Emma L. Giles

The Effectiveness of Financial Incentives for Health Behaviour Change: Systematic Review and Meta-Analysis

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. Data Sources Searches were of relevant electronic databases, research registers, www.google.com, and the reference lists of previous reviews; and requests for information sent to relevant mailing lists. Eligibility Criteria Controlled evaluations of the effectiveness of financial incentive interventions, compared to no intervention or usual care, to encourage healthy behaviour change, in non-clinical adult populations, living in high-income countries, were included. Study Appraisal and Synthesis The Cochrane Risk of Bias tool was used to assess all included studies. Meta-analysis was used to explore the effect of financial incentive interventions within groups of similar behaviours and overall. Meta-regression was used to determine if effect varied according to post-intervention follow up time, or incentive value. Results Seventeen papers reporting on 16 studies on smoking cessation (n = 10), attendance for vaccination or screening (n = 5), and physical activity (n = 1) were included. In meta-analyses, the average effect of incentive interventions was greater than control for short-term (≤six months) smoking cessation (relative risk (95% confidence intervals): 2.48 (1.77 to 3.46); long-term (>six months) smoking cessation (1.50 (1.05 to 2.14)); attendance for vaccination or screening (1.92 (1.46 to 2.53)); and for all behaviours combined (1.62 (1.38 to 1.91)). 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. Conclusions The available evidence suggests that financial incentive interventions are more effective than usual care or no intervention for encouraging healthy behaviour change. Trial Registration PROSPERO CRD42012002393

Carrots, sticks and health behaviours: a framework for documenting the complexity of financial incentive interventions to change health 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 communitys 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. Drawing on our experience of a recently completed systematic review, we identify nine domains that are required to describe any financial incentive intervention designed to help individuals change their health behaviours. These are: direction, form, magnitude, certainty, target, frequency, immediacy, schedule and recipient. Our framework should help researchers and policy-makers identify the most effective incentive configurations for helping individuals adopt healthy behaviours.

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

OBJECTIVE Financial incentives are effective in encouraging healthy behaviours, yet concerns about acceptability remain. We conducted a systematic review exploring acceptability of financial incentives for encouraging healthy behaviours. METHODS Database, reference, and citation searches were conducted from the earliest available date to October 2014, to identify empirical studies and scholarly writing that: had an English language title, were published in a peer-reviewed journal, and explored acceptability of financial incentives for healthy behaviours in members of the public, potential recipients, potential practitioners or policy makers. Data was analysed using thematic analysis. RESULTS Eighty one papers were included: 59 pieces of scholarly writing and 22 empirical studies, primarily exploring acceptability to the public. Five themes were identified: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Although there was consensus that if financial incentives are effective and cost effective they are likely to be considered acceptable, a number of other factors also influenced acceptability. CONCLUSIONS Financial incentives tend to be acceptable to the public when they are effective and cost-effective. Programmes that benefit recipients and wider society; are considered fair; and are delivered to individuals deemed appropriate are likely to be considered more acceptable.

Acceptability of Financial Incentives for Health Behaviours: A Discrete Choice Experiment

Background Healthy behaviours are important determinants of health and disease, but many people find it difficult to perform these behaviours. Systematic reviews support the use of personal financial incentives to encourage healthy behaviours. There is concern that financial incentives may be unacceptable to the public, those delivering services and policymakers, but this has been poorly studied. Without widespread acceptability, financial incentives are unlikely to be widely implemented. We sought to answer two questions: what are the relative preferences of UK adults for attributes of financial incentives for healthy behaviours? Do preferences vary according to the respondents’ socio-demographic characteristics? Methods We conducted an online discrete choice experiment. Participants were adult members of a market research panel living in the UK selected using quota sampling. Preferences were examined for financial incentives for: smoking cessation, regular physical activity, attendance for vaccination, and attendance for screening. Attributes of interest (and their levels) were: type of incentive (none, cash, shopping vouchers or lottery tickets); value of incentive (a continuous variable); schedule of incentive (same value each week, or value increases as behaviour change is sustained); other information provided (none, written information, face-to-face discussion, or both); and recipients (all eligible individuals, people living in low-income households, or pregnant women). Results Cash or shopping voucher incentives were preferred as much as, or more than, no incentive in all cases. Lower value incentives and those offered to all eligible individuals were preferred. Preferences for additional information provided alongside incentives varied between behaviours. Younger participants and men were more likely to prefer incentives. There were no clear differences in preference according to educational attainment. Conclusions Cash or shopping voucher-type financial incentives for healthy behaviours are not necessarily less acceptable than no incentives to UK adults.

Capturing Public Opinion on Public Health Topics: A Comparison of Experiences from a Systematic Review, Focus Group Study, and Analysis of Online, User-Generated Content.

Background Capturing public opinion toward public health topics is important to ensure that services, policy, and research are aligned with the beliefs and priorities of the general public. A number of approaches can be used to capture public opinion. Methods We are conducting a program of work on the effectiveness and acceptability of health promoting financial incentive interventions. We have captured public opinion on financial incentive interventions using three methods: a systematic review, focus group study, and analysis of online user-generated comments to news media reports. In this short editorial-style piece, we compare and contrast our experiences with these three methods. Results Each of these methods had their advantages and disadvantages. Advantages include tailoring of the research question for systematic reviews, probing of answers during focus groups, and the ability to aggregate a large data set using online user-generated content. However, disadvantages include needing to update systematic reviews, participants conforming to a dominant perspective in focus groups, and being unable to collect respondent characteristics during analysis of user-generated online content. That said, analysis of user-generated online content offers additional time and resource advantages, and we found it elicited similar findings to those obtained via more traditional methods, such as systematic reviews and focus groups. Conclusion A number of methods for capturing public opinions on public health topics are available. Public health researchers, policy makers, and practitioners should choose methods appropriate to their aims. Analysis of user-generated online content, especially in the context of news media reports, may be a quicker and cheaper alternative to more traditional methods, without compromising on the breadth of opinions captured.

Trading between healthy food, alcohol and physical activity behaviours.

BackgroundWhile recent lifestyle studies have explored the role that food, alcohol or physical activity have on health and wellbeing, few have explored the interplay between these behaviours and the impact this has on a healthy lifestyle. Given the long term health advantages associated with leading healthier lifestyles, this study seeks to: 1) explore the interplay between the food, alcohol and physical activity behaviours of young adults (aged 19–26 years) in the North East of England; 2) explore the trade-offs young adults make between their food, alcohol and physical activity behaviours; and 3) recognise the positive and negative associations between the three behaviours.MethodsQualitative self-reported lifestyle diaries and in-depth interviews were conducted with 50 young adults from the North East of England between February and June 2008. Qualitative thematic analysis was undertaken using Nvivo QSR software, and diary coding using Windiets software.ResultsYoung adults who attempt to achieve a ‘healthy lifestyle’ make trade-offs between the food and alcohol they consume, and the amounts of physical activity they undertake. There are negative reasons and positive consequences associated with these trade-offs. Young adults recognise the consequences of their behaviours and as a result are prepared to undertake healthy behaviours to compensate for unhealthy behaviours. They prefer certain strategies to promote healthier behaviours over others, in particular those that relate to personalised advice and support, more affordable ways to be healthier and easily-accessed advice from a range of media sources.ConclusionsYoung adults seek to compensate unhealthy behaviours (e.g. binge drinking) with healthy behaviours (e.g. physical activity). Creative solutions may be required to tackle these trade-offs and promote a balance across the food, alcohol and physical activity behaviours of this age group. Solutions that may be effective with this age group include environmental changes (e.g. green spaces and increasing the price of alcohol) designed to encourage and facilitate young people making healthier choices and improving their access to, and lowering the price of, healthy food products. Solutions must recognise these trade-offs and in particular, the strong reluctance of young adults to alter their higher-than-recommended levels of alcohol consumption.

Acceptability of financial incentives for health behaviour change to public health policymakers: a qualitative study

BackgroundProviding financial incentives contingent on healthy behaviours is one way to encourage healthy behaviours. However, there remains substantial concerns with the acceptability of health promoting financial incentives (HPFI). Previous research has studied acceptability of HPFI to the public, recipients and practitioners. We are not aware of any previous work that has focused particularly on the views of public health policymakers.Our aim was to explore the views of public health policymakers on whether or not HPFI are acceptable; and what, if anything, could be done to maximise acceptability of HPFI.MethodsWe recruited 21 local, regional and national policymakers working in England via gatekeepers and snowballing. We conducted semi-structured in-depth interviews with participants exploring experiences of, and attitudes towards, HPFI. We analysed data using the Framework approach.ResultsPublic health policymakers working in England acknowledged that HPFI could be a useful behaviour change tool, but were not overwhelmingly supportive of them. In particular, they raised concerns about effectiveness and cost-effectiveness, potential ‘gaming’, and whether or not HPFI address the underlying causes of unhealthy behaviours. Shopping voucher rewards, of smaller value, targeted at deprived groups were particularly acceptable to policymakers. Participants were particularly concerned about the response of other stakeholders to HPFI – including the public, potential recipients, politicians and the media.Overall, the interviews reflected three tensions. Firstly, a tension between wanting to trust individuals and promote responsibility; and distrust around the potential for ‘gaming the system’. Secondly, a tension between participants’ own views about HPFI; and their concerns about the possible views of other stakeholders. Thirdly, a tension between participants’ personal distaste of HPFI; and their professional view that they could be a valuable behaviour change tool.ConclusionsThere are aspects of design that influence acceptability of financial incentive interventions to public health policymakers. However, it is not clear that even interventions designed to maximise acceptability would be acceptable enough to be recommended for implementation. Further work may be required to help policymakers understand the potential responses of other stakeholder groups to financial incentive interventions.

Changing the lifestyles of young adults

Purpose – The purpose of this paper is to explore the costs and benefits that young adults perceive to be associated with adopting healthier food, alcohol and physical activity behaviours. Social marketing is used to identify and change behaviours within a segmented audience. The approach uses theoretical insights, and an appreciation of an individual’s environment, and a suite of methods to understand and suggest approaches to change behaviours. Design/methodology/approach – Focus groups were conducted between April and August 2007 with a sample of 54 young adults aged 19-24 years, from the North East of England. Qualitative thematic analysis was undertaken using Nvivo software. Findings – Young adults recognise future health benefits that they could gain from following healthier lifestyle behaviours; however, at their present age, their focus is on benefits such as weight regulation and improving one’s appearance. External competitive forces act against these benefits and result in time and effort costs...

A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol

BackgroundThe use of financial incentives and penalties to encourage uptake of healthy behaviors is increasingly seen as a viable intervention in developed countries. Previous reviews 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.MethodsSystematic 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 randomized controlled trial, cluster randomized controlled trial, controlled before and after study, or interrupted time series analysis. Two reviewers will independently screen the publications to ensure they meet the inclusion criteria. Quality will be assessed by two researchers, 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.DiscussionThis systematic review will provide policy-relevant recommendations for the use of financial incentives and penalties as a method of encouraging uptake of healthy behaviors.

The “Outcome Reporting in Brief Intervention Trials: Alcohol” [ORBITAL] framework: Protocol to determine a core outcome set for efficacy and effectiveness trials of alcohol screening and brief intervention

BackgroundThe evidence base to assess the efficacy and effectiveness of alcohol brief interventions (ABI) is weakened by variation in the outcomes measured and by inconsistent reporting. The ‘Outcome Reporting in Brief Intervention Trials: Alcohol’ (ORBITAL) project aims to develop a core outcome set (COS) and reporting guidance for its use in future trials of ABI in a range of settings.Methods/designAn international Special Interest Group was convened through INEBRIA (International Network on Brief Interventions for Alcohol and Other Drugs) to inform the development of a COS for trials of ABI. ORBITAL will incorporate a systematic review to map outcomes used in efficacy and effectiveness trials of ABI and their measurement properties, using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria. This will support a multi-round Delphi study to prioritise outcomes. Delphi panellists will be drawn from a range of settings and stakeholder groups, and the Delphi study will also be used to determine if a single COS is relevant for all settings. A consensus meeting with key stakeholder representation will determine the final COS and associated guidance for its use in trials of ABI.DiscussionORBITAL will develop a COS for alcohol screening and brief intervention trials, with outcomes stratified into domains and guidance on outcome measurement instruments. The standardisation of ABI outcomes and their measurement will support the ongoing development of ABI studies and a systematic synthesis of emerging research findings. We will track the extent to which the COS delivers on this promise through an exploration of the use of the guidance in the decade following COS publication.