Behavior analysts in the war on poverty: Developing an operant antipoverty program

Effects of economic context and reward amount on delay and probability discounting

Steep delay and shallow probability discounting are associated with myriad problem behaviors; thus, it is important to understand factors that influence the degree of discounting. The present study evaluated the effects of economic context and reward amount on delay and probability discounting. Two hundred thirteen undergraduate psychology students completed four delay- or probability-discounting tasks. Participants were exposed to hypothetical narratives involving four bank amounts ($750, $12,000, $125,000, and $2,000,000). The delayed/probabilistic amount was $3,000 for the two smaller bank amounts and $500,000 for the two larger bank amounts. The discounting tasks included five delays to, or probabilities of, receipt of the larger amount. The area under the empirical discounting function was calculated for each participant. Participants discounted delayed and uncertain outcomes more when the bank amount was smaller than the outcome (i.e., the economic context was low). Participants discounted the delayed larger amounts less than delayed smaller amounts, even when the relative economic context was the same. In contrast, probability discounting did not differ across magnitudes, which suggests that economic context may attenuate the magnitude effect in probability discounting. The results further highlight the importance of considering the economic context in delay and probability discounting.

Behavioral Interventions Contributing to Reducing Poverty and Inequities

Behavioral science has a long history of engaging in efforts to understand and address socially important issues. Poverty and inequities in health and development are among the most important and complex social issues facing the world today. With its Sustainable Development Goals (SDGs), the United Nations (2015) has focused attention and guidance on addressing key global challenges, including to "end poverty" (SDG 1), "ensure good health and well-being for all" (SDG3), and "reduce inequality within and among countries" (SDG 10). In this paper, we provide a framework and illustrative examples of contributions of behavioral science to these issues. We feature illustrative behavioral interventions at the individual, relationship, community, and societal levels. We highlight the diversity of issues, intervention methods, and settings reflected in applications of behavioral science. By joining methods from behavioral science, public health, and other disciplines-and the experiential knowledge of those most affected by inequities-behavioral methods can make significant contributions to collaborative efforts to assure health and well-being for all.

Using financial incentives to improve health service engagement and outcomes of adults experiencing homelessness: A scoping review of the literature

People experiencing homelessness (PEH) have high rates of acute and chronic health conditions, complex support needs and often face multiple barriers to accessing health services. Financial incentive (FI) interventions have been found effective in improving service engagement and health outcomes for a range of health conditions, populations and settings, but little is known about their impact on PEH. We conducted a scoping review to explore the impact of FI interventions on treatment retention, adherence and other health outcomes of PEH. We searched seven electronic databases from inception to September 2021 to identify peer-reviewed published English language studies that used FI interventions with adult PEH. A scoping review methodology was used to chart relevant data uniformly. Descriptive statistics and narrative syntheses were used to describe outcomes. Thirty-three quantitative articles related to 29 primary studies were published between 1990 and 2021 and met inclusion criteria. Studies targeted three areas of health behaviour change: decreasing substance use or increasing abstinence rates, preventing or treating infectious diseases or promoting lifestyle/general health goal attainment. A variety of FIs were used (cash/non-cash, escalating/fixed schedule, larger/smaller amounts, some/all behaviours rewarded, certain/uncertain reward) across studies. Twenty-six of the primary studies reported significantly better outcomes for the participants receiving FI compared to controls. There were mixed findings about the efficacy of cash versus non-cash FIs, non-cash FIs versus other interventions and higher versus lower value of incentives. Furthermore, there was limited research about long-term outcomes and impacts. FIs have promise in increasing abstinence from substances, engagement in infectious disease treatment, retention in health services and general lifestyle modifications for PEH. Future research should examine long-term impacts and the contribution of co-interventions and intermediary lifestyle behaviour changes.

Efficacy of Health Beliefs Model-Based Intervention in Changing Substance Use Beliefs among Mosul University Students: A Randomized Controlled Trial

Substance use disorders (SUD) are a significant health concern worldwide. Substance abuse is a persistent problem linked to high rates of illness and loss. These issues are also responsible for many healthcare workers and health bills. However, the Substance use problems are associated with capitalize health retrogradation, weakness and death due to impacts and exceed. Throughout Iraq, there is growing concern about the effects of violence and war on drug use. To see how effective HBM-based intervention is at changing college students' health beliefs about drug usage. Using a randomized controlled trial approach, experimental design is carried out throughout the current study to determine the efficacy of health beliefs model-based intervention in changing the belief related to substance use among university students in Mosul City from 26-November 2019 to 1-March 2021. The study sample consisted of 80 students who participated in the training program for behavioral change. The intervention for the experimental group involved a health education lecture about substance use. Analyzed data using SPSS, Version 23 using both descriptive statistics and inferential statistics (Means, SD, Number and percentage). These results revealed statistically significant differences among all concepts of the Health Belief Model related to substance use, adding to behavioral motivation, behavioral control and intention) overtime. On the contrary, the perceived barrier was the only belief that showed no significant changes over time. According to the findings, the design of an HBM-based study could impact students' cognition and conduct in the field of drug dependence. Given the positive association across HBM dimensions and pupils' opinions, notably in "significant advantages and regarded harshness," These beliefs seemed to have a strong connection to each other and the avoidance of alcoholism. Keywords: Efficacy, Health Beliefs Model, Belief, Substance Use, Students.

Being at work improves stress, craving, and mood for people with opioid use disorder: Ecological momentary assessment during a randomized trial of experimental employment in a contingency-management-based therapeutic workplace

Employment problems are common among people with substance use disorders (SUDs), and improving vocational functioning is an important aspect of SUD treatment. More detailed understanding of the psychosocial benefits of employment may help refine vocational interventions for people with SUDs. Here, we used ecological momentary assessment to measure possible affective improvements associated with work. Participants (n = 161) with opioid use disorder were randomized to work (job-skills training) in a contingency-management-based Therapeutic Workplace either immediately or after a waitlist delay. Throughout, participants responded via smartphone to randomly scheduled questionnaires. In linear mixed models comparing responses made at work vs. all other locations, being at work was associated with: less stress, less craving for opioids and cocaine, less negative mood, more positive mood, and more flow-like states. Some of these differences were also observed on workdays vs. non-workdays outside of work hours. These results indicate that benefits associated with work may not be restricted to being actually in the workplace; however, randomization did not reveal clear changes coinciding with the onset of work access. Overall, in contrast to work-associated negative moods measured by experience-sampling in the general population, Therapeutic Workplace participants experienced several types of affective improvements associated with work.

Abstinence-contingent wage supplements to promote drug abstinence and employment: Post-intervention outcomes

BACKGROUND

Substance use disorder, unemployment, and poverty are interrelated problems that have not been addressed adequately by existing interventions. This study evaluated post-intervention effects of abstinence-contingent wage supplements on drug abstinence and employment.

METHODS

Unemployed adults enrolled in opioid agonist treatment were randomly assigned to an abstinence-contingent wage supplement group (n = 44) or a usual care control group (n = 47). All participants could work with an employment specialist throughout a 12-month intervention period. Those in the abstinence-contingent wage supplement group earned stipends for working with the employment specialist and, after gaining employment, abstinence-contingent wage supplements for working in their community job but had to provide opiate- and cocaine-negative urine samples to maximize pay. To assess post-intervention effects of abstinence-contingent wage supplements and compare those effects to during-intervention effects, we analyzed urine samples and self-reports every 3 months during the 12-month intervention and the 12-month post-intervention period.

RESULTS

During the intervention, abstinence-contingent wage supplement participants provided significantly more opiate- and cocaine-negative urine samples than usual care control participants; abstinence-contingent wage supplement participants were also significantly more likely to become employed and live out of poverty than usual care participants during intervention. During the post-intervention period, the abstinence-contingent wage supplement and usual care control groups had similar rates of drug abstinence, similar levels of employment, and similar proportions living out of poverty.

CONCLUSIONS

Long-term delivery of abstinence-contingent wage supplements can promote drug abstinence and employment, but many patients relapse to drug use and cease employment when wage supplements are discontinued.

Remotely administered incentive-based treatment for alcohol use disorder with participant-funded incentives is effective but less accessible to low-income participants

The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, incentive cost has often been cited as a barrier to delivering this type of treatment. In the present randomized parallel groups trial, we systematically replicated a previous trial we conducted that employed remote alcohol monitoring and incentive delivery to promote abstinence from alcohol, but with the additional requirement for participants to partially self-fund their abstinence incentives. Treatment-seeking participants with alcohol use disorder (n = 92) who met inclusion criteria (n = 36) were randomized to either a Contingent or Noncontingent group (n = 18 each). Those not meeting inclusion criteria included 15 participants who agreed to the deposit requirement but failed to make the deposit payment. The Contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The Noncontingent group received matched incentives each day they successfully provided samples independent of alcohol content. Days abstinent in the Contingent group were 86%, which was significantly higher than the 44% recorded in the Noncontingent group, corresponding to an odds ratio of 8.2. Exploratory analyses revealed that the deposit requirement prevented participation in those with lower incomes and those with greater alcohol use. These results support the efficacy of this remotely deliverable alcohol abstinence reinforcement incentive intervention with a deposit requirement. However, the requirement to provide a monetary deposit to self-fund abstinence incentives may prevent those with greater alcohol use and/or those experiencing extreme poverty from participating in the intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Factors associated with obtaining employment among opioid use disorder patients enrolled in a therapeutic workplace intervention

BACKGROUND

Unemployment is a common problem among adults who have substance use disorder that often persists during treatment and recovery. We identified patient characteristics that were associated with obtaining employment among unemployed adults in opioid use disorder treatment.

METHODS

This analysis used data from participants (N = 91) who were enrolled in a randomized controlled trial evaluating the effectiveness of a therapeutic workplace in promoting drug abstinence and employment. After a 3-month training period (Phase 1), participants were randomly assigned to a study group and could work for 12 months with an employment specialist who assisted participants in obtaining employment (Phase 2). A logistic regression model was used to identify patient characteristics that were associated with obtaining employment.

RESULTS

Of the 91 participants, 39 (42.9 %) obtained employment. Compared to participants who did not obtain employment, participants who obtained employment worked more days in the therapeutic workplace during the training period (Phase 1) [OR (95 % CI) = 1.072 (1.015-1.132), p = .014], provided more opiate- and cocaine-negative urine samples while seeking employment [OR (95 % CI) = 1.015 (1.002-1.027), p = .025], and reported not usually being unemployed at study intake [OR (95 % CI) = 0.229 (0.080-0.652), p = .007].

CONCLUSIONS

Our analyses suggest that among unemployed adults in opioid use disorder treatment, those with the lowest rates of therapeutic workplace attendance, lowest rates of drug abstinence while seeking employment, and relatively long histories of unemployment are the least likely to obtain employment. These relations are potentially addressable at a practical level, and future research could build on these findings to improve the effectiveness of employment-based interventions.

Leveraging applied behavior analysis research and practice in the service of public health

Human behavior plays a central role in all domains of public health. Applied behavior analysis (ABA) research and practice can contribute to public health solutions that directly address human behavior. In this paper, we describe the field of public health, identify points of interaction between public health and ABA, summarize what ABA research has already contributed, and provide several recommendations for how ABA research and practice could continue to promote public health outcomes. A clearer focus on behavior and widespread adoption of research designs and interventions informed by the ABA literature could lead to better public health outcomes. Reciprocally, better integration of public health goals and strategies into ABA research, harnessing of technology, and more collaboration would help diversify and disseminate our applied science and could yield more effective and scalable interventions to prevent and treat public health problems.

Employment outcomes of substance use disorder patients enrolled in a therapeutic workplace intervention for drug abstinence and employment

Poverty is common among people who have substance use disorder. The therapeutic workplace addresses some of the interrelated and chronic problems of poverty, such as unemployment, lack of education and job skills, and drug use. A prior controlled trial showed that the therapeutic workplace was effective in promoting drug abstinence and self-reported community employment in unemployed adults in medication-assisted treatment for opioid use disorder. The current study extends this research by providing a detailed and objective analysis of employment outcomes using objective data abstracted from participants' pay stubs. Secondary analyses examined the types and patterns of employment that participants (N = 44) obtained during the trial, and the extent to which participants gained and maintained financially sufficient employment. Although most participants had relatively long histories of unemployment and underemployment, many participants (n = 26; 59%) obtained employment at some point during the intervention. Most participants worked part time and were employed in low-wage jobs, however. The mean number of hours worked per week was 20.6 h (range 5.5 to 41.3 h per week) and the mean hourly pay was $11.00 per hour (range $9.00 to $15.50 per hour). The most common type of employment was in food preparation and serving-related occupations (e.g., waiters and waitresses, restaurant cooks, and fast food counter workers). Many participants (n = 17; 65%) maintained employment in these jobs over several weeks, while others (n = 9; 35%) were employed sporadically for short durations. Additional supports may be needed for some chronically unemployed adults with substance use disorder to promote consistent employment in well-paying jobs.

Financial incentives promote engagement in employment services for unemployed adults in treatment for opioid use disorder

BACKGROUND

Promoting employment among unemployed adults with substance use disorder is a difficult challenge for which existing interventions have had limited effects. This study examined whether financial incentives could increase engagement in employment services for unemployed adults in treatment for opioid use disorder.

METHODS

The study was conducted from 2014 to 2019 in Baltimore, MD. After a 3-month abstinence initiation and training period, participants (N = 91) were randomly assigned to a Control group or an Incentive group and were invited to work with an employment specialist to seek employment in a community job for 12 months. Participants assigned to the Control group (n = 47) did not receive incentives for working with the employment specialist. Participants assigned to the Incentive group (n = 44) could earn financial incentives for working with the employment specialist, but had to provide opiate- and cocaine-negative urine samples to maximize pay.

RESULTS

Incentive participants attended the employment services and worked with the employment specialist on significantly more days than Control participants (41.8 % versus 1.1 % of days; OR = 40.42, 95 % CI = 32.46-48.38, p < .001), and for significantly more hours than Control participants (3.58 versus 1.25 h, on average; OR=2.34, 95 % CI=1.83-2.85, p < .001). Incentive participants were more likely to be retained than Control participants when analyses were based solely on attendance (HR=0.12, 95 % CI=0.06-0.25, p < .001) and attendance and employment combined (HR=0.15, 95 % CI=0.07-0.31, p < .001).

CONCLUSIONS

Financial incentives were effective in promoting engagement in employment services for individuals who often do not utilize employment services.

Spillover Effects of Job Skills Training on Substance Misuse Among Low-Income Youths With Employment Barriers: A Longitudinal Cohort Study

Objectives. To examine spillover effects of job skills training (vs basic services only [e.g., adult basic education, job readiness training]) on substance misuse among low-income youths with employment barriers.Methods. Data came from the National Longitudinal Survey of Youth 1997, a longitudinal cohort study of youths born between 1980 and 1984 in the United States. Based on respondents' reports of substance misuse (past-month binge drinking and past-year marijuana and other illicit drug use) from 2000 to 2016, we estimated substance misuse trajectories of job skills training (n = 317) and basic services (n = 264) groups. We accounted for potential selection bias by using inverse probability of treatment weighting.Results. Compared with the basic services group, the job skills training group showed notable long-term reductions in its illicit drug misuse trajectory, translating to a 56.9% decrease in prevalence rates from 6.5% in year 0 to 2.8% in year 16.Conclusions. Job skills training can be an important service component for reducing substance misuse and improving employment outcomes among youths with economic disadvantages and employment barriers.

Abstinence-contingent wage supplements to promote drug abstinence and employment: a randomised controlled trial

BACKGROUND

Poverty, unemployment and substance abuse are inter-related problems. This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting drug abstinence and employment in unemployed adults in outpatient treatment for opioid use disorder.

METHODS

A randomised controlled trial was conducted in Baltimore, MD, from 2014 to 2019. After a 3-month abstinence initiation and training period, participants (n=91) were randomly assigned to a usual care control group that received employment services or to an abstinence-contingent wage supplement group that received employment services plus abstinence-contingent wage supplements. All participants were invited to work with an employment specialist to seek employment in a community job for 12 months. Abstinence-contingent wage supplement participants could earn training stipends for working with the employment specialist and wage supplements for working in a community job, but had to provide opiate and cocaine-negative urine samples to maximise pay.

RESULTS

Abstinence-contingent wage supplement participants provided significantly more opiate and cocaine-negative urine samples than usual care control participants (65% vs 45%; OR=2.29, 95% CI 1.22 to 4.30, p=0.01) during the 12-month intervention. Abstinence-contingent wage supplement participants were significantly more likely to have obtained employment (59% vs 28%; OR=3.88, 95% CI 1.60 to 9.41, p=0.004) and lived out of poverty (61% vs 30%; OR=3.77, 95% CI 1.57 to 9.04, p=0.004) by the end of the 12-month intervention than usual care control participants.

CONCLUSION

Abstinence-contingent wage supplements can promote drug abstinence and employment.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02487745.

The Utility of Operant Conditioning to Address Poverty and Drug Addiction

Poverty is associated with poor health. This article reviews research on proximal and distal operant interventions to address drug addiction and poverty. Proximal interventions promote health behaviors directly. Abstinence reinforcement, a common proximal intervention for the treatment of drug addiction, can be effective. Manipulating familiar parameters of operant conditioning can improve the effectiveness of abstinence reinforcement. Increasing reinforcement magnitude can increase the proportion of individuals that respond to abstinence reinforcement, arranging long-term exposure to abstinence reinforcement can prevent relapse, and arranging abstinence reinforcement sequentially across drugs can promote abstinence from multiple drugs. Distal interventions reduce risk factors that underlie poor health and may have an indirect beneficial effect on health. In the case of poverty, distal interventions seek to move people out of poverty. The therapeutic workplace includes both proximal and distal interventions to treat drug addiction and poverty. In the therapeutic workplace, participants earn stipends or wages to work. The therapeutic workplace uses employment-based reinforcement in which participants are required to provide drug-free urine samples or take scheduled doses of addiction medications to work and/or maintain maximum pay. The therapeutic workplace has two phases, a training and an employment phase. Special contingencies appear required to promote skill development during the training phase, employment-based reinforcement can promote abstinence from heroin and cocaine and adherence to naltrexone, and the therapeutic workplace can increase employment. Behavior analysts are well-suited to address both poverty and drug addiction using operant interventions like the therapeutic workplace.