Abstract
Background
Despite success in increasing other health behaviors, financial incentives have shown limited to no effect on colorectal cancer (CRC screening. Little is known about the factors shaping why and for whom incentives improve screening.
Objective
To explore the perspective of participants enrolled in a larger, four-arm pragmatic trial at urban family medicine practices which assessed and failed to detect significant effects of financial incentives on at-home CRC screening completion.
Design
We performed a mixed methods study with a subset of randomly selected patients, stratified by study arm, following completion of the pragmatic trial.
Participants
Sixty patients (46.9% enrollment rate) who were eligible and overdue for colorectal cancer screening at the time of trial enrollment and who continued to receive care at family medicine practices affiliated with an urban academic health system completed the interview and questionnaire.
Main Measures
Using Andersen’s behavioral model, a semi-structured interview guide assessed motivators, barriers, and facilitators to screening completion and the impact of incentives on decision-making. Participants also completed a brief questionnaire evaluating demographics, screening beliefs, and clinical characteristics.
Key Results
The majority of patients (n = 49; 82%) reported that incentives would not change their decision to complete or not complete CRC screening, which was confirmed by qualitative data as largely due to high perceived health benefits. Those who stated financial incentives would impact their decision (n = 11) were significantly less likely to agree that CRC screening is beneficial (72.7% vs 95.9%; p < 0.05) or that CRC could be cured if detected early (63.6% vs 98.0%; p < 0.05).
Conclusions
Financial incentives are likely not an effective behavioral intervention to increase CRC screening for all but may be powerful for increasing short-term benefit and therefore completion for some. Targeting financial incentive interventions according to patient screening beliefs may prove a cost-effective strategy in primary care outreach programs to increase CRC screening.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
INTRODUCTION
Colorectal cancer (CRC) is the second leading cause of US cancer death.1 Failing to receive or stay current on CRC screening increases mortality risk over two-fold,2 yet nearly one-third of the US population aged 50 to 75 years old did not have a current CRC screening test in 2016.3 Direct mailing of a fecal immunochemical test (FIT) to patients has proven to increase screening4 but has not become widely adopted practice in part due to potential resource costs.5
As a behavioral health intervention, financial incentives can increase a variety of health behaviors6 and have been applied to FIT programs to increase efficiency and response. However, incentives have had limited success in increasing CRC screening with most trials indicating no effect7,8,9 and some finding modest effects10,11 or effects only in conjunction with other interventions.12 Targeting incentive programs according to patient risk or likely response is increasingly recognized as cost-effective practice, including for CRC screening.13,14,15,16 Little is known, however, about why and for whom financial incentives may succeed from the perspective of patients.17 We conducted a mixed methods study18 embedded within a pragmatic randomized controlled trial19 in order to explore why financial incentives often fail to increase rates of CRC screening and identify whether certain patient contexts and characteristics might improve their efficacy.
METHODS
From August to November 2018, we conducted an embedded mixed methods study18 with primary care patients at an urban, academic health system who were enrolled in a 4-arm randomized pragmatic clinical trial which evaluated and failed to detect significant effects of financial incentives on mailed FIT completion.19 The governing institutional review board approved all activities.
Participants
At trial enrollment (December 2015–July 2017), participants were aged 50–75 years and overdue for CRC screening (n = 897).19 Eligible patients received a mailed FIT kit and were randomized to one of four parallel arms to receive (1) no financial incentive; (2) an unconditional $10 incentive included with the mailing; (3) a $10 incentive conditional on FIT completion; or (4) participation in a lottery with a 1-in-10 chance of winning $100 conditional on FIT completion. Completion rates were not statistically superior among any of the incentive arms compared to the active control arm.19
Following trial completion, we invited a subset of eligible participants via mailed letter and follow-up telephone call to complete a one-time, semi-structured interview and questionnaire. We randomly identified and invited patients in batches, stratified by trial arm, until reaching data saturation. We chose to randomize and stratify sampling by trial arm to enhance variation of intervention exposure, primarily to understand how different financial incentives within the trial did or did not work.20 We contacted 369 patients and reached 128; of these, 71 agreed to participate, and 60 completed the interview, 15 per trial arm. To assess for representativeness, we compared the enrolled sample (n = 60) to each of the following groups: the overall trial sample (n = 897), the randomly selected recruitment sample (n = 369), those contacted for recruitment but not reached (n = 241), and those reached but not enrolled (n = 68). We found no significant differences by age or race/ethnicity (p < 0.05). For sex, males represented a significantly higher proportion of those contacted but not reached (46.5%) than of those who enrolled (31.7%; p = 0.038). There were no other significant differences by sex between groups.
Data Collection
As an embedded mixed methods study,21 domains of interest were identified a priori at the time of the pragmatic trial to understand why and how each of the four interventions, particularly the use of financial incentives, succeeded or failed to change behavior and improve FIT completion. We planned to quantify certain results, taking advantage of validated questionnaires where available, to speak to existing literature;22,23,24,25,26 where less relevant literature existed, we planned exploratory analysis and used open-ended questions. Utilizing convergent parallel design,21 we aligned domains across data collection tools (interview guide and questionnaire) to triangulate qualitative and quantitative findings. To evaluate how patient-level factors shaped mailed FIT completion, we developed a semi-structured interview guide using Andersen’s behavioral model27 including open- and closed-ended questions examining views on financial incentives and other facilitators or barriers to screening (see Online Supplement). Andersen’s behavioral model is a health services access and utilization framework which models individual care access and use as a function of the following three factors: predisposing factors, such as social structure and demographics; enabling factors, including personal, family, and community; and perceived and evaluated need factors.27 Participants also completed a brief questionnaire evaluating demographics,22 health,23 screening history,24 provider communication,25 and screening beliefs using previously validated measures.26 The questionnaire was verbally administered to participants at the time of the interview. Following verbal consent, trained research staff with no prior relationship to participants from the Mixed Methods Research Lab (MMRL) at the University of Pennsylvania conducted the interviews with eligible participants in-person or by phone (depending on participant preference). Interviews lasted 25–30 min on average, were audio-recorded, and were transcribed verbatim. All participants received $20.
Data Analysis
We analyzed the qualitative data using the constant comparative method, guided by modified grounded theory.18 We utilized a priori domains of interest based on Andersen’s behavioral model and inductively explored emergent themes within and across participants.18,27 We conducted a round of open coding on a subset of 4 interviews to identify initial themes. We then developed a coding dictionary guided by conceptual model (deductive codes) and themes identified during open coding (inductive codes) which included index, parent thematic, and child thematic codes with rules for each code type. All codes were applied at the question level for consistency. Two trained coders applied the refined codebook to the interview set, each coding 35 of the 60 interviews using NVivo, with 10 interviews independently double-coded by both coders. Overall inter-rater reliability was calculated on the double-coded interviews (kappa = 0.7), and we produced summary thematic reports. We then conducted targeted secondary analysis to quantify patient response by incentive impact. Two analysts independently coded the individual responses to the open incentives question and had 93.3% agreement; the discordant responses were resolved by a third reviewer. We conducted descriptive and bivariate analyses of quantitative data (Stata version 15.1, Stata Corp LP), using concurrent methods to triangulate quantitative patterns with qualitative data.18.
RESULTS
Patient Characteristics
The median age of participants was 60 years, and most were female (68%), non-Hispanic Black (68%), and without a college degree (53%). Over half (60%) preferred mailed FIT to colonoscopy or sigmoidoscopy (Tables 1 and 2).
Impact of Incentives
The majority of respondents (n = 49; 82%) reported incentives would not change their decision to complete a FIT (Table 1); 12% of these (n = 6) had never been screened for CRC using any modality. Those participants who reported incentives would impact their screening behaviors (n = 11) were significantly less likely to agree that CRC screening is beneficial (72.7% vs 95.9%; p < 0.05) or that CRC is curable if detected early (63.6% vs 98.0%; p < 0.05), and nearly half (n = 5; 46%) had never been screened (Table 3).
Qualitative data supported the quantitative findings and clarified how financial incentives shape FIT decisions (Table 4).
No Impact on Decision
Patients who stated incentives would not impact their decision-making largely reported they would complete the FIT regardless. These patients primarily cited their health as a driver of screening decisions, with financial incentives viewed as a bonus. Some, however, could never be financially motivated to complete the FIT, either because they preferred another screening method or would not participate in CRC screening regardless.
Impact on Decision
Among respondents who reported a financial incentive would impact their screening decision, several indicated they would return the FIT kit more quickly. Many noted, however, that any influence would depend on the amount, with suggestions varying from $10 to $500.
Motivators, Barriers, and Facilitators
To better understand how financial incentives impact decision-making, we assessed cross-cutting motivators, barriers, and facilitators to FIT completion (Table 5).
Motivators
Most commonly, respondents discussed personal beliefs, such as health preservation, mortality reduction, health scares, and known risk factors. Other motivators included the ease of mailed FIT and provider recommendation.
Barriers
While not every patient reported barriers, the most commonly mentioned were personal factors, such as forgetting or losing the test or being too busy or ill. Some indicated they would delay or not complete the test because they felt healthy or feared the results. Structural issues, including cost and difficulty accessing a post office, were common. Respondents also mentioned test-related factors, particularly disgust, embarrassment, or reliability concerns; disgust was particularly common among those who indicated financial incentives would impact their decision-making.
Facilitators
The main facilitator mentioned was direct outreach, encompassing provider recommendation, education, and reminders. Preferred medium varied, including text message, email, telephone, mail, and in-person reminders. Many also discussed handoff issues, preferring to receive or complete the kit at their provider’s office.
DISCUSSION
While financial incentives have had limited to no success in improving at-home CRC screening rates to date, this intervention has proven an effective strategy to improve other health behaviors. As Moller and colleagues suggest,28 a better understanding of the factors motivating patients’ responses to financial incentives may identify patient contexts and characteristics which improve the efficacy of financial incentive programs. This study provides novel insight from the patient perspective into such factors, including indication that differing beliefs and motivations may require tailored intervention approaches to be most effective.
The majority of participants (49; 82%) indicated that financial incentives would not impact their decision to complete the FIT kit or not. These patients typically reported being motivated to complete the FIT regardless of financial incentives due to desires to stay healthy and follow doctor recommendations, which comported with higher perceived health benefits of screening and belief in the curability of CRC if detected early. While the mechanisms by which financial incentives could be effective vary by individual (e.g., cue to action), these findings suggest that financial incentives may not increase screening for most patients. Common barriers such as forgetfulness, busyness, mailing difficulties, and costs could be addressed through frequently mentioned facilitators, such as enhanced outreach, reminders, in-clinic hand-off of FIT kits, and reimbursement for any costs. Such interventions may not be effective, however, among the subset of participants who reported that financial incentives would not influence their decision but have never been screened (6/49; 12%). Previous research has examined persistent barriers to CRC screening, such as fear of results,29,30,31 but further investigation into such barriers among this predominately Black, urban population may be productive.
Participants who responded that incentives would influence decision-making (11; 18%) also reported lower perceived benefits of screening and ability to cure CRC if detected early. These beliefs may contribute to the group’s higher likelihood of never before being screened using any modality. Here, bolstering the effect of the cross-cutting facilitators mentioned above, financial incentives may influence patient decisions because these patients do not perceive many benefits to FIT completion and thus lack intrinsic motivation.28 Substantial financial incentives may be required, however, to sufficiently increase perceived benefit-to-effort ratio and to avoid the “peanuts” effect, where incentives are perceived as too small given a high-stakes context, such as one’s health, and subsequently undermine motivation.32 For example, of the subset of patients who reported never being screened but that incentives would impact their decision (5/11; 46%), none completed the FIT during the trial despite being randomized to receive a financial incentive; this may be because the incentive was too low.19
Limitations
This study has limitations, including use of self-reported data subject to recall or social desirability bias and sampling from a patient cohort at a single academic center. Participants differed significantly by sex from those who were contacted to participate but not reached; thus, participant beliefs and responses may differ in meaningful ways from those unreached and from those who decided not to participate in this study. Study participants were not significantly different, however, than the overall pragmatic trial participants in sex, age, or race/ethnicity, enabling contextual insight that can broadly help to explain why financial incentives did not succeed for most participants in the trial.
CONCLUSION
Findings indicate financial incentives in colorectal screening programs may impact patient decision-making to complete screening differently based on certain beliefs, with most patients indicating that incentives do not influence decisions. Future studies evaluating the impact of financial incentives should consider stratifying by baseline screening beliefs and history to further evaluate differential impact across patient screening beliefs. This may more accurately identify strategies to improve the targeting and cost-effectiveness of mailed FIT outreach programs, particularly financial incentive interventions, thus increasing the uptake of overall CRC screening.
Data availability
The quantitative datasets analyzed during the current study are available from the corresponding author on reasonable request. Given the challenges of fully de-identifying qualitative data, the raw data cannot be shared publicly. However, the authors are open to sharing summary data on a case-by-case basis as allowed by human subjects policies.
References
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67(1):7-30. https://doi.org/10.3322/caac.21387
Doubeni CA, Corley DA, Quinn VP, et al. Effectiveness of screening colonoscopy in reducing the risk of death from right and left colon cancer: a large community-based study. Gut. 2018;67(2):291-298. https://doi.org/10.1136/gutjnl-2016-312712
Centers for Disease Control and Prevention (CDC). Colorectal Cancer Screening Rates. Published June 29, 2020. Accessed February 27, 2021. https://www.cdc.gov/cancer/ncccp/screening-rates/index.htm
Mehta SJ, Khan T, Guerra C, et al. A Randomized Controlled Trial of Opt-in Versus Opt-Out Colorectal Cancer Screening Outreach. Am J Gastroenterol. 2018;113(12):1848-1854. https://doi.org/10.1038/s41395-018-0151-3
Dougherty MK, Brenner AT, Crockett SD, et al. Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis. JAMA Intern Med. 2018;178(12):1645-1658. https://doi.org/10.1001/jamainternmed.2018.4637
Giles EL, Robalino S, McColl E, Sniehotta FF, Adams J. The Effectiveness of Financial Incentives for Health Behaviour Change: Systematic Review and Meta-Analysis. PLoS ONE. 2014;9(3). https://doi.org/10.1371/journal.pone.0090347
Bakhai S, Ahluwalia G, Nallapeta N, Mangat A, Reynolds JL. Faecal immunochemical testing implementation to increase colorectal cancer screening in primary care. BMJ Open Qual. 2018;7(4):e000400. https://doi.org/10.1136/bmjoq-2018-000400
Green BB, Anderson ML, Cook AJ, et al. Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities: A Randomized Clinical Trial. JAMA Netw Open. 2019;2(7):e196570. https://doi.org/10.1001/jamanetworkopen.2019.6570
Gupta S, Miller S, Koch M, et al. Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial. Off J Am Coll Gastroenterol ACG. 2016;111(11):1630-1636. https://doi.org/10.1038/ajg.2016.286
Kullgren JT, Dicks TN, Fu X, et al. Financial Incentives for Completion of Fecal Occult Blood Tests Among Veterans. Ann Intern Med. 2014;161(10_Supplement):S35-S43. https://doi.org/10.7326/M13-3015
Mehta SJ, Feingold J, Vandertuyn M, et al. Active Choice and Financial Incentives to Increase Rates of Screening Colonoscopy–A Randomized Controlled Trial. Gastroenterology. 2017;153(5):1227-1229.e2. https://doi.org/10.1053/j.gastro.2017.07.015
Redwood D, Holman L, Zandman-Zeman S, Hunt T, Besh L, Katinszky W. Collaboration to Increase Colorectal Cancer Screening Among Low-Income Uninsured Patients. Prev Chronic Dis. 2011;8(3). Accessed October 14, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103574/
Kim DD, Cohen JT, Wong JB, et al. Targeted Incentive Programs For Lung Cancer Screening Can Improve Population Health And Economic Efficiency. Health Aff (Millwood). 2019;38(1):60-67. https://doi.org/10.1377/hlthaff.2018.05148
Lairson DR, DiCarlo M, Myers RE, et al. Cost-effectiveness of targeted and tailored interventions on colorectal cancer screening use. Cancer. 2008;112(4):779-788. https://doi.org/10.1002/cncr.23232
Myers RE, Sifri R, Hyslop T, et al. A randomized controlled trial of the impact of targeted and tailored interventions on colorectal cancer screening. Cancer. 2007;110(9):2083-2091. https://doi.org/10.1002/cncr.23022
Sutherland K, Christianson JB, Leatherman S. Impact of Targeted Financial Incentives on Personal Health Behavior. Med Care Res Rev. 2008;65(6_suppl):36S-78S. https://doi.org/10.1177/1077558708324235
Hagoel L, Rennert G, Feder‐Bubis P. Laypersons’ views of material incentives for enhancing colorectal cancer screening. Health Expect Int J Public Particip Health Care Health Policy. 2015;18(5):1194-1203. https://doi.org/10.1111/hex.12094
Creswell J. 2013 Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th ed. SAGE Publications, Inc
Mehta SJ, Pepe RS, Gabler NB, et al. Effect of Financial Incentives on Patient Use of Mailed Colorectal Cancer Screening Tests: A Randomized Clinical Trial. JAMA Netw Open. 2019;2(3):e191156-e191156. https://doi.org/10.1001/jamanetworkopen.2019.1156
Rendle KA, Abramson CM, Garrett SB, Halley MC, Dohan D. Beyond exploratory: a tailored framework for designing and assessing qualitative health research. BMJ Open. 2019;9(8):e030123. https://doi.org/10.1136/bmjopen-2019-030123
Creswell JW, Plano Clark VL. 2018 Designing and Conducting Mixed Methods Research. 3rd ed. SAGE Publications, Inc
Cahill S, Singal R, Grasso C, et al. Do Ask, Do Tell: High Levels of Acceptability by Patients of Routine Collection of Sexual Orientation and Gender Identity Data in Four Diverse American Community Health Centers. PLOS ONE. 2014;9(9):e107104. https://doi.org/10.1371/journal.pone.0107104
World Health Organization, Control (U.S.) C for D. Tobacco Questions for Surveys: A Subset of Key Questions from the Global Adult Tobacco Survey (GATS): Global Tobacco Surveillance System. World Health Organization; 2011. Accessed August 15, 2021. https://apps.who.int/iris/handle/10665/87331
Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Questionnaire. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2016. Accessed August 15, 2021. https://www.cdc.gov/brfss/questionnaires/pdf-ques/2016_BRFSS_Questionnaire_FINAL.pdf
Ling BS, Klein WM, Dang Q. Relationship of communication and information measures to colorectal cancer screening utilization: results from HINTS. J Health Commun. 2006;11 Suppl 1:181-190. https://doi.org/10.1080/10810730600639190
Tiro JA, Vernon SW, Hyslop T, Myers RE. Factorial Validity and Invariance of a Survey Measuring Psychosocial Correlates of Colorectal Cancer Screening among African Americans and Caucasians. Cancer Epidemiol Prev Biomark. 2005;14(12):2855-2861. https://doi.org/10.1158/1055-9965.EPI-05-0217
Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10.
Moller AC, Ntoumanis N, Williams GC. Financial Incentives May Influence Health Behaviors, But Do We End Up With Less Than We Paid For? A Self-determination Theory Perspective. Ann Behav Med. 2019;53(11):939-941. https://doi.org/10.1093/abm/kaz038
Vrinten C, Waller J, Wagner C von, Wardle J. Cancer Fear: Facilitator and Deterrent to Participation in Colorectal Cancer Screening. Cancer Epidemiol Prev Biomark. 2015;24(2):400-405. https://doi.org/10.1158/1055-9965.EPI-14-0967
Moser RP, Arndt J, Han PK, Waters EA, Amsellem M, Hesse BW. Perceptions of cancer as a death sentence: Prevalence and consequences. J Health Psychol. 2014;19(12):1518-1524. https://doi.org/10.1177/1359105313494924
Coronado GD, Schneider JL, Sanchez JJ, Petrik AF, Green B. Reasons for non-response to a direct-mailed FIT kit program: lessons learned from a pragmatic colorectal-cancer screening study in a federally sponsored health center. Transl Behav Med. 2015;5(1):60-67. https://doi.org/10.1007/s13142-014-0276-x
Thirumurthy H, Asch DA, Volpp KG. The Uncertain Effect of Financial Incentives to Improve Health Behaviors. JAMA. 2019;321(15):1451. https://doi.org/10.1001/jama.2019.2560
Acknowledgements
We are grateful for the support and insights provided by all investigators, research staff, and particularly to the study participants for taking the time to speak to us about their experiences.
Funding
This study was funded by a Health Research Formula Grant Award through the Abramson Cancer Center at the University of Pennsylvania from the Commonwealth of Pennsylvania. Dr. Mehta’s time was supported by grant number K08CA234326 from the National Cancer Institute of the National Institutes of Health. Shannon Ogden is supported by a NIDA training grant (T32DA041898).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Dr. Mehta has received an honorarium from the American Gastroenterological Association. No other conflicts declared.
Additional information
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Prior Presentation
Aspects of this manuscript were presented at the 2019 Annual Meeting of the American Public Health Association (APHA) in Philadelphia, PA.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Clifton, A.B.W., Mehta, S.J., Wainwright, J.V. et al. Exploring Why Financial Incentives Fail to Affect At-home Colorectal Cancer Screening: a Mixed Methods Study. J GEN INTERN MED 37, 2751–2758 (2022). https://doi.org/10.1007/s11606-021-07228-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-021-07228-z