The effect of introducing a financial incentive to promote application of fluoride varnish in dental practice in Scotland: a natural experiment Healthcare providers’ views on the acceptability of financial incentives for breastfeeding: a qualitative study A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol Coupling Financial Incentives With Direct Mail in Population-Based Practice Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors You can't pay me to quit: the failure of financial incentives for smoking cessation in head and neck cancer patients. Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013-15 Study. 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. Strategies for maximizing consent rates for child dental health surveys: a randomised controlled trial 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. Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial Randomised controlled trial using social support and financial incentives for high risk pregnant smokers: Significant Other Supporter (SOS) program Social norms and financial incentives to promote employees' healthy food choices: A randomized controlled trial. Some Recent Developments on Financial Incentives for Smoking Cessation Among Pregnant and Newly Postpartum Women Enhancing physical activity and reducing obesity through smartcare and financial incentives: A pilot randomized trial. Financial Incentives for Linkage to Care and Viral Suppression Among HIV-Positive Patients: A Randomized Clinical Trial (HPTN 065) Patient navigation and financial incentives to promote smoking cessation in an underserved primary care population: A randomized controlled trial protocol. A Mixed-Methods Randomized Controlled Trial of Financial Incentives and Peer Networks to Promote Walking Among Older Adults The Use of Physician Financial Incentives and Feedback to Improve Pediatric Preventive Care in Medicaid Managed Care Financial incentives to improve adherence to antipsychotic maintenance medication in non-adherent patients: a cluster randomised controlled trial. The effect of physician disclosure of financial incentives on trust. The Cessation in Pregnancy Incentives Trial (CPIT): study protocol for a randomized controlled trial Protocol for study of financial incentives for smoking cessation in pregnancy (FISCP): randomised, multicentre study
Background Financial incentives are often used to influence professional practice , yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood . In keeping with clinical guidelines , Childsmile ( Scotl and ’s oral health improvement programme ) advocates twice yearly fluoride varnish application ( FVA ) for children in dental practice . To support implementation Childsmile offered dental practitioners a fee-per-item payment for varnishing 2–5-year-olds ’ teeth through a pilot . In October 2011 payment was extended to all dental practitioners . This paper compares FVA pre- and post-roll-out and explores the financial incentive ’s behavioural mechanisms . Methods A natural experimental approach using a longitudinal cohort of dental practitioners ( n = 1090 ) compared FVA pre- ( time 1 ) and post- ( time 2 ) financial incentive . Responses from practitioners who did not work in a Childsmile pilot practice when considering their 2–5-year-old patients ( novel incentive group )  were compared with all other responses ( continuous incentive group ) . The Theoretical Domains Framework ( TDF ) was used to measure change in behavioural mechanisms associated with the incentive . Analysis of covariance was used to investigate FVA rates and associated behavioural mechanisms in the two groups . Results At time 2 , 709 74 % , of eligible responders , were followed up . In general , FVA rates increased over time for both groups ; however , the novel incentive group experienced a greater increase ( β [ 95 % CI ] = 0.82 [ 0.72 to 0.92 ] ) than the continuous incentive group . Despite this , only 33 % of practitioners reported ‘ always ’ varnishing increased risk 2–5-year-olds ’ teeth following introduction of the financial incentive , 19 % for st and ard risk children . Domain scores at time 2 ( adjusting for time 1 ) increased more for the novel incentive group ( compared to the continuous incentive group ) for five domains : knowledge , social/professional role and identity , beliefs about consequences , social influences and emotion . Conclusions In this large , prospect i ve , population -wide study , a financial incentive moderately increased FVA in dental practice . Novel longitudinal use of a vali date d theoretical framework to underst and behavioural mechanisms suggested that financial incentives operate through complex inter-linked belief systems . While financial incentives are useful in narrowing the gap between clinical guidelines and FVA , multiple intervention approaches are required Background Despite a gradual increase in breastfeeding rates , overall in the UK there are wide variations , with a trend towards breastfeeding rates at 6–8 weeks remaining below 40 % in less affluent areas . While financial incentives have been used with varying success to encourage positive health related behaviour change , there is little research on their use in encouraging breastfeeding . In this paper , we report on healthcare providers ’ views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle . This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster r and omised controlled trial . Methods Fifty – three healthcare providers were interviewed about their views on financial incentives for breastfeeding . Participants were purposively sample d to include a wide range of experience and roles associated with supporting mothers with infant feeding . Semi-structured individual and group interviews were conducted . Data were analysed thematically drawing on the principles of Framework Analysis . Results The key theme emerging from healthcare providers ’ views on the acceptability of financial incentives for breastfeeding  was their possible impact on ‘ facilitating or impeding relationships ’ . Within this theme several additional aspects were discussed : the mother ’s relationship with her healthcare provider and services , with her baby and her family , and with the wider community . In addition , a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women . Conclusion Healthcare providers believe that financial incentives could have both positive and negative impacts on a  mother ’s relationship with her family , baby and healthcare provider . When design ing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted , while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low Background The use of financial incentives and penalties to encourage uptake of healthy behaviors is increasingly seen as a viable intervention in developed countries . Previous review s of the effectiveness of financial incentives and penalties for encouraging the uptake of healthy behaviors have focused on individual behaviors making it difficult to draw overall conclusions about the effectiveness of such interventions . This systematic review will explore the effectiveness of financial incentives and penalties for encouraging a wide range of behaviors , including : smoking cessation , increased physical activity , healthier dietary intake , sensible patterns of alcohol consumption , safe sun , safe sex , and primary preventive clinical behaviors . Methods Systematic methods will be used to search existing literature and screen studies for inclusion . All studies that meet the following inclusion criteria will be included in the review : participants were 18 years old or older and living in high-income countries ; interventions included cash or cash-like incentives to promote the uptake of healthy behaviors , or cash or cash-like penalties to discourage unhealthy behaviors ; the comparator was usual care or no intervention ; study design was r and omized controlled trial , cluster r and omized controlled trial , controlled before and after study , or interrupted time series analysis . Two review ers will independently screen the publications to ensure they meet the inclusion criteria . Quality will be assessed by two research ers , working independently , using the Cochrane risk of bias tool . Meta- analysis will be conducted , if appropriate . Any studies identified as at ‘ high risk of bias ’ will be excluded from meta- analysis . Discussion This systematic review will provide policy-relevant recommendations for the use of financial incentives and penalties as a method of encouraging uptake of healthy behaviors 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 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 A prospect i ve r and omised study was conducted at a tertiary care hospital to evaluate the effects of financial incentives for smoking cessation targeted at a high-risk population . METHODS Patients with a past history of head and neck cancer were voluntarily enrolled over a two-year period . They were r and omised to a cash incentives or no incentive group . Subjects were offered enrolment in smoking cessation courses .  Smoking by-product levels were assessed at 30 days , 3 months and 6 months . Subjects in the incentive group received $ 150 if smoking cessation was confirmed . RESULTS Over 2 years , 114 patients with an established diagnosis of head and neck cancer were offered enrolment . Twenty-four enrolled and 14 attended the smoking cessation classes . Only two successfully quit smoking at six months . Both these patients were in the financially incentivised group and received $ 150 at each test visit . CONCLUSION Providing a financial incentive for smoking cessation to a population already carrying a diagnosis of head and neck cancer in order to promote a positive behaviour change was unsuccessful Employers commonly use adjustments to health insurance premiums as incentives to encourage healthy behavior , but the effectiveness of those adjustments is controversial . We gave 197 obese participants in a workplace wellness program a weight loss goal equivalent to 5 percent of their baseline weight . They were r and omly assigned to a control arm , with no financial incentive for achieving the goal , or to one of three intervention arms offering an incentive valued at $ 550 . Two intervention arms used health insurance premium adjustments , beginning the following year ( delayed ) or in the first pay period after achieving the goal ( immediate ) . A third arm used a daily lottery incentive separate from premiums . At twelve months there were no statistically significant differences in mean weight change either between the control group ( whose members had a mean gain of 0.1 pound ) and any of the incentive groups ( delayed premium adjustment , -1.2 pound ; immediate premium adjustment , -1.4 pound ; daily lottery incentive , -1.0 pound ) or among the intervention groups . The apparent failure of the incentives to promote weight loss suggests that employers that encourage weight reduction through workplace wellness programs should test alternatives to the conventional premium adjustment approach by using alternative incentive design s , larger incentives , or both 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 Background Poor response rates can jeopardise the validity of the findings of epidemiological surveys . The aim of this study was to undertake a r and omised controlled trial to determine the effectiveness of different strategies for maximizing parental consent rates for dental health surveys of young children . Methods The trial took place within the 2007/2008 NHS Epidemiological Dental Health Survey of 5-year-old children in the North West of Engl and . Schools were r and omised to one of five interventions : multiple letters to parents ; promoting the research by providing additional information to parents and children ; a financial incentive to the school ; a financial incentive to the school administrator plus direct mailing to parents ; and a control intervention comprising of usual practice , that is a single letter home to parents via the children . Results A total of 335 schools ( 11,088 children ) were recruited . The mean percentage consent rates ranged from 47 % ( financial incentive to school administrator plus direct mailing ) to 63 % ( multiple letters ) . Pair-wise comparisons indicated that the multiple letter group had a statistically significantly greater consent rate than the financial incentive to the school administrator plus direct mailing group and promoting the research by providing additional information group , but was not statistically significantly different from the financial incentive to the school group and the control group . Conclusions There was little evidence to show that any of the five interventions made a significant difference to consent rates when compared to the control group . Financial incentives to schools were less effective than multiple reminder letters to parents . Trials should be built into surveys to test different interventions , in different context s to exp and the evidence base for improving consent rates in health surveillance programmes 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 ABSTRACT BACKGROUND More than half of adults in the United States do not attain the minimum recommended level of physical activity to achieve health benefits . The optimal design of financial incentives to promote physical activity is unknown . OBJECTIVE To compare the effectiveness of individual versus team-based financial incentives to increase physical activity . DESIGN R and omized , controlled trial comparing three interventions to control . PARTICIPANTS Three hundred and four adult employees from an organization in Philadelphia formed 76 four-member teams . INTERVENTIONS All participants received daily feedback on performance towards achieving a daily 7000 step goal during the intervention ( weeks 1– 13 ) and follow-up ( weeks 14– 26 ) periods . The control arm received no other intervention . In the three financial incentive arms , drawings were held in which one team was selected as the winner every other day during the 13-week intervention . A participant on a winning team was eligible as follows : $ 50 if he or she met the goal ( individual incentive ) , $ 50 only if all four team members met the goal ( team incentive ) , or $ 20 if he or she met the goal individually and $ 10 more for each of three teammates that also met the goal ( combined incentive).MAIN MEASURES Mean proportion of participant-days achieving the 7000 step goal during the intervention . KEY RESULTS Compared to the control group during the intervention period , the mean proportion achieving the 7000 step goal was significantly greater for the combined incentive ( 0.35 vs. 0.18 , difference : 0.17 , 95 % confidence interval [ CI ] : 0.07–0.28 , p < 0.001 ) but not for the individual incentive ( 0.25 vs 0.18 , difference : 0.08 , 95 % CI : -0.02–0.18 , p = 0.13 ) or the team incentive ( 0.17 vs 0.18 , difference : -0.003 , 95 % CI : -0.11–0.10 , p = 0.96 ) . The combined incentive arm participants also achieved the goal at significantly greater rates than the team incentive ( 0.35 vs. 0.17 , difference : 0.18 , 95 % CI : 0.08–0.28 , p < 0.001 ) , but not the individual incentive ( 0.35 vs. 0.25 , difference : 0.10 , 95 % CI : -0.001–0.19 , p = 0.05 ) . Only the combined incentive had greater mean daily steps than control ( difference : 1446 , 95 % CI : 448–2444 , p ≤ 0.005 ) . There were no significant differences between arms during the follow-up period ( weeks 14– 26 ) . CONCLUSIONS Financial incentives rewarded for a combination of individual and team performance were most effective for increasing physical activity . Trial Registration Clinical trials.gov identifier : NCT02001194 Smoking  cessation interventions have posed significant challenges for health professionals , particularly when directed at high risk , low income , pregnant smokers . Typical quit rates for pregnant women who receive publicly financed obstetrical care have rarely exceeded 12–16%.1 As many as 70 % of women who quit smoking during pregnancy relapse within one year of delivery.2 Two areas that have received particular attention as possible adjuncts to behaviour change are the use of reinforcements and social supports . Reinforcement in the form of incentives/rewards for positive behaviours has been controversial as an intervention strategy . Some argue that the “ overjustification effect ” of external rewards may cause subjects to lose internal motivation to modify behaviour over the long term.3 However , results of several studies , including two meta-analyses on reinforcement , provide compelling evidence that positive reinforcement provides positive behavioural changes.4 - 8 A second area of study that has been explored in the behaviour change research is the role of social support in motivating and sustaining selected behaviour change . Recent studies have empirically linked tobacco quit rates with daily interaction with a supportive “ other , ” preferably one who did not smoke.9 10 The primary objective of our intervention was to determine whether the combination of bolstered social support and financial incentives had an effect in significantly reducing smoking behaviour among low income , high risk , pregnant and postpartum women who participate in Oregon 's Women , Infants , and Children ( WIC ) program .  The Significant Other Supporter ( SOS ) program was a r and omised , experimentally design ed smoking cessation study implemented in four Oregon WIC program sites . Criteria for entry into the study included the following : age 15 years or older ; self reported smoker ( “ even a puff in the last seven days ” ) ; English speaker/reader ; WIC eligible ; and 28 weeks gestation or less . Eligible subjects were r and omised into one of two groups , and were OBJECTIVE Population -level strategies to improve healthy food choices are needed for obesity prevention . We conducted a r and omized controlled trial of 2672 employees at the Massachusetts General Hospital who were regular customers of the hospital cafeteria with all items labeled green ( healthy ) , yellow ( less healthy ) , or red ( unhealthy ) to determine if social norm ( peer-comparison ) feedback with or without financial incentives increased employees ' healthy food choices . METHODS Participants were r and omized in 2012 to three arms : 1 ) monthly letter with social norm feedback about healthy food purchases , comparing employee to " all " and to " healthiest " customers ( feedback-only ) ; 2 ) monthly letter with social norm feedback plus small financial incentive for increasing green purchases ( feedback-incentive ) ; or 3 ) no contact ( control ) . The main outcome was change in proportion of green-labeled purchases at the end of 3-month intervention . Post-hoc analyses examined linear trends . RESULTS At baseline , the proportion of green-labeled purchases ( 50 % ) did not differ between arms . At the end of the 3-month intervention , the percentage increase in green-labeled purchases was larger in the feedback-incentive arm compared to control ( 2.2 % vs. 0.1 % , P=0.03 ) , but the two intervention arms were not different . The rate of increase in green-labeled purchases was higher in both feedback-only ( P=0.04 ) and feedback-incentive arms ( P=0.004 ) compared to control . At the end of a 3-month wash-out , there were no differences between control and intervention arms . CONCLUSIONS Social norms plus small financial incentives increased employees ' healthy food choices over the short-term . Future research will be needed to assess the impact of this relatively low-cost intervention on employees ' food choices and weight over the long-term . TRIAL REGISTRATION Clinical Trials.gov : NCT01604499 Smoking during pregnancy is a leading preventable cause of poor pregnancy outcomes and immediate and longer-term adverse health outcomes among exposed offspring . Developing more effective smoking cessation interventions for pregnant women has been a public health priority for more than 30 years . We review developments over the past 3 years ( 2012–2015 ) on the use of financial incentives to promote smoking cessation among pregnant women . We search ed the literature for reports on primary and secondary analyses and review s of controlled trials on this topic published in peer- review ed journals using the search engine PubMed , review ed bibliographies of published articles , and consulted expert colleagues . The search revealed several important developments , with the following three being especially noteworthy . First , the review identified four new r and omized controlled trials , three of which further supported the efficacy of this treatment approach . One of the three trials supporting efficacy also included the first econometric analysis of this treatment approach showing financial incentives with pregnant smokers to be highly cost-effective . Second , two Cochrane review s were published during this 3-year period covering the more recent and earlier efficacy trials . Meta-analyses in both review s supported the efficacy of the approach . Lastly , the first effectiveness trial was reported demonstrating that  financial incentives increased abstinence rates above control levels when implemented by obstetrical clinic staff in a large urban hospital working with community tobacco interventionists . Overall , there is a growing and compelling body of evidence supporting the efficacy and cost-effectiveness of  financial incentives for smoking cessation among pregnant women OBJECTIVE A pilot r and omized trial assessed the feasibility and effectiveness of an intervention combining Smartcare ( activity tracker with a smartphone application ) and financial incentives . METHODS A three-arm , open-label r and omized controlled trial design involving traditional education , Smartcare , and Smartcare with financial incentives was involved in this study . The latter group received financial incentives depending on the achievement of daily physical activity goals ( process incentive ) and weight loss targets ( outcome incentive ) . Male university students ( N = 105 ) with body mass index of ≥27 were enrolled . RESULTS The average weight loss in the traditional education , Smartcare , and Smartcare with financial incentives groups was -0.4 , -1.1 , and -3.1 kg , respectively , with significantly greater weight loss in the third group ( both Ps < 0.01 ) . The final weight loss goal was achieved by 0 , 2 , and 10 participants in the traditional education , Smartcare , and Smartcare with financial incentives groups ( odds ratio for the Smartcare with financial incentive vs. Smartcare = 7.27 , 95 % confidence interval : 1.45 - 36.47 ) . Levels of physical activity were significantly higher in this group . CONCLUSIONS The addition of financial incentives to Smartcare was effective in increasing physical activity and reducing obesity Importance Achieving linkage to care and viral suppression in human immunodeficiency virus (HIV)-positive patients improves their well-being and prevents new infections . Current gaps in the HIV care continuum substantially limit such benefits . Objective To evaluate the effectiveness of financial incentives on linkage to care and viral suppression in HIV-positive patients . Design , Setting , and Participants A large community-based clinical trial that r and omized 37 HIV test and 39 HIV care sites in the Bronx , New York , and Washington , DC , to financial incentives or st and ard of care . Interventions Participants at financial incentive test sites who had positive test results for HIV received coupons redeemable for $ 125 cash-equivalent gift cards upon linkage to care .  HIV-positive patients receiving antiretroviral therapy at financial incentive care sites received $ 70 gift cards quarterly , if virally suppressed . Main Outcomes and Measures Linkage to care : proportion of HIV-positive persons at the test site who linked to care within 3 months , as indicated by CD4 + and /or viral load test results done at a care site . Viral suppression : proportion of established patients at HIV care sites with suppressed viral load ( < 400 copies/mL ) , assessed at each calendar quarter . Outcomes assessed through laboratory test results reported to the National HIV Surveillance System . Results A total of 1061 coupons were dispensed for linkage to care at 18 financial incentive test sites and 39 359 gift cards were dispensed to 9641 HIV-positive patients eligible for gift cards at 17 financial incentive care sites . Financial incentives did not increase linkage to care ( adjusted odds ratio , 1.10 ; 95 % CI , 0.73 - 1.67 ; P = .65 ) . However , financial incentives significantly increased viral suppression . The overall proportion of patients with viral suppression was 3.8 % higher ( 95 % CI , 0.7%-6.8 % ; P = .01 ) at financial incentive sites compared with st and ard of care sites . Among patients not previously consistently virally suppressed , the proportion virally suppressed was 4.9 % higher ( 95 % CI , 1.4%-8.5 % ; P = .007 ) at financial incentive sites . In addition , continuity in care was 8.7 % higher ( 95 % CI , 4.2%-13.2 % ; P < .001 ) at financial incentive sites . Conclusions and Relevance Financial incentives , as used in this study ( HPTN 065 ) , significantly increased viral suppression and regular clinic attendance among HIV-positive patients in care . No effect was noted on linkage to care . Financial incentives offer promise for improving adherence to treatment and viral suppression among HIV-positive patients . Trial Registration clinical trials.gov Identifier : Despite the high risk of tobacco-related morbidity and mortality among low-income persons , few studies have connected low-income smokers to evidence -based treatments . We will examine a smoking cessation intervention integrated into primary care . To begin , we completed qualitative formative research to refine an intervention utilizing the services of a patient navigator trained to promote smoking cessation . Next , we will conduct a r and omized controlled trial combining two interventions : patient navigation and financial incentives . The goal of the intervention is to promote smoking cessation among patients who receive primary care in a large urban safety-net hospital . Our intervention will encourage patients to utilize existing smoking cessation re sources ( e.g. , quit lines , smoking cessation groups , discussing smoking cessation with their primary care providers ) . To test our intervention , we will conduct a r and omized controlled trial , r and omizing 352 patients to the intervention condition ( patient navigation and financial incentives ) or an enhanced traditional care control condition .  We will perform follow-up at 6 , 12 , and 18 months following the start of the intervention . Evaluation of the intervention will target several implementation variables : reach ( participation rate and representativeness ) , effectiveness ( smoking cessation at 12 months [ primary outcome ] ) , unintended consequences ( e.g. , purchase of illicit substances with incentive money ) , adoption ( use of intervention across primary care suites ) , implementation ( delivery of intervention ) , and maintenance ( smoking cessation after conclusion of intervention ) . Improving the implementation of smoking cessation interventions in primary care setting s serving large underserved population s could have substantial public health impact , reducing cancer-related morbidity/mortality and associated health disparities Background . Financial incentives and peer networks could be delivered through eHealth technologies to encourage older adults to walk more . Methods . We conducted a 24-week r and omized trial in which 92 older adults with a computer and Internet access received a pedometer , daily walking goals , and weekly feedback on goal achievement .  Participants were r and omized to  weekly feedback only ( Comparison ) , entry into a lottery with potential to earn up to $ 200 each week walking goals were met ( Financial Incentive ) , linkage to four other participants through an online message board ( Peer Network ) , or both interventions ( Combined ) . Main outcomes were the proportion of days walking goals were met during the 16-week intervention and 8-week follow-up . We conducted a content analysis of messages posted by Peer Network and Combined arm participants . Results . During the 16-week intervention , there were no differences in the proportion of days walking goals were met in the Financial Incentive ( 39.7 % ; p = .78 ) , Peer Network ( 24.9 % ; p = .08 ) , and Combined ( 36.0 % ; p = .77 ) arms compared with the Comparison arm ( 36.0 % ) . During 8 weeks of follow-up , the proportion of days walking goals were met was lower in the Peer Network arm ( 18.7 % ; p = .025 ) but not in the Financial Incentive ( 29.3 % ; p = .50 ) or Combined ( 24.8 % ; p = .37 ) arms , relative to the Comparison arm ( 34.5 % ) . Messages posted by participants focused on barriers to walking and provision of social support . Conclusions . Financial incentives and peer networks delivered through eHealth technologies did not result in older adults  walking more Objective . Immunizations and other cost-effective preventive services remain underused by many children , especially those living in poverty . Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns , we design ed and tested an intervention combining these strategies . We studied whether a system of semiannual assessment and feedback , coupled with financial incentives , could improve pediatric preventive care in a Medicaid health maintenance organization ( HMO ) . Methodology . We r and omly assigned primary care sites serving children in a Medicaid HMO to one of three groups : a feedback group ( where physicians received written feedback about compliance scores ) , a feedback and incentive group ( where physicians received feedback and a financial bonus when compliance criteria were met ) , and a control group . We evaluated compliance with pediatric preventive care guidelines  through semiannual chart audits during the years 1993 to 1995 . Results . Compliance with pediatric preventive care improved dramatically in the study period . Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores ( from 56%–73 % ) , as well as scores for immunizations ( from 62%–79 % ) and other preventive care ( from 54%–71 % ) . However , no significant differences were observed between either intervention group and the control group , nor were there any interaction ( group-by-time ) effects . Conclusions . Feedback to physicians , with or without financial incentives , did not improve pediatric preventive care in this Medicaid HMO during a time of rapid , secular improvements in care . Possible explanations include the context and timing of the intervention , the magnitude of the financial incentives , and lack of physician awareness of the intervention BACKGROUND Poor adherence to long-term antipsychotic injectable ( LAI ) medication in patients with psychotic disorders is associated with a range of negative outcomes . No psychosocial intervention has been found to be consistently effective in improving adherence . OBJECTIVES To test whether or not offering financial incentives is effective and cost-effective in improving adherence and to explore patient and clinician experiences with such incentives . DESIGN A cluster r and omised controlled trial with economic and nested qualitative evaluation . The intervention period lasted for 12 months with 24 months ' follow-up . The unit of r and omisation was mental health teams in the community . SETTING Community teams in secondary mental health care . PARTICIPANTS Patients with a diagnosis of schizophrenia , schizoaffective psychosis or bipolar illness , receiving ≤ 75 % of their prescribed LAI medication . In total , 73 teams with 141 patients ( intervention n = 78 and control n = 63 ) were included . INTERVENTIONS Participants in the intervention group received £ 15 for each LAI medication . Patients in the control group  received treatment as usual . MAIN OUTCOME MEASURES PRIMARY OUTCOME adherence to LAI medication  ( the percentage of received out of those prescribed ) . SECONDARY OUTCOMES percentage of patients with at least 95 % adherence ; clinical global improvement ; subjective quality of life ; satisfaction with medication ; hospitalisation ; adverse events ; and costs . Qualitative evaluation : semistructured interviews with patients in the intervention group and their clinicians . RESULTS PRIMARY OUTCOME outcome data were available for 131 patients .  Baseline adherence was 69 % in the intervention group and 67 % in the control group . During the intervention period , adherence was significantly higher in the intervention group than in the control group ( 85 % vs. 71 % ) [ adjusted mean difference 11.5 % , 95 % confidence interval ( CI ) 3.9 % to 19.0 % ; p = 0.003 ] . Secondary outcome : patients in the intervention group showed statistically significant improvement in adherence of at least 95 % ( adjusted odds ratio 8.21 , 95 % CI 2.00 to 33.67 ; p = 0.003 ) and subjective quality of life ( difference in means 0.71 , 95 % CI 0.26 to 1.15 ; p = 0.002 ) . Follow-ups : after incentives stopped , adherence did not differ significantly between groups , neither during the first 6 months ( adjusted difference in means -7.4 % , 95 % CI -17.0 % to 2.1 % ; p = 0.175 ) nor during the period from month 7 to month 24 ( difference in means -5.7 % , 95 % CI -13.1 % to 1.7 % ; p = 0.130 ) . Cost-effectiveness : the average costs of the financial incentives was £ 303 . Overall costs per patient were somewhat higher in the intervention group , but the difference was not significant . Semistructured interviews : the majority of patients and clinicians reported positive experiences with the incentives beyond their monetary value . These included improvement in the therapeutic relationship . The majority of both patients and clinicians perceived no negative impact after the intervention was stopped after 1 year . CONCLUSIONS Financial incentives are effective in improving adherence to LAI medication . Health-care costs ( including costs of the financial incentive ) are unlikely to be increased substantially by this intervention . Once the incentives stop , the advantage is not maintained . The experiences of both patients and clinicians are largely , but not exclusively , positive . Whether or not financial incentives are effective for patients with more favourable background , those on oral mediation or for shorter or longer time periods remains unknown . TRIAL REGISTRATION Current Controlled Trials IS RCT N77769281 . FUNDING This project was funded by the National Institute for Health Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 20 , No. 70 . See the NIHR Journals Library website for further project information 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 Seventy percent of women in Scotl and have at least one baby , making pregnancy an opportunity to help most young women quit smoking before their own health is irreparably compromised . By quitting during pregnancy their infants will be protected from miscarriage and still birth as well as low birth weight , asthma , attention deficit disorder and adult cardiovascular disease . In the UK , the NICE guidelines : ‘ How to stop smoking in pregnancy and following childbirth ’ ( June 2010 ) highlighted that little evidence exists in the literature to confirm the efficacy of financial incentives to help pregnant smokers to quit . Its first research recommendation was to determine : Within a UK context , are incentives an acceptable , effective and cost-effective way to help pregnant women who smoke to quit ? Design and methods This study is a phase II exploratory individually r and omized controlled trial comparing st and ard care for pregnant smokers with st and ard care plus the additional offer of financial voucher incentives to engage with specialist cessation services and /or to quit smoking during pregnancy .  Participants ( n = 600 ) will be pregnant smokers identified at maternity booking who , when contacted by specialist cessation services , agree to having their details passed to the NHS Smokefree Pregnancy Study Helpline to discuss the trial . The NHS Smokefree Pregnancy Study Helpline will be responsible for telephone consent and follow-up in late pregnancy . The primary outcome will be self reported smoking in late pregnancy verified by cotinine measurement . An economic evaluation will refine cost data collection and assess potential cost-effectiveness while qualitative research interviews with clients and health professionals will assess the level of acceptance of this form of incentive payment . The research questions are : What is the likely therapeutic efficacy ? Are incentives potentially cost-effective ? Is individual r and omization an efficient trial design without introducing outcome bias ? Can incentives be introduced in a way that is feasible and acceptable ? Discussion This phase II trial will establish a workable design to reduce the risks associated with a future definitive phase III multicenter r and omized controlled trial and establish a framework to assess the costs and benefits of financial incentives to help pregnant smokers to quit . Trial registration Current Controlled Trials IS RCT Introduction Maternal smoking during pregnancy is associated with adverse perinatal and postnatal health outcomes . The efficacy of nicotine replacement therapies in helping pregnant smokers to quit is not clearly demonstrated ; therefore new interventions should be proposed and assessed . Financial incentives rewarding abstinence from tobacco smoking is one of the promising options . Objective To assess the efficacy of financial incentives on smoking abstinence among French pregnant smokers . Methods and analysis Participants : pregnant smokers aged ≥18 years , smoking at least five manufactured or three roll-your-own cigarettes per day , and pregnant for < 18 weeks of amenorrhoea ( WA ) . Setting : participants will be recruited , included and followed-up at monthly face-to-face visits in 16 maternity wards in France . Interventions : participants will be r and omised to a  control or an  intervention group .  After a predefined quit date , participants in the control group will receive € 20 vouchers at the completion of each visit but no financial incentive for smoking abstinence . Participants in the intervention group will be rewarded for their abstinence by vouchers on top of the € 20 show-up fee . The amount of reward for abstinence will increase as a function of duration of abstinence to stimulate longer periods of abstinence . Main outcome measure : complete abstinence from quit date to the last predelivery visit . Secondary outcome measures : point prevalence abstinence , time to relapse to smoking , birth weight , fetal growth restriction , preterm birth . Main data analysis : outcomes will be analysed on an intention-to-treat ( ITT ) basis . The ITT population is defined as all r and omised smoking pregnant women . Ethics and dissemination The research protocol was approved by the ethics committee ( Comité de Protection des Personnes , CPP ) of the Pitié-Salpêtrière Hospital on 15 May 2015 , and Amendment No 1 was approved on 13 July 2015 . Results will be presented at scientific meetings and published . Trial registration number NCT02606227 ; Pre- results
Our framework should help research ers and policy-makers identify the most effective incentive configurations for helping individuals adopt healthy behaviours
Financial incentive interventions are increasingly used as a method of encouraging healthy behaviours , from attending for vaccinations to taking part in regular physical activity .
There is a growing body of research on the effectiveness of financial incentive interventions for health behaviours .
Wide variations in the nature of these interventions make it difficult to draw firm conclusions about what makes an effective incentive , for whom and under what circumstances .
Whilst there has been some recognition of the theoretical complexity of financial incentive interventions for health behaviours , there is no framework that categorises these interventions .
This limits the research community 's ability to clearly establish which components of financial incentives interventions are more and less effective , and how these components might interact to enable behavioural change .
We propose a framework for describing health-promoting financial incentive interventions .