screening prevalence was 7.2% in the mailed reminder cohort, 6.9% in the mailed reminder + incentive cohort, and 6.5% in the no mailed reminder cohort. The cost of implementing interventions in the Central Region was approximately 53% lower than in the Adirondack Region.

CONCLUSIONS

Screening uptake was low and did not differ significantly across the 2 regions or within the 3 cohorts. The incentive payment and mailed reminder did not appear to be effective in increasing CRC screening. The total cost of implementation was lower in the Central Region because of efficiencies generated from lessons learned during the first round of implementation in the Adirondack Region. More varied multicomponent interventions may be required to facilitate the completion of CRC screening among Medicaid beneficiaries.

Participant Satisfaction and Perceptions About Program Impact in the Medicaid Incentives for Prevention of Chronic Disease Pilot Program

PURPOSE

Evaluate the Centers for Medicare & Medicaid Incentives for Prevention of Chronic Diseases (MIPCD) program in terms of participant satisfaction and self-reported program impact.

DESIGN

Participant survey (mail/telephone follow-up), English and Spanish (N = 2274).

SETTINGS

Ten states in MIPCD program.

PARTICIPANTS

Medicaid beneficiaries.

INTERVENTION

Incentive-based health promotion programs targeting diabetes prevention and management, smoking cessation, and weight, hypertension, and cholesterol management.

MEASURES

Dependent measures are (1) overall program satisfaction and (2) self-reported program impact, operationalized as whether program helped with understanding health issues, learning ways to take care of health, and encouraging healthy lifestyle changes.

ANALYSIS

Multilevel multivariable ordinal logistic regression models to identify predictors of overall program satisfaction and program impact.

RESULTS

Sixty-seven percent were very satisfied with the program, and 76% strongly agreed the program encouraged healthy lifestyle changes. Age (59+ vs <45 years) and being female predicted overall program satisfaction. Satisfaction with specific aspects of the program including communication with staff, accessibility, and incentives predicted higher overall satisfaction. Age (45-52 vs <45 years) and being black or Hispanic predicted higher program impact. Points redeemable for rewards performed worse than money-valued incentives in terms of encouraging lifestyle changes (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.11-0.82). Participants receiving incentives valued at $25 to <$100 were more likely to report higher agreement that the program helped them learn ways to care for their health (OR, 1.72; 95% CI, 1.21-2.44) and encouraged lifestyle changes (OR, 1.46; 95% CI, 1.02-2.10), compared to participants receiving incentives valued at $0 to <$25. Incentives valued at $100 to <$400 predicted higher agreement that the program helped with understanding of health issues (OR, 1.62; 95% CI, 1.13-2.33), compared to incentives valued at $0 to <$25.

CONCLUSION

Effective chronic disease prevention programs are needed for Medicaid populations. Study findings highlight important considerations for incentive-based programs.

Maternal Behavioral Health: Fertile Ground for Behavior Analysis

The World Health Organization has identified four behavioral health priorities as risk factors for noncommunicable diseases in maternal populations: tobacco use, harmful alcohol use, poor nutrition, and lack of physical activity. These risk factors also significantly affect pregnant and immediately postpartum mothers, doubling the health risk and economic burden by adversely affecting maternal and birth or infant outcomes. Psychosocial and behavioral interventions are ideal for pregnant and immediately postpartum women as opposed to pharmacotherapy. Among other behavioral interventions, the use of incentives based on the principles of reinforcement has been a successful yet controversial way to change health behaviors. Implementing an incentive-based intervention in maternal health often brings up social validity concerns. The existing guideline on how to develop and conduct research in incentive-based interventions for maternal health lacks enough information on the specific variables to control for to maintain the intervention's effectiveness. This article outlines some of the critical variables in implementing an effective behavior-analytic intervention and addressing social validity concerns to change maternal behaviors in a sustainable manner, along with specific research topics needed in the field to prevent adverse maternal, birth, and infant outcomes.

Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients

PURPOSE

Cardiac rehabilitation (CR) improves medical outcomes after myocardial infarction or coronary revascularization. Lower socioeconomic status (SES) patients are less likely to participate in and complete CR. The aim of this study was to test whether financial incentives may increase participation and adherence to CR among lower-SES patients.

METHODS

Patients eligible to participate in CR with Medicaid insurance coverage were approached for inclusion. Patients were placed on an escalating incentive schedule of financial incentives contingent upon CR attendance. CR participation was compared to a usual care group of 101 Medicaid patients eligible for CR in the 18months prior to the study. Attendance (participating in ≥one CR sessions) and adherence (sessions completed out of 36) were compared between groups. The study was conducted in Vermont, USA, 2013-2015.

RESULTS

Of 13 patients approached to be in the study and receive incentives, 10 (77%) agreed to participate. All 10 patients completed at least one session of CR, significantly greater than the 25/101 (25%) in the control condition (p<0.001). Of patients in both groups who attended at least one session of CR, adherence was higher in the intervention group (average of 31.1 sessions completed vs. 13.6 in the control group, p<0.001). CR completion rates were also higher during the intervention with 8 of 10 (80%) intervention patients completing all 36 sessions compared to only 2 of 25 (8%) control patients (p<0.001).

CONCLUSIONS

Financial incentives may be an efficacious strategy for increasing CR participation and adherence among Medicaid patients.

A contingency management method for 30-days abstinence in non-treatment seeking young adult cannabis users

BACKGROUND

Rates of young adult cannabis use are rising, perceived harm is at its historical nadir, and most users do not want to quit. Most studies evaluating effects of cannabis use in young adults are cross-sectional, limiting causal inference. A method to reliably induce abstinence periods in cannabis users would allow assessment of the effects of abstinence and resumption of use on a variety of outcomes in a within-subjects, repeated measures design.

METHODS

We examined the efficacy and feasibility of a voucher-based contingency management procedure for incentivizing one month of continuous cannabis abstinence among young adults who reported at least weekly cannabis use, volunteered to participate in a laboratory study, and did not express a desire to discontinue cannabis use long-term. Continuous cannabis abstinence was reinforced with an escalating incentive schedule, and self-report of abstinence was confirmed by frequent quantitative assays of urine cannabis metabolite (THCCOOH) concentration. New cannabis use during the abstinence period was determined using an established algorithm of change in creatinine-adjusted cannabis metabolite concentrations between study visits.

RESULTS

Thirty-eight young adults, aged 18-25 years, enrolled and 34 (89.5%) attained biochemically confirmed 30-day abstinence. Among those who attained abstinence, 93.9% resumed regular use within two-weeks of incentive discontinuation.

CONCLUSION

Findings support the feasibility and efficacy of contingency management to elicit short-term, continuous cannabis abstinence among young adult, non-treatment seeking, regular cannabis users. Further work should test the effectiveness of this contingency management procedure for cannabis abstinence in periods longer than one month, which may be required to evaluate some effects of abstinence.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pain reduction and financial incentives to improve glucose monitoring adherence in a community health center

Self-monitoring of blood glucose is a critical component of diabetes management. However, patients often do not maintain the testing schedule recommended by their healthcare provider. Many barriers to testing have been cited, including cost and pain. We present a small pilot study to explore whether the use of financial incentives and pain-free lancets could improve adherence to glucose testing in a community health center patient population consisting largely of non-English speaking ethnic minorities with low health literacy. The proportion of patients lost to follow-up was 17%, suggesting that a larger scale study is feasible in this type of setting, but we found no preliminary evidence suggesting a positive effect on adherence by either financial incentives or pain-free lancets. Results from this pilot study will guide the design of larger-scale studies to evaluate approaches to overcome the variety of barriers to glucose testing that are present in disadvantaged patient populations.

A New Frontier: Integrating Behavioral and Digital Technology to Promote Health Behavior

Modifiable behavioral risk factors such as cigarette smoking, physical inactivity, and obesity contribute to over 40 % of premature deaths in the USA. Advances in digital and information technology are creating unprecedented opportunities for behavior analysts to assess and modify these risk factors. Technological advances include mobile devices, wearable sensors, biomarker detectors, and real-time access to therapeutic support via information technology. Integrating these advances with behavioral technology in the form of conceptually systematic principles and procedures could usher in a new generation of effective and scalable behavioral interventions targeting health behavior. In this selective review of the literature, we discuss how technological tools can assess and modify a range of antecedents and consequences of healthy and unhealthy behavior. We also describe practical, methodological, and conceptual advantages for behavior analysts that stem from the use of technology to assess and treat health behavior.