A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol The effect of introducing a financial incentive to promote application of fluoride varnish in dental practice in Scotland: a natural experiment You can't pay me to quit: the failure of financial incentives for smoking cessation in head and neck cancer patients. Healthcare providers’ views on the acceptability of financial incentives for breastfeeding: a qualitative study Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013-15 Study. Social norms and financial incentives to promote employees' healthy food choices: A randomized controlled trial. Randomised controlled trial using social support and financial incentives for high risk pregnant smokers: Significant Other Supporter (SOS) program A Mixed-Methods Randomized Controlled Trial of Financial Incentives and Peer Networks to Promote Walking Among Older Adults Coupling Financial Incentives With Direct Mail in Population-Based Practice Effects of financial incentives for the purchase of healthy groceries on dietary intake and weight outcomes among older adults: A randomized pilot study 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. Effects of Financial Incentives on Saving Outcomes and Material Well-Being: Evidence From a Randomized Controlled Trial in Uganda.
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 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 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 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 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 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  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 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 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 Providing financial incentives can be a useful behavioral economics strategy for increasing fruit and vegetable intake among consumers . It remains to be determined whether financial incentives can promote intake of other low energy-dense foods and if consumers who are already using promotional tools for their grocery purchases may be especially responsive to receiving incentives . This r and omized controlled trial tested the effects of offering financial incentives for the purchase of healthy groceries on 3-month changes in dietary intake , weight outcomes , and the home food environment among older adults . A secondary aim was to compare frequent coupon users ( FCU ) and non-coupon users ( NCU ) on weight status , home food environment , and grocery shopping behavior .  FCU ( n = 28 ) and NCU ( n = 26 ) were r and omly assigned to either an incentive or a control group . Participants in the incentive group received $ 1 for every healthy food or beverage they purchased . All participants completed 3-day food records and a home food inventory and had their height , weight , and waist circumference measured at baseline and after 3 months . Participants who were responsive to the intervention and received financial incentives significantly increased their daily vegetable intake ( P = 0.04 ) . Participants in both groups showed significant improvements in their home food environment ( P = 0.0003 ) . No significant changes were observed in daily energy intake or weight-related outcomes across groups ( P < 0.12 ) . FCU and NCU did not differ significantly in any anthropometric variables or the level at which their home food environment may be considered ' obesogenic ' ( P > 0.73 ) . Increased consumption of vegetables did not replace intake of more energy-dense foods . Incentivizing consumers to make healthy food choices while simultaneously reducing less healthy food choices may be important 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 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
There was not convincing evidence that effects were different between different groups of behaviours .
Meta-regression found some , limited , evidence that effect sizes decreased as post-intervention follow-up period and incentive value increased .
However , the latter effect may be confounded by the former .
The available evidence suggests that financial incentive interventions are more effective than usual care or no intervention for encouraging healthy behaviour change .
BACKGROUND Financial incentive interventions have been suggested as one method of promoting healthy behaviour change .
OBJECTIVES To conduct a systematic review of the effectiveness of financial incentive interventions for encouraging healthy behaviour change ; to explore whether effects vary according to the type of behaviour incentivised , post-intervention follow-up time , or incentive value .