Objective: To review existing evidence on the potential of incentives to undermine or “crowd out” intrinsic motivation, in order to establish whether and when it predicts financial incentives to crowd out motivation for health-related behaviors. Method: We conducted a conceptual analysis to compare definitions and operationalizations of the effect, and reviewed existing evidence to identify potential moderators of the effect. Results: In the psychological literature, we find strong evidence for an undermining effect of tangible rewards on intrinsic motivation for simple tasks when motivation manifest in behavior is initially high. In the economic literature, evidence for undermining effects exists for a broader variety of behaviors, in settings that involve a conflict of interest between parties. By contrast, for health related behaviors, baseline levels of incentivized behaviors are usually low, and only a subset involve an interpersonal conflict of interest. Correspondingly, we find no evidence for crowding out of incentivized health behaviors. Conclusion: The existing evidence does not warrant a priori predictions that an undermining effect would be found for health-related behaviors. Health-related behaviors and incentives schemes differ greatly in moderating characteristics, which should be the focus of future research.

The use of financial incentives to change health-related behaviour is often opposed by members of the public. We investigated whether the acceptability of incentives is influenced by their effectiveness, the form the incentive takes, and the particular behaviour targeted. We conducted discrete choice experiments, in 2010 with two samples (n = 81 and n = 101) from a self-selected online panel, and in 2011 with an offline general population sample (n = 450) of UK participants to assess the acceptability of incentive-based treatments for smoking cessation and weight loss. We focused on the extent to which this varied with the type of incentive (cash, vouchers for luxury items, or vouchers for healthy groceries) and its effectiveness (ranging from 5% to 40% compared to a standard treatment with effectiveness fixed at 10%). The acceptability of financial incentives increased with effectiveness. Even a small increase in effectiveness from 10% to 11% increased the proportion favouring incentives from 46% to 55%. Grocery vouchers were more acceptable than cash or vouchers for luxury items (about a 20% difference), and incentives were more acceptable for weight loss than for smoking cessation (60% vs. 40%). The acceptability of financial incentives to change behaviour is not necessarily negative but rather is contingent on their effectiveness, the type of incentive and the target behaviour.

In two studies, we inquired whether patients accept medical recommendations that come from a computer program rather than from a physician. In study 1, we found that subjects, when deciding whether to have an operation or not in different medical scenarios, were more likely to follow a recommendation that came from a physician than one that came from a computer program. Subjects stated that they would feel less responsible when following a recommendation than when deciding against it. Following a physician's recommendation reduced the feeling of responsibility more than following that of a computer program. The difference in feeling of responsibility when following versus when not following a recommendation partly mediated subjects' inclination to follow the physician more. In our second study, we found that subjects were more decision seeking when they received a recommendation or decision from a computer program, and they were more decision seeking when they had to accept a decision than when they received a recommendation. Subjects also trusted the physician more than the computer program to make a good recommendation or decision.

In an online study conducted separately in the UK and the US, participants rated the acceptability and fairness of four interventions: two types of financial incentives (rewards and penalties) and two types of medical interventions (pills and injections). These were stated to be equally effective in improving outcomes in five contexts: (a) weight loss and (b) smoking cessation programmes, and adherence in treatment programmes for (c) drug addiction, (d) serious mental illness and (e) physiotherapy after surgery. Financial incentives (weekly rewards and penalties) were judged less acceptable and to be less fair than medical interventions (weekly pill or injection) across all five contexts. Context moderated the relative preference between rewards and penalties: participants from both countries favoured rewards over penalties in weight loss and treatment for serious mental illness. Only among US participants was this relative preference moderated by perceived responsibility of the target group. Overall, participants supported funding more strongly for interventions when they judged members of the target group to be less responsible for their condition, and vice versa. These results reveal a striking similarity in negative attitudes towards the use of financial incentives, rewards as well as penalties, in improving outcomes across a range of contexts, in the UK and the USA. The basis for such negative attitudes awaits further study.

Healthcare workers (HCWs) are an important priority group for vaccination against influenza, yet, flu vaccine uptake remains low among them. Psychosocial studies of HCWs' decisions to get vaccinated have commonly drawn on subjective expected utility models to assess predictors of vaccination, assuming HCWs' choices result from a rational information-weighing process. By contrast, we recast those decisions asa commitment to vaccination and we aimed to understand why HCWs may want to (rather than believe they need to) get vaccinated against the flu. This article outlines the development and validation of a 9-item measure of cognitive empowerment towards flu vaccination (MoVac-flu scale) and an 11-item measure of cognitive empowerment towards vaccination advocacy. Both scales were administered to 784 frontline NHS HCWs with direct patient contact between June 2014 and July 2015. The scales exhibited excellent reliability and a clear unidimensional factor structure. An examination of the nomological network of the cognitive empowerment construct in relation to HCWs' vaccination against the flu revealed that this construct was distinct from traditional measures of risk perception and the strongest predictor of HCWs' decisions to vaccinate. Similarly, cognitive empowerment in relation to vaccination advocacy was a strong predictor of HCWs' engagement with vaccination advocacy. These findings suggest that the cognitive empowerment construct has important implications for advancing our understanding of HCWs' decisions to vaccinate as well as their advocacy behavior.

Purpose: This study aims to determine the efficacy of the Peer Education Project (PEP), a school-based, peer-led intervention designed to support secondary school students to develop the skills and knowledge they need to safeguard their mental health and that of their peers.Methodology: Six schools from across England and the Channel Islands took part in an evaluation of the PEP across the 2016/2017 academic year. 45 trained peer educators from the sixth form and 455 year 7 students completed pre-and post-questionnaires assessing their emotional and behavioural difficulties, perceived school climate, and knowledge, skills and confidence related to mental health. Findings: Results indicate that participation in the PEP is associated with significant improvement in key skills among both peer educators and student trainees, and in understanding of key terms and readiness to support others among trainees.Most students would recommend participation in the programme to other students.

Of children with mental health problems who access specialist help, 50% show reliable improvement on self-report measures at case closure and 10% reliable deterioration. To contextualise these figures it is necessary to consider rates of improvement for those in the general population. This study examined rates of reliable improvement/deterioration for children in a school sample over time. N = 9074 children (mean age 12; 52% female; 79% white) from 118 secondary schools across England provided self-report mental health (SDQ), quality of life and demographic data (age, ethnicity and free school meals (FSM) at baseline and 1 year and self-report data on access to mental health support at 1 year). Multinomial logistic regressions and classification trees were used to analyse the data. Of 2270 (25%) scoring above threshold for mental health problems at outset, 27% reliably improved and 9% reliably deteriorated at 1-year follow up. Of 6804 (75%) scoring below threshold, 4% reliably improved and 12% reliably deteriorated. Greater emotional difficulties at outset were associated with greater rates of reliable improvement for both groups (above threshold group: OR = 1.89, p < 0.001, 95% CI [1.64, 2.17], below threshold group: OR = 2.23, p < 0.001, 95% CI [1.93, 2.57]). For those above threshold, higher baseline quality of life was associated with greater likelihood of reliable improvement (OR = 1.28, p < 0.001, 95% CI [1.13, 1.46]), whilst being in receipt of FSM was associated with reduced likelihood of reliable improvement (OR = 0.68, p < 0.01, 95% CI [0.53, 0.88]). For the group below threshold, being female was associated with increased likelihood of reliable deterioration (OR = 1.20, p < 0.025, 95% CI [1.00, 1.42]), whereas being from a non-white ethnic background was associated with decreased likelihood of reliable deterioration (OR = 0.66, p < 0.001, 95% CI [0.54, 0.80]). For those above threshold, almost one in three children showed reliable improvement at 1 year. The extent of emotional difficulties at outset showed the highest associations with rates of reliable improvement.

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