Capsule Commentary on Shapiro et al., Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial
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Shapiro and colleagues assessed the efficacy of an intervention that combines monetary incentives and promotion of intrinsic motivation to improve blood pressure (BP) control among low-income and racial/ethnic minority patients.1 Uncontrolled hypertension is a leading cause of premature death in these subgroups.2 The investigators found short-term improvements in BP control at 6 months when the incentives ended, although the effects had largely faded by 12 months. These findings are consistent with several other studies and highlight the challenges for inducing long-lasting behavior change, especially among high-risk, disadvantaged groups.
Personal incentives have been a common strategy for encouraging healthy behavior. On the whole, the literature has found that incentives can be effective, with incentive structure being one key determinant of success.3 Personal incentives have been part of, but not the focus of, some successful BP control interventions, such as the BARBER-1 trial.4 A common critique has been that incentives may crowd out the intrinsic motivation of recipients to perform a task, in this case making patients less willing to control their hypertension after incentives for BP control have been removed. To address this, the investigators paired a combination of contingent and lottery incentives with an “identity intervention” aimed at boosting intrinsic motivation for BP control. Yet the enhanced intervention did not improve patient activation or self-efficacy scores at intervention’s end. One interpretation is that the identity intervention was not intensive enough to maintain intrinsic motivation. Another possibility is that loss of intrinsic motivation is not the key driver of post-intervention recidivism, as field-based studies of incentives have not found evidence of motivation crowd-out.5 More work is needed to understand the role of intrinsic motivation in real-world health decisions and the best interventions for boosting intrinsic motivation.
Socioeconomically disadvantaged, black, and Latino patients are frequently underrepresented in hypertension trials relative to their contribution to overall hypertension prevalence. This study deserves commendation for tailoring a behavioral intervention to these groups. We need more evidence on the causes of behavioral recidivism among high-risk groups, including upstream factors like financial stress and discrimination, in order to better craft effective solutions.
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Conflict of Interest
The author declares that he does not have a conflict of interest.
- 1.Shapiro MF, Shu SB, Goldstein NJ, Victor RG, Fox CR, Tseng C-H, et al. Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: A Randomized Trial. J Gen Intern Med https://doi.org/10.1007/s11606-019-05269-z
- 4.Victor RG, Ravenell JE, Freeman A, Leonard D, Bhat DG, Shafiq M, et al. Effectiveness of a Barber-Based Intervention for Improving Hypertension Control in Black Men: The BARBER-1 Study: A Cluster Randomized TrialBarbers Check BP, Control HTNJAMA Intern Med 2011;171(4):342-50. https://doi.org/10.1001/archinternmed.2010.390.CrossRefGoogle Scholar
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