Design and baseline characteristics of participants in the TRial of Economic Incentives to Promote Physical Activity (TRIPPA): a randomized controlled trial of a six month pedometer program with financial incentives. Cohort Profile: The Korean Genome and Epidemiology Study (KoGES) Consortium Design and baseline characteristics of participants in the Enhancing Physical Activity and Reducing Obesity through Smartcare and Financial Incentives (EPAROSFI): A pilot randomized controlled trial. Designing theoretically-informed implementation interventions Impact of Bridging Income Generation with Group Integrated Care (BIGPIC) on Hypertension and Diabetes in Rural Western Kenya Study protocol for a cluster-randomised controlled trial of an NCD access to medicines initiative: evaluation of Novartis Access in Kenya Knowledge of dietary and behaviour-related determinants of non-communicable disease in urban Senegalese women. Behavioural interventions for type 2 diabetes: an evidence-based analysis. Characterizing Herbal Medicine Use for Noncommunicable Diseases in Urban South Africa Design and baseline characteristics of the 10 Small Steps Study: a randomised controlled trial of an intervention to promote healthy behaviour using a lifestyle score and personalised feedback Neighborhood clustering of non-communicable diseases: results from a community-based study in Northern Tanzania Knowledge, Attitudes, and Practices Associated with Chronic Kidney Disease in Northern Tanzania: A Community-Based Study Improving antiretroviral therapy adherence in resource‐limited settings at scale: a discussion of interventions and recommendations The effects of cash and lottery incentives on mailed surveys to physicians: a randomized trial. National Institutes of Health State-of-the-Science Conference Statement: Tobacco Use: Prevention, Cessation, and Control Coupling Financial Incentives With Direct Mail in Population-Based Practice Traditional medicine practices among community members with chronic kidney disease in northern Tanzania: an ethnomedical survey Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial The effect of physician disclosure of financial incentives on trust. Examining the use of process evaluations of randomised controlled trials of complex interventions addressing chronic disease in primary health care—a systematic review protocol Issues in psychopharmacology. Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors Methods and Strategies to Recruit African Americans into Cancer Prevention Surveillance Studies
Non-communicable diseases ( NCDs ) are emerging as the predominant global health challenge of this century . Physical inactivity is one of the primary risk factors for NCDs . Therefore , increasing physical activity levels is a public health imperative . The arrival of affordable wearable technologies , such as wireless pedometers , provides one strategy for encouraging walking . However , the effectiveness of these technologies in promoting sustained behavior change has not been established . Insights from economics suggest that incentives may be a useful strategy for increasing maintenance and effectiveness of behavior change interventions , including physical activity interventions that rely on wearable technologies . The aim of this trial is to test the effectiveness of a common wireless pedometer with or without one of two types of incentives ( cash or donations to charity ) for reaching weekly physical activity goals . We present here the design and baseline characteristics of participants of this four arm r and omized controlled trial . 800 full-time employees ( desk-bound office workers ) belonging to 15 different worksites ( on average , 53 ( sd : 37 ) employees at each worksite ) were successfully r and omized to one of four study arms . If shown to be effective , wearable technologies in concert with financial incentives may provide a scalable and affordable health promotion strategy for governments and employers seeking to increase the physical activity levels of their constituents Worldwide globalization and Westernization in social and economic aspects have led to drastic changes in South Korea during the past several decades . These changes include individual health behaviours , which were reflected as increased prevalence of non-communicable chronic diseases ( NCDs ) , such as type 2 diabetes mellitus ( T2DM ) , hypertension , obesity and cardiovascular disease ( CVD ) . These NCDs are known to be caused by both environmental risk factors and predisposing genetic factors . Population decline is another issue in South Korea ; the recorded fertility rate was 1.3 births per woman , and 10 % of the population were elderly individuals aged 65 years according to the Population and Housing Census results of 2005 - 2010 . We have also been observing an increased influx and efflux of the population due to globalization . In particular , there has been a rising tendency in the marriage-based inflow of South Asian women during the last decade . To attempt to solve public health issues result ing from these population trends and prepare for personalized and preventive health care in the future , the Korean government ( National Research Institute of Health ( NIH ) , Centers for Disease Control and Prevention and the Ministry of Health and Welfare , Korea ) initiated a large prospect i ve cohort study with government funding , named the Korean genome and epidemiology study ( KoGES ) . The study is a consortium project consisting of six prospect i ve cohort studies that would be categorized into population -based and geneenvironment model studies ( Figure 1 ) . The aim of the KoGES was to establish a genome epidemiological study platform for the research community with a health data base and biobank , to investigate the genetic and environmental aetiology of common complex diseases in Koreans ( i.e. T2DM , hypertension , obesity , metabolic syndrome , osteoporosis , CVD , and cancer ) and causes of death with longterm follow-up . The ultimate goal of the KoGES was to develop comprehensive and applicable health care guidelines for common complex diseases in Koreans , reduce the burden of chronic diseases and improve the quality of life BACKGROUND An activity tracker combined with a smartphone application ( smartcare ) may help people track and receive feedback on their own activities . However , activity trackers themselves generally fail to drive long-term sustained engagement for a majority of users . One potential strategy for increasing the effectiveness of smartcare is through the use of incentives . The purpose of this pilot r and omized trial is to test the feasibility of our intervention and to assess the extent to which smartcare with or without financial incentives can increase physical activity levels and reduce weight over a 12-week period . METHODS / DESIGN This study employs a three-arm , open-label r and omized controlled trial design : control ( st and ard basic education ) , smartcare , and smartcare plus financial incentives .  Male university students with body mass index ≥ 27 are enrolled . Our primary and secondary endpoints are the amount of weight loss and the level of physical activity respectively . The weight loss goal is 3 % of baseline at week 4 , 5 % at week 8 , and 7 % at week 12 . The daily physical activity goal was individualized according to the participants ' weight . Process incentives are accumulated when participants met daily physical activity goals , and outcome incentives are provided when they met weight reduction goals . DISCUSSION Given the global increase in physical inactivity and obesity , there is a growing need for effective , scalable , and affordable health promotion strategies . Our proof-of-concept study will provide the evidence for the combination of rising health promotion technology of activity trackers and smartphone applications with the modern concept of behavioral economics using financial incentives Clinical and health services research is continually producing new findings that may contribute to effective and efficient patient care . However , the transfer of research findings into practice is unpredictable and can be a slow and haphazard process . Ideally , the choice of implementation strategies would be based upon evidence from r and omised controlled trials or systematic review s of a given implementation strategy . Unfortunately , review s of implementation strategies consistently report effectiveness some , but not all of the time ; possible causes of this variation are seldom reported or measured by the investigators in the original studies . Thus , any attempts to extrapolate from study setting s to the real world are hampered by a lack of underst and ing of the effects of key elements of individuals , interventions , and the setting s in which they were trialled . The explicit use of theory offers a way of addressing these issues and has a number of advantages , such as providing : a generalisable framework within which to represent the dimensions that implementation studies address , a process by which to inform the development and delivery of interventions , a guide when evaluating , and a way to allow for an exploration of potential causal mechanisms . However , the use of theory in design ing implementation interventions is method ologically challenging for a number of reasons , including choosing between theories and faithfully translating theoretical constructs into interventions . The explicit use of theory offers potential advantages in terms of facilitating a better underst and ing of the generalisability and replicability of implementation interventions . However , this is a relatively unexplored method ological area Background Rural setting s in Sub-Saharan Africa ( SSA ) consistently report low participation in non-communicable disease ( NCD ) treatment programs and poor outcomes . Objective The objective of this study is to assess the impact of the implementation of a patient-centered rural NCD care delivery model called Bridging Income Generation through grouP Integrated Care ( BIGPIC ) . Design The study prospect ively tracked participation and health outcomes for participants in a screening event and compared linkage frequencies to a historical comparison group . Participants Rural Kenyan participants attending a voluntary NCD screening event were included within the BIGPIC model of care . Interventions The BIGPIC model utilizes a context ualized care delivery model design ed to address the unique barriers faced in rural setting s. This model emphasizes the following steps : ( 1 ) find patients in the community , ( 2 ) link to peer/microfinance groups , ( 3 ) integrate education , ( 4 ) treat in the community , ( 5 ) enhance economic sustainability and ( 6 ) generate dem and for care through incentives . Main Measures The primary outcome is the linkage frequency , which measures the percentage of patients who return for care after screening positive for either hypertension and /or diabetes . Secondary measures include retention frequencies defined as the percentage of patients remaining engaged in care throughout the 9-month follow-up period and changes in systolic ( SBP ) and diastolic blood pressure ( DBP ) and blood sugar over 12 months . Key Results Of the 879 individuals who were screened , 14.2 % were confirmed to have hypertension , while only 1.4 % were confirmed to have diabetes . The implementation of a comprehensive microfinance-linked , community-based , group care model result ed in 72.4 % of screen-positive participants returning for subsequent care , of which 70.3 % remained in care through the 12 months of the evaluation period . Patients remaining in care demonstrated a statistically significant mean decline of 21 mmHg in SBP [ 95 % CI ( 13.9 to 28.4 ) , P < 0.01 ] and 5 mmHg drop in DBP [ 95 % CI ( 1.4 to 7.6 ) , P < 0.01 ] . Conclusions The implementation of a context ualized care delivery model built around the unique needs of rural SSA participants led to statistically significant improvements in linkage to care and blood pressure reduction Introduction Novartis recently launched Novartis Access , an initiative to provide a basket of reduced price medicines for non-communicable diseases ( NCDs ) to be sold through the public and private non-profit sectors in programme countries . This study will evaluate the impact of Novartis Access on the availability and price of NCD medicines at health facilities and households in Kenya , the first country to receive the programme . Methods and analysis This study will be a cluster-r and omised controlled trial . 8 counties in Kenya will be r and omly assigned to the intervention or control group using a covariate constrained r and omisation method to maximise balance on demographic and health characteristics . In intervention counties , public and private non-profit health facilities will be able to order Novartis Access NCD medicines from the Mission for Essential Drugs and Supplies ( MEDS ) . Data will be collected from a r and om sample of 384 health facilities and 800 households at baseline , midline after 1-year of intervention , and end-line after 2 years . Quarterly surveillance data will also be collected from health facilities and a sub sample of households through phone-based interviews . Households will be eligible if at least one resident has been previously diagnosed and prescribed a medicine for an NCD addressed by Novartis Access , including hypertension and diabetes . The primary outcomes will be availability and price of NCD medicines at health facilities , and availability , price , and expenditures on NCD medicines at households . Impacts will be estimated using intention-to-treat analysis . Ethics and dissemination This protocol was approved by the Institutional Review Boards at Strathmore University and at Boston University . Informed consent will be obtained from all participants at the start of the trial . The findings of the trial will be disseminated through peer- review ed journals , international conferences , and meetings and events organised with local stakeholders . Trial registration number NCT02773095 OBJECTIVE To assess knowledge of dietary and behaviour-related determinants of non-communicable disease ( NCD ) of urban Senegalese women . DESIGN A cross-sectional , population study using an interviewer-administered knowledge question naire , developed and vali date d for this study . The question naire consisted of 24 items with six scores measuring knowledge of : ( 1 )  diet- and behaviour-related causes of NCD ; ( 2 ) diet quality -NCD relationship ; ( 3 )  fruit and vegetable link with NCD ; ( 4 ) health consequences of obesity ; ( 5 ) causes of cardiovascular disease ( CVD ) ; and ( 6 ) causes of certain cancers . SUBJECTS A r and om sample of 301 women aged 20 - 50 years . RESULTS The knowledge scores developed suggest that the health consequences of obesity ( mean score of 65.4 % ) were best understood followed by causes of CVD ( mean score of 60.6 % ) , because obesity , smoking , high blood cholesterol and dietary fat were well recognised as risk factors for CVD . Subjects scored least for their knowledge of the protective effect of fruit and vegetables ( mean score of 19.9 % ) . Knowledge of causes of certain cancers ( mean score of 36.1 % ) was also low . Women who worked outside the home had better knowledge for two scores but otherwise no relationship was found between knowledge and literacy , formal education or body mass index . CONCLUSIONS Findings suggest reasonable overall knowledge concerning diet and behaviour with NCD , especially given the relatively new context of the obesity epidemic in Senegal . However , there was poor knowledge of the benefit of eating fruit and vegetables and other preventable causes of certain cancers . Education targeting the benefits of vegetables and fruit may have the greatest impact on NCD prevention UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis  BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine whether behavioural interventions are effective in improving glycemic control in adults with type 2 diabetes . BACKGROUND Diabetes is a serious chronic condition affecting millions of people worldwide and is the sixth leading cause of death in Canada . In 2005 , an estimated 8.8 % of Ontario 's population had diabetes , representing more than 816,000 Ontarians . The direct health care cost of diabetes was $ 1.76 billion in the year 2000 and is projected to rise to a total cost of $ 3.14 billion by 2016 . Much of this cost arises from the serious long-term complications associated with the disease including : coronary heart disease , stroke , adult blindness , limb amputations and kidney disease . Type 2 diabetes accounts for 90 - 95 % of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older , prevalence in younger population s is increasing due to a rise in obesity and physical inactivity in children . Data from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) has shown that tight glycemic control can significantly reduce the risk of developing serious complications in type 2 diabetics . Despite physicians ' and patients ' knowledge of the importance of glycemic control , Canadian data has shown that only 38 % of patients with diabetes have HbA1C levels in the optimal range of 7 % or less . This statistic highlights the complexities involved in the management of diabetes , which is characterized by extensive patient involvement in addition to the support provided by physicians . An enormous dem and is , therefore , placed on patients to self-manage the physical , emotional and psychological aspects of living with a chronic illness . Despite differences in individual needs to cope with diabetes , there is general agreement for the necessity of supportive programs for patient self-management . While traditional programs were didactic models with the goal of improving patients ' knowledge of their disease , current models focus on behavioural approaches aim ed at providing patients with the skills and strategies required to promote and change their behaviour . Several meta-analyses and systematic review s have demonstrated improved health outcomes with  self-management support programs in type 2 diabetics . They have all , however , either looked at a specific component of self-management support programs ( i.e. self-management education ) or have been conducted in specific population s. Most review s are also qualitative and do not clearly define the interventions of interest , making findings difficult to interpret . Moreover , heterogeneity in the interventions has led to conflicting evidence on the components of effective programs . There is thus much uncertainty regarding the optimal design and delivery of these programs by policymakers . EVIDENCE -BASED ANALYSIS OF EFFECTIVENESS : RESEARCH QUESTIONS Are behavioural interventions  effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics ( e.g. delivery of intervention , length of intervention , mode of instruction , interventionist etc . ) ? INCLUSION CRITERIA English Language Published between January 1996 to August 2008 Type 2 diabetic adult population ( > 18 years)R and omized controlled trials ( RCTs ) Systematic review s , or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control ( HbA1c ) with extractable data Studies with a minimum of 6-month follow up EXCLUSION CRITERIA Studies with a control group other than usual care Studies with a sample size < 30 Studies without a clearly defined intervention OUTCOMES OF INTEREST PRIMARY OUTCOME glycemic control ( HbA1c ) SECONDARY OUTCOMES systolic blood pressure ( SBP ) control , lipid control , change in smoking status , weight change , quality of life , knowledge , self-efficacy , managing psychosocial aspects of diabetes , assessing dissatisfaction and readiness to change , and setting and achieving diabetes goals . SEARCH STRATEGY A search was performed in OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , The Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1996 and August 2008 . Abstract s were review ed by a single author and studies meeting the inclusion criteria outlined above were obtained . Data on population characteristics , glycemic control outcomes , and study design were extracted . Reference lists were also checked for relevant studies . The quality of the evidence was assessed as being either high , moderate , low , or very low according to the GRADE methodology . SUMMARY OF FINDINGS The search identified 638 citations published between 1996 and August 2008 , of which 12 met the inclusion criteria and one was a meta- analysis ( Gary et al. 2003 ) . The remaining 11 studies were RCTs ( 9 were used in the meta- analysis ) and only one was defined as small ( total sample size N=47 ) . SUMMARY OF PARTICIPANT DEMOGRAPHICS ACROSS STUDIES : A total of 2,549 participants were included in the 11 identified studies . The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years . Most studies reported gender with a mean percentage of females of approximately 67 % . Of the eleven studies , two focused only on women and four included only Hispanic individuals . All studies evaluated type 2 diabetes patients exclusively . STUDY CHARACTERISTICS : The studies were conducted between 2002 and 2008 . Approximately six of 11 studies were carried out within the USA , with the remaining studies conducted in the UK , Sweden , and Israel ( sample size ranged from 47 to 824 participants ) . The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality ( based on the Consort Checklist ) . Differences in quality were mainly due to method ological issues such as inadequate description of r and omization , sample size calculation allocation concealment , blinding and uncertainty of the use of intention-to-treat ( ITT ) analysis . Patients were recruited from several setting s : six studies from primary or general medical practice s , three studies from the community ( e.g. via advertisements ) , and two from outpatient diabetes clinics . A usual care control group was reported in nine of 11 of the studies and two studies reported some type of minimal diabetes care in addition to usual care for the control group . INTERVENTION CHARACTERISTICS : All of the interventions examined in the studies were mapped to the 2007 Self-management Mapping Guide . The interventions most often focused on problem solving , goal setting and encouraging participants to engage in activities that protect and promote health ( e.g. modifying behaviour , change in diet , and increase physical activity ) . All of the studies examined comprehensive interventions targeted at least two self-care topics ( e.g. diet , physical activity , blood glucose monitoring , foot care , etc . ) . Despite the homogeneity in the aims of the interventions , there was substantial clinical heterogeneity in other intervention characteristics such as duration , intensity , setting , mode of delivery ( group vs. individual ) , interventionist , and outcomes of interest ( discussed below ) . DURATION , INTENSITY AND MODE OF DELIVERY : Intervention duration s ranged from 2 days to 1 year , with many falling into the range of 6 to 10 weeks . The rest of the interventions fell into categories of ≤ 2 weeks ( 2 studies ) , 6 months ( 2 studies ) , or 1 year ( 3 studies ) . Intensity of the interventions varied widely from 6 hours over 2 days , to 52 hours over 1 year ; however , the majority consisted of interventions of 6 to 15 hours . Both individual and group sessions were used to deliver interventions . Group counselling was used in five studies as a mode of instruction , three studies used both individual and group sessions , and one study used individual sessions as its sole mode of instruction . ( ABSTRACT Economic challenges associated with noncommunicable diseases ( NCDs ) and the sociocultural outlook of many patients especially in Africa have increased dependence on traditional herbal medicines ( THMs ) for these diseases . A cross-sectional descriptive study design ed to determine the prevalence of and reasons for THM use in the management of NCDs among South African adults was conducted in an urban , economically disadvantaged area of Cape Town , South Africa . In a cohort of 1030 participants recruited as part of the existing Prospect i ve Urban and Rural Epidemiological ( PURE ) study , 456 individuals were identified . The overall prevalence of THM use was 27 % , of which 61 % was for NCDs . Participants used THM because of a family history ( 49 % ) and sociocultural beliefs ( 33 % ) . Hypertensive medication was most commonly used concurrently with THM . Healthcare professionals need to be aware of the potential dualistic use of THM and conventional drugs by patients , as this could significantly influence health outcomes . Efforts should be made to educate patients on the potential for drug/herb interactions Background Non-communicable diseases ( NCDs ) are the leading causes of death globally and are associated with a limited set of common , modifiable health behaviours : tobacco use , physical inactivity , harmful use of alcohol and unhealthy diet . General practice offers an ideal avenue for addressing such health behaviours on a population -wide basis . This paper describes the protocol of a multiple health behaviour change intervention design ed for implementation in general practice and summarises the baseline characteristics of its participants . Method / Design The 10 Small Steps ( 10SS ) study , a r and omised controlled trial , involved 4,678 adult general practice patients in Queensl and , Australia .  Self-reported data were collected to establish the proportion of participants meeting recommended guidelines for ten health behaviours : physical activity , body mass index , alcohol , smoking and six dietary behaviours . Participants were r and omised to four groups : contact at baseline only ( ' single intervention ' and corresponding control group ) and contact at baseline and 3 months ( ' dual intervention ' and corresponding control group ) . At each contact the participants received a computer-tailored feedback and one page information sheet according to their allocation to intervention or control groups . Change in the intervention group compared to the control group was assessed at 3 and 12 months after baseline data collection .Responses were summed to calculate an individual lifestyle score ( the Prudence Score ) , which ranged from 0 to 10 . The baseline response was 56.5 % ( 4678 of 8343 invited participants ) and the study sample was primarily female ( 68.7 % ) with an average age of 47 years . The mean Prudence Score was 5.8 ( 95%CI 5.75 - 5.85 ) . Discussion Baseline data from the 10SS study show that nearly all participants engage in some health behaviours but relatively few adhere simultaneously to a core set of dietary and lifestyle behaviours associated with risk of NCDs . Ample scope exists to improve health behaviour to reduce NCDs in the general practice setting and the 10SS study trial will provide data on the extent to which a minimal computer-tailored intervention can meet this objective . The protocol developed for the 10SS study has potential for translation into routine general practice as it has minimal impact on practice routine whilst contributing to primary prevention objectives .Trial Registration The Australian New Zeal and Clinical Trials Registry Background In order to begin to address the burden of non-communicable diseases ( NCDs ) in sub-Saharan Africa , high quality community-based epidemiological studies from the region are urgently needed . Cluster- design ed sampling methods may be most efficient , but design ing such studies requires assumptions about the clustering of the outcomes of interest . Currently , few studies from Sub-Saharan Africa have been published that describe the clustering of NCDs . Therefore , we report the neighborhood clustering of several NCDs from a community-based study in Northern Tanzania . Methods We conducted a cluster- design ed cross-sectional household survey  between January and June 2014 . We used a three-stage cluster probability sampling method to select thirty-seven sampling areas from twenty-nine neighborhood clusters , stratified by urban and rural . Households were then r and omly selected from each of the sampling areas , and eligible participants were tested for chronic kidney disease ( CKD ) , glucose impairment including diabetes , hypertension , and obesity as part of the CKD-AFRiKA study . We used linear mixed models to explore clustering across each of the samplings units , and we estimated absolute-agreement intra-cluster correlation ( ICC ) coefficients ( ρ ) for the neighborhood clusters . Results We enrolled 481 participants from 346 urban and rural households .  Neighborhood cluster sizes ranged from 6 to 49 participants ( median : 13.0 ; 25th–75th percentiles : 9–21 )  . Clustering varied across neighborhoods and differed by urban or rural setting . Among NCDs , hypertension ( ρ = 0.075 ) exhibited the strongest clustering within neighborhoods followed by CKD ( ρ = 0.440 ) , obesity ( ρ = 0.040 ) , and glucose impairment ( ρ = 0.039 ) . Conclusion The neighborhood clustering was substantial enough to contribute to a design effect for NCD outcomes including hypertension , CKD , obesity , and glucose impairment , and it may also highlight NCD risk factors that vary by setting . These results may help inform the design of future community-based studies or r and omized controlled trials examining NCDs in the region particularly those that use cluster-sampling methods Background Non-communicable diseases ( NCDs ) are a leading cause of death among adults in sub-Saharan Africa , and chronic kidney disease ( CKD ) is a growing public health threat . Underst and ing knowledge , attitudes , and practice s associated with NCDs is vital to informing optimal policy and public health responses in the region , but few community-based assessment s have been performed for CKD . To address this gap , we conducted a cross-sectional survey of adults in northern Tanzania using a vali date d instrument . Methods Between January and June 2014 , we administered a structured survey to a r and om sample of adults from urban and rural communities . The vali date d instrument consisted of 25 items design ed to measure knowledge , attitudes , and practice s associated with kidney disease . Participants were also screened for CKD , diabetes , hypertension , and human immunodeficiency virus . Results We enrolled 606 participants from 431 urban and rural households .  Knowledge of the etiologies , symptoms , and treatments for kidney disease was low ( mean score 3.28 out of 10 ; 95 % CI 2.94 , 3.63 ) . There were no significant differences by CKD status . Living in an urban setting and level of education had the strongest independent associations with knowledge score . Attitudes were characterized by frequent concern about the health ( 27.3 % ; 20.2 , 36.0 % ) , economic ( 73.1 % ; 68.2 , 77.5 % ) , and social impact ( 25.4 % ; 18.6 , 33.6 % ) of kidney disease . Practice s included the use of traditional healers ( 15.2 % ; 9.1 , 24.5 % ) and traditional medicines ( 33.8 % ; 25.0 , 43.9 % ) for treatment of kidney disease as well as a willingness to engage with mobile-phone technology in CKD care ( 94.3 % ; 90.1 , 96.8 % ) . Conclusions Community-based adults in northern Tanzania have limited knowledge of kidney disease . However , there is a modest knowledge base upon which to build public health programs to exp and awareness and underst and ing of CKD , but these programs must also consider the variety of means by which adults in this population meet their healthcare needs . Finally , our assessment of local attitudes suggested that such public health efforts would be well-received Abstract Introduction : Successful population ‐level antiretroviral therapy ( ART ) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale‐up and , ultimately , the end of AIDS . Although many people living with HIV are adhering well , others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy . Despite the importance of ART adherence , supportive interventions have generally not been implemented at scale . The objective of this review is to summarize the recommendations of clinical , research , and public health experts for scalable ART adherence interventions in re source ‐limited setting s. Methods : In July 2015 , the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in re source ‐limited setting s. This article summarizes that discussion with recent up date s. It is not a systematic review , but rather provides practical considerations for programme implementation based on evidence from individual studies , systematic review s , meta‐analyses , and the World Health Organization Consoli date d Guidelines for HIV , which include evidence from r and omized controlled trials in low‐ and middle‐income countries . Interventions are categorized broadly as education and counselling ; information and communication technology‐enhanced solutions ; healthcare delivery restructuring ; and economic incentives and social protection interventions . Each category is discussed , including descriptions of interventions , current evidence for effectiveness , and what appears promising for the near future . Approaches to intervention implementation and impact assessment are then described . Results and discussion : The evidence base is promising for currently available , effective , and scalable ART adherence interventions for re source ‐limited setting s. Numerous interventions build on existing health care infrastructure and leverage available re sources . Those most widely studied and implemented to date involve peer counselling , adherence clubs , and short message service ( SMS ) . Many additional interventions could have an important impact on ART adherence with further development , including st and ardized counselling through multi‐media technology , electronic dose monitoring , de central ized and differentiated models of care , and livelihood interventions . Optimal targeting and tailoring of interventions will require improved adherence measurement . Conclusions : The opportunity exists today to address and resolve many of the challenges to effective ART adherence , so that they do not limit the potential of ART to help bring about the end of AIDS Low response rates , especially among physicians , are a common problem in mailed survey research . We conducted a r and omized trial to examine the effects of cash and lottery incentives on response rates .  A total of 4,850 subjects were r and omized to one of three interventions accompanying a mailed survey-no incentive ( n = 1,700 ) , cash payment [ three levels of Hong Kong dollars ( HKD ) $ 10 , $ 20 , and $ 40 ; N = 50 in each subgroup ] , or entry into a lottery ( three levels of HKD$1,000 , $ 2,000 , and $ 4,000 ; N = 1,000 in each subgroup ) on receipt of the completed question naire . The response rates were higher among those offered incentives than those without ( 19.8 % vs. 16.8 % , P = .012 ) . Cash was the more effective incentive compared to lottery ( 27.3 % vs. 19.4 % , P = .017 ) . Response also increased substantially between the first and second mailings ( 14.2 % vs. 18.8 % , P > .001 ) . In addition , those with specialist qualifications were more willing to participate in mailed surveys . We found no significant differences in response outcomes among the various incentive arms . Cash reward at the $ 20 level was the most cost-effective intervention , in terms of cost per responder . Further systematic examination of the effects of different incentive strategies in epidemiologic studies should be encouraged National Institutes of Health ( NIH ) consensus and state-of-the-science statements are prepared by independent panels of health professionals and public representatives on the basis of 1 ) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality ( AHRQ ) , 2 ) presentations by investigators working in areas relevant to the conference questions during a 2-day public session , 3 ) questions and statements from conference attendees during open discussion periods that are part of the public session , and 4 ) closed deliberations by the panel during the remainder of the second day and the morning of the third . This statement is an independent report of the panel and is not a policy statement of the NIH or the federal government . The statement reflects the panel 's assessment of medical knowledge available at the time the statement was written . Thus , it provides a snapshot in time of the state of knowledge on the conference topic . When reading the statement , keep in mind that new knowledge is inevitably accumulating through medical research . Tobacco use is the leading preventable cause of premature death in the United States . Each year , more than 440000 Americans die of tobacco-related disease , accounting for 1 in every 5 deaths . Cigarette smoking is responsible for more than 30 % of cancer deaths annually in the United States . Smoking also contributes substantially to deaths from heart disease , stroke , and chronic obstructive pulmonary disease . According to current estimates , 21 % of American adults ( 44.5 million individuals ) and 22 % of American high school students ( 3.75 million individuals ) smoke . Cigarettes are the predominant form of tobacco that Americans consume , but tobacco consumption also includes smokeless tobacco , cigars , and pipes . In addition to the toll in human lives , tobacco use is an enormous economic burden on society . From 1995 to 1999 , estimated annual smoking-attributable economic costs in the United States were $ 75.5 billion for direct medical care for adults and $ 81.9 billion for lost productivity . Tobacco use per capita has decreased from about 14 pounds per year in the 1950s to about 5 pounds per year in 2000 , suggesting that public health interventions have been effective . Yet it is unlikely that the United States will reach the Healthy People 2010 objectives of reducing smoking prevalence to 12 % or less in adults and 16 % or less in youth . Further progress in reducing tobacco use is an important challenge facing the public health , medical , and political communities . For these reasons , the National Cancer Institute and the NIH 's Office of Medical Applications of Research sponsored a State-of-the-Science Conference on Tobacco Use : Prevention , Cessation , and Control on 12 - 14 June 2006 in Bethesda , Maryl and . The key questions to be addressed at the State-of-the-Science Conference were : 1 ) What are the effective population - and community-based interventions to prevent tobacco  use in adolescents and young adults , including among diverse population s ? 2 ) What are the effective strategies for increasing consumer dem and for and use of proven , individually oriented cessation treatments , including among diverse population s ? 3 ) What are the effective strategies for increasing the implementation of proven , population -level , tobacco-use cessation strategies , particularly by health care systems and communities ? 4 ) What is the effect of smokeless tobacco product marketing and use on overall harm to the population from tobacco use ? 5 ) What is the effectiveness of prevention and of cessation interventions in population s with co-occurring morbidities and risk behaviors ? 6 ) What research is needed to make the most progress and greatest public health gains nationally and internationally ? At the conference , invited experts presented information pertinent to these questions , and a systematic literature review prepared under contract with AHRQ was summarized . The evidence report ( www.ahrq.gov/clinic/epcix.htm ) emphasized r and omized , controlled trials ; systematic review s ; and other experimental or observational studies with more than 100 participants . During the conference , attendees provided both oral and written statements in response to the key questions . The panel members weighed this evidence as they addressed the key conference questions . 1 . What Are the Effective  Population - and Community-Based Interventions  to Prevent Tobacco Use in Adolescents and Young Adults , Including among Diverse population s ? Never starting to use tobacco is a much better strategy than having to stop . Tobacco use usually begins primarily during adolescence . Almost 25 % of 12th grade rs have smoked in the previous 30 days , and almost all adult daily smokers tried cigarettes before age 18 years . Research reports suggest a flattening of the past decade 's downward trend in adolescent smoking .  Adolescents ( 13 to 18 years of age ) and young adults ( 18 to 24 years of age ) are susceptible to cultural influences , including family , friends , peers , media , community , and tobacco marketing influence . Gender , racial/ethnic background , socioeconomic status , geography , and sexual orientation all influence tobacco use and the effectiveness of strategies to prevent it , which means that many preventive strategies are needed . What We Know Previous review s have identified 3 effective general population approaches to preventing tobacco use in adolescents and young adults : 1 ) increased prices through taxes on tobacco products ; 2 ) laws and regulations that prevent young people from gaining access to tobacco products , reduce their exposure to tobacco smoke , and restrict tobacco industry advertising ; and 3 ) mass media campaigns . Previous review s show that school-based intervention programs aim ed at preventing tobacco use in adolescents are effective in the short term . Comprehensive statewide programs have also reduced overall tobacco use in young adults . What We Need to Learn Although previous evidence shows that clean indoor air and youth access policies reduce adolescent smoking rates , we need to know more about the effectiveness of these policies in specific population s. The evidence that culturally sensitive programs are more effective in reducing smoking among adolescents and young adults is not adequate to support a firm conclusion . We need to develop school-based strategies that lead to sustained reduction in starting tobacco use . 2 . What Are the Effective Strategies for Increasing Consumer Dem and for and Use of Proven , Individually Oriented Cessation Treatments , Including among Diverse Population s ? About 70 % of the 44.5 million adult smokers in the United States want to quit , but of those who try to quit in a given year , fewer than 5 % succeed . Effective treatments can double or triple quit rates , but too few smokers try these interventions and too few physicians offer them . What We Know Previous systematic review s identified effective strategies for increasing use of the following proven individually oriented cessation treatments . A mass media education campaign uses brief , recurring messages to inform and to motivate tobacco users to quit . It is effective in increasing tobacco use cessation when combined with other interventions . For example , media messages that direct viewers to call for further information or support increase use of telephone-based tobacco cessation information or support services . Proactive telephone smoking cessation support occurs when the health care provider initiates contact with the smoker . Advice to stop smoking is effective , especially when combined with other interventions , such as educational approaches or pharmacologic therapies . Increasing the unit price for tobacco products increases tobacco use cessation and reduces consumption regardless of the smoker 's ethnicity , gender , and socioeconomic status . Reducing out-of-pocket costs for effective cessation therapiesfor example , because health insurance pays for the serviceincreases their use . Making smokers aware of their health insurance 's coverage policy can increase use of smoking cessation treatments . Culturally tailored , gender-specific , and language -appropriate programs show promise . What We Need to Learn Generic interventions may be less effective than interventions tailored to specific population s , so we need to underst and how best to tailor interventions . To increase dem and for treatments , smokers must want them , expect them , and ask for them . We need to learn how to make treatments more attractive to tobacco users . We need to create a sustained dem and for effective treatments . 3 . What Are the Effective Strategies for Increasing the Implementation of Proven , Population -Level Tobacco Use Cessation Strategies , Particularly by Health Care Systems and Communities ? Despite strong evidence that a variety of pharmacologic and behavioral interventions increase tobacco cessation , only a small proportion of tobacco users ever try them . Strategies that target individual tobacco users may be effective but fail to reach most smokers . Community-level strategies target broad geographic population s ( for example , cities ) or smaller , more localized groups of people ( for example , military bases , colleges ) . Clinical setting s in which to implement community-level strategies range in scope from individual practice s to large integrated organizations . What We Know Community-based interventions aim to increase dem and for cessation interventions ( media campaigns , higher prices , smoke-free environments ) or facilitate access to cessation services ( community-level quit lines , offering cessation services in community setting s ) . Evidence suggests that media campaigns , telephone-counseling programs ( quit lines ) , and increases in tobacco prices and taxes are effective . Providing cessation services in non clinical community setting s shows some promise , but the literature lacks good evidence of community setting interventions in the United States . Financial incentives are being used increasingly to encourage a wide array of health behaviors because of their well-established efficacy . However , little is known about how to translate incentive-based strategies to public health practice geared toward improving population -level health , and a dearth of research exists on how individuals respond to incentives through public health communication strategies such as direct mail . This study reports results of a population -based r and omized controlled trial testing a direct mail , incentive-based intervention for promoting mammography uptake . The study population was composed of a r and om sample of Minnesota women enrolled in Medicare fee-for-service and overdue for breast cancer screening . Participants ( N = 18,939 ) were r and omized into three groups : ( 1 ) Direct Mail only , ( 2 ) Direct Mail plus Incentive , and ( 3 ) Control . Both direct mail groups received two mailers with a message about the importance of mammography ; however , Mail plus Incentive mailers also offered a $ 25 incentive for getting a mammogram . Logistic regression analyses measured intervention effects . Results showed the odds for receiving mammography were significantly higher for the Direct Mail plus Incentive group compared with both Direct Mail only and Control groups . The use of incentives also proved to be cost-effective . Additionally , the Direct Mail only group was more likely to receive mammography than the Control group . Findings offer experimental evidence on how the population -based strategy of direct mail coupled with a financial incentive can encourage healthy behavior , as well as how incentive-based programs can be translated into health promotion practice aim ed at achieving population -level impact Background In sub-Saharan Africa , chronic kidney disease ( CKD ) is being recognized as a non-communicable disease ( NCD ) with high morbidity and mortality . In countries like Tanzania , people access many sources , including traditional medicines , to meet their healthcare needs for NCDs , but little is known about traditional medicine practice s among people with CKD . Therefore , we sought to characterize these practice s among community members with CKD in northern Tanzania . Methods Between December 2013 and June 2014 , we administered a previously-developed survey to a r and om sample of adult community-members from the Kilimanjaro Region ; the survey was design ed to measure traditional medicine practice s such as types , frequencies , reasons , and modes . Participants were also tested for CKD , diabetes , hypertension , and HIV as part of the CKD-AFRiKA study . To identify traditional medicines used in the local treatment of kidney disease , we review ed the qualitative sessions which had previously been conducted with key informants . Results We enrolled 481 adults of whom 57 ( 11.9 % ) had CKD . The prevalence of traditional medicine use among adults with CKD was 70.3 % ( 95 % CI 50.0–84.9 % ) , and among those at risk for CKD ( n = 147 ; 30.6 % ) , it was 49.0 % ( 95 % CI 33.1–65.0 % ) . Among adults with CKD , the prevalence of concurrent use of traditional medicine and biomedicine was 33.2 % ( 11.4–65.6 % ) . Symptomatic ailments ( 66.7 % ; 95 % CI 17.3–54.3 ) , malaria/febrile illnesses ( 64.0 % ; 95 % CI 44.1–79.9 ) , and chronic diseases ( 49.6 % ; 95 % CI 28.6–70.6 ) were the most prevalent uses for traditional medicines . We identified five plant – based traditional medicines used for the treatment of kidney disease : Aloe vera , Commifora africana , Cymbopogon citrullus , Persea americana , and Zanthoxylum chalybeum . Conclusions The prevalence of traditional medicine use is high among adults with and at risk for CKD in northern Tanzania where they use them for a variety of conditions including other NCDs . Additionally , many of these same people access biomedicine and traditional medicines concurrently . The traditional medicines used for the local treatment of kidney disease have a variety of activities , and people with CKD may be particularly vulnerable to adverse effects . Recognizing these traditional medicine practice s will be important in shaping CKD treatment programs and public health policies aim ed at addressing CKD Background The scale-up of antiretroviral treatment ( ART ) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis , non-communicable diseases ( NCDs ) and mental health disorders . Depression is one such disorder that is associated with higher rates of non-adherence , progression to AIDS and greater mortality . Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90 % of those on ART and is in line with the recent 90 - 90 - 90 Joint United Nations Programme on HIV/AIDS ( UNAIDS ) targets . The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART . Methods The study design is a pragmatic , parallel group , stratified , cluster r and omised trial in 40 clinics across two rural districts of the North West Province of South Africa . The unit of r and omisation is the clinic , with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Question  naire ( PHQ-9 ) . Control group clinics are implementing the South African Department of Health ’s Integrated Clinical Services Management model , which aims to reduce fragmentation of care in the context of rising multimorbidity , and which includes training in the Primary Care 101 ( PC101 ) guide covering communicable diseases , NCDs , women ’s health and mental disorders . In intervention clinics , we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care . We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling ( eight sessions , individual or group ) , as well as adherence counselling sessions ( one session , individual ) . The co- primary patient outcomes are a reduction in PHQ-9 scores of at least 50 % from baseline and viral load suppression rates measured at 6 and 12 months , respectively . Discussion The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in re source -constrained setting s . Trial registration Clinical Trials.gov ( NCT02407691 ) registered on 19 March 2015 ; Pan African Clinical Trials Registry ( 201504001078347 ) registered on 19/03/2015 ; South African National Clinical Trials Register ( SANCTR ) ( DOH-27 - 0515 - 5048 ) NHREC number 4048 issued on 21/04/2015 BACKGROUND Many physicians receive financial incentives to limit their ordering of expensive tests and procedures . While Medicare m and ates disclosure of incentives , it is not clear how to inform patients without undermining trust . METHODS Our objective was to determine public opinion about physician  disclosure of financial incentives and how this might be best communicated to patients . The 2002 General Social Survey included 2765 interviews from a probability sample of English-speaking US households . The interview included questions about financial incentives and an audiotaped scenario of a physician discussing the impact of financial incentives on ordering a magnetic resonance image . Respondents heard 1 of 6 r and omly selected disclosure strategies . The measurements included ratings of trust , satisfaction , agreement with the physician 's decision , and likelihood of remaining with the physician/health plan or seeking a second opinion . RESULTS Nearly half ( 48.8 % ) of respondents had previously heard of financial incentives to limit test ordering . Of the respondents , 94.8 % wanted to be told about incentives , at the time of enrollment in a health plan ( 80.5 % ) , by a health plan representative ( 44.8 % ) , their physician ( 17.1 % ) , or both ( 38.1 % ) . Of the 6 different disclosure strategies , " addressing emotions " and " negotiation " were associated with the best outcomes , while " common enemy " and " denying influences " were most negatively perceived . Black and Hispanic subjects were less likely to express satisfaction or trust and more likely to disenroll or seek a second opinion . CONCLUSIONS The public wants information about physician financial incentives . Specific communication styles enhance how this information is conveyed to patients , increasing trust and supporting the physician-patient relationship Background R and omised controlled trials ( RCTs ) of complex interventions in primary health care ( PHC ) are needed to provide evidence -based programmes to achieve the Declaration of Alma Ata goal of making PHC equitable , accessible and universal and to effectively address the rising burden from chronic disease . Process evaluations of these RCTs can provide insight into the causal mechanisms of complex interventions , the context ual factors , and inform as to whether an intervention is ineffective due to implementation failure or failure of the intervention itself . To build on this emerging body of work , we aim to consoli date the methodology and methods from process evaluations of complex interventions in PHC and their findings of facilitators and barriers to intervention implementation in this important area of health service delivery . Methods Systematic review of process evaluations of r and omised controlled trials of complex interventions  which address prevalent major chronic diseases in PHC setting s. Published process evaluations of RCTs will be identified through data base and clinical trial registry search es and contact with authors . Data from each study will be extracted by two review ers using st and ardised forms . Data extracted include descriptive items about ( 1 ) the RCT , ( 2 ) about the process evaluations ( such as methods , theories , risk of bias , analysis of process and outcome data , strengths and limitations ) and ( 3 ) any stated barriers and facilitators to conducting complex interventions . A narrative synthesis of the findings will be presented . Discussion Process evaluation findings are valuable in determining whether a complex intervention should be scaled up or modified for other context s. Publishing this protocol serves to encourage transparency in the reporting of our synthesis of current literature on how process evaluations have been conducted thus far and a deeper underst and ing of potential challenges and solutions to aid in the implementation of effective interventions in PHC beyond the research setting . Systematic review registration PROSPERO Although pharmacologic treatment remains a critical element in the short- and long-term management of schizophrenia  , the past decade has been a challenging time in terms of real progress . Despite the introduction of several new medications as well as the conduct of larger and more diverse clinical trials , there remains considerable debate as to how far we have progressed in addressing some of the fundamental unmet needs in treating this disorder . A theme in this issue of Schizophrenia Bulletin addresses a number of topics in this context . Although the notion of careful , systematic , and critical summaries of all relevant r and omized controlled trials is not a new one , the Cochrane Schizophrenia Group is relatively young . Clive Adams , one of its founders , and colleagues provide the rationale and history of the group as well as review ing its methods and contributions . The Bulletin also carries a “ Cochrane Corner ” in each issue to alert the field to schizophrenia-related review s. Systematic meta-analyses are playing an increasingly important role in informing both the research agenda and clinical practice . The work of the Cochrane collaboration has been enormously valuable in this process . In recent years , the field of schizophrenia research has benefited from the application of various clinical trial method ologies to enhance the study of treatment outcomes and determine generalizability . Large effectiveness trials have provided data to exp and our knowledge base beyond that which is provided by traditional efficacy trials . Stroup and Geddes provide examples of each type of trial to illustrate their relative advantages and disadvantages . Within the context of different trial design s , Leucht et al provide an overview addressing critical aspects of trial design , potential population sampling bias , endpoint choices and definitions , quality of assessment s , data analysis and reporting , as well as , other potential sources of bias or confounds relevant to the interpretation of clinical trials data in schizophrenia . One of the most difficult challenges in the design , conduct , analysis , and interpretation of clinical trials is the problem of dropouts — those individuals who do not complete the trial , often for unknown reasons . A variety of statistical techniques have been developed and applied in order to address this issue ; however , none is entirely satisfactory . Rabinowitz and Davidov discuss the association of dropout and outcome in trials of antipsychotic medication and its implication s for strategies to address missing data . Another strategy to minimize dropouts in acute treatment trials would be to shorten the length of the trial , particularly when placebo control groups are included . Addressing this issue and drawing on recent meta- analysis suggesting that a substantial proportion of antipsychotic drug response occurs within the first 2 weeks , McMahon and colleagues present an exploratory analysis from short-term placebo controlled clinical trial data suggesting the potential feasibility of reducing the duration of such trials . Much more work needs to be done to determine the benefits and risks of such an approach , but this is a very valuable first step . In the final article , we provide a review of unanswered questions in the pharmacologic treatment of schizophrenia .  Despite numerous trials being conducted with antipsychotic medication , there are many clinical decisions that must be made on a day-to-day basis for which sufficient data are not available to provide an adequate evidence base . We hope that these articles will provide a snapshot of current challenges and opportunities for further progress in the design , conduct , and interpretation of psychopharmacologic trials in schizophrenia Consider the following paradox : few people would balk if research ers offered smokers $ 1,000 to participate in a year-long r and omized trial of a smoking cessation intervention , yet many would find it distasteful for a large employer to pay its smoking employees an extra $ 1,000 if they remained smoke-free for one year . Such discrepant judgments are underst and able from the perspective of classical economics . Research participants merit compensation for the risks and opportunity costs they endure in the service of public health , whereas individuals should need no reward for promoting their own well being . However , contrary to traditional theories of rationality , people frequently fail to make health-promoting choices , particularly when such choices require short-term sacrifices to foster long-term goals .1,2 Thus , corporate and government health plan leaders are increasingly applying extrinsic motivations such as financial incentives and other programs to augment health – particularly cardiovascular health – while hopefully increasing productivity and restraining costs.3 , 4 Early evidence suggests that financial incentives can effectively promote the cardioprotective behaviors of smoking cessation,5 , 6 weight loss,7 , 8 and cholesterol reduction.9  Incentives are also currently being studied as a means of promoting warfarin adherence.10 Although the results of these early studies are promising , further research is needed to determine which incentive structures and amounts are optimal , assess the ability of incentives to produce sustained behavior changes , and evaluate the cost-effectiveness of implementing incentive programs  . Ethical dimensions of the incentives themselves are also in need of further analysis . For example , some have charged that financial incentive programs are coercive , inequitable , and inconsistent with shared social values.11 Others have even suggested that implementing incentive programs serves to punish patients for their illnesses.12 In this essay , we outline the rationale for incentive programs to promote cardiovascular health , identify the ethical arguments that have been used to challenge such programs , and assess the merits of these arguments Objective : Recruitment of African Americans into health research studies is a major challenge . This report describes a study of different methods and strategies to recruit African Americans into a population -based assessment of cancer behavioral risk factors . Methods : African Americans ages 18 to 70 years in North Carolina ( n = 5,000 ) were r and omly selected from the Department of Motor Vehicle rosters and assigned at r and om to one of five different recruitment strategies based on variations of approach letters ( generic versus culturally sensitive ) and inclusion , exclusion , or promise of a small incentive . Prospect i ve participants were sent an 11-page question naire by mail but could complete it by telephone or Internet as well as by mail . Results : The overall response rate was 17.5 % ( 747 completed surveys of 4,276 delivered ) : 655 , 84 , and 8 by mail , Internet , and telephone , respectively . Among eligible respondents , response was significantly higher for incentive-based than nonincentive strategies ; 23.9 % for the generic letter plus incentive compared with 15.8 % for the generic letter only ( P < 0.001 ) . The culturally sensitive letter had little effect on participation ( 15.8 % for both the generic and culturally sensitive letters ) . The  mean age of eligible respondents was 43.9 years , 41 % were male , 37 % were college graduates , and 75 % were overweight/obese . There were no differences in respondent characteristics by assigned recruitment strategy . Conclusions : Incentive-based strategies yielded the highest survey responses , whereas a culturally sensitive letter did not appreciably increase participation among African Americans in North Carolina . This study adds to what is known about culturally sensitive recruitment strategies for African Americans and challenges their usefulness in survey-based studies
Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy .
The rising epidemic of non-communicable diseases ( NCDs ) poses substantial health and economic challenges to both individuals and society .
Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs .
Yet , whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematic ally addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal .
In this systematic review we aim to determine whether there is an evidence base for any of these strategies .