Financial incentives for chlamydia testing: A review of the literature

1. Financial incentives for chlamydia testing: A review of the literature Darko Molinar and Anthony Nardone Office Sexual Health Promotion, HIV/STI Department

2. Background • Several reviews (incl. Kane et al. 2004;Sutherland et al. 2008) concluded patient-targeted economic incentives are: • Successful in effecting “simple behaviour” change • e.g. immunisation, treatment adherence, etc. • Less successful for “complex behaviour” change • e.g. smoking cessation, weight loss, increasing physical activity etc. • Increase participation rates but do not necessarily impact on the outcome of interest

3. Background: NCSP & incentives • Variety of economic incentives used by some NCSP programme areas to increase chlamydia screening • e.g. Lottery (“Wee for a Wii”), £10 shopping vouchers etc • NCSP position statement (November 2008) • Incentives need to be proportionate (e.g. pens but not alcohol) • Justifiable under public scrutiny • NCSP/DH press statement (March 2009) • Evaluation of impact of using incentives • Literature review of available evidence

4. Aims and objectives • Identify and summarise studies, where patient financial incentives have been employed to encourage chlamydia screening, in order to inform policy development. • Review literature for evidence of patient financial incentives to encourage uptake of chlamydia screening and other relevant sexual health initiatives; • Identify possible unintended consequences of financial incentives to encourage uptake of STI screening.

5. Methods • Review of English language peer reviewed literature (April 1987-March 2009) • All study types included • Various combinations of search terms used: • Electronic databases (PubMeD; EMBase; PsychInfo; Cochrane) • Internet search engine (Google) • Manual search of conference abstracts (2003-2008): • International Society for Sexually Transmitted Diseases Research; British Association for Sexual Health and HIV; NCSP • Citation search of selected references

6. Results • 5 studies of chlamydia screening • 1 study of postal chlamydia screening uptake • 2 studies of repeat testing following diagnosis with chlamydia (Ct) or gonorrhoea (Gc) • 2 studies of participation in sexual health surveys, with chlamydia testing offered • 5 studies of other sexual health initiatives • 2 studies of attendance at sexual health workshops (Carey et al. 2005; Kamb et al. 1998;) • 1 study of attendance for test-of-cure for Gc (Chacko et al. 1987) • 1 qualitative study - perspectives of high risk youth on chlamydia screening (Blake et al. 2003)

7. Postal Ct screening uptake ClaSS study - Low et al. 2007 • Cross-sectional community based prevalence study of chlamydia • Self-test kits posted to 16-39 yr olds on GP clinic lists • 27 surgeries in Bristol and Birmingham, UK, in 2001/2 • Randomised Control Trial (RCT): • Sample of young people recruited from a single GP clinic (n=836) • Randomly allocated to either £10 voucher or no incentive • Incentives had no significant effect on uptake: • uptake in incentive arm was 73/418 vs. 69/418 in the control arm

8. Repeat testing • Kissinger et al. 2000 • Time-series in an urban STD clinic in USA (n=962) • Follow-up of 14-34 yr old women diagnosed with Ct • $20 to return for 1 and 4 month follow-up • Incentives found to increase return rate (adjusted OR 1.9) • Malotte et al. 2004; Gift et al. 2005 • RCT 14-30 yr olds diagnosed with Ct/Gc (n=421) in 2 STD clinics in USA • Allocated to one of three possible interventions to return for follow-up appointment within 3-4 months: 1. Verbal recommendation given at diagnosis (standard) 2. Standard and financial incentive ($20) 3. Standard, motivational interview and telephone reminder at month 3 • Follow up rates highest with telephone reminder. Financial incentive performed no better than standard

9. Sexual health surveys • Erens et al. 2005 (NATSAL*): • In pilot stage individuals were randomised to being offered £5 voucher or £5 charity donation to participate in study • Response rate when given £5 voucher > 1997 study when no incentive offered, but charity donation had no effect • Incentives used in subsequent NATSAL survey in 2001 • Eggleston et al. 2005 • Case series with no control group in Baltimore USA (n=100) • $10 offered for telephone survey of sexual health in 18-35 yr olds • $40 offered in addition for returned urine samples. • 86% mailed back urine sample * National Survey of Sexual Attitudes and Lifestyles

10. Discussion Population groups • Incentives have often been directed at disadvantaged populations (Kane et al 2004) • Ethical argument that incentives should be focussed on disadvantaged populations (Cookson 2008) • NCSP screening provision and coverage currently higher in more socio-economically deprived areas Size and type of incentive • Kane et al. 2004: • Incentives relevant to behaviour change sought have been shown to be more effective than more diffuse incentives • Cash/coupons have greater effect than lottery/gifts for simple behaviour change • Malotte et al. 1998: higher cash value resulted in higher return rates for TB skin tests among injecting drug users

11. Discussion (2) Timing of incentive • Longer time periods between health seeking and payment associated with poorer participation (Malotte et al. 2004) Sustained behaviour change • Incentives shown to increase participation in programmes, but little evidence of impact on long-term behaviour change: • e.g. Kamb et al 1998: $15 increased attendance at STI risk-reduction sessions (55% v 37%) but post-study STD rate same at 6, 12 and 24 months • Ct screening can be seen as a simple behaviour change but: • To achieve the aims of NCSP will require young people to test regularly between 16 and 24 years of age • Incentives may inhibit intrinsic motivation of individuals young people to screen regularly • Individuals should be aware that incentives are only a temporary support to help them achieve their personal health goals (Kane et al 2004)

12. Discussion (3) Ethical considerations (Draper et al. 2009) • Incentive should not be coercive • The level of coercion will depend not only on the size of the incentive but also on the characteristics of the recipient • Any incentives should avoid purposefully exploiting a potential participant’s weakness or vulnerability, such as financial need Unintended consequences • As the NCSP targets 15-24 yr olds, payment for Ct screening could be misconstrued as encouragement for starting/increasing sexual activity at a young age • Systems to detect any possible deception to obtain the reward

13. Conclusions • Limited evidence base available • 1 RCT directly relevant to NCSP • 9 studies peripheral to chlamydia screening • Many questions remain unanswered • Need for strong evaluation of current initiatives to inform policy development • Database of different financial incentives used • PCT information reported by evaluation forms • Further analysis and evaluation through use of routine NCSP data: • Compare screening in programme areas (PA) using and not using incentives as well as within PA • User evaluation of incentives

14. References • Cookson R. (2008) Should disadvantaged people be paid to take care of their health? Yes. BMJ337; 140 • Draper H et al. (2009) Offering payments, reimbursements and incentives to patients and family doctors to encourage participation in research. Fam Prac26(3):231-238. • Eggleston E et al. (2005) Monitoring STI prevalence using telephone surveys and mailed urine specimens: a pilot test. Sex Transm Inf 81:236-238 • Erens B et al. (2005)National survey of sexual attitudes and Lifestyles II: Technical report. • Gift TL et al (GCAP Study Group) (2005) Acost-effectiveness analysis of interventions to increase repeat testing in patients treated for gonorrhoea or chlamydia at public sexually transmitted disease clinics. Sex Trans Diseases32(9):542-549 • Jochelson K. (2007) Paying the patient – Improving health using financial incentives. King’s Fund. London • Kamb M et al. (1998) What about money? Effect of small monetary incentives on enrolment, retention and motivation to change behaviour in an HIV/STD prevention counselling intervention. Sex Trans Inf 74: 253-255 • Kane RL et al. (2004) A structured review of the effect of economic incentives on consumers’ Preventative behaviour. Am J Prev Med27(4): 327-352 • Kissinger P et al. (2000) The effect of modest monetary incentives on follow up rates in sexually transmitted disease studies. Int J STD & AIDS 11:27-30 • Low N et al. (2007) Epidemiological, social, diagnostic and economic evaluation of population screening for genital chlamydial infection. Health Technol Assess11(8) • Malotte CK et al (1998) Tuberculosis screening and compliance with return for skin test reading among active drug users. Am J Public Health88:792-796 • Malotte CK et al (GCAP Study Group) (2004) Comparison of methods to increase repeat testing in persons treated for gonorrhoea and/or chlamydia at public sexually transmitted disease clinics. Sex Trans Diseases31:637-642 • Stevens-Simon C et al. (1997) A randomized trial of the Dollar-a-Day Program. JAMA 277: 977-82 • Sutherland et al. (2008) Paying the patient: does it work? A review of patient targeted incentives. Health Foundation, London