Professor Ivo Vlaev, University of Warwick:
"It’s widely accepted that we need to find new ways of addressing public health issues such as obesity and inactivity. Changing behaviour is likely to be just as important as developing new treatments and technologies – but we know it isn’t easy to do.
We already know about some effective ways of changing behaviour – tax on cigarettes, for example. But what if people were rewarded – with cash or a voucher – for making healthy lifestyle choices? There is now increasing interest in patient incentives, which seek to do just that. Incentives have potentially wide applicability – from encouraging people to give up smoking, to vaccinate their children, or to attend a screening appointment. But how much do we know about whether they work – and why?
Behavioural science – the study of factors which influence behaviour – tells us that people may change their attitudes and beliefs as a result of education campaigns. But it also suggests that behaviour can sometmes change spontaneously as a response to triggers in the environment. This is how incentives seek to work.
There is some evidence that incentives can work for things like medication compliance, but the evidence is less clear on how well they work for more complex behaviours like smoking or obesity. This NIHR Highlight explores the effect of incentives in a range of situations, and the findings are mixed: while they seemed to work well in some cases, in others they actually made things worse.
This may be because there are a lot of variables at play in the way we design and use incentives. To start with, different patient populations may have very different motivations and drivers. Incentives can be designed in many different ways too – from the level and type of reward offered, to the point at which they can be claimed. For instance, to incentivise attendance at a weight loss class, should we offer an incentive at the start, at the end, or following evidence of sustained weight loss?
The evidence described in the Highlight gives some insights into when and how incentives might work. For smoking cessation, linking the incentive to evidence of quitting was important. It was also notable that the benefits didn’t always last once the incentive stopped – a recognised concern about incentive use. In the study where incentives had a negative effect, it’s possible that the particular patient group – who in this case had a history of non-attendance at screening, and tended not to have active symptoms – were less amenable to the idea of an incentive. Clearly, careful consideration of the particular context and patient group is vital.
The Highlight also shows how incentives may trigger strong – and not always positive – responses. Research suggests that many people may find them unpalatable or feel that they are unfair. This needs to be borne in mind too when planning an incentive scheme.
This evidence helps shape our understanding of the use of incentives, but gaps remain. There is a need for future research to consider how we might combine different types of incentive, or use techniques such as commitment contracts. "
About the author: Prof Vlaev is interested in human decision-making and behaviour change. He has advised the DHSC, Public Health England, Cabinet Office and many others on the application of lessons from behavioural science in public policy.