TB Notes Newsletter

No. 1, 2011

The following article is reprinted in full from the New Jersey Medical School Global Tuberculosis Institute newsletter, Northeastern Spotlight, Winter 2011; vol. 5, no. 4, with permission of the author and the newsletter editor.

Behavioral/Social Science Contribution to TB Control - Incentives and Enablers in TB Control

There is growing interest in the use of incentives in many aspects of public life. Incentive programs have paid students for improved grades and/or attendance and welfare recipients for seeking work, in addition to employee health initiatives in which corporations give bonuses for employees’ smoking cessation or weight loss.¹ Incentives are given to patients as a reward for being adherent — they may not be directly related to the patient’s TB treatment. Incentives may include movie tickets, phone cards, and gift cards for groceries or clothes. In contrast, enablers are given to patients to remove barriers to treatment, such as transportation tokens or coupons, or assistance with child care. Enablers are meant to assist patients in adhering to TB treatment.

It is important to tailor incentives and enablers to the population being served. Carol Pozsik identified incentives and enablers appropriate in a rural setting, such as groceries, gasoline, or fishing equipment.² In a Harlem, NY, on-site DOT program, El-Sadr stressed the importance of group incentives that build social cohesion such as holiday dinners, trips to amusement parks, and parties to celebrate treatment completion.³

Current Clinical Practice in the U.S.

Incentives and enablers have long been used in TB control in the United States. While recent CDC guidelines do not specifically address incentives and enablers, they are presented as a “best practice” for ensuring adherence in the CDC Self-Study Module #9.⁴

TB/LTBI Studies on Incentives/Enablers

The literature offers a substantial number of studies demonstrating that incentives and enablers led to positive treatment outcomes in developing countries. In the United States, the practice of providing incentives and enablers has become so common that few studies examining the practice exist. Bock found that when given a modest cash equivalent for each tuberculosis therapy session they attended, DOT patients became significantly more likely to complete therapy, compared with patients treated in a prior period.⁵

In the early 2000s, four randomized clinical trials examined the effect of monetary incentives as compared to peer workers in relation to LTBI treatment in high-risk populations. Two of these studies found higher completion in participants who received monetary incentives compared to those who had a peer worker, despite the fact that the peers provided DOT for LTBI.^6,7 The other two found no differences.^8,9 In Newark, NJ, provision of a nutritional supplement was associated with improved treatment outcomes for patients on LTBI therapy.¹⁰

Findings from the Health Psychology Literature

Despite an ongoing practice of rewarding medical providers for their performance, it is only recently that healthcare programs have begun to reward patients. Such rewards, or incentives, generally fall into two categories: 1) rewarding patients each time they exhibit a certain behavior, such as showing up for a DOT appointment or producing a urine sample free of illicit substances;⁵  and 2) rewarding patients for reaching a pre-defined goal, such as losing 10 pounds or quitting smoking.¹¹ In TB, incentives have been used for both purposes.

Findings from research in behavioral economics and psychology suggest ways in which incentives may be made more persuasive to patients.¹¹ For instance, lottery-based incentives can be more effective than lump-sum payments. Behavioral economists have found that individuals tend to overestimate the probability of unlikely events such as winning a lottery, and also tend to minimize small costs and benefits (the “peanuts effect”). Therefore, rewarding patients by entering them in a lottery for those who have achieved a specified goal may be more effective than offering all of them small rewards. Also, gradually increasing the size of the incentive (e.g., $4 per visit in the first month, $6 in the second month, etc.) gives patients more to lose when they miss appointments and have to start again. Finally, small incremental rewards are more effective than one large reward. For that reason, most studies that focused on adherence have relied on small, frequent rewards.^12,13  While the incentives typically provided in DOT programs meet this third suggestion, they generally have not used graduated reward systems or included the element of chance.

Ethical Concerns about Incentives

Several aspects of incentivized health behaviors have provoked ethical concerns. Financial incentives may infringe on the autonomy of individuals to exercise particular personal preferences, such as tobacco use. Furthermore, the prospect of financial gain through incentives may exercise disproportionate influence on individuals of limited means, and incentives are therefore inequitable. Proponents respond that the effect of incentives is to provide individuals with an additional choice of incentives versus the undesired behavior, and that because incentives are tied to a specific event of behavior change and do not preclude future choices to return to the behavior, they cannot properly be thought of as restricting autonomy. Because incentives do not actually create additional burdens for vulnerable populations but offer new sources of potential reward, their effect is not truly inequitable.

Privacy concerns about incentives revolve around the need to monitor behaviors through blood, urine, or other analyses, which increases the involvement of employers and government in individuals’ lives. These concerns must be balanced against the legitimate concerns of public and corporate entities to control behaviors that add to their burden of healthcare or other costs.

An additional critique of financial incentives based on their societal implications suggests that monetizing health-promoting behaviors subverts the social value of those behaviors. This concern is relevant to incentivizing individual adherence to treatment of infectious disease, which has the public health benefit of reducing disease transmission in addition to the individual benefit of cure. Proponents of incentives argue that the power of extrinsic motivations (e.g., incentives) to override intrinsic motivations (e.g., taking actions to benefit society or an individual’s long-term interests) has not been determined empirically. The practical benefit of extrinsic motivations to further a goal outweighs the theoretical risks that wider appeals to intrinsic motivations may be undermined.¹⁴

This final point about the collective benefits of promoting individual behavior through extrinsic reward is part of the rationale for incentivizing treatment for TB disease. This argument can be extended to treatment of latent TB infection (TLTBI) in that TLTBI is an important step toward the elimination of tuberculosis.

—By Paul Colson, PhD, Program Director,
and Julie Franks, PhD, Health Educator and Evaluator,
Charles P. Felton National TB Center at Harlem Hospital.
Thanks to Tal Gross, PhD, Mailman School of Public Health, Columbia University

References

1. Belluck P. For forgetful, cash helps the medicine go down. NYT June 13, 2010.
2. Pozsik CJ. Compliance with tuberculosis therapy. Med Clinics of N Am 1993; 77(6):1289-301.
3. El-Sadr W, Medard F, Dickerson M. The Harlem family model: a unique approach to the treatment of tuberculosis. J Pub Hlth Mgmt Prac 1995.1(4):48-51.
4. CDC. Module 9: Patient Adherence to Tuberculosis Treatment. Available at www.cdc.gov/tb/education/ssmodules/module9/ss9reading3.htm. Accessed on November 17, 2010.
5. Bock NN, Sales R-M, Rogers T, DeVoe B. A spoonful of sugar…: improving adherence to tuberculosis treatment using financial incentives. Int J Tuberc 2001;5(1):96-98.
6. Malotte CK, Hollingshead JR, Larro M. Incentives vs outreach workers for latent tuberculosis treatment in drug users. Am J Prev Med 2001;20:103-7.
7. Tulsky JP, Pilote L, Hahn JA, et al. Adherence to isoniazid prophylaxis in the homeless: a randomized controlled trial. Arch Intern Med 2000;160:697-702.
8. Chaisson RE, Barnes GL, Hackman J, et al. A randomized, controlled trial of interventions to improve adherence to isoniazid therapy to prevent tuberculosis in injection drug users. Am J Med 2001;110:610-5.
9. Morisky DE, Malotte CK, Ebin V, et al. Behavioral interventions for the control of tuberculosis among adolescents. Public Health Rep 2001;116:568-74.
10. Mangura BT, Passannante M, Reichman l. An incentive in tuberculosis preventive therapy for an inner city population. Int J Tberc Lung Dis 1999:1(16):567-568.
11. Volpp KG, Pauly MV, Loewenstein G, Bangsberg D. P4P4P: an agenda for research on pay-for-performance for patients. Health Aff (Millwood) 2009;28:206-14.
12. Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive-based approaches for weight loss: a randomized trial. JAMA 2008;300:2631-7.
13. Tulsky JP, Hahn JA, Long HL, et al. Can the poor adhere? Incentives for adherence to TB prevention in homeless adults. Int J Tuberc Lung Dis 2004;8:83-91.
14. Halpern SD, Madison KM, Volpp KG. Patients as mercenaries? The ethics of using financial incentives in the war on unhealthy behaviors. Circ Cardiovasc Qual Outcomes 2009; 2: 514-516.