Would you be more willing to lose weight, stop smoking or get vaccinated if you were paid to do it?
These are propositions that scientists have studied at length, and occasionally have been put into practice, as was seen during Philadelphia's COVID-19 vaccination push last year.
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But research on the effectiveness of using money as an incentive to kickstart healthy behaviors has found mixed results. And then there is the question of whether it is ethical to try to influence people in this way.
Recent research has focused on whether cash incentives can help obese people lose weight. The obesity epidemic continues to be a serious health concern in the U.S., with nearly 42% of adults considered obese. Yet, scientists still haven't been able to completely understand what is driving it. And its associations with income are complex.
Though women with the highest incomes are less likely to be obese, that's not the case among men, according to the latest CDC research. Overall, the obesity rate among men with high incomes and those with low incomes is effectively the same. And among Black men, the obesity rate is higher among those with the highest incomes.
Yet, the same research also found that college graduates – regardless of sex – were less likely to be obese. And other research has found people who live in lower-income neighborhoods generally have poorer access to fresh, healthy foods and safe places to exercise, and often less time to devote to changing their lifestyles.
So, is a cash incentive the answer?
A new study published in JAMA Internal Medicine suggests it could be. The researchers found that simply giving people weight-loss tools, like diet books and fitness trackers, or access to a weight loss program, may not be enough to cause significant change.
They found that people who were offered cash incentives for the number of pounds they lost or for completing certain activities were more likely to lose weight than those who were only given weight-loss tools.
The study included 688 low-income people with obesity between ages 18-70 who were treated at health systems in New York City or Los Angeles. They were randomly broken into three groups. An outcome-based group received payments based on the percentage of their weight loss; a goal-directed group was paid based on achieving specific weight-loss behaviors, like getting 75 minutes of physical activity each week; the third group was not paid.
At the six-month mark, 49% of the people in the outcome-based group had lost at least 5% of their initial body weight. That was true of 39% of people in the goal-directed group, but only 22% of those in the group that was not paid. The people in the outcome-based group earned $440.44, on average; those in the goal-directed group averaged $303.56.
Outside experts told NBC News that these findings are encouraging, but said implementing such incentives in a real-world setting could be challenging, although insurance companies and employers have taken a similar approach by offering lower premiums and other incentives for people who lose weight.
These incentives are based on the idea of positive reinforcement, in which an immediate reward is given to encourage people to stick to new behaviors that will not show any obvious benefits for months or even years. Different political or cultural views, however, may influence how receptive a person is to these types of incentives, experts said.
However, other research examining how financial incentives can influence weight loss remains mixed. One study found that positive and negative financial reinforcements were associated with weight loss. Yet, a another analysis found that incentives may initially increase weight loss, but that they have no long-term effect on the ability to maintain a healthy weight. Once the rewards end, they people are no longer motivated to keep the weight off.
Last year, the COVID-19 vaccination program put financial incentives in the spotlight. Many states and cities offered incentives, including a ticket for a $5 million lottery, to influence people to get vaccinated. But it only had a small effect on the overall vaccination uptake, and many people only got the initial shot in the two-dose series.
Researchers at Columbia University and the University of the Witwatersrand, Johannesburg conducted a systematic review of studies that examined the use of incentives for the COVID-19 vaccination program.
Many studies raised ethical concerns that the incentives could be construed as coercive and manipulative, leading to more suspicion of the vaccine and the government. The incentives also did nothing to address the concerns that people had about the vaccine.
Interestingly though, financial incentives have worked for other vaccination programs in the U.S. including hepatitis B. And studies have found that financial incentives work for smoking cessation and exercise.
More research is needed to understand people's underlying motivations for changes in health behavior, and which types of incentives work best for specific groups of people.