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The effect of a monetary incentive in increasing the return rate of a survey to family physicians.

The barrage of requests family physicians receive to complete mail surveys often results in physicians who are unwilling, or unable due to time constraints, to complete each survey they receive. Thus, to obtain an acceptable response rate, state-of-the-art mail survey techniques must be used. This article reports the results of the use of a modest ($1) monetary incentive to increase a survey response rate. A random sample of 600 American Academy of Family Physicians members were mailed a survey of firearm safety counseling; half received a $1 incentive whereas the remaining half served as a control group. The response rate in the incentive group was 63% compared to 45% in the control group [chi 2 (1, N = 251) = 16.0, p < .001]. Further, the use of the incentive appears to be more cost-effective than a third follow-up (postcard reminder) mailing.

Chi-Square Distribution↗

Monetary incentives in support of academic achievement: results of a randomized field trial involving high-achieving, low-resource, ethnically diverse urban adolescents.

Significant resources have been directed at understanding and alleviating the achievement gap in education. Most programs focused on this aim rely on a top-down approach, including funding for infrastructure improvement, curriculum development, class size, and teacher salaries. This article presents findings from a randomized field trial that evaluates a bottom-up approach in which high-achieving students of diverse racial and ethnic backgrounds from poor families are given monetary incentives to maintain their academic standing. The evaluation was designed to explore the role of monetary incentives as a mechanism for promoting resiliency in the face of poverty-related challenge. Discussion of what motivates students to learn is framed as a function of normal cognitive and socioemotional development in challenging environments. Evaluation findings indicate that monetary incentives are effective in promoting academic success to different degrees and for different reasons depending on students' perception of the meaning of the incentive in relation to their emergent identity.

Adolescent↗

A randomised controlled trial to determine the effect on response of including a lottery incentive in health surveys [ISRCTN32203485].

BACKGROUND: Postal questionnaires are an economical and simple method of data collection for research purposes but are subject to non-response bias. Several studies have explored the effect of monetary and non-monetary incentives on response. Recent meta-analyses conclude that financial incentives are an effective way of increasing response rates. However, large surveys rarely have the resources to reward individual participants. Three previous papers report on the effectiveness of lottery incentives with contradictory results. This study aimed to determine the effect of including a lottery-style incentive on response rates to a postal health survey. METHODS: Randomised controlled trial. SETTING: North and West Birmingham. 8,645 patients aged 18 or over randomly selected from registers of eight general practices (family physician practices). INTERVENTION: Inclusion of a flyer and letter with a health questionnaire informing patients that returned questionnaires would be entered into a lottery-style draw for pound 100 of gift vouchers. CONTROL: Health questionnaire accompanied only by standard letter of explanation. MAIN OUTCOME MEASURES: Response rate and completion rate to questionnaire. RESULTS: 5,209 individuals responded with identical rates in both groups (62.1%). Practice, patient age, sex and Townsend score (a postcode based deprivation measure) were identified as predictive of response, with higher response related to older age, being female and living in an area with a lower Townsend score (less deprived). CONCLUSION: This RCT, using a large community based sample, found that the offer of entry into a lottery style draw for pound 100 of High Street vouchers has no effect on response rates to a postal health questionnaire.

Adult↗

Compliance with tuberculosis drug regimens: incentives and enablers offered by public health departments.

OBJECTIVES: This research examined incentives implemented by public health departments to encourage tuberculosis patients to comply with tuberculosis drug regimens. METHODS: A questionnaire addressing incentives was mailed to the directors of each state's health department during May 1995. All 50 states and the District of Columbia returned questionnaires. RESULTS: The survey results indicate that public health departments in almost all states are implementing the incentives advocated by tuberculosis experts. CONCLUSIONS: The implementation of these incentives may help to explain why the incidence of tuberculosis resumed its long-term decline in the United States during 1993 after a decade of resurgence.

Health Care Surveys↗

Skin temperature biofeedback for multiple sessions with monetary incentives.

This study evaluated the relative effectiveness of two incentive contingencies in learning biofeedback-assisted control of peripheral skin temperature: positive versus positive/negative monetary incentives. Both incentive groups of 10 participated in six sessions, including pre- and posttraining voluntary control sessions, and four intervening sessions with visual feedback and monetary contingencies. Each session consisted of adaptation, resting baseline, feedback or voluntary control, and a final resting baseline. The results indicated no significant difference in response control between groups and an over-all decline in temperature within sessions. Self-control was evidenced by the slower rate of decline in temperature for the first as compared to the last session, and feedback control by the attenuation in the rate of decline in the last three training sessions. Based on data from other physiological responses, these findings are not likely due to habituation effects. It was concluded that response control should not necessarily be defined in terms of increasing temperature but rather by reference to an appropriate comparison condition. Motivational effects should be further investigated with alternative incentive contingencies.

Biofeedback, Psychology↗

Measuring incentives to health promotion in older adults. Understanding neglected health promotion in older adults.

Health promotion increases longevity and allows older persons to maintain an independent and satisfying life. Determining reasons why an older person participates in health promotion activities through incentives may allow further insight into ways to promote health. As deeper understanding of motivation is gained by health professionals, successful influences to health behavior may be clarified. A nurse's role in health promotion could be to assist in planning a health promotion program, especially after incentives have been identified for a particular person. The Incentive-Health Promotion Scale revealed that the major incentives to health promotion in study sample were "feel good" and "fitness and health".

Aged↗

Markets for individual health insurance: can we make them work with incentives to purchase insurance?

Simple income-based incentives to purchase health insurance (tax credits or deductions, or subsidies) are unlikely to succeed in significantly reducing the number of uninsured because income is not a good predictor of the extent to which individuals use medical service. Proposals to provide incentives to low-income people so they will purchase individual health insurance need to address the inherent tension between the interests of low-risk and high-risk people who rely on individual coverage. If carriers are forced to cover all applicants and to community rate premiums, low-risk people will drop coverage or not apply for it because premiums will exceed their expected need for insurance. Concern for people who currently have access to individual coverage calls for careful examination of options to permit incentive programs to succeed with the individual insurance markets. In particular, attention should focus on using alternatives to simple income-based subsidies to spread the burden of high-risk people's costs broadly, rather than impose the costs on low-risk people who purchase individual coverage. This paper describes three such alternatives. One uses risk adjustments and two rely on reinsurance so that carriers are compensated for the higher costs of covering high-risk people who use incentives to buy insurance. One alternative also permits risk selection by insurance carriers.

Economic Competition↗

How to promote prevention--economic incentives or legal regulations or both?

Legal regulations of the work environment are probably regarded as the main tools for promoting prevention at the workplace. Legal regulations are expressed as occupational exposure limits, bans, and taxes. Taxes can be regarded as economic incentives as well, and other economic incentives are insurance systems for employers' and consumers' actions. The latter have been found to have profound effects regarding environmental issues and may also, in the future, be a powerful tool for workplace-related prevention. The research in this area is rather limited, but there are some research results that can be obtained from the area of environmental economics. This paper discusses some examples in which legal regulations, economic incentives, or both have been used. Legal regulations and market-based economic incentives may produce similar results, but the economic cost and political feasibility typically differ. This situation makes the selection and design of instruments an important field for future research.

Health Policy↗

Incentive downshifts evoke search repertoires in rats.

Negative incentive contrast effects (NCEs) have typically been attributed to frustration or the decremental generalization of learned associations. The purpose of these experiments was to clarify the relation of NCEs to the repertoires of functional search behaviors evoked by incentive downshifts. Rats shifted from 32% to 4% sucrose-solution decreased consummatory responses but increased nose-down locomotion, orientation, location entries, and sampling of alternatives relative to unshifted controls. These changes in behavior were terminated or failed to occur under incentive upshifts. Furthermore, reward downshifts did not produce avoidance of the location of the shifted incentive. Increased search occurred whether or not alternative reward locations were available. Together the evidence suggests that NCEs are related to evoked search modes supporting a repertoire of functional behaviors related to finding food.

Animals↗

Orbitofrontal cortex and representation of incentive value in associative learning.

Clinical evidence indicates that damage to ventromedial prefrontal cortex disrupts goal-directed actions that are guided by motivational and emotional factors. As a consequence, patients with such damage characteristically engage in maladaptive behaviors. Other research has shown that neurons in the corresponding orbital region of prefrontal cortex in laboratory animals encode information regarding the incentive properties of goals or expected events. The present study investigates the effect of neurotoxic orbitofrontal cortex (OFC) lesions in the rat on responses that are normally influenced by associations between a conditioned stimulus (CS) and the incentive value of reinforcement. Rats were first trained to associate a visual CS with delivery of food pellets to a food cup. As a consequence of learning, rats approached the food cup during the CS in anticipation of reinforcement. In a second training phase, injection of LiCl followed consumption of the food unconditioned stimulus (US) in the home cage, a procedure used to alter the incentive value of the US. Subsequently, rats were returned to the conditioning chamber, and their responding to the CS in the absence of the food US was tested. Lesions of OFC did not affect either the initial acquisition of a conditioned response to the light CS in the first training phase or taste aversion learning in the second training phase. In the test for devaluation, however, OFC rats exhibited no change in conditioned responding to the visual CS. This outcome contrasts with the behavior of control rats; after devaluation of the US a significant decrease occurred in approach to the food cup during presentation of the CS. The results reveal an inability of a cue to access representational information about the incentive value of associated reinforcement after OFC damage.

Animals↗

Social Security, retirement incentives, and retirement behavior: an international perspective.

Escalating rates of early retirement are imposing fiscal pressure on retirement systems around the world. In some developed countries, the labor-force participation rates of men ages 60-64 have fallen by 75 percent over the last three decades. One explanation for this striking decline is social security program provisions which create disincentives to continued labor-force participation by older workers. There are substantial differences among developed nations in the labor-force participation of older workers. While two-thirds of 60-year-old American males are working, only one-quarter of men that age are working in Belgium. Over the entire 55-65 age range, 63 percent of American males are working, compared with only 40 percent of French males and 33 percent of Belgians males. There is strong evidence that the early retirement provisions of social security systems in developed countries determine the modal age of retirement. There is a strong relationship between early retirement ages and labor-force withdrawal rates; for example, in France, 60 percent of those working at the early entitlement age of 60 leave the labor force at that age. The core of this analysis is the construction of "implicit tax/subsidy rates" on additional work at older ages through each nation's social security system. These rates measure the change in a worker's retirement wealth entitlement from delaying retirement for one year, relative to the amount that would have been earned over that year. The U.S. Social Security system has an actuarial adjustment for delayed benefits claiming and other features that avoid financial incentives to leave the labor force at age 62 for a married worker, there is a slight disincentive to work for single workers and high wage earners. However, at ages 65 and older there is a stronger incentive to leave the labor force, with implicit tax rates on work of 19 percent for married workers and 33 percent for single workers. By comparison, other nations do not have actuarially fair adjustments, and as a result impose substantial taxes on additional work at older ages. In several countries, implicit tax rates on work at older ages approach or exceed 100 percent. This is because by delaying retirement, workers forgo benefits which often replace close to their full wage, in addition to having to pay the high payroll taxes required to finance generous social security benefits. There is a striking correlation across nations between high implicit tax rates on additional work and low labor-force participation rates among older workers. This suggests that social security program incentives are an important determinant of retirement. These findings have important policy implications for reforming social security programs in the United States and abroad. Policymakers must consider how program reforms will affect incentives for continued work at older ages.

Actuarial Analysis↗

The effect of incentive spirometry on chest expansion and breathing work in patients with chronic obstructive airway diseases: comparison of two methods.

BACKGROUND: Chronic obstructive airway diseases (COAD), characterized by mucus hypersecretion, lead to exercise intolerance. Incentive spirometry has been used to prevent postoperative pulmonary atelectasis. METHODS: To compare the efficacy of two incentive spirometers, Coach (volume-oriented) and Triflo (flow-oriented), in the work of breathing in COAD patients, 22 patients were randomized in this study: 12 patients (Triflo-II group) initially used Triflo-II for 10 minutes and then Coach for the same period. In contrast, the Coach group, including 10 patients, started with Coach followed by Triflo-II. After receiving incentive spirometry, lung expansion and work of breathing were assessed. RESULTS: Patients in the Coach group significantly increased chest wall expansion (p = 0.041), as compared with patients using Triflo-II. Similarly, there was also a significantly increased abdominal wall expansion in the Coach group (p = 0.0056), compared with that in the Triflo-II group. The need of accessory muscle assistance for breathing in the Coach group was significantly less than in the Triflo-II group (p = 0.047). It was easier for patients in the Coach group to start a breath (p = 0.0058) than for those in the Triflo-II group. For the entire group, 17 patients (77.3%) preferred Coach to assist their breathing, and only 4 patients (18.2%) favored Triflo-II. CONCLUSION: COAD patients achieved a larger expansion of the chest and abdomen with a Coach device. Our data provide a good rationale for an outcome study on the use of incentive spirometer in COAD patients.

Adult↗

The effects of increasing incentives on adherence to tuberculosis directly observed therapy.

SETTING: Six New York State Department of Health tuberculosis (TB) directly observed therapy (DOT) programs in public, private and community facilities in New York City. OBJECTIVE: A key feature of the TB DOT program was provision of incentives to motivate patients and increase adherence to therapy. The study hypothesis was that adherence will improve as the value of incentives increases and bonuses are added in a schedule of increasing rewards. DESIGN: The study population consisted of 365 patients in six inner city TB DOT programs. Interviews, clinical data and attendance records for 3+ years were analyzed. RESULTS: Patients who adhered (attending 80% of prescribed DOT visits each month of treatment) and those who did not were similar on seven demographic factors (e.g., age and sex), but were significantly different on clinical and social variables. Previous TB, resistance to rifampin, human immunodeficiency virus infection, psychiatric illness, homelessness, smoking and drug use were related to non-adherence. High adherence was significantly associated with fewer months in treatment (P < 0.016). Logistic regression showed that the odds that a patient would adhere to therapy were greater with increased incentives. Odds of adherence were significantly lower with rifampin resistance and psychiatric illness. CONCLUSION: Increasing incentives is associated with improved adherence to therapy in inner city TB populations.

Adult↗

A spoonful of sugar...: improving adherence to tuberculosis treatment using financial incentives.

OBJECTIVE: To determine whether incentives increase adherence to directly observed therapy (DOT) for tuberculosis (TB) treatment. METHODS: The TB program gave a five-dollar grocery coupon for each DOT appointment kept to 55 patients who had missed at least 25% of DOT doses over a 4-week period. Treatment completion rates were compared with an historic control group of 52 patients who began treatment a year earlier, who would have been eligible for incentives but did not receive them. RESULTS: Incentive program patients were more likely than control patients to complete therapy within 32 weeks (OR 5.73, 95%CI 2.25-14.84) and 52 weeks (OR 7.29, 95%CI 2.45-22.73). CONCLUSION: Patient incentives can increase adherence to DOT in TB programs.

Antitubercular Agents↗

The recruitment of normal healthy volunteers: a review of the literature on the use of financial incentives.

Unresolved issues of ethical, methodological, and legal concerns in the use of normal healthy volunteers persist. Financial incentives in their recruitment offer a unique ethical dilemma because of questions surrounding payment. A review of literature was conducted to obtain research systematically examining volunteer motivation and the role offinancial incentives. The primary selection criterion was motivation and payment to volunteers; seven studies met the criterion for review. Studies that have systematically investigated volunteer motivation have found financial rewards to be an important motivator among normal healthy volunteers in their decision to participate in clinical trials. Also evident is that differences based on demographic characteristics exist in the motivation and rates of volunteerism. Ethical issues surrounding the use of normal healthy volunteers are discussed, with attention to the issue offinancial incentives (e.g., economically vulnerable volunteers, undue inducements). Regulations, guidelines, and recommendations are discussed with regard to volunteers and financial incentives.

Bioethical Issues↗

Influence of a monetary incentive upon attentional modification of short-lead prepulse inhibition and long-lead prepulse facilitation of acoustic startle.

Short-lead prepulse inhibition and long-lead prepulse facilitation of startle are greater during attended than ignored prestimuli. The present work examined whether this attentional modification is influenced by monetary incentive. Participants (43 college students) were randomly assigned to receive a small performance-based monetary incentive or were instructed to try their best. The task was to judge the duration of tones of one of two pitches during a series of 48 tones. Prepulse inhibition of startle eyeblink EMG was assessed at 60, 120, and 240 ms, and prepulse facilitation was assessed at 4,500 ms following tone onset. Short-lead percent prepulse inhibition was greater during attended than ignored prestimuli only at 120 ms among paid participants. Long-lead prepulse facilitation was greater for attended than ignored tones, but this effect did not vary with incentive condition. This study demonstrates that attentional modification of short-lead prepulse inhibition is sensitive to a monetary incentive and provides a basis for further examination of motivational effects on early attentional processing.

Acoustic Stimulation↗

Can the poor adhere? Incentives for adherence to TB prevention in homeless adults.

SETTING: Community-based population of homeless adults living in San Francisco, California. OBJECTIVE: To compare the effect of cash and non-cash incentives on 1) adherence to treatment for latent tuberculosis infection, and 2) length of time needed to look for participants who missed their dose of medications. DESIGN: Prospective, randomized clinical trial comparing a 5 dollar cash or a 5 dollar non-cash incentive. All participants received directly observed preventive therapy and standardized follow-up per a predetermined protocol. Completion rates and amount of time needed to follow up participants was measured. RESULTS: Of the 119 participants, 102 (86%) completed therapy. There was no difference between the cash and non-cash arms. Completion was significantly higher among males (OR 5.65, 95%CI 1.36-23.40, P = 0.02) and persons in stable housing at study entry (OR 4.86, 95%CI 1.32-17.94, P = 0.02). No substance use or mental health measures were associated with completion. Participants in the cash arm needed significantly less follow-up to complete therapy compared to the non-cash arm (P = 0.03). In multivariate analysis, non-cash incentive, use of crack cocaine, and no prior preventive therapy were associated with more follow-up time. CONCLUSION: Simple, low cost incentives can be used to improve adherence to TB preventive therapy in indigent adults.

Adult↗

Physician-perceived incentives for association with nurse practitioners.

A 1985 study was conducted concerning physician motivation to form an association with nurse practitioners. The study explored NP-association incentives in relation to year of physician graduation from medical school, physician specialty and type of practice. Subjects for the study were 58 Arizona physicians associated in practice with nurse practitioners. Data were collected via mail questionnaires. Data analysis included descriptions of the demographic characteristics, factor analysis, analysis of variance and a specific comparison test. Results indicated physicians perceived increased accessibility to their services and improved quality of their care as being the most important incentives for NP association. Economic incentives were a low priority for the majority of respondents. There were significant differences related to physician specialty. Internists placed less importance on all incentives than other specialties did; emergency medicine physicians placed more importance on physician satisfaction; obstetricians and gynecologists placed more importance on economics. The relatively low importance ratings of the internal medicine physicians may represent a resistance to extension of hospital privileges to nurse practitioners.

Attitude of Health Personnel↗