Design of financial incentive interventions to improve lifestyle behaviors and health outcomes: A systematic review

Financial incentives for smoking cessation among (expectant) parents: a systematic review of facilitators and barriers to implementation

OBJECTIVE

Financial incentives, provided following validated smoking cessation, hold substantial potential to cost-effectively promote cessation. To facilitate wider adoption, we systematically reviewed evidence addressing the barriers and facilitators to successful implementation of incentive-based smoking cessation interventions among (expectant) parents.

DATA SOURCES

We conducted a systematic search to identify scientific and grey literature across nine electronic databases, from inception to 15 August 2024. Search terms included combinations of "smoking cessation", "incentive", "pregnancy", "preconception" and "parent".

STUDY SELECTION

Eligible records reported and reflected on the implementation of smoking cessation programmes with incentives for (expectant) parents. Inclusion criteria were applied by two reviewers independently, with discrepancies resolved through consensus. Of 1100 unique records identified, 37 met inclusion criteria.

DATA EXTRACTION

Characteristics of the studies, interventions, incentives and implementation, along with barriers and facilitators, were independently extracted by two reviewers. Thematic analysis identified barriers and facilitators. Subgroup analysis explored patterns specific to lower socioeconomic populations.

DATA SYNTHESIS

Studies reported on implementation in the USA (n=18), UK (n=10), Australia (n=4), the Netherlands (n=2), New Zealand (n=1), France (n=1) and international contexts (n=1). Barriers included misalignment with participants' context and resources, recruitment and retention challenges, limited reliability of abstinence verification and high resource demands. Facilitators included ensuring acceptability, accessibility, feasibility, funding and integration into health services.

CONCLUSIONS

With the cost-effectiveness of financial incentives for smoking cessation among (expectant) parents already well-documented, this first systematic synthesis of the barriers and facilitators to implementing them in daily practice offers valuable guidance for advancing implementation efforts.

PROSPERO REGISTRATION NUMBER

2023:CRD42023407648.

Physical activity experience of patients with hypertension: a systematic review and synthesis of qualitative literature

BACKGROUND

Hypertension continues to increase in prevalence, and it has become a major cause of increased mortality globally. Physical activity (PA) has been shown to be a first-line treatment for controlling blood pressure. However, participation rates in PA are still poor. Therefore, it's imperative to explore the factors that affect patient PA adherence.

METHODS

A synthesis of qualitative research of the PA experience of patients with hypertension was conducted. We systematically searched for qualitative studies published in English from inception to May 2023 in the databases of PubMed, Embase, Web of Science, CINAHL, PsycINFO, and Cochrane Library. The Joanna Briggs Institute tool was used to extract data, and the Capability, Opportunity, Motivation-Behaviour model was used to synthesize data.

RESULTS

This qualitative research included 17 studies, identified 85 findings, summarized 9 categories, and finally meta-aggregated 3 synthesized findings, including capabilities of patients with hypertension, PA opportunities and PA motivators. The capabilities included age, other health problems, and PA knowledge and skills. Opportunities included time constraints, environmental factors, physical activity resources, and social support. Motivators included self-efficacy, pursuing physical health, and experience from PA.

CONCLUSION

The available evidence contributes to a comprehensive understanding of the barriers and facilitators of PA in patients with hypertension. Most of these barriers can be addressed and improved. When designing and implementing physical activity programs for patients with hypertension, an individualized PA program should first be designed, tailored to the patient's capacity. Secondly, patients should be provided with additional PA resources and enhanced social support. Lastly, patients' motivation can be increased by enhancing their PA experience.

Financial incentives to stop smoking: Potential financial consequences of different reward schedules

INTRODUCTION

Financial incentives to stop smoking (FISS) programs have been implemented internationally to encourage people who smoke to quit smoking. However, such programs require that the financial reward structure and its resulting effects on smoking quit rates are considered. We analyzed a number of scenarios for FISS reward schedules for current smoking individuals in Ireland, with a view to identify the potential implications in terms of financial consequences and expected effects.

METHODS

Using national QuitManager services data 2021-2023, we defined smoking quit rates for smokers currently using the national Health Services Executive stop smoking services in Ireland. Smoking quit rates at 4, 12 and 52 weeks were defined, and additionally defined by sex, age and education level. Using scenarios assuming different FISS reward sizes, structures and targeted population sub-groups, we estimated the number of additional quitters, budget impact, and incremental cost-effectiveness ratio.

RESULTS

A FISS program, if implemented for a cohort of 3500 smokers can result in a budget impact ranging €250000 - €870000. The cost-effectiveness trade-off between different payment schedules and the expected effect size suggested that FISS are cost-effective even at a moderate effect size. A FISS program implemented to approximately 20000 smokers nationally would cost between €2.0 million and €4.8 million, subject to the chosen reward schedule. Across social groups, FISS is more cost-effective for females, individuals in the youngest age group, and individuals with a medium level of education.

CONCLUSIONS

This analysis highlights the importance of considering different FISS schedules and potential quit effects, when designing such programs. We highlight that FISS programs should be targeted at certain social groups to achieve highest long-term smoking cessation rates. We also identified important challenges that decision-makers face when designing the reward structure of FISS programs. The acceptability or otherwise of the FISS structures may differ among stakeholders and should be explored.

How and why do financial incentives contribute to helping people stop smoking? A realist review

BACKGROUND

Tobacco smoking remains a key cause of preventable illness and death globally. In response, many countries provide extensive services to help people to stop smoking by offering a variety of effective behavioural and pharmacological therapies. However, many people who wish to stop smoking do not have access to or use stop smoking supports, and new modes of support, including the use of financial incentives, are needed to address this issue. A realist review of published international literature was undertaken to understand how, why, for whom, and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women.

METHODS

Systematic searches were undertaken from inception to February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Study selection was inclusive of all study designs. Twenty-two studies were included. Using Pawson and Tilley's iterative realist review approach, data collected were screened, selected, coded, analysed, and synthesised into a set of explanatory theoretical findings.

RESULTS

Data were synthesised into six Context-Mechanism-Outcome Configurations and one overarching programme theory after iterative rounds of analysis, team discussion, and expert panel feedback. Our programme theory shows that financial incentives are particularly useful to help people stop smoking if they have a financial need, are pregnant or recently post-partum, have a high threshold for behaviour change, and/or respond well to external rewards. The incentives work through a number of mechanisms including the role their direct monetary value can play in a person's life and through a process of reinforcement where they can help build confidence and self-esteem.

CONCLUSION

This is the first realist review to synthesise how, why, and for whom financial incentives work among those attempting to stop smoking, adding to the existing evidence demonstrating their efficacy. The findings will support the implementation of current knowledge into effective programmes which can enhance the impact of stop smoking care.

PROSPERO REGISTRATION NUMBER

CRD42022298941.

The impact of financial incentives on physical activity for employees in the context of workplace health promotion: a systematic review

OBJECTIVES

The global increase in physical inactivity is progressively evolving into a significant health challenge. Alongside the promotion of more active leisure pursuits, elevating physical activity in the workplace has come into focus. Financial incentives are not only a popular but also a promising tool in this regard. According to behavioral economics, they are able to initiate physical activity and thus create the basis for behavioral change.

METHODS

The present systematic review was prepared according to the current PRISMA guidelines and with reference to the Cochrane Handbook. A systematic literature search of 6 electronic databases and 3 study registers was conducted to identify relevant literature. Both randomized controlled trials (RCTs) as well as non-RCTs were included. The Cochrane Risk-of-Bias Tool and the ROBINS-I Tool were used to assess the risk of bias of individual studies, whereas the GRADE approach was used to evaluate the quality of evidence for all studies related to physical activity outcomes. A narrative synthesis was conducted.

RESULTS

Six studies were included in the review. Among the total of 2646 participants, the average age ranged from 35.5 to 43.3 years, and women accounted for between 48.6% and 88%. Risk of bias was rated as "high" in 3 studies, "moderate" in 2, and "low" in 1. The quality of evidence was assessed as "moderate." Four of the 6 studies reported positive effects on physical activity during the incentive period.

CONCLUSIONS

Workplace health promotion incorporating financial incentives has the potential to positively impact the physical activity levels of employees.

Public attitudes to implementing financial incentives in stopsmoking services in Ireland

INTRODUCTION

Financial incentives improve stop-smoking service outcomes. Views on acceptability can influence implementation success. To inform implementation planning in Ireland, public attitudes on financial incentives to stop smoking were measured.

METHODS

A cross-sectional telephone survey was administered to 1000 people in Ireland aged ≥15 years in 2022, sampled through random digit dialing. The questionnaire included items on support for financial incentives under different conditions. Prevalence of support was calculated with 95% Confidence Intervals (CIs) and multiple logistic regression identified associated factors using adjusted odds ratios (AORs) with 95% CIs.

RESULTS

Almost half (47.0%, 95% CI: 43.9-50.1) of the participants supported at least one type of financial incentive to stop smoking, with support more prevalent for shopping vouchers (43.3%, 95% CI: 40.3-46.5) than cash payments (32.1%, 95% CI: 29.2-35.0). Support was similar for universal and income-restricted schemes. Of those who supported financial incentives, the majority (60.6%) believed the maximum amount given on proof of stopping smoking should be under €250 (median=100, range: 1-7000). Compared to their counterparts, those of lower education level (AOR=1.49; 95% CI: 1.10-2.03, p=0.010) and tobacco/e-cigarette users (AOR=1.43; 95% CI: 1.02-2.03, p=0.041) were significantly more likely to support either financial incentive type, as were younger people.

CONCLUSIONS

While views on financial incentives to stop smoking in Ireland were mixed, the intervention is more acceptable in groups experiencing the heaviest burden of smoking-related harm and most capacity to benefit. Engagement and communication must be integral to planning for successful implementation to improve stop-smoking service outcomes.