Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors 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. Coupling Financial Incentives With Direct Mail in Population-Based Practice Financial incentives for smoking cessation in low-income smokers: study protocol for a randomized controlled trial The Use of Physician Financial Incentives and Feedback to Improve Pediatric Preventive Care in Medicaid Managed Care Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013-15 Study. Effects of Financial Incentives on Saving Outcomes and Material Well-Being: Evidence From a Randomized Controlled Trial in Uganda. 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. Incentives in Diabetic Eye Assessment by Screening (IDEAS): study protocol of a three-arm randomized controlled trial using financial incentives to increase screening uptake in London A Pilot Randomized Trial of Financial Incentives or Coaching to Lower Serum Phosphorus in Dialysis Patients.
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 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 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 Abstract Background Tobacco smoking is the leading avoidable cause of death in high-income countries . The smoking-related disease burden is borne primarily by the least educated and least affluent groups . Thus , there is a need for effective smoking cessation interventions that reach to , and are effective in this group . Research suggests that modest financial incentives are not very effective in helping smokers quit . What is not known is whether large financial incentives can enhance longer-term ( 1 year ) smoking cessation rates , outside clinical and workplace setting s . Trial design A r and omized , parallel groups , controlled trial . Methods Participants : Eight hundred low-income smokers in Switzerl and ( the less affluent third of the population , based on fiscal taxation ) . Intervention : A smoking cessation program including : ( a ) financial incentives given during 6 months ; and ( b ) Internet-based counseling . Financial rewards will be offered for biochemically verified smoking abstinence after 1 , 2 , and 3 weeks and 1 , 3 , and 6 months , for a maximum of 1,500 CHF ( 1,250 EUR , 1,500 USD ) for those abstinent at all time-points . All participants , including controls , will receive Internet-based , individually-tailored , smoking cessation counseling and self-help booklets , but there will be no in-person or telephone counseling , and participants will not receive medications . The control group will not receive financial incentives . Objective : To increase smoking cessation rates . Outcome : Smoking abstinence after 6 and 18 months , not contradicted by biochemical tests . We will assess relapse after the end of the intervention , to test whether 6-month effects translate into sustained abstinence 12 months after the incentives are withdrawn . R and omization : Will be done using sealed envelopes drawn by participants . Blinding : Is not possible in this context . Discussion Smoking prevention policies and interventions have been least effective in the least educated , low-income groups . Combining financial incentives and Internet-based counseling is an innovative approach that , if proven acceptable and effective , could be later implemented on a large scale at a reasonable cost , decrease health disparities , and save many lives . Trial registration Current Controlled Trials IS RCT N04019434 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 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 The use of savings products to promote financial inclusion has increasingly become a policy priority across sub-Saharan Africa , yet little is known about how families respond to varying levels of savings incentives and whether the promotion of incentivized savings in low-re source setting s may encourage households to restrict expenditures on basic needs . Using data from a r and omized controlled trial in Ug and a , we examine : 1 ) whether low-income households enrolled in an economic-empowerment intervention consisting of matched savings , workshops , and mentorship  reduced spending on basic needs and 2 ) how varied levels of matching contributions affected household savings and consumption behavior . We compared primary school-attending AIDS-affected children ( N = 1,383 ) r and omized to a control condition with two intervention arms with differing savings-match incentives : 1:1 ( Bridges ) and 1:2 ( Bridges PLUS ) . We found that : 1 ) 24 months post-intervention initiation , children in Bridges and Bridges PLUS were more likely to have accumulated savings than children in the control condition ; 2 ) higher match incentives ( Bridges PLUS ) led to higher deposit frequency but not higher savings in the bank ; 3 ) intervention participation did not result in material hardship ; and 4 ) in both intervention arms , participating families were more likely to start a family business and diversify their assets 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 Diabetes is an increasing public health problem in the UK and globally . Diabetic retinopathy is a microvascular complication of diabetes , and is one of the leading causes of blindness in the UK working age population . The diabetic eye screening programme in Engl and aims to invite all people with diabetes aged 12 or over for retinal photography to screen for the presence of diabetic retinopathy . However , attendance rates are only 81 % , leaving many people at risk of preventable sight loss . Methods This is a three arm r and omized controlled trial to investigate the impact of different types of financial incentives ( based on principles from behavioral economics ) on increasing attendance at  diabetic eye screening appointments in London . Eligible participants will be aged 16 or over , and are those who have been invited to screening appointments annually , but who have not attended , or telephoned to rearrange an appointment , within the last 24 months . Eligible participants will be r and omized to one of three conditions:1.Control condition ( usual invitation letter)2.Fixed incentive condition ( usual invitation letter , including a voucher for £ 10 if they attend their appointment)3.Probabilistic incentive condition ( invitation letter , including a voucher for a 1 in 100 chance of winning £ 1000 if they attend their appointment ) . Participants will be sent invitation letters , and the primary outcome will be whether or not they attend their appointment . One thous and participants will be included in total , r and omized with a ratio of 1.4:1:1 . In order to test whether the incentive scheme has a differential impact on patients from different demographic or socio-economic groups , information will be recorded on age , gender , distance from screening center , socio-economic status and length of time since they were last screened . A cost-effectiveness analysis will also be performed . Discussion This study will be the first trial of financial incentives for improving uptake of diabetic eye screening . If effective , the intervention may suggest a cost-effective way to increase screening rates , thus reducing unnecessary blindness . Trial registration IS RCT N14896403 , 25 February OBJECTIVE Among chronic hemodialysis patients , hyperphosphatemia is common and associated with mortality . Behavioral economics and complementary behavior-change theories may offer valuable approaches to achieving phosphorus ( PO4 ) control . The aim was to determine feasibility of implementing financial incentives and structured coaching to improve PO4 in the hemodialysis setting . DESIGN AND METHODS This pilot r and omized controlled trial was conducted in 3 urban dialysis units for 10 weeks among 36 adults with elevated serum PO4 ( median > 5.5 mg/dL over 3 months ) . INTERVENTIONS Twelve participants each were r and omized to : ( 1 ) financial incentives for lowering PO4 , ( 2 ) coaching about dietary and medication adherence , or ( 3 ) usual care . PO4 was measured during routine clinic operations . Each incentives arm participant received the equivalent of $ 1.50/day if the PO4 was ≤5.5 mg/dL or > 5.5 mg/dL but decreased ≥0.5 mg/dL since the prior measurement . The coach was instructed to contact coaching arm participants at least 3 times per week . MAIN OUTCOME MEASURES The outcome measures included : ( 1 ) enrollment rate , ( 2 ) dropout rate , and ( 3 ) change in PO4 from beginning to end of 10-week intervention period . RESULTS Of 66 eligible patients , 36 ( 55 % ) enrolled . Median age was 53 years , 83 % were black race , and 78 % were male . Median baseline PO4 was 6.0 ( interquartile range 5.6 , 7.5 ) . Using stratified generalized estimation equation analyses , the monthly decline in PO4 was -0.32 mg/dL ( 95 % CI -0.60 , -0.04 ) in the incentives arm , -0.40 mg/dL ( -0.60 , -0.20 ) in the coaching arm , and -0.24 mg/dL ( -0.60 , 0.08 ) in the usual care arm . No patients dropped out . All intervention arm participants expressed interest in receiving similar support in the future . CONCLUSIONS This pilot trial demonstrated good feasibility in enrollment and implementation of novel behavioral health strategies to reduce PO4 in dialysis patients
Assured , or " sure thing , " incentives and objective behavioral assessment in particular appear to moderate incentive effectiveness .
The effect estimate from the meta- analysis suggests that financial incentives increase exercise session attendance for interventions up to 6 months in duration .
CONTEXT Less than 5 % of U.S. adults accumulate the required dose of exercise to maintain health .
Behavioral economics has stimulated renewed interest in economic-based , population -level health interventions to address this issue .
Despite widespread implementation of financial incentive-based public health and workplace wellness policies , the effects of financial incentives on exercise initiation and maintenance in adults remain unclear .