Wellness Incentives, Equity, and the 5 Groups Problem

Schmidt, Harald

doi:10.2105/ajph.2011.300348

Cited by 23 publications

(23 citation statements)

References 9 publications

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“…The typologies of women reported by Nichter and colleagues 110 and Radley and colleagues 113 for smoking cessation incentive programmes in pregnancy, and the typology for a wider range of wellness incentives described by Schmidt,271 resonate with our data and influence engagement and behaviour outcomes. These typologies have important implications for policy decisions about whether incentives are universal, the preferred option in our study, or targeted to those who have the capacity to benefit and/or who are most likely to succeed.…”

Section: Fit With the Literaturesupporting

confidence: 80%

“…Indeed, typologies of the impact of incentives on five groups of individuals -the 'lucky ones', the 'yes I can' group, the 'I'll do it tomorrow' group, the 'unlucky ones' and the 'leave me alone' group -have implications for whether incentives should be universal, targeted or abandoned. 271 Unintended consequences are reported in some studies, with gaming to receive the incentive seeming more likely if the incentive rewards attendance rather than the actual desired behaviour. Incentive studies for complex lifestyle behaviours are therefore predominantly hypothesis generating and have largely targeted individuals and further research into targeting other populations is indicated, for example families, communities and workplaces.…”

Section: Discussionmentioning

confidence: 99%

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Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

Morgan

Hoddinott

Thomson

et al. 2015

Health Technology Assessment

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BackgroundSmoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.AimTo understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design.DesignEvidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.SettingUK.ParticipantsThe qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking.Methods(1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test.ResultsOut of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A ‘ladder’ logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical ‘ladder’ towards smoking cessation and breastfeeding. Incentive interventions provide opportunity ‘rungs’ to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women’s capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave ‘healthily’ risk them feeling pressurised and failing. To avoid ‘losing face’, women may disengage.LimitationsIncluded studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population.ConclusionsIncentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.Study registrationThis study is registered as PROSPERO CRD42012001980.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Fit With the Literaturesupporting

confidence: 80%

Section: Discussionmentioning

confidence: 99%

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

Morgan

Hoddinott

Thomson

et al. 2015

Health Technology Assessment

View full text Add to dashboard Cite

show abstract

“…Where incentives have this effect, it is a clearcut case of long term harm. When the benefits are substantial, the disparities may become even more inequitable31; the health status of groups that are at the lower end of the social ladder might be at risk of moving even farther from groups at the higher end. Patterns of systematic disadvantage may become further entrenched as a result.…”

Section: What Are the Potential Long Term Harms Of Health Incentive Imentioning

confidence: 99%

Health incentive research and social justice: does the risk of long term harms to systematically disadvantaged groups bear consideration?

Wild

Pratt

2016

J Med Ethics

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The ethics of health incentive research-a form of public health research-are not well developed, and concerns of justice have been least examined. In this paper, we explore what potential long term harms in relation to justice may occur as a result of such research and whether they should be considered as part of its ethical evaluation. 'Long term harms' are defined as harms that contribute to existing systematic patterns of disadvantage for groups. Their effects are experienced on a long term basis, persisting even once an incentive research project ends. We will first establish that three categories of such harms potentially arise as a result of health incentive interventions. We then argue that the risk of these harms also constitutes a morally relevant consideration for health incentive research and suggest who may be responsible for assessing and mitigating these risks. We propose that responsibility should be assigned on the basis of who initiates health incentive research projects. Finally, we briefly describe possible strategies to prevent or mitigate the risk of long term harms to members of disadvantaged groups, which can be employed during the design, conduct and dissemination of research projects.

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“…Another large employer in the financial industry rewarded employees for meeting personalized goals, such as exercising four times a week or increasing fruit and vegetable intake. Such progress-oriented incentives may be particularly useful for motivating individuals with complex conditions or a number of health risk factors, as small steps may be perceived attainable (6).…”

Section: Health Policy and Managementmentioning

confidence: 99%

Financial Incentives: Only One Piece of the Workplace Wellness Puzzle Comment on “Corporate Wellness Programs: Implementation Challenges in the Modern American Workplace”

Busum

Mattke

2013

Int J Health Policy Manag

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Wellness Incentives, Equity, and the 5 Groups Problem

Cited by 23 publications

References 9 publications

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

Health incentive research and social justice: does the risk of long term harms to systematically disadvantaged groups bear consideration?

Financial Incentives: Only One Piece of the Workplace Wellness Puzzle Comment on “Corporate Wellness Programs: Implementation Challenges in the Modern American Workplace”

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