YPMED-04194; No of Pages 13 Preventive Medicine xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed

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Emma L. Giles a,⁎, Shannon Robalino a, Falko F. Sniehotta a, Jean Adams a, Elaine McColl b

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

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Keywords: Healthy behaviours Critical review Systematic review Financial incentives Behaviour change

Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX, UK Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, 4th Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, Tyne and Wear NE2 4HH, UK b

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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 health 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. © 2015 Elsevier Inc. All rights reserved.

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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . Information sources . . . . . . . . . . . . . . . . . . . . Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . Paper selection and data collection . . . . . . . . . . . . . . Quality assessment . . . . . . . . . . . . . . . . . . . . . Synthesis of results . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Citation mapping . . . . . . . . . . . . . . . . . . . . . . What makes HPFI acceptable or unacceptable? . . . . . . . . Theme 1: fair exchange . . . . . . . . . . . . . . . Theme 2: design and delivery of HPFI . . . . . . . . . Theme 3: effectiveness and cost-effectiveness of HPFI . . Theme 4: recipients of HPFI . . . . . . . . . . . . . Theme 5: impact of HPFI on individuals and wider society

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⁎ Corresponding author. E-mail addresses: [email protected] (E.L. Giles), [email protected] (S. Robalino), [email protected] (F.F. Sniehotta), [email protected] (J. Adams), [email protected] (E. McColl).

http://dx.doi.org/10.1016/j.ypmed.2014.12.029 0091-7435/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

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Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . Statement of principal findings . . . . . . . . . . . . . . . . Strength and weaknesses of included work . . . . . . . . . . Strengths and weaknesses of this review . . . . . . . . . . . Interpretation of findings and implications for policy, practice Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethics approval . . . . . . . . . . . . . . . . . . . . . . . . . Financial disclosure . . . . . . . . . . . . . . . . . . . . . . . Conflict of interest statement . . . . . . . . . . . . . . . . . . . Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . Appendix A. Supplementary data . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . .

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This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines (Moher et al., 2009). Given the nonstandard nature of the inclusion criteria and data collected, we did not register our protocol in advance. A copy of the a-priori protocol is available from the authors on request. No substantive changes to the protocol were made.

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Information sources

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Electronic databases were searched from the earliest date available (indicated in brackets below) until 1st October 2014, for primary research and scholarly

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Poor engagement in healthy behaviours is a key determinant of morbidity and mortality and results in social, healthcare and economic costs (Swann et al., 2010). Despite efforts to encourage healthy behaviours, unhealthy behaviours remain common (Department, Of Health, 1998, 2004). Providing financial incentives to encourage healthy behaviours is one method to encourage uptake of healthy behaviours. Health promoting financial incentives (HPFI) are cash or cash-like rewards provided contingent on performance of healthy behaviours (Adams et al., 2013). Our recent systematic review of the effectiveness of HPFI found that financial incentives were around 1.5 to 2.5 times more effective for promoting healthy behaviours than no intervention or usual care (Giles et al., 2014). In the United States of America (USA), the 2010 Affordable Care Act allowed employers to offer rewards, or impose penalties, for those meeting healthy behaviour targets such as quitting smoking (Madison et al., 2011). Similar HPFI operate within the German social health insurance scheme (Schmidt, 2008). In the United Kingdom (UK), the current government has signalled their interest in using HPFI as part of their ‘nudge’ agenda (Department, Of Health, 2010). Despite this empirical and political support for HPFI, the acceptability of HPFI interventions has been questioned (Cookson, 2008; Popay, 2008). Acceptability of public health interventions must be considered from the point of view of a number of stakeholders. In relation to HPFI, these include potential recipients, professionals and policy makers responsible for intervention implementation, and the general public who may finance interventions through taxation. All of these groups must be willing and able to engage with an intervention (Craig et al., 2008), if HPFI are to be widely implemented. Acceptability of interventions can be explored in primary research. However, scholarly critique also constitutes valuable evidence, as it is likely to reflect the opinion of important stakeholders. We conducted a review to bring together both empirical evidence and scholarly writing on the acceptability of HPFI. We were particularly interested in what features of HPFI have been identified as potentially acceptable and unacceptable, the range of methods that have been used to determine acceptability, and the range of individuals in which acceptability has been explored.

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writing, exploring the acceptability of HPFI. Databases searched were: Medline (1946), Embase (1980), Web of Knowledge (1970), Cumulative Index to Nursing and Allied Health Literature (1981), PsycINFO (1806), Applied Social Science Index and Abstracts (1970), Sociological Abstracts (ProQuest, 1952), Scopus (1960), The Philosopher's Index (OVID, 1940), the Cochrane library (Issue 3), Social Science Citation Index (1970) and the International Bibliography for the Social Sciences (1951). An example of the full electronic search used in Medline is shown in Appendix A. The search was adapted as required for other databases. All studies included in our systematic review of the effectiveness of HPFI (Giles et al., 2014) were considered for inclusion, and reference and citation searches of included papers as well as relevant reviews identified in the search were conducted.

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Papers that met the following criteria were included: had an English language title; were published in a peer-reviewed journal; and explored the acceptability of HPFI from the perspective of: members of the public, potential recipients, potential practitioners who may be involved in delivering HPFI, or policy makers. Specifically, all included papers used the term ‘acceptable’, ‘accept’, ‘acceptability’, ‘unacceptable’ ‘ethics’, ‘moral’ or some variation of these. HPFI were defined as cash or cash-like rewards, which were provided contingent on change in a healthy behaviour. Only papers exploring acceptability of HPFI delivered to adults living in high income economies (defined by the World Bank as those countries with a Gross National Income of $12,276 or more per capita in 2010) were included. Empirical studies were defined as papers reporting primary data. Scholarly writing was defined as referenced writing; for example, position papers and editorials (Cookson, 2008; Madison et al., 2011; Popay, 2008; Schmidt, 2008).

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Paper selection and data collection

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After exclusion of duplicates, one researcher (ELG) screened titles and excluded those definitely not relevant. Next, the same researcher screened remaining titles and abstracts, again excluding those definitely not relevant. Finally, remaining full texts were screened by two researchers independently (ELG & JA) to identify those meeting the inclusion criteria. If in doubt, papers were retained at any stage for inspection by both reviewers, with disagreements resolved by discussion.

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Quality assessment

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Quality assessment of scholarly writing was not undertaken as no appropriate tool could be identified. The quality of empirical research papers using qualitative methods was assessed using a tool developed for this purpose (Barnard et al., 2010; Petticrew and Roberts, 2005). Papers using quantitative methods were assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool (Effective Public Health Practice Project, 2009). Two researchers (ELG and JA) conducted quality appraisal independently and disagreements were resolved by discussion. Papers using mixed methods were appraised using both tools as appropriate.

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Synthesis of results

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Data was extracted by one researcher (ELG) and summarised in tabular 162 form. Empirical studies were considered to be too heterogeneous for meta- 163 analysis. Although three studies did use, or adapt, the same questionnaire, 164

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

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Eighty one papers met the inclusion criteria: 22 empirical studies (Allan et al., 2012; Arterburn et al., 2008; Bonevski et al., 2011, 2012; Cameron and Ritter, 2007; Ducharme et al., 2010; Hoddinott et al., 2014; Kim et al., 2011; Long et al., 2008; Luyten et al., 2013; Lynagh et al., 2011; Mantzari et al., 2012; Meads et al., 2013; Meredith et al., 2011; Mhurchu et al., 2011; Park et al., 2012; Parke et al., 2013; Promberger et al., 2011, 2012; Raiff et al., 2013; Ritter and Cameron, 2007; Thomson et al., 2012) and 59 pieces of scholarly writing (see Fig. 1 and Tables 1 and 2) (Ashcroft, 2011; Ashcroft et al., 2008; Aveyard and Bauld, 2011; Axtell-Thompson, 2012; Blacksher, 2008; Blumenthal-Barby and Burroughs, 2012; Burry, 2006; Cawley, 2014;

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Results

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Cookson, 2008; Dreger, 2012; Donatelle et al., 2004; Grant, 2002; Grant, 2006; Goel, 2012; Halpern et al., 2009; Haveman, 2010; Higgins et al., 2012; Horwitz et al., 2013; Kennedy, 2012; Klein, 2012; Klein and Karlawish, 2010; Kowal, 2006; Lawson and Howard, 2012; Lesser and Puhl, 2014; Lewis, 2008; Loeppke, 2012; London et al., 2012; Lunze and Paasche-Orlow, 2013; Luyten et al., 2011; Madison et al., 2011; Malone and Jason, 1990, Marteau et al., 2009; Marteau et al., 2008; Meredith et al., 2014; O'Donnell, 2012; Oliver, 2009; Oliver, 2012; Oliver and Brown, 2012; Pearson and Lieber, 2009; Petry, 2010; Popay, 2008; Robison, 1998; Roozen, 2009; Schmidt, 2008, 2012, 2009a, 2009b, 2012; Schmidt et al., 2009a; 2009b; 2012; Serxner, 2013; Sindelar, 2008; Stephens, 2014; Ten Have et al., 2013; Terry, 2013; Terry and Anderson, 2011; Voigt, 2012; Volpp and Galvin, 2014; Volpp et al., 2009; Volpp et al., 2011; Wu, 2012). Further three papers were included at the title and abstract stage but none of these texts could be located (Botelho, 2012; McCormack, 1996; TUTEN et al., 2012) and they were excluded from the review. Empirical studies collected data using surveys (n = 13), including one Discrete Choice Experiment (Promberger et al., 2012); (Arterburn et al., 2008; Bonevski et al., 2012; Hoddinott et al., 2014; Kim et al., 2011; Long et al., 2008; Luyten et al., 2013; Lynagh et al., 2011; Meads et al., 2013; Meredith et al., 2011; Park et al., 2012; Promberger et al., 2011; Raiff et al., 2013; Ritter and Cameron, 2007), individual semistructured interviews (n = 3) (Allan et al., 2012; Cameron and Ritter, 2007; Mantzari et al., 2012), mixed methods (n = 4) (Bonevski et al., 2011; Ducharme et al., 2010; Mhurchu et al., 2011; Thomson et al., 2012) and one thematic analysis of media coverage (Parke et al., 2013). Study populations were primarily members of the public (n = 17) (Allan et al., 2012; Arterburn et al., 2008; Bonevski et al., 2012; Hoddinott et al., 2014; Kim et al., 2011; Long et al., 2008; Luyten et al., 2013; Lynagh et al., 2011; Mantzari et al., 2012; Meads et al., 2013; Meredith et al., 2014; Mhurchu et al., 2011; Park et al., 2012; Promberger et al., 2011, 2012; Raiff et al., 2013; Thomson et al., 2012), or health professionals and managers (n = 3) (Cameron and Ritter, 2007; Ducharme et al., 2010; Ritter and Cameron, 2007). One

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adaptations were so substantial that there was too little combinable data to justify meta-analysis (Long et al., 2008; Lynagh et al., 2011). Instead, thematic synthesis of all included papers was undertaken, focusing on issues related to the acceptability of HPFI. In this, findings from empirical studies were integrated with issues discussed in scholarly writing. The full texts of included papers were uploaded into NVivo 10 QSR International software and thematically coded (Barnett-Page and Thomas, 2009). The first stage involved close reading and identification of codes (Bryman, 2004; Strauss, 2003). Next, papers were re-read and codes were checked to ensure that no data was missed. Thirdly, codes were sorted into categories, with some codes being merged with others or re-named, and new codes emerging. Finally, codes were interpreted in light of the research questions. The first three stages were completed by one researcher (ELG). The final stage was led by one researcher (ELG) with discussion and verification by a second (JA). Once the coding was finalised a narrative was built by describing, linking and interpreting the codes. The themes are presented in the results, with representative quotes illustrating each theme presented in boxes. In addition, these quotes provide ‘evidence’ to support our results and justification for the conclusions we draw. Each quotation included in the boxes is identified both by a formal citation, and as either an ‘empirical paper’ or ‘scholarly writing’ to clarify the source of different statements. A citation map was drawn to show the citation links between included papers. This allowed key papers in the corpus of included papers to be identified.

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Fig. 1. PRISMA flow diagram.

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

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Table 1 Summary of aims, methods and participants in empirical studies included in the review. Paper

Aim

Methods (n)

Participants

Country

t1:4

Allan et al. (2012)

Interviews (n = 14).

Adults aged 27–61, who were registered on the Quit4U database.

UK

t1:5

Arterburn et al. (2008)

Telephone survey (n = 153).

Adults aged 18–79, insured for at least two years, BMI N25 kg/m2, with health conditions.

USA

t1:6

Bonevski et al. (2011)

To explore the reasons why individuals eligible to receive a financial incentive for smoking cessation fail to collect the reward. To describe the attitudes of adult patients with metabolic syndrome, towards hypothetical financial incentive programmes, where rewards are linked to enrolment in weight management programmes and weight loss. To explore perceptions on financial incentives for smoking cessation.

Disadvantaged welfare agency clients who smoked. Relevant staff and managers.

Australia

t1:7

Bonevski et al. (2012)

Six client focus groups (n = 32), six staff focus groups (n = 35), in-depth interviews with managers (n = 8). Self-administered survey with those taking part in focus groups (n = 67). In-person survey (n = 383).

t1:8

Cameron and Ritter (2007)

Qualitative individual interviews (n = 30).

Australia

t1:9

Ducharme et al. (2010)

t1:10

Hoddinott et al. (2014)

Drug and alcohol practitioners, service managers and policy-makers. Substance abuse treatment counsellors. Representative sample of adults.

t1:11

Kim et al. (2011)

USA

t1:12

Long et al. (2008)

USA

t1:13

Luyten et al. (2013)

Survey (n = 1049).

Worksite (General Electric) smokers. Patients waiting in primary care practice waiting rooms. Representative sample of adults.

t1:14

Lynagh et al. (2011)

Self-administered survey (n = 213).

Pregnant smokers.

Australia

t1:15

Mantzari et al. (2012)

Pregnant women.

UK

t1:16

Meads et al. (2013)

NHS patients.

UK

t1:17

Meredith et al. (2011)

Qualitative individual interviews (n = 36). Contingent valuation survey (n = 132). Contingency management programme and an exit interview (n = 15).

Healthy smokers.

USA

t1:18 Q1

Mhurchu et al., 2012

Pacific and Maori individuals, Auckland, New Zealand.

New Zealand

t1:19

Park et al. (2012)

Six focus groups (n = 36) and self-administered survey with all participants. In-person survey (n = 1010).

Individuals living in the US.

USA

t1:20

Parke et al. (2013)

Thematic content analysis (n = 210 included articles).

UK

t1:21 t1:22

Promberger et al. (2011) Promberger et al. (2012)

National and local news coverage in newspapers, popular websites and news-media targeted at health care providers. Individuals living in the UK and US. Individuals living in the UK.

t1:23

Raiff et al. (2013)

Smokers, non-smokers and healthcare providers.

USA

t1:24

Ritter and Cameron (2007)

t1:25

Thomson et al. (2012)

235 236 237 238 239 240 241 242 243 244

Cross-sectional survey (n = 1144).

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Telephone survey (n = 317).

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To assess public support for financial incentives to promote smoking cessation. To describe UK mass media coverage of incentive schemes targeted at different client groups.

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To assess the acceptability of financial incentives. To assess whether the acceptability of financial incentives is affected by their effectiveness, the incentive format and the target behaviour. To assess the acceptability of an internet-based contingency management intervention.

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To identify clinician's attitudes towards contingency management. To investigate the uptake, impact and meanings of a breastfeeding incentive intervention.

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Self-administered survey (n = 458).

On-line survey (n = 188). Three discrete choice experiments (n = 699). Two internet-based contingency management experiments and an acceptability questionnaire (n = 536). Survey (n = 102). In-depth interviews (n = 26).

study included a mixed population of clinicians, health professionals, administrative staff and members of the public (Bonevski et al., 2011), and one study reported the content of media coverage of relevant information (Parke et al., 2013). Quality appraisal of empirical studies is summarised in Fig. 2 and Table 3. Qualitative studies were largely rated as ‘good’. However many quantitative studies did not include a clearly representative sample, justify their sample size, or provide good evidence of generalisability of findings. Acceptability is, by its nature, subjective. Nevertheless, no aspects of reliability or validity of survey instruments were discussed or

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Socially disadvantaged individuals.

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Mailed surveys (n = 1959).

C

To assess counsellor attitudes towards financial incentives. To survey public attitudes towards financial incentives for smoking cessation during pregnancy and breastfeeding. Process evaluation of a worksite intervention to promote smoking cessation. To report on the acceptability of financial incentives for patients. To assess public preferences on vaccination policy options. To report on the acceptability of financial incentives. To explore how financial incentives can encourage pregnant women to quit smoking. To explore the acceptability and pricing of financial incentives in NHS patients. To develop an internet-based contingency management smoking cessation programme, and to evaluate the feasibility and acceptability of the programme. To explore public opinion on the use of financial incentives to promote healthier food purchases.

T

To assess the acceptability of financial incentives; the factors associated with acceptability; and preferred incentive amounts. To assess the efficacy and effectiveness of contingent financial incentives.

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t1:3

Australia

USA UK

Belgium

UK and USA UK

Drug and alcohol treatment clinicians Australia and programme managers. Women initiating breastfeeding. UK

reported. Three studies used adaptations of the same survey instrument 245 (Long et al., 2008; Lynagh et al., 2011). 246 Citation mapping

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Fig. 3 shows the number of times that included papers were cited by other included papers. Forty two included papers cited at least one other included paper, and 40 were cited by at least one other included paper. The most frequently cited papers were Marteau et al. (2009) – a piece of scholarly writing in a high profile general medical

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Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

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Table 2 Summary of scholarly writing included in the review. Paper

Description

Countrya

t2:4 t2:5 t2:6 Q2 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20 t2:21 t2:22 t2:23 t2:24

Ashcroft et al. (2008) Ashcroft (2011) Aveyard and Bauld (2011) Axtell-Thompson (2012) Blacksher (2008) Blumenthal-Barby and Burroughs (2012) Burry (2006) Cawley (2014) Cookson (2008) Donatelle et al. (2004) Dreger (2012) Goel (2012) Grant (2002) Grant (2006) Halpern et al. (2009) Haveman (2010) Horwitz et al. (2013) Kennedy (2012) Klein (2012) Klein and Karlawish (2010)

A response to an article by Cookson (2008) and Popay (2008). Review of ethical controversies surrounding financial incentives for health promotion, with a focus on personal autonomy. A response to a systematic review summarising the effectiveness of incentives for smoking cessation (Cahill and Perera, 2011). Discussion paper prompted by changes in health care plans. Discussion paper prompted by policy proposals in the US. Discussion paper prompted by rising interest in the use of financial incentives for encouraging healthy behaviours.

UK UK UK USA USA USA Australia USA UK USA USA USA USA USA USA USA USA USA USA USA

t2:25

Kowal (2006)

t2:26 t2:27 t2:28 t2:29

Lawson and Howard (2012) Lesser and Puhl (2014) Lewis (2008)

Discussion paper prompted by social contracts between the Australian Government and Aboriginal communities. An essay prompted by changes to the Patient Protection and Affordable Care Act of 2010. Discussion paper prompted by the increasing use of financial incentives to encourage individuals to look after their own health. Review of the literature surrounding incentive and contingency management interventions to promote smoking cessation. Review of the literature surrounding wellness programmes. Discussion paper prompted by a peer-reviewed article (Oliver, 2012). Discussion paper prompted by the perceived need to clarify the meaning of “incentive”. Discussion paper prompted by the rising use of incentives by government and private institutions to actualise policy agendas. Discussion paper prompted by the increasing use of financial incentives by government and corporation health plan leaders. Discussion paper prompted by the increasing use of financial and non-financial incentives in health care. Review of the literature focusing on randomised controlled trials to identify challenges for workplace wellness programmes. Discussion paper prompted by a peer-reviewed article (Oliver, 2012). Discussion paper prompted by the 20th anniversary of the ‘four models’ framework on the physician–patient relationship. Discussion paper prompted by the increasing use of incentives to change health behaviours and a lack of prior evidence on the appropriateness of incentives use for older adults. Discussion paper prompted by health-related shared responsibility agreements signed between the Australian Government and Indigenous communities. Discussion paper prompted by a peer-reviewed article (Oliver, 2012).

USA USA

t2:30 t2:31 t2:32 t2:33 t2:34 t2:35 t2:36 t2:37 t2:38 t2:39 t2:40

Loeppke (2012) London et al. (2012) Lunze and Paasche-Orlow (2013) Luyten et al. (2011) Madison et al. (2011) Malone and Jason (1990) Marteau et al. (2008) Marteau et al. (2009) Meredith et al. (2014) O'Donnell (2012)

Discussion paper prompted by changes to the Patient Protection and Affordable Care Act of 2010. Discussion paper prompted by a desire to investigate whether contingency management is a useful intervention for treating substance abuse. Guidance on outcome-based incentive schemes, based on a summary of a review of the literature and expert discussions. Discussion paper prompted by a lack of guidance on the ethics of financial incentives. Discussion paper prompted by the increasing use of economic incentives for healthy behaviours.

Belgium USA USA UK UK USA USA

t2:41 t2:42 t2:43 t2:44 t2:45 t2:46

Oliver (2009) Oliver (2012) Oliver and Brown (2012) Pearson and Lieber (2009) Petry (2010) Popay (2008)

t2:47 t2:48 t2:49 t2:50 t2:51 t2:52 t2:53

Robison (1998) Roozen (2009) Schmidt (2008) Schmidt et al. (2009) Schmidt et al. (2009) Schmidt et al. (2012) Schmidt (2012)

t2:54 t2:55 t2:56 t2:57

Serxner (2013) Sindelar (2008) Stephens (2014) Ten Have et al., 2012

t2:58 t2:59

Terry (2013) Terry and Anderson (2011)

t2:60 t2:61 t2:62 t2:63 t2:64 Q6 t2:65

Voigt (2012) Volpp et al. (2009) Volpp et al. (2011) Volpp and Galvin (2014) Wharf Higgins 2012 Wu (2012)

Discussion paper prompted by the increasing challenges posed to governments bodies in improving public health. Discussion paper prompted by the increasing use of financial incentives to promote healthy behaviours. Discussion paper prompted by smoking cessation interventions at individual and group levels. A response to a published book summarising the use of nudges (Thaler and Sunstein, 2008). Discussion paper prompted by the increasing use of financial incentives to change behaviours. Integrated review paper prompted by the increasing use of contingency management programmes. Discussion paper prompted by the increasing use of financial incentives in a workplace setting; and the Affordable Care Act allowing employers to provide discounts for health-promoting behaviours. Discussion paper prompted by increasing research interests into financial incentives. Discussion paper in response to a published book summarising the use of nudges (Thaler and Sunstein, 2008). Discussion paper prompted by the use of financial incentives in health policy. Discussion paper prompted by the use of financial incentives schemes by employers to promote healthy behaviours. Discussion paper prompted by scientific research into contingency management. Discussion paper prompted by the increasing use of financial incentives to encourage individuals to look after their own health. Discussion of four main problems related to reinforcement schemes. A review of other studies on incentives. Discussion paper prompted by the increasing use of bonuses in the German social health insurance market. Discussion paper prompted by the increasing use of bonuses in prevention programmes. Discussion paper prompted by the (then) current health reform bill. Discussion paper prompted by the increasing use of incentives in the workplace setting. Discussion paper prompted by the increasing use of bonuses in the German social health insurance market, given the first introduction of the Statutory Health Insurance Scheme in 1989. Strategic thought paper prompted by the increasing use of incentives within population health management. Discussion paper prompted by recent innovations in economic theory. A response to an article by Lynagh, Sanson-Fisher and Bonevski (2012). Development of an ethical framework on programmes to prevent overweight and obesity prompted by a rise in the use of such programmes. Discussion paper prompted by changes to the Patient Protection and Affordable Care Act of 2010. Discussion paper prompted by controversy surrounding incentives, authorised by the Patient Protection and Affordable Care Act. Discussion paper prompted by the increasing use of incentives in health policy. Discussion paper prompted by increasing use of Pay for Performance schemes. Discussion paper prompted by Section 2705 of the Patient Protection and Affordable Care Act. Discussion paper prompted by the increasing use of financial incentives for healthy behaviours. Discussion paper prompted by a peer-reviewed article (Oliver, 2012). Discussion paper prompted by an idea to propose a novel pay-for-performance programme to reward achievement of health goals.

t2:66

a

U

N C O

R

R

E

C

T

E

D

P

R O

O

F

t2:3

Australia USA

USA USA USA

UK USA UK USA USA UK

Q3

USA The Netherlands UK UK USA USA USA USA USA New Zealand The Netherlands USA USA UK USA USA USA USA USA

This is the country in which the first author was based at the time of publication.

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

Q4 Q5

F

O

Is there a clear statement of findings?

Was the data analysis sufficiently rigorous?

Have ethical issues been taken into consideraon?

P

Bonevski, Bryant & Paul, 2011

R O

Allan, Radley & Williams, 2012

Has the relationship between researcher and participant been adequately considered?

Was the data collected in a way that addressed the research issue?

Was the recruitment strategy appropriate to the aims?

Was the research design appropriate to the aims?

Is a qualitative methodology appropriate?

E.L. Giles et al. / Preventive Medicine xxx (2015) xxx–xxx

Was there a clear statement of aims?

6

Cameron and Rier, 2007

E

D

Ducharme et al., 2010

Mantzari, Vogt & Marteau,

C

T

2012

E

Mhurchu et al., 2011

R

Thomson et al., 2012

R

Parke et al., 2013

journal – and Long et al., (2008) – an empirical study describing the survey instrument used in subsequent research.

C

253 254

O

Fig. 2. Quality assessment of qualitative empirical papers.

What makes HPFI acceptable or unacceptable?

256 257

The thematic synthesis identified five themes: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Most included papers explored acceptability from the point of view of the general public. Where this was not the case, this is highlighted in Tables 1 and 2 and in the discussion below.

259 260 261 262 263 264 265 266 267 268 269

U

258

N

255

Theme 1: fair exchange Health promoting financial incentives involve an exchange between the recipient and the incentive provider. The recipient benefits from both the behaviour incentivised and the incentive offered, whilst the provider benefits from the improvement in public health brought about by the change in behaviour. This ‘fair exchange’ was identified as an important aspect of acceptability by a number of authors (see Box 1a).

Some authors of included papers argued that if parties act voluntarily, the mutual benefits of HPFI make them acceptable. This was the case when HPFI offset the opportunity costs of giving up non-healthy behaviours, providing additional motivation for behaviour change (see Box 1b). Other authors argued that as the target recipients of HPFI are often vulnerable groups, who are most in need of financial resources, the choice to engage is rarely ‘voluntary’. Instead, these authors view HPFI as coercive (Blumenthal-Barby and Burroughs, 2012). The ‘fair exchange’ of HPFI is also contested by some who argue that HPFI discriminate against those who pursue healthy behaviours without the need for incentives and those who are unable to comply with behavioural change programmes (see Box 1c) (Schmidt et al., 2009).

270 271

Theme 2: design and delivery of HPFI Health promoting financial incentives are complex interventions that can vary in at least nine domains (Adams et al., 2013). The design and delivery of HPFI, in part, contributed to whether they were perceived as acceptable or not. Additionally, if HPFI were found to be effective, they tended to be more accepted. In general, if HPFI are safe, focused on the recipients, minimise intrusion into their daily lives, and

283 284

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

272 273 274 275 276 277 278 279 280 281 282

285 286 287 288 289

E.L. Giles et al. / Preventive Medicine xxx (2015) xxx–xxx Table 3 Quality assessment of quantitative empirical papers.

t3:3

Study

t3:4 t3:5 t3:6 t3:7 t3:8 t3:9 t3:10 t3:11 t3:12 Q7 t3:13 t3:14 t3:15 t3:16 t3:17 t3:18 t3:19 t3:20 t3:21 t3:22 Q8 t3:23 t3:24 t3:25 t3:26

Was a survey What was the appropriate response rate? for the aim?

Is the sample Are the measures representative reported objective of the population? and reliable?

Was there a Were appropriate Was there justification of statistical evidence of the sample size? analyses any other bias? performed?

Surveys Arterburn et al. (2008) Bonevski et al. (2012) Kim et al. (2011) Hoddinott et al. (2014) Long et al. (2008) Luyten et al. (2013) Lynagh et al. (2011) Meads et al., 2014 Meredith et al. (2011) Park et al. (2012) Promberger et al. (2011) Raiff et al. (2013) Ritter and Cameron (2007)

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes. Yes Yes

79% 69% Unclear Unclear 89% Unclear 90% Unclear Unclear 93%. UK = 59 US = 8% Unclear 19%.

Yes Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear

No No Unclear Unclear No Unclear No Unclear Unclear No Unclear Unclear Unclear

No No No Yes No. No No No No Yes No Yes No

Mixed methods Bonevski et al. (2011) Ducharme et al. (2010)

Yes Yes

Unclear Unclear

Hoddinnot et al., 2014 Mhurchu et al. (2011)

Yes Yes

100% CTN = 61% Non-CTN = 60% OTP = 58 Unclear Unclear

Unclear Unclear

No No objective measures. Discussion of reliability. Unclear Unclear

Discrete choice experiment Promberger et al. (2012)

Yes

Study 1: = 20% Study 2: = 33% Study 3: not stated

Unclear

No

Yes Unclear Yes Yes Yes Yes Yes Unclear Unclear Yes Yes Yes Yes

Yes Unclear

No Yes

Yes Yes

Yes No

Yes Yes

Yes Yes

No

Yes

Yes

R O

O

F

No Yes Yes Yes Yes Yes Yes Unclear Unclear Yes Yes Yes Yes

299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324

T

C

E

297 298

R

295 296

R

293 294

are of an effective – but not too large – amount, then they are viewed as acceptable. Two particular concerns were raised in reference to appropriate providers of HPFI. Firstly, empirical research has found that many socioeconomically disadvantaged individuals are not willing to accept government funded HPFI under any circumstances — although reasons for this have not been explored. Secondly, the potentially negative impact of HPFI administered by doctors on doctor–patient relationships is considered problematic (see Box 2a). Incentives which are provided with higher frequency (Volpp et al., 2009, 2011) and nearer to the point of behaviour were considered more acceptable (see Box 2b) (Schmidt et al., 2012). Providing flexible incentives, particularly as cash, gives recipients more choice over how they use incentive payments and may be preferred by recipients (Schmidt et al., 2009). However, shopping vouchers were viewed as more acceptable to both the general public and practitioners involved in helping disadvantaged smokers quit (Bonevski et al., 2011; Mhurchu et al., 2011), as they provide some control on recipients' spending. Similarly, there were arguments in included papers favouring both incentives for process behaviours (e.g. attending behaviour change sessions) and for behavioural outcomes (e.g. smoking cessation) (Robison, 1998; Schmidt et al., 2012; Volpp et al., 2009). These contrasting opinions likely reflect the varying population groups in which acceptability of HPFI was explored (see Box 2c).

N C O

291 292

U

290

E

D

P

t3:1 t3:2

7

Theme 3: effectiveness and cost-effectiveness of HPFI There was a strong consensus that if HPFI have been demonstrated to be effective and cost-effective (Volpp et al., 2009), they are more likely to be acceptable. One included empirical paper confirmed this relationship between effectiveness and acceptability, reporting that the acceptability of hypothetical HPFI to members of the public increased as stated effectiveness increased (see Box 3a) (Promberger et al., 2012). In contrast, some arguments in favour of cost-effectiveness were highly simplistic. For example, one author argued that HPFI do not incur financial costs to providers until behaviour change has occurred. This ignores the costs of, for example, front line staff introducing and

explaining programmes to participants (Giles et al., 2014; Johnston and Sniehotta, 2010). There is a growing evidence that HPFI can be as effective as other behaviour change strategies (Cahill and Perera, 2008; Giles et al., 2014; Kane et al., 2004; Kavanagh et al., 2009), but little evidence for cost-effectiveness has been published (see Box 3b). A common criticism of HPFI was that they offer only short term motivation. Additionally, external motivators are argued to reduce internal motivation for change, hence offering limited support for long term change once HPFIs are removed (Robison, 1998). Some authors argue that these issues are inherent limiters of effectiveness and hence acceptability. Others argue that this only means HPFI need to be used within the context of a wider behaviour change and maintenance programme (see Box 3c).

325

Theme 4: recipients of HPFI Pregnant women and disadvantaged groups were generally thought of as appropriate, or deserving, groups for HPFI. However, more vulnerable groups were also identified as at most risk of being coerced into behaviour change by HPFI. There was a consistent finding that individuals currently engaging in behaviours identified as potential targets for HPFI rated incentives as more acceptable than those who did not stand to gain immediately from HPFI (see Box 4a). One paper argued that American drug and alcohol clinicians are more accepting of HPFI than Britons or Australians because of relevant international differences in the transactional nature of healthcare provision (see Box 4b) (Ritter and Cameron, 2007). Some concern was raised with providing cash incentives to help control substance misuse as rewards could be used to fund the very behaviour it is designed to prevent (Roozen, 2009). In practice, programmes circumvent this by providing vouchers that can be exchanged for a limited range of goods and services, rather than cash, and this likely influences why vouchers tend to be considered more acceptable to both the public and drug and alcohol practitioners (see Box 4c) (Cameron and Ritter, 2007; Oliver and Brown, 2012; Parke et al., 2013; Petry, 2010).

338

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

326 327 328 329 330 331 332 333 334 335 336 337

339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358

E.L. Giles et al. / Preventive Medicine xxx (2015) xxx–xxx

C

T

E

D

P

R O

O

F

8

R

R

O

363

reward (see Box 5a). The large number of other barriers to healthy behaviours that have been identified, suggests that this is simplistic (Axtell-Thompson, 2012). In contrast, some authors argued that HPFI are paternalistic and undermine individual autonomy by placing undue emphasis on bringing one's behaviour into line with that deemed

Box 1 Quotations to illustrate the ‘Fair exchange’ theme.

C

361 362

Theme 5: impact of HPFI on individuals and wider society Some authors argued that HPFI can encourage individuals to take responsibility for themselves, thereby promoting autonomy (Marteau et al., 2009). This assumes that all individuals wish to pursue healthy behaviours, and all that holds them back is the absence of a short term

1a “… The person offering the incentive means to make one choice more attractive to the person responding to the incentive than any other alternative. Both parties stand to gain from the resulting choice.” (Scholarly paper; Grant, 2002: page 29) 1b “In some cases, incentives take the form of additional money that could help counterbalance some of the costs of engaging in healthier behaviours, such as the costs of physician visits, the costs of fresh produce…” (Scholarly paper; Madison et al., 2011: page 16). “Bonuses are viewed as a way of incentivizing and rewarding responsible behaviour.” (Scholarly paper; Schmidt, 2008: page 199). “In such cases, cash payments may be used, not to induce the recipient to choose something they would not otherwise choose, but to provide an immediate positive reward for complying with short-term steps necessary to effectuate a longer term goal.” (Scholarly paper; Madison et al., 2011: page 16). 1c “… Coercion typically works by forcing an agent to do something through fear of the consequences of not doing it.” (Scholarly paper; Long et al., 2008: page 195). “…researchers, clinicians and society have voiced concerns about CM [contingency management] interventions … calling it ‘unethical to pay people for what they should be doing anyway’.” (Scholarly paper; Petry, 2010: page 105). “Attainment incentives provide welcome rewards for employees who manage to comply but may be unfair for those who struggle, particularly if they fail.” (Scholarly paper; Schmidt et al., 2009: page e3(1))

N

360

U

359

E

Fig. 3. Citation mapping — cited by another included paper.

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

364 365 366 367 368

E.L. Giles et al. / Preventive Medicine xxx (2015) xxx–xxx

9

Box 2 Quotations to illustrate the ‘Design and delivery of HPFI’ theme.

380 381 382

D

E

T

C

379

E

377 378

R

375 376

Box 3 Quotations to illustrate the ‘Effectiveness and cost-effectiveness’ theme.

R

373 374

Some authors proposed that HPFI offer the potential to enhance community spirit by providing opportunities to engage in collective action to reduce the negative impacts of individual lifestyle choices and behaviours (Ashcroft et al., 2008). Alongside the perception that HPFI are particularly attractive to more disadvantaged individuals, this is suggested as a potential mechanism for decreasing socio-economic inequalities in health (see Box 5d) (Voigt, 2012). In contrast, other authors argued that, as barriers to change are fewer in more advantaged communities, HPFI may be most effective in these groups and so exacerbate health inequalities (Oliver, 2009). There is growing evidence that a range of public health and health care interventions that rely on voluntary behaviour change are more effective in more affluent groups leading to a widening of inequalities (see Box 5e) (Capewell and Graham, 2010; White et al., 2009).

N C O

371 372

acceptable by providers of HPFI (see Box 5b) (Halpern et al., 2009; Marteau et al., 2009). Some commentators raised the possibility that HPFI may provide perverse incentives to engage in unhealthy behaviours or encourage individuals to ‘game the system’ (Aveyard and Bauld, 2011; Axtell-Thompson, 2012). Although there is some evidence from Honduras (Lagarde et al., 2007) that the introduction of HPFI associated with a number of ‘well child’ behaviours was associated with an increase in the fertility rate, documented accounts of widespread ‘gaming the system’ are rare (see Box 5c). The potential for a perpetuating cycle of personal failure was also discussed. Lack of success in behaviour change, emphasised by failure to gain a reward, may lead to demotivation and even greater difficulty in future attempts at behaviour change.

3a “Potentially large health benefits [result] from a modest increase in health expenditure” (Scholarly paper; Marteau et al., 2009: page 984) “A particularly attractive feature of financial incentive[s], when tied to the outcome of weight loss, is that payments occur only when weight loss is achieved. Thus, individuals who do not achieve any weight loss do not place any additional financial burden on purchasers, beyond the costs of supervised weigh-ins.” (Empirical paper; Arterburn et al., 2008: page 75) 3b “Many of these problems are the same as those reported in research on targeted means tested policies. These programmes are difficult to target, administratively costly, and they have little transformative potential at the individual or societal level.” (Scholarly paper; Popay, 2008: page 141) “Waste of money — Poor use of the public purse, where there are many competing demands.” (Scholarly paper; Marteau et al., 2009: page 984) “…many people question the effectiveness of incentive programmes in improving health.” (Editorial paper, page 5)6 “Programmes that incentivize behaviors might also be wasteful if they promote efforts to achieve better health in one particular way, when another, less costly or more easily attainable route might have been equally or more successful.” (Scholarly paper; Madison et al., 2011: page 19) 3c “One consistently mentioned issue is that the behavior will revert to baseline once reinforcers are no longer offered.” (Scholarly paper; Petry, 2010: page 1507) “It is commonly argued that external reinforcement strategies are advantageous for promoting initial change…However, a considerable body of experimental evidence indicates that motivators can actually decrease internal motivation to perform a wide variety of targeted behaviors.” (Scholarly paper; Robison, 1998: page 4) “The concept of incentives carries an inherent risk of undermining personal responsibility for health and people's intrinsic motivations to promote their own health. Provision of incentives may diminish people's sense of responsibility to contribute to the common good.” (Scholarly paper; Lunze and Paasche-Orlow, 2013: page 661)

U

369 370

P

R O

O

F

2a “For instance, a monetary payment, if administered from the doctor to the patient, might damage the traditional trust-based nature of the doctor– patient relationship.” (Scholarly paper; Oliver and Brown, 2012: page 220) 2b “Even with other health behaviors, Warner and Murt found that larger rewards had a greater impact than smaller ones, and repeated reinforcement was preferable to one-time incentives.” (Scholarly paper; Malone and Jason, 1990: page 318) 2c “Participants stressed that such a programme should be easy to use, with rewards that could be either accumulated or used at a time that suited them.” (Empirical paper; Mhurchu et al., 2011: page 336) “The framing of questions appears to matter, with respondents replying more favorably when statements were framed as rewards as opposed to punishments.” (Empirical paper; Long et al., 2008: page 1651) “In health promotion, the most frequent misuse of reinforcement occurs when it is applied to outcomes rather than behaviors.” (Scholarly paper; Robison, 1998: page 2) “Attainment-incentive programmes make no distinction between those who try but fail and those who do not try.” (Scholarly paper; Schmidt et al., 2012: page e3(2)) “… people may be more motivated to avoid loss (ie, penalties or surcharges) than to make equivalent gains. Others believe that rewards for healthy behavior are more consistent with … creating a partnership culture.” (Scholarly paper; Loeppke, 2012: page 894)

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

383 384 385 386 387 388 389 390 391 392 393 394 395 396

10

E.L. Giles et al. / Preventive Medicine xxx (2015) xxx–xxx

Box 4 Quotations to illustrate the ‘Recipients of HPFI’ theme.

P

R O

O

F

4a “Among participants in one study, smokers were significantly more likely to think that it is a good idea to pay smokers to quit smoking, and obese participants were more likely to think it is a good idea to pay people to lose weight.” (Scholarly paper; Wu, 2012: page 262) “Many women who smoke in pregnancy are among the most disadvantaged in society. If incentives have a place in smoking cessation, it is perhaps this group who might be seen as the most deserving.” (Scholarly paper; Aveyard and Bauld, 2011: page 1) “Most participants ‘disagreed’ or ‘strongly disagreed’ that paying women to quit smoking during pregnancy is a good idea.” (Empirical paper Lynagh et al., 2011: page 1031) “If the incentives motivate people in higher socioeconomic groups more than those in lower socioeconomic groups, however, they could exacerbate health inequalities.” (Scholarly paper; Oliver, 2009: page 705) 4b “For instance, it is possible that Americans are in general more comfortable than the British (who are accustomed to their ‘free at the point of use’ National Health Service) with accepting a ‘health care transaction’ as what could be considered by some to be a ‘market transaction’.” (Scholarly paper; Oliver and Brown, 2012: page 207) “A concern regarding contingency management in the Australian context was the fact that the model was American and based on an abstinence framework.” (Empirical paper; Cameron and Ritter, 2007: page 185) 4c “…individuals who misuse drugs or alcohol, and society's and even treatment providers' perceptions about individuals with problematic substance use…renders these procedures [i.e. incentives] unpalatable with these populations.” (Scholarly paper; Petry, 2010: page 1507)

Statement of principal findings

399

This is the first systematic review to focus on the acceptability of HPFI that we are aware of. Of 81 papers that met the inclusion criteria, less than a third presented empirical data. Most empirical studies involved surveys of the public. In-depth qualitative work and studies across a range of stakeholders were rare or absent.

C

E

Box 5 Quotations to illustrate the ‘Impact of HPFI on individuals and wider society’ theme.

C

O

R

R

5a “Facilitates autonomy when it makes it more likely that people act in line with their considered preferences.” (Scholarly paper; Marteau et al., 2009: page 984) 5b “The first concern is that financial incentives may unduly infringe upon individuals' decision-making autonomy.” (Scholarly paper; Halpern et al., 2009: page 2) “… phenomena of fear of anticipated regret. Coercion typically works by forcing an agent to do something through fear of the consequences of not doing it.” (Scholarly paper; Ashcroft, 2011: page 195) 5c “The view that participants might misuse the rewards or lie to get them was a common objection …” (Empirical paper; Parke et al., 2013, page 9) “Incentives have been criticised as potentially coercive, and could even encourage unhealthy behaviours or game playing to ensure eligibility” (Empirical paper; Thomson et al., 2012, page 2) 5d “On one view it could be argued that bonus schemes have nothing but a positive effect on solidarity.” (Scholarly paper; Schmidt, 2008: page 212) “Cash incentives create an obligation on recipients to change their behaviour in ways that minimise the burden on fellow citizens” (Scholarly paper; Ashcroft et al., 2008: page 311) “If incentive schemes can remove barriers to healthy behaviours among disadvantaged groups, they could make a contribution to the reduction of health inequalities.” (Scholarly paper; Voigt, 2012: page 271) 5e “Perhaps the most vigorous charge levied against financial incentives is that because people differ in their abilities to modify unhealthy behaviors, linking payment to the successful achievement of health outcomes discriminates against those with greater environmental, economic, or genetic barriers to change.” (Scholarly paper; Halpern et al., 2009: page 3) “If the incentives motivate people in higher socioeconomic groups more than those in lower socioeconomic groups, however, they could exacerbate health inequalities.” (Scholarly paper; Oliver, 2009: page 705) “Like means tested benefits, these transfers are stigmatising, separating off poor people from society. But they are doubly stigmatising because they also label people as irresponsible, unwilling to behave in socially acceptable ways.” (Scholarly paper; Popay, 2008: page 141) “… there is the concern that [HPFI] … undermine prosocial behaviours.” (Scholarly paper; Ashcroft, 2011: page 196)

N

402 403

U

400 401

D

398

Issues concerning acceptability of HPFI fell into five themes: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Throughout, there were contradictions in included papers. There was a strong underlying consensus that if HPFI are shown to be effective and costeffective then they are likely to be considered acceptable, but other factors also influenced acceptability — not always in a predictable way. A lack of relevant data meant we were not able to come to any clear conclusions on whether acceptability varied according to

E

Discussion

T

397

Please cite this article as: Giles, E.L., et al., Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.029

404 405 406 407 408 409 410 411 412

E.L. Giles et al. / Preventive Medicine xxx (2015) xxx–xxx

Strengths and weaknesses of this review

473

We believe that all papers meeting the inclusion criteria were identified. Three papers that were included at the title and abstract stage

432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469

474

C

430 431

E

428 429

R

426 427

R

424 425

N C O

422 423

U

420 421

F

472

418 419

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The majority of empirical papers included in the review used a quantitative or mixed qualitative/quantitative approach, meaning that larger samples (largely using convenience sampling) were included, but depth of opinion was lacking. Acceptability is a complex phenomenon and it is likely that more in-depth, qualitative research will shed more light on these complexities than survey-based quantitative research. Although more general discussion of the acceptability of HPFI was provided in the 59 pieces of scholarly writing, few of these drew consistently on the empirical papers (see Fig. 3) meaning that this scholarly critique was not always evidence-informed. However, some of these pieces of scholarly writing were published in high profile empirical journals and are likely to have been widely read, and considered to be grounded in empirical evidence. Although empirical data is not the only source of knowledge, nor did scholarly writing tend to be in-depth philosophical or ethical debates. As such, we felt the level of consideration of acceptability of HPFI across all included papers lacked depth. Whilst quality appraisal was undertaken for the empirical papers, this was not possible for the scholarly writing as no relevant tool could be located. Formal quality appraisal identified that qualitative components of empirical studies tended to be medium or high quality. Quantitative components were mostly poor in terms of representativeness and generalisability of the sample, justification of sample size and reliability and validity of tools. In some ways this reflects the nature of the work included in the review — acceptability is a subjective concept and criterion validity of tools is hard to confirm. There is a dearth of empirical work on the acceptability of HPFI, particularly the specifics of when HPFI are and are not acceptable and from the perspective of a range of stakeholders. Whilst views from members of the public were explored in 17 of the 22 empirical papers, only a minority focused on the views of health practitioners and organisations tackling health behaviours (n = 4). Scholarly writing tended to explore acceptability from the perspective of the general public, or from a nonspecific viewpoint, where the specifics of ‘for whom’ acceptability was being considered were not clear. No attempt was made in any included papers to explore whether and how acceptability varied according to socio-demographic characteristics of members of the public. If HPFI are to be targeted to particular population groups, then understanding which groups might find them most acceptable would be valuable. Similarly, a wide variety of stakeholders are likely to be involved in commissioning, design and delivery of any HPFI, and understanding acceptability in these groups would help with smooth implementation (Craig et al., 2008). Empirical research was also undertaken in a narrow range of countries, with the main settings being the UK (n = 7), USA (n = 7), UK and USA (n = 1), Australia (n = 5), The Netherlands (n = 1) and New Zealand (n = 1). Whilst it has been suggested that acceptability may vary internationally, and be related to differences in how health care is currently funded (Ritter and Cameron, 2007), there is little empirical evidence to support this conclusion. Further work exploring this would be valuable to help policy makers and practitioners understand if acceptability data is generalisable or not across countries. Finally, the disciplines of those undertaking the empirical research were fairly narrow, being public health (n = 9), medicine and psychology (n = 11), and social science and sociology (n = 2). Individuals from some disciplinary backgrounds may be more sympathetic to HPFI than others, but it was not possible to explore this.

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could not be located and so were excluded from the review (Botelho, 2012; McCormack, 1996; TUTEN et al., 2012). Nonetheless, we feel that data saturation was achieved. Using thematic analysis gave greater flexibility allowing themes to emerge from the data. The lack of an apriori theoretical framework is, however, considered a disadvantage of thematic analysis by some (Braun and Clarke, 2006). A wide range of arguments and counterarguments were found in relation to the acceptability of HPFI. The heterogeneity and contradictions in the included papers highlight the contested nature of HPFI. Whilst we were able to identify some aspects of HPFI that influence acceptability, the exact nature of an ‘acceptable’ HPFI is not clear and appears to be context-specific. Including both quantitative and qualitative empirical work in the same systematic review is unusual. It is particularly rare to include non-empirical work in a systematic review. As such, there was little in the way of guidance available to us to help guide our review. We drew on aspects of standard systematic reviewing methodology (Petticrew and Roberts, 2005; The Cochrance Collaboration, 2011), as well as meta-ethnography in developing our methods (Britten et al., 2002; Noblit et al., 1988). Whilst we believe that we have conducted a rigorous and thorough review, other approaches may have been equally appropriate. In conducting this review, we adopted the perspective that both empirical findings and scholarly writing were equally valid. Although we found it interesting that scholarly writing did not appear to draw strongly from empirical findings, empirical research is not the only source of knowledge. Multidisciplinary approaches are required to gain a holistic appreciation of the complexity of acceptability of HPFI.

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the nature of the behaviour incentivised or the population rating acceptability.

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Interpretation of findings and implications for policy, practice and research

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We found a variety of issues surrounding acceptability of HPFI relating to fair exchange, design and delivery, effectiveness and costeffectiveness, recipients, and impact on individuals and wider society. However, disagreements in the literature exist in all areas. The one consistent finding was that demonstrated effectiveness and costeffectiveness are key determinants of acceptability. Although HPFI are sometimes viewed as more contentious than other health behaviour change interventions, the requirement that an intervention must be effective and cost-effective to be acceptable is likely to be universal. As there is growing evidence of effectiveness of HPFI (Cahill and Perera, 2008; Giles et al., 2014; Kane et al., 2004; Kavanagh et al., 2009; Paul-Ebhohimhen and Avenell, 2008; Wall et al., 2006), this finding also suggests that better communication of the existing effectiveness evidence to all relevant stakeholders could increase the acceptability of HPFI. Further work is required to determine the best methods of communicating this evidence. Future empirical research on the long term effectiveness of HPFI, and whether they undermine intrinsic motivation, would also be helpful to respond to concerns in these areas (Thomson et al., 2014). Given the lack of qualitative data we found, it is difficult to get a clear idea of the depth and strength of feeling towards HPFI. Similarly there remains little evidence on the particular types, format, size, and scheduling of financial incentives, which are most acceptable (Cahill and Perera, 2008; Giles et al., 2014; Kane et al., 2004; Kavanagh et al., 2009; Paul-Ebhohimhen and Avenell, 2008; Wall et al., 2006). Future work would benefit from adopting qualitative approaches to explore acceptability in-depth with the public, practitioners who may be involved in delivering HPFI, and policy makers who may have to defend their implementation. In addition, large scale quantitative surveys with population-representative samples would help determine if certain socio-demographic characteristics are associated with the acceptability of HPFI.

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Ethical approval was not required for this secondary analysis of published work.

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This work is produced under the terms of a Career Development Fellowship research training fellowship issued by the NIHR to JA, grant number: CDF-2011-04-001. The views expressed are those of the authors and not necessarily those of the NHS, The National Institute for Health Research or the Department of Health. JA & ELG are funded in part, and FFS is funded in full by Fuse: the Centre for Translational Research in Public Health, a UKCRC Public Health Research Centre of Excellence. Funding for Fuse from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Appendix A. Supplementary data

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Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ypmed.2014.12.029.

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The available evidence suggests that HPFI are acceptable when they are considered effective and cost-effective; if they provide benefits to individual recipients and wider society; when they are considered fair; and when they are delivered to individuals who are deemed acceptable recipients. Other factors also influenced acceptability, but not always in a predictable way disagreement exists in relation to the specific aspects of these issues that make HPFI acceptable. Further research is required to explore acceptability across a wider range of stakeholders, and how acceptability varies according to the nature of HPFI interventions and the populations rating acceptability. Studies using both indepth qualitative methods, and quantitative survey methods in population-representative cohorts, are required to address these gaps.

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