The impact of patient financial incentives to promote blood donation and compliance with health care

The purpose of this thesis is to examine the impact of financial incentives to promote health behaviour change. Financial incentives include tangible rewards as cash, vouchers and lotteries that are offered to individuals conditional to the fulfilment of health guidelines. Despite the growing use of such patient incentives in practice, some fundamental questions are yet to be answered: (1) Are financial incentives effective? (2) What type and size of incentive is more effective? (3) Do patient income and past health behaviour moderate the impact of incentives? These questions are analysed in the context of (a) blood donation and (b) compliance with health care including adherence to treatment, disease screening, immunisation and appointment keeping. Behavioural economics, in particular prospect theory, provide the theoretical foundations for this work and substantiate my hypotheses about the effect of financial incentives. I perform the first meta-analyses in the literature to quantify the impact of patient financial incentives to promote blood donation (chapter 3) and compliance (chapter 4). These results show that financial incentives do not promote blood donation but increase compliance with health care, particularly for low income patients. Two large field studies were developed to further examine the effect of incentives in compliance - testing pioneer incentive schemes. I test the impact of a certain (£5 voucher) versus uncertain (£200 lottery) incentive framed either as a gain or loss to promote Chlamydia screening (chapter 5). I also develop the first study ever testing preferences for sequences of events in the field – using the naturalistic setting of colorectal cancer. This study compared the effect of a €10 incentive offered at the end of screening versus two €5 incentives offered at the beginning and end of screening (chapter 6). The former showed the voucher framed as a gain was the most effective incentive and the latter showed that smaller two €5 incentives increase screening more than a single €10 incentive (which had a detrimental effect compared to no incentive). I fundamentally contribute to the literature by showing that (i) patient financial incentives do not increase the quantity of blood donations and may have an adverse effect on quality, providing empirical evidence to a long-standing policy debate. Furthermore (ii) small certain rewards around £5 are likely to be the optimal incentive for compliance with health care, (iii) higher incentives may be more effective if offered as smaller segregated incentives of the same amount and (iv) incentives have over twice the impact on low income patients than on more affluent patients

Incentivizing blood donation: systematic review and meta-analysis to test Titmuss’ hypotheses

Objectives: Titmuss hypothesized that paying blood donors would reduce the quality of the blood donated and would be economically inefficient. We report here the first systematic review to test these hypotheses, reporting on both financial and nonfinancial incentives. Method: Studies deemed eligible for inclusion were peer-reviewed, experimental studies that presented data on the quantity (as a proxy for efficiency) and quality of blood donated in at least two groups: those donating blood when offered an incentive, and those donating blood with no offer of an incentive. The following were searched: MEDLINE, EMBASE and PsycINFO using OVID SP, CINAHL via EBSCO and CENTRAL, the Cochrane Library, Econlit via EBSCO, JSTOR Health and General Science Collection, and Google. Results: The initial search yielded 1100 abstracts, which resulted in 89 full papers being assessed for eligibility, of which seven studies, reported in six papers, met the inclusion criteria. The included studies involved 93,328 participants. Incentives had no impact on the likelihood of donation (OR = 1.22 CI 95% 0.91–1.63; p = .19). There was no difference between financial and nonfinancial incentives in the quantity of blood donated. Of the two studies that assessed quality of blood, one found no effect and the other found an adverse effect from the offer of a free cholesterol test (β = 0.011 p < .05). Conclusion: The limited evidence suggests that Titmuss’ hypothesis of the economic inefficiency of incentives is correct. There is insufficient evidence to assess their likely impact on the quality of the blood provided

Retirement saving choices: review of the literature and policy implications

Pension reforms in many countries have resulted in more choice and risk to individuals, decreasing the dependability on State public pensions. However, it is not clear how research has addressed this issue and how much is know about retirement saving decisions. With this paper, we provided two major contributions to the literature on retirement saving. As a starting point, we developed a general chart of retirement saving choices, extending the work of Hurd and Panis (2006). These authors focused exclusively on choices at job change or retirement age and we extended their diagram to all main decisions at each stage of retirement saving, providing a more comprehensive framework. We then used this diagram as the yardstick to perform the systematic review and evaluate the breadth of research in the last 20 years. We found 130 papers and identified the most studied retirement choices and the under- researched areas. Most papers focused on asset allocation, decision to save and contribution rate. Less attention was given to decisions at retirement age and voluntary savings. Furthermore, very few papers studied the psychological and social influences in retirement saving decisions. Policy implications and future research are discussed