April 22, 2019 – Patient preferences for incentives in a healthy behavior change do not necessarily align with industry best practices, calling into question the best path forward for patient motivation tactics.
According to a new study published in the Journal of the American Medical Association (JAMA) Open Access, parents of children who are obese do not favor patient motivation and incentive programs that adhere to industry best practices.
Pediatric patients who are obese are often prescribed family-based therapy, which includes family members and parent or guardian caregivers in healthy behavior changes. Family-based therapy includes monthly in-person counseling, 60 minutes of daily physical activity, reduced screen time, food and exercise logs, and a commitment to healthy eating from all family members.
This healthcare intervention can be exceptionally burdensome for families. The program is demanding, challenging, and cost-intensive, the researchers acknowledged, and therefore has a very high attrition rate.
“Strategies to reduce attrition and motivate families within this effective treatment program are needed,” the researchers said.
“Financial incentive programs have long been used to promote treatment engagement and healthy behaviors,” they continued. “By providing people with immediate and consistent gratification for engaging in challenging behaviors that have uncertain and delayed benefits, incentives can keep participants engaged long enough to observe the long-term benefits of behavior change.”
But a survey of parents with children ages six to 17 who are obese revealed that programs that allow patients to earn money as they go and that guarantee a payoff at the end are more preferable than lottery systems or loss aversion systems.
Loss aversion systems give patients a payout at the start of an intervention and deducts earnings for pitfalls.
The researchers specifically asked about which attributes are most appealing to parents and other family members. Surveyed attributes included monetary value of incentive, payment structure, the goal of being incentivized, and the person being incentivized.
Parents overwhelmingly preferred larger incentives compared to other model attributes. Only one-in-five respondents said they preferred a lottery system with a larger reward than a smaller, but guaranteed, reward.
Additionally, parents preferred systems that are gain-framed, meaning they earned a large payout by the end of the study.
There were some promising results, the researchers said. For example, parents said they would be willing to accept lower payments if a program included both the child and parent, used positive reinforcement, and rewarded physical activity improvements rather than weight loss. This finding suggests parents value the key elements of patient behavior change over financial gain.
However, the researchers did find a disparity between patient preferences and best practices for incentive programs.
“Behavioral economic theory and empirical evidence support the use of loss-framed incentives and lotteries for motivating behavior change,” the researchers explained. “These incentive designs use loss aversion, where individuals strive to prevent losses rather than obtain equivalent gains. Incentive designs also capitalize on people’s tendencies to overestimate their probability of winning lotteries.”
This mismatch in patient preference and the evidence indicate a debate for healthcare professionals designing patient motivation and incentive programs.
“If incentives are unacceptable to their target populations, uptake of voluntary programs will remain low,” the researchers noted.
Medical professionals will need to weigh the benefits of either a preferred or evidence-based approach.
There is some theory backing the surveyed parents’ preferences, the researchers indicated. Because the intervention design includes a pediatric population, focusing on self-efficacy is crucial.
“Children are still developing competence in self-care skills and may be demoralized by loss-framed rewards when they do not to meet goals, especially since goal attainment may be out of the child’s control,” the researchers said. “Children may also be demoralized when they meet their goals but do not win a lottery.”
More data is necessary to make a final call, the researchers said, being careful to mention that incentive programs do depend on the unique patient population.
“Parent preferences for the design of incentives differ from behavioral economic and behavior change theory,” the research team concluded. “It is unclear whether the incentive that would reduce attrition and maximize the effectiveness of [family-based therapy] should align with researcher best practices or with parent preferences. An [randomized control trial] that evaluates the efficacy and cost-effectiveness of different [family-based therapy] incentive designs is needed.”