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EPPI, systematic review, research synthesis, research methods, ncrm, esrc A systematic review of the evidence for incentive schemes to encourage positive health and other social behaviours in young people. Summary Minimize EPPI, systematic review, research synthesis, research methods, ncrm, esrc

Background

This systematic review is the third and final product of a programme of work funded by the English Department of Health. The programme is located within the larger context of the recent Public Health White Paper, Choosing Health (Department of Health, 2004), which emphasises the significance of individual choice in determining a wide range of health and social behaviours, and the potential of incentives to aid behaviour change. If tangible incentives are effective in helping young people to develop and maintain healthy and prosocial behaviours, this is of importance to the formulation of health promotion policies.

An initial scoping exercise (Kavanagh et al., 2005) indicated that there was a considerable body of relevant evidence. A companion study (Trouton et al., 2005) documented a range of current incentive schemes based both in the UK and elsewhere. This systematic review brings together the relevant research literature to examine the effectiveness or otherwise of incentives in encouraging positive health and other social behaviours in young people. It also examines ongoing incentive-based schemes in more detail. A number of systematic reviews of incentives in health care contexts with other populations have been conducted (Achat et al., 1999; Giuffrida and Torgerson, 1997; Hey and Perera, 2005; Hey and Perera, 2005; Kane et al., 2004), but none have examined the use of incentives with young people in health, educational and community contexts in this way.

Existing research in the fields of psychology and, to a lesser extent, economics, highlights a number of unresolved issues regarding the impact and utility of incentive schemes. One question is to what extent our behaviour is shaped by extrinsic factors, such as incentives or environmental modification, or by intrinsic factors, which are more personal in nature and possibly less amenable to external influence. It is argued by some that the use of extrinsic rewards may discourage the development of the intrinsic motivation needed if behaviour changes are to be sustained in the long term (Cameron et al., 2001; Deci et al., 1999). There are other unanswered questions concerning the best way of designing incentive-based schemes for different populations, settings and purposes.

Research questions

Two broad research questions drove this systematic review and provided the conceptual basis for a systematic map of relevant research in the area. The first question was about effectiveness:

What is the best available evidence of the effectiveness or otherwise of incentive schemes to improve health and other social behaviours in young people aged 11–19?

The second question focused on processes:

In what conditions are incentive schemes more or less effective?

For example:

  • In which areas (e.g. health, education) do they work best?
  • For which groups of young people do incentive schemes work best (e.g. at-risk young people)?
  • Are universal or targeted approaches more effective?

Mapping the research

Altogether our literature searches produced 9,843 records. These were narrowed down to a total of 181 reports of 129 separate studies which were included in the first, mapping stage of the review. The majority of studies were conducted in the USA (N=88), with only 28 studies being carried out in the UK. A wide range of incentives was employed, from cash payments to entry into raffles or lotteries. Financial incentives in the form of cash payments or reduced-cost access to a range of resources were used in over half of the studies.

Many studies covered more than one topic area. Fifty studies described a focus on one or more health behaviours, 61 upon at least one educational behaviour, and 32 studies focused on one or more social behaviours.

The research in depth

A smaller number of studies were examined in more detail for the in-depth review. Sixteen outcome evaluations met our inclusion criteria and were judged to be methodologically sound. Nine were conducted in the USA, two in the UK and one each in Canada, Finland, Germany and the Netherlands. The interventions fell into three categories: nine studies which focused on a range of positive health behaviour changes; six which considered the impact of incentives on educational outcomes; and one study with other social outcomes.

Analysis of these studies showed that single or dual component incentive schemes are effective in encouraging positive health behaviours where a simple or single action is required, rather than a sustained health behaviour change. The Child Health Programme as described in the White Paper covers screening and immunisations which are single event health behaviours shown in our review as likely to benefit from the use of incentives to encourage uptake. The government target to reduce health inequalities as measured by infant mortality by 2010 focuses on interventions to improve services and support for pregnant women, new mothers and their babies. The highest rate of infant mortality is in children born to teenage mothers. We found non-financial incentives to be effective in encouraging teenage mothers to attend an early post-natal health clinic. 

The interventions were also shown to be effective in reducing smoking behaviours in the context of school-based competitions. These findings are based on a small number of studies, none of which were conducted in the UK, but they are consistent with other systematic review evidence. We found no evidence that single or dual component incentive schemes are effective in improving either the levels of effort applied to educational tests or attendance levels in school.

Overall single or dual component incentive schemes do not appear to offer policy-makers or practitioners a simple route to ensuring general positive behaviour changes in young people. However, they may be useful in particular settings and for particular groups.

Process evaluations

Of the sixteen trials included in the in-depth review, only seven provided formal process evaluations. Most of these studies investigated process issues regarding participants’ perceptions of the intervention, facilitators and barriers to implementation, and the accessibility and reach of the programme. Coverage of other process issues relating to the content and quality of the programmes, human resources issues and cost-effectiveness was scantier.

The following are issues for consideration when developing incentive-based interventions for piloting. Incentives do appear to be perceived favourably by participants, particularly where they are used in a straightforward way to reward a single behaviour. However, those who failed to reach targets despite their efforts sometimes had negative reactions including mention of lowered self-esteem. In designing incentive-based interventions, it is important to recognise the potential for harm, such as undesirable kinds of peer pressure, and it is important that the behaviour change required is achievable. The required behaviours need to be logged and rewarded consistently, and interventions designed to foster the required behaviour need to be implemented properly and consistently. Large-scale incentive-based schemes in particular require staff with the necessary skills and commitment to supporting young people through a scheme, and in turn such schemes require sound systems in place to support them. Consideration should be given to ensuring that the size or type of incentive on offer is sufficient to motivate change in young people.

Ongoing incentive schemes

Our earlier work (Trouton et al., 2005) located and described 37 ongoing schemes which use incentives to encourage positive behaviours in young people. These schemes can be divided into three broad groups: 15 fall under the heading of health promotion, 9 are related to education, and 13 target other social behaviours. We collated information about the evaluation status of the schemes and requested copies of all available evaluations from the schemes’ organisers. Evaluation is a key issue as it provides information regarding the impact of schemes on young people’s behaviours and whether they achieve their stated aims. We found that the most common approaches to evaluation were either post-intervention surveys or no formal evaluation at all. Only five of the schemes have implemented or are intending to implement evaluations using a control group design, a methodology which provides the most robust results.

Recommendations

A clear recommendation is the need to design and pilot single or dual component interventions to promote the uptake of simple or single event preventive health behaviours in young people. Such interventions could include immunisation or screening programmes, and accessing pre- and post-natal health services. We also recommend that classroom-based incentive schemes which aim to delay the onset of or reduce levels of smoking should be piloted and evaluated in well-designed RCTs.

Any future incentive-based interventions should access, and take into account, the views of young people on what are important areas of behaviour change to them, and what types of incentive-based interventions might be acceptable to them. This is an essential first step in designing and implementing acceptable and effective interventions.

Future evaluation research in this area should prioritise the use of randomised controlled trials, as this approach to evaluation makes it easiest to attribute any observed differences in outcomes to intervention effects. Where a cluster trial design is used, researchers should present intra-cluster correlations. All evaluations should be accompanied by well designed process evaluations.

Those conducting publicly funded incentive schemes should be encouraged to conduct reliable evaluations of the interventions that they implement with young people. Funders will need to ensure that funds are ring-fenced for such evaluations and that providers have access to research support.

References

Achat H, McIntyre P, Burgess M (1999) Health care incentives in immunisation. Australian and New Zealand Journal of Public Health 23: 285–288.

Cameron J, Banko KM, Pierce WD (2001) Pervasive negative effects of rewards on intrinsic motivation: the myth continues. The Behavior Analyst 24: 247–260.

Deci EL, Koestner R, Ryan RM (1999) A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychological Bulletin 125: 627–688.

Department of Health (2004) Choosing Health: Making healthier choices easier. London: The Stationery Office.

Giuffrida A, Torgerson DJ (1997) Should we pay the patient: review of financial incentives to enhance patient compliance. British Medical Journal 315: 703–707.

Hey K, Perera R (2005) Quit and Win contests for smoking cessation. In: The Cochrane Database of Systematic Reviews, 2005: Issue 2. Art. No.: CD004986.pub2. DOI: 10.1002/14651858.CD004986.pub2.

Hey K, Perera R (2005) Competitions and incentives for smoking cessation. The Cochrane Database of Systematic Reviews, 2005: Issue 2. Art. No.: CD004307.pub2. DOI: 10.1002/14651858.CD004307.pub2.

Kane RL, Johnson PE, Town RJ, Butler M (2004) Economic Incentives for Preventive Care. Rockville, Maryland, USA: Agency for Healthcare Research and Quality.

Kavanagh J, Trouton A, Oakley A, Harden A (2005) A Scoping Review of the Evidence for Incentive Schemes to Encourage Positive Behaviours in Young People. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London.

Trouton A, Kavanagh J, Oakley A, Harden A, Powell C (2005) A Summary of Ongoing Activity in the use of Incentive Schemes to Encourage Positive Behaviours in Young People. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London.

This report should be cited as: Kavanagh J, Trouton A, Oakley A, Powell C (2006) A systematic review of the evidence for incentive schemes to encourage positive health and other social behaviours in young people. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London.

  
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