Whether attending screening appointments, taking medication correctly, quitting smoking, or increasing physical activity, there are many situations where changing behaviour is important for health. However, it is often not clear how best to help people make healthy changes. In the case of tobacco or alcohol consumption, there is good evidence that financial disincentives, such as increasing sales taxes, do deter these harmful behaviours. But these approaches are not suitable in many situations. There is increasing interest in the use of financial incentives, such as small cash rewards, to promote particular desirable behaviours.
Evidence to date about the effectiveness of financial incentives is mixed. The NIHR has funded a range of studies exploring the use of incentives in different circumstances, and how people feel about them. This Highlight explores this evidence and considers how incentives can be helpful in healthcare, for who and in what circumstances.
- Overall, reviews of evidence suggest that financial incentives are effective for promoting a range of behaviours, but there are limitations
- Effects seemed to be most sustainable for smoking cessation, and to last for several months after the incentive ended
- For other behaviours, the effectiveness of incentives appears likely to drop off over time and particularly once the incentive stops
- There is a lack of clear evidence on which type of incentive is most likely to be effective in which circumstances, and also at what level incentives need to be set
- Incentives evoke strong reactions, positive and negative, so they need to be used with care
- Some people (patients and healthcare professionals) may consider them unfair, or as rewarding people for not doing something they should
- However, it seems to be quite widely accepted that incentives might work for some people, in some circumstances.
But if you try a reward scheme, and even if it seems quite unpalatable and it works, then the justification is right there.
Anonymous, HTA study 10/31/02
What are financial incentives and what do we already know?
Financial incentives seem to show promise for short term behaviour changes such as quitting smoking during pregnancy. An important next step in this research will be determining if, how and when the incentives are given can improve their impact whilst maintaining cost effectiveness. Smaller, more frequent incentives linked to habitual behaviours such as physical activity are particularly interesting given recent improvements in real time tracking technology.
Hugo Harper, Principal Advisor, Behavioural Insights Team
Financial incentives are rewards (which may be cash or alternatives such as store vouchers, or entries into prize draws) that are given to people as a reward for changing a particular behaviour. Economic motivations shape a wide range of everyday behaviours, but many uncertainties remain about the effectiveness and acceptability of offering financial incentives to people in order to change their health-related behaviours.
Research into the effectiveness of financial incentives has yielded mixed results. Although they appear to be effective in changing some health behaviours in some circumstances, results are often inconsistent and may last for only a short time – often only as long as the incentive is in place. Incentives can vary widely in design and approach, so it is sometimes complex to identify which elements are likely to be effective for which groups. Important factors include not only the behaviour in question, but the value and timeliness of the financial incentive and how it is awarded, the patient and their circumstances and beliefs, and the social and professional context in which the incentive is used. Additionally, research suggests that consideration should be given to the risk of unintended consequences, and the acceptability of financial incentives to the public and healthcare professionals.
Research and systematic reviews have partially unpicked some important features of financial incentives and how and why they might work. Recent NIHR research has added to this understanding.
NIHR research has explored the use of incentives in a range of settings, and with different populations. The results have varied, suggesting that incentives are context-dependent, and need to be planned carefully according to the needs and preferences of different groups.
Systematic reviews – which provide an overview of all existing evidence – suggest that financial incentives are generally more effective than usual care or no intervention. These reviews looked at effectiveness across a range of behaviours, including smoking cessation, weight loss and screening attendance. The effects lasted between three and six months for smoking cessation, but for other behaviours did not last long after the incentive stopped. There was not enough evidence to indicate which types of incentive (cash, vouchers, lottery entry or others) were most effective, and a lack of evidence on cost-effectiveness.
Attendance at check-ups and screening
Reviews of evidence have suggested that incentives could be an effective way to encourage people to attend screening appointments or check-ups. That may be the case for some population groups or appointment types, but an NIHR trial found that offering small financial incentives – such as £10 in cash, or the opportunity to win £1,000 in a lottery – did not improve attendance at eye screening for people with diabetes. The study recruited people who had not attended their eye screening appointment in the last two years. Some received a standard invitation; others the £10 reward; and a third group, the chance to enter a lottery to win £1,000. Patients in the two incentive groups were actually less likely to attend their appointments than those who received the standard invitation. The reasons for this unexpected result were not clear, but all the patients involved were from relatively deprived groups with a history of non-attendance. They were also younger than average and likely to have no apparent symptoms, which may reduce motivation to attend. The researchers also suggested that the offer of an incentive may cause a negative reaction, if the recipient believes that the screening must be unpleasant if they have to be paid to do it. This is supported by the finding that the lottery offer – to win a much larger sum – was associated with the lowest levels of attendance.
Financial incentives may be useful for supporting smoking cessation in the general population, although there are some limitations. A systematic review of 21 trials found that after six months or more, people receiving incentives were more likely to have quit than those who did not. This was supported by another review which also found that incentives continued to be effective at six months follow-up. However, there was mixed evidence about continuing effectiveness once the incentive stopped, with one of the reviews finding this was the case, but the other reporting ongoing success in only three out of 21 trials. In two US trials, quit rates were two to three times higher amongst those who received incentives, but the amounts paid were high (US$750-800). Achieving longer-term success in this case seemed to require substantial amounts which may not be feasible in practice.
Financial incentives also show potential for supporting smoking cessation in pregnancy. A review of evidence found that providing vouchers contingent on testing for smoking were effective in reducing smoking rates in late pregnancy, compared to vouchers without testing, although the studies reviewed were variable in design. In this case, linking the incentive to the desired outcome was clearly an important feature of the incentive design. Further qualitative work with participants suggested that the level of incentive, and how the incentive interacted with other elements of the intervention, were also important.
Financial incentives could play a role in encouraging adherence to anti-psychotic medications, although the advantage may not be maintained once the incentive stops. A small trial offered a £15 incentive to one group of patients for each medication taken, whilst a second group received usual care. Patients receiving the incentive were more likely to take the medication (85% vs 71%) but when the incentives stopped, adherence returned to the same level as those who had not received the incentives. The majority of patients and clinicians felt positive about the use of incentives, and the costs were relatively low.
Parental financial incentives have often been cited as a possible approach to encourage uptake of vaccinations. In fact, evidence appears to be limited, according to an NIHR systematic review, and not sufficient to show effectiveness. The review did find limited evidence that incentives might not work as well as quasi-mandatory schemes, such as preventing children from starting school until vaccinations are complete.
I suppose it’s not about necessarily having £50.00 or the £100.00 or whatever, it’s about the recognition that you’ve done something, that you’ve achieved something.
Anonymous, HTA study 10/31/02
Are financial incentives acceptable?
Financial incentives can evoke strong reactions, both positive and negative. As well as considering the effectiveness of incentives in changing behaviour, NIHR research has looked at what patients, the public and healthcare professionals think about the use of financial incentives in healthcare.
Both patients and healthcare professionals accepted that incentives might work in some circumstances, when interviewed as part of two NIHR studies. Women asked about the use of incentives to stop smoking in pregnancy felt that, for some, the idea of a reward or recognition for managing to quit could be a motivator. Families in the vaccination study conceded that an incentive could be effective for disadvantaged parents, whilst some healthcare professionals cited examples from their experience where incentives had worked.
However, many people seemed to believe that it is morally wrong to offer a financial reward for behaviours such as stopping smoking in pregnancy, breastfeeding, or vaccinating a child. Participants considered it unfair that people might in effect be rewarded for failing to do something considered their responsibility – particularly vaccinating their children. Some suggested that parents might deliberately delay vaccinating in order to claim the incentive later. Healthcare professionals in the vaccination study echoed these views, expressing concern that individual responsibility could be eroded.
Universal incentives, where everyone in a particular group receives the incentive, regardless of behaviour, were considered fairer by patients, but there were concerns they might not be effective. Further research into public views on incentives found that people were most likely to accept their use if they could be shown to be effective and cost-effective. People also emphasised the need for fairness.
Both patients and healthcare professionals agreed that there would always be some people for whom an incentive would not be enough to change an entrenched behaviour or strongly held belief. For example, some people choose not to vaccinate their children because they believe it to be dangerous. Most people felt that a financial incentive would be unlikely to change minds in these cases.
Concern was also expressed by both patients and healthcare professionals about the cost of incentives, and how the health service could pay for them.
I don’t think anyone should get the cash bonus, I’d feel like, as a parent that took my child to all of his appointments, I’m being penalised because of it.
Anonymous, HTA Study 11/97/01
About the research
This Highlight is based on the following studies:
Funded by the NIHR
Judah G, Darzi A, Vlaev I, Gunn L, King D, King D, et al. Incentives in Diabetic Eye Assessment by Screening (IDEAS) trial: a three-armed randomised controlled trial of financial incentives. Health Serv Deliv Res 2017;5(15)
Morgan H, Hoddinott P, Thomson G, Crossland N, Farrar S, Yi D, et al. Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design. Health Technol Assess 2015;19(30)
Adams J, Bateman B, Becker F, Cresswell T, Flynn D, McNaughton R, et al. Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study, and discrete choice experiment. Health Technol Assess 2015;19(94)
Priebe S, Bremner SA, Lauber C, Henderson C, Burns T. Financial incentives to improve adherence to antipsychotic maintenance medication in non-adherent patients: a cluster randomised controlled trial. Health Technol Assess 2016;20(70)
Supported through an NIHR Fellowship
Emma L. Giles , Shannon Robalino, Elaine McColl, Falko F. Sniehotta, Jean Adams. The Effectiveness of Financial Incentives for Health Behaviour Change: Systematic Review and Meta-Analysis. PLOSOne. March 2014.
Giles EL, Robalino S, Sniehotta FF, Adams J, McColl E. Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods. Preventive Medicine. 2015 Apr; 73:145-58.
Giles EL, Sniehotta FF, McColl E, Adams J. Acceptability of financial incentives and penalties for encouraging uptake of healthy behaviours: focus groups. BMC Public Health. 2015 Jan 31; 15:58.
Emma L. Giles, Frauke Becker, Laura Ternent, Falko F. Sniehotta, Elaine McColl, Jean Adams. Acceptability of Financial Incentives for Health Behaviours: A Discrete Choice Experiment. PLOSOne. June 2016.
Partly supported by the NIHR
Cahill K,Hartmann‐Boyce J,Perera R. Incentives for smoking cessation.Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD004307.DOI: 10.1002/14651858.CD004307.pub5. (also supported by theNuffield Department of Primary Care Health Sciences, University of Oxford; and the NHS Research and Development Fund).
Funded through other sources
Mantzari E, Vogt F, Shemilt I, Wei Y, Higgins JP, Marteau TM. Personal financial incentives for changing habitual health-related behaviors: A systematic review and meta-analysis. Preventive medicine. 2015 Jun 1;75:75-85.
Marteau TM, Ashcroft RE, Oliver A. Using financial incentives to achieve healthy behaviour. BMJ. 2009 Apr 9;338:b1415.
Professor Ivo Vlaev, University of Warwick
"It’s widely accepted that we need to find new ways of addressing public health issues such as obesity and inactivity. Changing behaviour is likely to be just as important as developing new treatments and technologies – but we know it isn’t easy to do.
We already know about some effective ways of changing behaviour – tax on cigarettes, for example. But what if people were rewarded – with cash or a voucher – for making healthy lifestyle choices? There is now increasing interest in patient incentives, which seek to do just that. Incentives have potentially wide applicability – from encouraging people to give up smoking, to vaccinate their children, or to attend a screening appointment. But how much do we know about whether they work – and why?
Behavioural science – the study of factors which influence behaviour – tells us that people may change their attitudes and beliefs as a result of education campaigns. But it also suggests that behaviour can sometimes change spontaneously as a response to triggers in the environment. This is how incentives seek to work.
There is some evidence that incentives can work for things like medication compliance, but the evidence is less clear on how well they work for more complex behaviours like smoking or obesity. This NIHR Highlight explores the effect of incentives in a range of situations, and the findings are mixed: while they seemed to work well in some cases, in others they actually made things worse.
This may be because there are a lot of variables at play in the way we design and use incentives. To start with, different patient populations may have very different motivations and drivers. Incentives can be designed in many different ways too – from the level and type of reward offered, to the point at which they can be claimed. For instance, to incentivise attendance at a weight loss class, should we offer an incentive at the start, at the end, or following evidence of sustained weight loss?
The evidence described in the Highlight gives some insights into when and how incentives might work. For smoking cessation, linking the incentive to evidence of quitting was important. It was also notable that the benefits didn’t always last once the incentive stopped – a recognised concern about incentive use. In the study where incentives had a negative effect, it’s possible that the particular patient group – who in this case had a history of non-attendance at screening, and tended not to have active symptoms – were less amenable to the idea of an incentive. Clearly, careful consideration of the particular context and patient group is vital.
The Highlight also shows how incentives may trigger strong – and not always positive – responses. Research suggests that many people may find them unpalatable or feel that they are unfair. This needs to be borne in mind too when planning an incentive scheme.
This evidence helps shape our understanding of the use of incentives, but gaps remain. There is a need for future research to consider how we might combine different types of incentive, or use techniques such as commitment contracts."
About the author: Prof Vlaev is interested in human decision-making and behaviour change. He has advised the DHSC, Public Health England, Cabinet Office and many others on the application of lessons from behavioural science in public policy.
He is a professor at Warwick Business School. Full bio: www.wbs.ac.uk/about/person/ivo-vlaev
Produced by the University of Southampton on behalf of NIHR through the NIHR Dissemination Centre