Financial incentives for COVID-19 vaccines in a rural low-resource setting: a cluster-randomized trial.
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ABSTRACT:
SUBMITTER: Duch R
PROVIDER: S-EPMC10719106 | biostudies-literature | 2023 Dec
REPOSITORIES: biostudies-literature
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Financial incentives for COVID-19 vaccines in a rural low-resource setting: a cluster-randomized trial.
Duch Raymond R Asiedu Edward E Nakamura Ryota R Rouyard Thomas T Mayol Alberto A Barnett Adrian A Roope Laurence L Violato Mara M Sowah Dorcas D Kotlarz Piotr P Clarke Philip P
Nature medicine 20231127 12
We implemented a clustered randomized controlled trial with 6,963 residents in six rural Ghana districts to estimate the causal impact of financial incentives on coronavirus disease 2019 (COVID-19) vaccination uptake. Villages randomly received one of four video treatment arms: a placebo, a standard health message, a high cash incentive (60 Ghana cedis) and a low cash incentive (20 Ghana cedis). For the first co-primary outcome-COVID-19 vaccination intentions-non-vaccinated participants assigned ...[more]
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Project description:ImportancePrior studies found that financial incentives have small, positive direct effects in increasing COVID-19 vaccination rates, but unmeasured social spillovers (ie, changes in outcomes among untreated individuals who are socially exposed to policy beneficiaries) may diminish the overall effect of such policies.ObjectiveTo assess the spillover effects of a COVID-19 vaccination financial incentive and assess whether incorporating estimates of spillover meaningfully affects broader evaluations of policy effectiveness.Design, setting, and participantsThis population-level, address-cluster randomized clinical trial was conducted in November 2021. Participants were all adult (aged ≥18 years) residents of Ravensburg, Germany, who were randomly assigned to the treatment or control group. One resident in each address cluster was randomly selected to be an address-cluster representative. Address-cluster representatives in the treatment group received the treatment letter; all other cohabitants at that same address received the control letter. All individuals in addresses randomly assigned to the control group were mailed a control letter. Intention-to-treat data analysis was conducted from January 2022 to May 2024.InterventionControl letters informed recipients about 7 upcoming free COVID-19 vaccination events. Treatment letters were identical to control letters, except they also offered €40 (US $41.46) for getting vaccinated at one of the events.Main outcome and measurePrimary and booster COVID-19 vaccination uptake was observed and recorded on site during the public vaccination events. Primary vaccinations were defined as either the first dose of a 1-dose vaccine or the first or second dose of a 2-doses vaccine. Boosters were defined as any dose after primary vaccination. Three types of commonly used treatment effects were analyzed: direct, spillover, and overall.ResultsAmong 41 548 Ravensburg residents (mean [SD] age, 49.96 [19.04] years; 51.3% female), 796 (1.9%) were vaccinated at 1 of the 7 public vaccination events. The direct, spillover, and overall effects of receiving a financial incentive on primary vaccinations were all nonsignificant. For booster vaccinations, the direct effect was negative but not statistically significant (-0.32 percentage points [95% CI, -0.77 to 0.14 percentage points]; P = .17), whereas the overall effect (-0.30 percentage points [95% CI, -0.51 to -0.09 percentage points]; P = .006) was significantly negative. The spillover effect was significantly negative (-0.29 percentage points [95% CI, -0.53 to -0.06 percentage points]; P = .01), but only for the first vaccination events.Conclusions and relevanceThis trial found null direct effects on COVID-19 vaccination uptake and negative effects on booster uptake among individuals who did not receive but were indirectly exposed to the financial incentives. The timing of this spillover suggests that cohabitants of financial incentive recipients postponed booster vaccination, thereby undermining the potential effectiveness of this policy.Trial registrationISRCTN identifier: ISRCTN59503725.
| S-EPMC11806395 | biostudies-literature
Project description:ImportanceAlthough breastfeeding has a positive effect on an infant's health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.ObjectiveTo assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum.Design, setting, and participantsThe Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015, and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40%. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant's estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).InterventionsUsual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk.Main outcomes and measuresThe primary outcome was electoral ward area-level 6- to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6- to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks.ResultsIn the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, -0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, -0.2 to 4.8; P = .07).Conclusions and relevanceFinancial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.Trial registrationInternational Standard Randomized Controlled Trial Registry: ISRCTN44898617.
| S-EPMC5839268 | biostudies-literature
Project description:Uptake of human papillomavirus (HPV) vaccinations by 17- to 18-year-old girls in England is below (<35%) target (80%). This trial assesses (a) the impact of financial incentives on uptake and completion of an HPV vaccination program, and (b) whether impacts are moderated by participants' deprivation level. It also assesses the impact of incentives on decision quality to get vaccinated, as measured by attitudes toward the vaccination and knowledge of its consequences.One thousand 16- to 18-year-old girls were invited to participate in an HPV vaccination program: 500 previously uninvited, and 500 unresponsive to previous invitations. Girls randomly received either a standard invitation letter or a letter including the offer of vouchers worth £ 45 (€ 56; $73) for undergoing 3 vaccinations. Girls attending their first vaccination appointment completed a questionnaire assessing decision quality to be vaccinated. Outcomes were uptake of the first and third vaccinations and decision quality.The intervention increased uptake of the first (first-time invitees: 28.4% vs. 19.6%, odds ratio [OR] = 1.63, 95% confidence interval [CI; 1.08, 2.47]; previous nonattenders: 23.6% vs. 10.4%, OR = 2.65, 95% CI [1.61, 4.38]) and third (first-time invitees: 22.4% vs. 12%, OR = 2.15, 95% CI [1.32, 3.50]; previous nonattenders: 12.4% vs. 3%, OR = 4.28, 95% CI [1.92, 9.55]) vaccinations. Impacts were not moderated by deprivation level. Decision quality was unaffected by the intervention.Although the intervention increased completion of HPV vaccinations, uptake remained lower than the national target, which, in addition to cost effectiveness and acceptability issues, necessitates consideration of other ways of achieving it.
| S-EPMC4312136 | biostudies-other
Project description:IntroductionPoor asthma control in adolescents is partly attributed to inadequate asthma education for self-management. This study is set to determine the effectiveness of the "KmAsthma" self-management app in improving the control of asthma among adolescents in a low-resource setting.MethodsThe two-arm 6-month cluster randomized controlled trial, will aim at enrolling 120 day scholars aged 12-19 years in secondary schools with a clinician's diagnosis and self-reported uncontrolled asthma in Kampala City Uganda. The primary endpoint of asthma control will be measured as a change in mean Asthma Control Test (ACT) scores. Asthma quality of life, adherence to medications, and self-efficacy will also be assessed. The iMprovIng the ContROl of aSthma (MICROS) study will employ the "KmAsthma" app for self-management education. The intervention group will receive the app on their smartphones and training on its eight sections: the profile, asthma history, goals, inspirations, reminders, connect, information about asthma, and emergency support. Participants will navigate these sections to set asthma control goals, schedule medication reminders, log daily symptoms, and receive guidance for attacks. All participants will be encouraged to seek routine care. A study nurse will follow up with each participant via the phone six weeks post-intervention. The MICROS study was approved by the Makerere University School of Medicine Research and Ethics Committee and the Uganda National Council of Science and Technology. This protocol is registered on Clinicaltrials.gov (NCT05850806).ConclusionThe MICROS study will provide comprehensive insights into how effective a mHealth intervention can be an aid for adolescents in a low-resource setting in managing their asthma. The findings of this study will contribute to filling the gap leading to unsatisfactory asthma control in adolescents.
| S-EPMC10695141 | biostudies-literature
Project description:BackgroundEmerging interventions that rely on and harness variability in behavior to adapt to individual performance over time may outperform interventions that prescribe static goals (e.g., 10,000 steps/day). The purpose of this factorial trial was to compare adaptive vs. static goal setting and immediate vs. delayed, non-contingent financial rewards for increasing free-living physical activity (PA).MethodsA 4-month 2 × 2 factorial randomized controlled trial tested main effects for goal setting (adaptive vs. static goals) and rewards (immediate vs. delayed) and interactions between factors to increase steps/day as measured by a Fitbit Zip. Moderate-to-vigorous PA (MVPA) minutes/day was examined as a secondary outcome.ResultsParticipants (N = 96) were mainly female (77%), aged 41 ± 9.5 years, and all were insufficiently active and overweight/obese (mean BMI = 34.1 ± 6.2). Participants across all groups increased by 2389 steps/day on average from baseline to intervention phase (p < .001). Participants receiving static goals showed a stronger increase in steps per day from baseline phase to intervention phase (2630 steps/day) than those receiving adaptive goals (2149 steps/day; difference = 482 steps/day, p = .095). Participants receiving immediate rewards showed stronger improvement (2762 step/day increase) from baseline to intervention phase than those receiving delayed rewards (2016 steps/day increase; difference = 746 steps/day, p = .009). However, the adaptive goals group showed a slower decrease in steps/day from the beginning of the intervention phase to the end of the intervention phase (i.e. less than half the rate) compared to the static goals group (-7.7 steps vs. -18.3 steps each day; difference = 10.7 steps/day, p < .001) resulting in better improvements for the adaptive goals group by study end. Rate of change over the intervention phase did not differ between reward groups. Significant goal phase x goal setting x reward interactions were observed.ConclusionsAdaptive goals outperformed static goals (i.e., 10,000 steps) over a 4-month period. Small immediate rewards outperformed larger, delayed rewards. Adaptive goals with either immediate or delayed rewards should be preferred for promoting PA.Trial registrationClinicalTrials.gov ID: NCT02053259 registered prospectively on January 31, 2014.
| S-EPMC5372290 | biostudies-literature
Project description:BackgroundDespite progress in vaccination coverage, timeliness of childhood vaccination remains a challenge in many settings. We aimed to assess if mobile phone-based reminders and incentives to health workers and caregivers could increase timely neonatal vaccination in a rural, low-resource setting.MethodsWe conducted an open-label cluster randomized controlled 1:1:1 trial with three arms in 15 communities in Northern Ghana. Communities were randomized to 1) a voice call reminder intervention; 2) a community health volunteer (CHV) intervention with incentivized rewards; 3) control. In the voice call reminder arm, a study staff member made voice calls to mothers shortly after birth to encourage vaccination and provide personalized information about available vaccination services. In the incentive arm, CHVs promoted infant vaccination and informed women with recent births about available vaccination opportunities. Both CHVs and women were provided small monetary incentives for on-time early infant vaccination in this arm, delivered using mobile phone-based banking applications. No study activities were conducted in control communities. A population-based survey compared vaccination coverage across arms in the pre-intervention and intervention periods. The primary endpoint was completion of at least one dose of Polio vaccine within 14 days of life and BCG vaccination within 28 days of life.ResultsSix-hundred ninety births were identified; 106, 88, and 88 from pre-intervention and 150, 135, and 123 in the intervention period, in the control, voice call reminder and CHV incentive arms, respectively. In adjusted intent-to-treat analysis, voice call reminders were associated with 10.5 percentage point (95% CI: 4.0, 17.1) higher coverage of on-time vaccination, while mobile phone-based incentives were associated with 49.5 percentage point (95% CI: 26.4, 72.5) higher coverage.ConclusionCommunity-based interventions using mobile phone technologies can improve timely early vaccination coverage. A CHV approach with incentives to community workers and caregivers was a more effective strategy than voice call reminders. The impact of vaccination "nudges" via voice calls may be constrained in settings where network coverage and phone ownership are limited.Trial registrationThis trial was registered at ClinicalTrials.gov; NCT03797950.
| S-EPMC8133473 | biostudies-literature
Project description:ObjectivesThis study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR).BackgroundParticipation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events.MethodsA total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO2) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year.ResultsPatients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079).ConclusionsFinancial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).
| S-EPMC6599560 | biostudies-literature
Project description:IntroductionExperts continue to debate how to increase COVID-19 vaccination rates. Some experts advocate for financial incentives. Others argue that financial incentives, especially large ones, will have counterproductive psychological effects, reducing the percent of people who want to vaccinate. Among a racially and ethnically diverse U.S. sample of lower income adults, for whom vaccine uptake has lagged compared with higher income adults, we empirically examine such claims about relatively large and small guaranteed cash payments.MethodsIn 2021, we conducted a randomized, controlled experiment among U.S. residents with incomes below $80,000 who reported being unvaccinated against COVID-19. Study participants were randomized to one of four study arms. In two arms, respondents first learned about a policy proposal to pay $1,000 or $200 to those who received COVID-19 vaccination and were then asked if, given that policy, they would want to vaccinate. In the two other arms, respondents received either an educational message about this vaccine or received no vaccine information and were then asked if they wanted to vaccinate for COVID-19. The primary analyses estimated and compared the overall percentage in each study arm that reported wanting to vaccinate for COVID-19. In other analyses, we estimated and compared these percentages for subgroups of interest, including gender, race/ethnicity, and education.Main resultsAmong 2,290 unvaccinated adults, 79.7% (95%CI, 76.4-83.0%) of those who learned about the proposed $1,000 payment wanted to get vaccinated, compared with 58.9% (95%CI, 54.8-63.0%) in the control condition without vaccine information, a difference of 20 percentage points. Among those who learned of the proposed $200 payment, 74.8% (95% CI, 71.3-78.4%) wanted to vaccinate. Among those who learned only about the safety and efficacy of COVID-19 vaccines, 68.9% (95% CI, 65.1-72.7%) wanted to vaccinate. Findings were consistent across various subgroups.DiscussionDespite several study limitations, the results do not support concerns that the financial incentive policies aimed to increase COVID-19 vaccination would have counterproductive effects. Instead, those who learned about a policy with a large or small financial incentive were more likely than those in the control condition to report that they would want to vaccinate. The positive effects extended to subgroups that have been less likely to vaccinate, including younger adults, those with less education, and racial and ethnic minorities. Financial incentives of $1,000 performed similarly to those offering only $200.
| S-EPMC10022800 | biostudies-literature
Project description:BackgroundPenetration and participation of real life implementation of lifestyle change programs to prevent type 2 diabetes has been challenging. This is particularly so among low income individuals in the United States. The purpose of this study is to examine the effectiveness of financial incentives on attendance and weight loss among Medicaid beneficiaries participating in the 12-month Diabetes Prevention Program (DPP).MethodsThis is a cluster-randomized controlled trial with two financial incentive study arms and an attention control study arm. Medicaid beneficiaries with prediabetes from 13 primary care clinics were randomly assigned to individually earned incentives (IND; 33 groups; n = 309), a hybrid of individual- and group-earned incentives (GRP; 30 groups; n = 259), and an attention control (AC; 30 groups; n = 279). Up to $520 in incentives could be earned for attaining attendance and weight loss goals over 12 months. Outcomes are percent weight loss from baseline, achieving 5% weight loss from baseline, and attending 75% of core and 75% of maintenance DPP sessions. Linear mixed models were used to examine weight change and attendance rates over the 16 weeks and 12 months.ResultsThe percent weight change at 16 weeks for the IND, GRP, and AC participants were similar, at - 2.6, - 3.1%, and - 3.4%, respectively. However, participants achieving 5% weight loss in the IND, GRP, and AC groups was 21.5, 24.0% (GRP vs AC, P < 0.05), and 15.2%. Attendance at 75% of the DPP core sessions was significantly higher among IND (60.8%, P < 0.001) and GRP (64.0%, P < 0.001) participants than among AC (38.6%) participants. Despite substantial attrition over time, attendance at 75% of the DPP maintenance sessions was also significantly higher among IND (23.0%, P < 0.001) and GRP (26.1%, P < 0.001) participants than among AC (11.0%) participants.ConclusionsFinancial incentives can improve the proportion of Medicaid beneficiaries attending the 12-month DPP and achieving at least 5% weight loss.Trial registrationClinicalTrials.gov NCT02422420 ; retrospectively registered April 21, 2015.
| S-EPMC7580006 | biostudies-literature
Project description:BackgroundFinancial incentives can motivate desirable health behaviors, including adult HIV testing. Data regarding the effectiveness of financial incentives for HIV testing in children, who require urgent testing to prevent mortality, are lacking.MethodsIn a five-arm unblinded randomized controlled trial, adults living with HIV attending 19 HIV clinics in Western Kenya, with children 0-12 years of unknown HIV status, were randomized with equal allocation to $0, $1.25, $2.50, $5 or $10. Payment was conditional on child HIV testing within 2 months. Block randomization with fixed block sizes was used; participants and study staff were unblinded at randomization. Primary analysis was intent-to-treat, with predefined primary outcomes of completing child HIV testing and time to testing.ResultsOf 452 caregivers, 90, 89, 93, 92 and 88 were randomized to $0, $1.25, $2.50, $5.00, and $10.00, respectively. Of those, 31 (34%), 31 (35%), 44 (47%), 51 (55%), and 54 (61%) in the $0, $1.25, $2.50, $5.00, and $10.00 arms, respectively, completed child testing. Compared with the $0 arm, and adjusted for site, caregivers in the $10.00 arm had significantly higher uptake of testing [relative risk: 1.80 (95% CI 1.15--2.80), P = 0.010]. Compared with the $0 arm, and adjusted for site, time to testing was significantly faster in the $5.00 and $10.00 arms [hazard ratio: 1.95 (95% CI 1.24--3.07) P = 0.004, 2.42 (95% CI 1.55--3.79), P < 0.001, respectively).ConclusionFinancial incentives are effective in improving pediatric HIV testing among caregivers living with HIV.RegistrationNCT03049917.
| S-EPMC7791594 | biostudies-literature