Promoting Healthy Childhood Behaviors With Financial Incentives: A Narrative Review of Key Considerations and Design Features for Future Research

In the last decade, there has been a robust increase in research using financial incentives to promote healthy behaviors as behavioral economics and new monitoring technologies have been applied to health behaviors. Most studies of financial incentives on health behaviors have focused on adults, yet many unhealthy adult behaviors have roots in childhood and adolescence. The use of financial incentives is an attractive but controversial strategy in childhood. In this review, we first propose 5 general considerations in designing and applying incentive interventions to children. These include: 1) the potential impact of incentives on intrinsic motivation, 2) ethical concerns about incentives promoting undue influence, 3) the importance of child neurodevelopmental stage, 4) how incentive interventions may influence health disparities, and 5) how to finance effective programs. We then highlight empirical findings from randomized trials investigating key design features of financial incentive interventions, including framing (loss vs gain), timing (immediate vs delayed), and magnitude (incentive size) effects on a range of childhood behaviors from healthy eating to adherence to glycemic control in type 1 diabetes. Though the current research base on these subjects in children is limited, we found no evidence suggesting that loss-framed incentives perform better than gain-framed incentives in children and isolated studies from healthy food choice experiments support the use of immediate, small incentives versus delayed, larger incentives. Future research on childhood incentives should compare the effectiveness of gain versus loss-framing and focus on which intervention characteristics lead to sustained behavior change and habit formation.

An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations

OBJECTIVES

A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization.

METHODS

Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group.

RESULTS

From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; P = .02).

CONCLUSIONS

A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.

Tailored Medication Adherence Incentives Using mHealth for Children With High-Risk Asthma (TAICAM): Protocol for a Randomized Controlled Trial

Background

Poor adherence to inhaled corticosteroid medications for children with high-risk asthma is both well documented and poorly understood. It has a disproportionate prevalence and impact on children of minority demographics in urban settings. Financial incentives have been shown to be a compelling method to engage those in a high-risk asthma population, but whether adherence can be maintained by offering financial incentives and how these incentives can be used to sustain high adherence are unknown.

Objective

The aim of this study is to determine the marginal effects of a financial incentive–based intervention on inhaled corticosteroid adherence, health care system use, and costs.

Methods

Participants include children aged 5 to 12 years who have had either at least two hospitalizations or one hospitalization and one emergency department visit for asthma in the year prior to their enrollment (and their caregivers). Participants are given an electronic inhaler sensor in order to track their medication use over a period of 7 months. After a 1-month period of observation, participants are randomized to 1 of 3 arms for a 3-month period. Participants in arm 1 receive daily text message reminders, feedback, and gain–framed, nominal financial incentives; participants in arm 2 receive daily text message reminders and feedback only, and participants in arm 3 receive no reminders, feedback, or incentives. All participants are subsequently observed for an additional 3-month period with no reminders, feedback, or incentives to assess whether any sustained effects are apparent.

Results

Study enrollment began in September 2019 with a target sample size of N=125 children. As of June 2020, 61 children have been enrolled. Data collection is estimated to be completed in June 2022, and analyses will be completed by June 2023.

Conclusions

This study will provide data that will help to determine whether a financial incentive–based mobile health intervention for promoting inhaled corticosteroid use can be effective in patients with high-risk asthma over longer periods.

Trial Registration

Clinicaltrial.gov NCT03907410; https://clinicaltrials.gov/ct2/show/NCT03907410

International Registered Report Identifier (IRRID)

DERR1-10.2196/16711