The Patient - Patient-Centered Outcomes Research

, Volume 12, Issue 6, pp 571–592 | Cite as

Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review

  • Jacqueline RoseleurEmail author
  • Gillian Harvey
  • Nigel Stocks
  • Jonathan Karnon
Systematic Review


Background and Objective

Medication adherence is poor in patients with chronic conditions. Behavioral economic interventions may reduce biases that are associated with poor adherence. The objective of this review is to map the available evidence on behavioral economic interventions to improve medication adherence in adults with chronic conditions in high-income settings.


We conducted a scoping review and reported the study using the Joanna Briggs Institute Reviewers’ Manual and the PRISMA Extension for Scoping Review checklist. We searched PubMed, EMBASE, SCOPUS, PsycINFO, EconLit, and CINAHL from database inception to 29 August, 2018 for peer-reviewed studies and included a search of the gray literature. Data on study characteristics, study design, and study outcomes were extracted by one reviewer. Twenty-five percent of the studies were verified by a second reviewer.


Thirty-four studies, targeting diabetes mellitus, human immunodeficiency virus, and cardiovascular and renal diseases met our inclusion criteria. All but two studies were from the USA. The majority of interventions used financial incentives, often in conjunction with other behavioral economic concepts. Non-financial interventions included framing, social influences, reinforcement, and feedback. The effectiveness of interventions was mixed.


Behavioral economic informed interventions show promise in terms of improving medication adherence. However, there is no single simple intervention. This review highlighted the importance of targeting non-adherent patients, understanding their reasons for non-adherence, providing reminders and feedback to patients and physicians, and measuring clinical outcomes in addition to medication adherence. Further research in settings that differ from the US health system is needed.


Author Contributions

JR made substantial contributions to the conception and design, acquisition, analysis, and interpretation of data, and was involved in drafting the final manuscript. GH and NS made substantial contributions to the conception and interpretation of data, and were involved in drafting the final manuscript. JK made substantial contributions to the conception and design, analysis, and interpretation of data, and was involved in drafting the final manuscript. All authors read and approved the final manuscript. JR is the overall guarantor.

Compliance with Ethical Standards


No funding was received for this scoping review. The funding sources for the included studies were predominantly from the National Institutes of Health and not-for-profit foundations. Five studies did not report funding sources and four studies were industry supported.

Conflict of interest

Jacqueline Roseleur, Gillian Harvey, Nigel Stocks, and Jonathan Karnon have no conflicts of interest that are directly relevant to the content of this article.

Ethics Approval

As this scoping review uses data available in the public domain, no ethics application was required.

Supplementary material

40271_2019_377_MOESM1_ESM.docx (14 kb)
Supplementary material 1 (DOCX 13 kb)


  1. 1.
    Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular disease: meta-analysis on 376,162 patients. Am J Med. 2012;125(9):882–7. Scholar
  2. 2.
    Vrijens B, Vincze G, Kristanto P, Urquhart J, Burnier M. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008;336(7653):1114–7. Scholar
  3. 3.
    Nieuwlaat R, Wilczynski N, Navarro T, Hobson N, Jeffery R, Keepanasseril A, et al. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2014. Scholar
  4. 4.
    Halpern SD, French B, Small DS, Saulsgiver K, Harhay MO, Audrain-McGovern J, et al. Randomized trial of four financial-incentive programs for smoking cessation. N Engl J Med. 2015;372(22):2108–17. Scholar
  5. 5.
    Mitchell MS, Goodman JM, Alter DA, John LK, Oh PI, Pakosh MT, et al. Financial incentives for exercise adherence in adults: systematic review and meta-analysis. Am J Prev Med. 2013;45(5):658–67. Scholar
  6. 6.
    Patel MS, Volpp KG, Rosin R, Bellamy SL, Small DS, Fletcher MA, et al. A randomized trial of social comparison feedback and financial incentives to increase physical activity. Am J Health Promot. 2016;30(6):416–24. Scholar
  7. 7.
    van der Swaluw K, Lambooij MS, Mathijssen JJP, Schipper M, Zeelenberg M, Berkhout S, et al. Commitment lotteries promote physical activity among overweight adults: a cluster randomized trial. Ann Behav Med. 2018;52(4):342–51. Scholar
  8. 8.
    Loewenstein G, Brennan T, Volpp KG. Asymmetric paternalism to improve health behaviors. JAMA. 2007;298(20):2415–7. Scholar
  9. 9.
    Ariely D. Predictably irrational. New York: Harper Collins; 2008.Google Scholar
  10. 10.
    O’Donoghue T, Rabin M. Doing it now or later. Am Econ Rev. 1999;89(1):103–24. Scholar
  11. 11.
    Kullgren JT, Hafez D, Fedewa A, Heisler M. A scoping review of behavioral economic interventions for prevention and treatment of type 2 diabetes mellitus. Curr Diabetes Rep. 2017;17(9):73. Scholar
  12. 12.
    Roseleur J, Harvey G, Stocks N, Karnon J. Behavioral economic insights to improve medication adherence in adults with chronic conditions: a scoping review protocol. JBI Database System Rev Implement Rep. 2019. Scholar
  13. 13.
    Peters MD, Godfrey CM, McInerney P, Soares CB, Khalil H, Parker D. Chapter 11: Scoping Reviews. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute reviewers’ manual. The Joanna Briggs Institute, 2017. Available from
  14. 14.
    Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. Scholar
  15. 15.
    Lee JL, Maciejewski M, Raju S, Shrank WH, Choudhry NK. Value-based insurance design: quality improvement but no cost savings. Health Aff (Millwood). 2013;32(7):1251–7. Scholar
  16. 16.
    Sensharma A, Yabroff KR. Do interventions that address patient cost-sharing improve adherence to prescription drugs? A systematic review of recently published studies. Expert Rev Pharmacoecon Outcomes Res. 2019;19(3):263–77. Scholar
  17. 17.
    Schwebel FJ, Larimer ME. Using text message reminders in health care services: a narrative literature review. Internet Interv. 2018;13:82–104. Scholar
  18. 18.
    Vervloet M, Linn AJ, van Weert JC, de Bakker DH, Bouvy ML, van Dijk L. The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature. J Am Med Inf Assoc. 2012;19(5):696–704. Scholar
  19. 19.
    Aromataris E, Riitano D. Constructing a search strategy and searching for evidence: a guide to the literature search for a systematic review. Am J Nurs. 2014;114(5):49–56. Scholar
  20. 20.
    McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40–6. Scholar
  21. 21.
    Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan: a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. Scholar
  22. 22.
    Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at
  23. 23.
    Jiang J, Smith-Ray R, Taitel MS, Hou JG, Singh T, Orr G. The association between medication self-monitoring using an incentivized digital health program and claims-based medication adherence. Value Health. 2018;21:S110. Scholar
  24. 24.
    Shapiro MF, Shu SB, Goldstein NJ, Fox CR, Villa ES, Flores M, et al. Impact of a behavioral economics intervention on control of hypertension among very poor, predominantly minority adults: a randomized trial. J Gen Intern Med. 2014;29:S116–7.Google Scholar
  25. 25.
    Russaw A, Abrahamson T, Mack, C, Dinuit V, Glivings M, Nnadozie N (2014). Message framing utilization in hypertension research with African American Women, ProQuest Dissertations and Theses.Google Scholar
  26. 26.
    Asch DA, Troxel AB, Stewart WF, Sequist TD, Jones JB, Hirsch AG, et al. Effect of financial incentives to physicians, patients, or both on lipid levels: a randomized clinical trial. JAMA. 2015;314(18):1926–35. Scholar
  27. 27.
    Kessler JB, Troxel AB, Asch DA, Mehta SJ, Marcus N, Lim R, et al. Partners and alerts in medication adherence: a randomized clinical trial. J Gen Intern Med. 2018;33(9):1536–42.CrossRefGoogle Scholar
  28. 28.
    Kimmel SE, Troxel AB, French B, Loewenstein G, Doshi JA, Hecht TE, et al. A randomized trial of lottery-based incentives and reminders to improve warfarin adherence: the Warfarin Incentives (WIN2) Trial. Pharmacoepidemiol Drug Saf. 2016;25(11):1219–27. Scholar
  29. 29.
    Kimmel SE, Troxel AB, Loewenstein G, Brensinger CM, Jaskowiak J, Doshi JA, et al. Randomized trial of lottery-based incentives to improve warfarin adherence. Am Heart J. 2012;164(2):268–74. Scholar
  30. 30.
    Reddy A, Huseman TL, Canamucio A, Marcus SC, Asch DA, Volpp K, et al. Patient and partner feedback reports to improve statin medication adherence: a randomized control trial. J Gen Intern Med. 2017;32(3):256–61. Scholar
  31. 31.
    Reese PP, Bloom RD, Trofe-Clark J, Mussell A, Leidy D, Levsky S, et al. Automated reminders and physician notification to promote immunosuppression adherence among kidney transplant recipients: a randomized trial. Am J Kidney Dis. 2017;69(3):400–9. Scholar
  32. 32.
    Reese PP, Kessler JB, Doshi JA, Friedman J, Mussell AS, Carney C, et al. Two randomized controlled pilot trials of social forces to improve statin adherence among patients with diabetes. J Gen Intern Med. 2016;31(4):402–10. Scholar
  33. 33.
    Reese PP, Mgbako O, Mussell A, Potluri V, Yekta Z, Levsky S, et al. A pilot randomized trial of financial incentives or coaching to lower serum phosphorus in dialysis patients. J Ren Nutr. 2015;25(6):510–7. Scholar
  34. 34.
    Volpp K, Loewenstein G, Troxel A, Doshi J, Price M, Laskin M, et al. A test of financial incentives to improve warfarin adherence. BMC Health Serv Res. 2008;8:272. Scholar
  35. 35.
    Volpp KG, Troxel AB, Long JA, Ibrahim SA, Appleby D, Smith JO, et al. A randomized controlled trial of negative co-payments: the CHORD trial. Am J Manag Care. 2015;21(8):e465–73.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Volpp KG, Troxel AB, Mehta SJ, Norton L, Zhu J, Lim R, et al. Effect of electronic reminders, financial incentives, and social support on outcomes after myocardial infarction: the HeartStrong randomized clinical trial. JAMA Intern Med. 2017;177(8):1093–101. Scholar
  37. 37.
    Choudhry NK, Isaac T, Lauffenburger JC, Gopalakrishnan C, Lee M, Vachon A, et al. Effect of a remotely delivered tailored multicomponent approach to enhance medication taking for patients with hyperlipidemia, hypertension, and diabetes: the STIC2IT cluster randomized clinical trial. JAMA Intern Med. 2018;178(9):1182–9. Scholar
  38. 38.
    Riesen WF, Noll G, Dariolo R. Impact of enhanced compliance initiatives on the efficacy of rosuvastatin in reducing low density lipoprotein cholesterol levels in patients with primary hypercholesterolaemia. Swiss Med Wkly. 2008;138(29–30):420–6.PubMedGoogle Scholar
  39. 39.
    Wu JR, Corley DJ, Lennie TA, Moser DK. Effect of a medication-taking behavior feedback theory-based intervention on outcomes in patients with heart failure. J Card Fail. 2012;18(1):1–9. Scholar
  40. 40.
    Garza KB, Owensby JK, Braxton Lloyd K, Wood EA, Hansen RA. Pilot study to test the effectiveness of different financial incentives to improve medication adherence. Ann Pharmacother. 2016;50(1):32–8. Scholar
  41. 41.
    Davidson TM, McGillicuddy J, Mueller M, Brunner-Jackson B, Favella A, Anderson A, et al. Evaluation of an mHealth medication regimen self-management program for African American and Hispanic uncontrolled hypertensives. J Pers Med. 2015;5(4):389–405. Scholar
  42. 42.
    Petry NM, Alessi SM, Byrne S, White WB. Reinforcing adherence to antihypertensive medications. J Clin Hypertens (Greenwich). 2015;17(1):33–8. Scholar
  43. 43.
    Boutin-Foster C, Offidani E, Kanna B, Ogedegbe G, Ravenell J, Scott E, et al. Results from the trial using motivational interviewing, positive affect, and self-affirmation in African Americans with hypertension (TRIUMPH). Ethn Dis. 2016;26(1):51–60. Scholar
  44. 44.
    Frias J, Virdi N, Raja P, Kim Y, Savage G, Osterberg L. Effectiveness of digital medicines to improve clinical outcomes in patients with uncontrolled hypertension and type 2 diabetes: prospective, open-label, cluster-randomized pilot clinical trial. J Med Internet Res. 2017;19(7):e246. Scholar
  45. 45.
    Kranker K. The efficacy of using financial incentives to change unhealthy behaviors among a rural chronically ill and uninsured population. Am J Health Promot. 2018;32(2):301–11. Scholar
  46. 46.
    Raiff BR, Jarvis BP, Dallery J. Text-message reminders plus incentives increase adherence to antidiabetic medication in adults with type 2 diabetes. J Appl Behav Anal. 2016;49(4):947–53. Scholar
  47. 47.
    Rigsby MO, Rosen MI, Beauvais JE, Cramer JA, Rainey PM, O’Malley SS, et al. Cue-dose training with monetary reinforcement: pilot study of an antiretroviral adherence intervention. J Gen Intern Med. 2000;15(12):841–7.CrossRefGoogle Scholar
  48. 48.
    Javanbakht M, Prosser P, Grimes T, Weinstein M, Farthing C. Efficacy of an individualized adherence support program with contingent reinforcement among nonadherent HIV-positive patients: results from a randomized trial. J Int Assoc Physicians AIDS Care (Chic). 2006;5(4):143–50. Scholar
  49. 49.
    Rosen MI, Dieckhaus K, McMahon TJ, Valdes B, Petry NM, Cramer J, et al. Improved adherence with contingency management. AIDS Patient Care STDS. 2007;21(1):30–40. Scholar
  50. 50.
    Sorensen JL, Haug NA, Delucchi KL, Gruber V, Kletter E, Batki SL, et al. Voucher reinforcement improves medication adherence in HIV-positive methadone patients: a randomized trial. Drug Alcohol Depend. 2007;88(1):54–63. Scholar
  51. 51.
    Foster C, McDonald S, Frize G, Ayers S, Fidler S. “Payment by results”: financial incentives and motivational interviewing, adherence interventions in young adults with perinatally acquired HIV-1 infection: a pilot program. AIDS Patient Care STDS. 2014;28(1):28–32. Scholar
  52. 52.
    Cook PF, Carrington JM, Schmiege SJ, Starr W, Reeder B. A counselor in your pocket: feasibility of mobile health tailored messages to support HIV medication adherence. Patient Prefer Adherence. 2015;9:1353–66. Scholar
  53. 53.
    Moore BA, Rosen MI, Wang Y, Shen J, Ablondi K, Sullivan A, et al. A remotely-delivered CBT and contingency management therapy for substance using people with HIV. AIDS Behav. 2015;19(Suppl. 2):156–62. Scholar
  54. 54.
    Metsch LR, Feaster DJ, Gooden L, Matheson T, Stitzer M, Das M, et al. Effect of patient navigation with or without financial incentives on viral suppression among hospitalized patients with HIV infection and substance use: a randomized clinical trial. JAMA. 2016;316(2):156–70. Scholar
  55. 55.
    Alsan M, Beshears J, Armstrong WS, Choi JJ, Madrian BC, Nguyen MLT, et al. A commitment contract to achieve virologic suppression in poorly adherent patients with HIV/AIDS. AIDS. 2017;31(12):1765–9. Scholar
  56. 56.
    El-Sadr WM, Donnell D, Beauchamp G, Hall HI, Torian LV, Zingman B, et al. Financial incentives for linkage to care and viral suppression among HIV-positive patients: a randomized clinical trial (HPTN 065). JAMA Intern Med. 2017;177(8):1083–92. Scholar
  57. 57.
    Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive-based approaches for weight loss: a randomized trial. JAMA. 2008;300(22):2631–7. Scholar
  58. 58.
    Kullgren JT, Troxel AB, Loewenstein G, Asch DA, Norton LA, Wesby L, et al. Individual- versus group-based financial incentives for weight loss: a randomized, controlled trial. Ann Intern Med. 2013;158(7):505–14. Scholar
  59. 59.
    Thangada ND, Garg N, Pandey A, Kumar N. The emerging role of mobile-health applications in the management of hypertension. Curr Cardiol Rep. 2018;20(9):78. Scholar
  60. 60.
    Zaugg V, Korb-Savoldelli V, Durieux P, Sabatier B. Providing physicians with feedback on medication adherence for people with chronic diseases taking long-term medication. Cochrane Database Syst Rev. 2018. Scholar
  61. 61.
    Conn VS, Ruppar TM, Chase JA, Enriquez M, Cooper PS. Interventions to improve medication adherence in hypertensive patients: systematic review and meta-analysis. Curr Hypertens Rep. 2015;17(12):94. Scholar
  62. 62.
    Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, Rodgers A, et al. Mobile telephone text messaging for medication adherence in chronic disease: a meta-analysis. JAMA Intern Med. 2016;176(3):340–9. Scholar
  63. 63.
    Orr JA, King RJ. Mobile phone SMS messages can enhance healthy behaviour: a meta-analysis of randomised controlled trials. Health Psychol Rev. 2015;9(4):397–416. Scholar
  64. 64.
    Petrie KJ, Perry K, Broadbent E, Weinman J. A text message programme designed to modify patients’ illness and treatment beliefs improves self-reported adherence to asthma preventer medication. Br J Health Psychol. 2012;17(1):74–84. Scholar
  65. 65.
    Gatwood J, Hohmeier KC, Brooks IM. Beyond the reminder: the next steps in pharmacist-driven, mHealth patient engagement. J Am Pharm Assoc (2003). 2019;59(2S):S21–4. Scholar
  66. 66.
    Brewer NT, DeFrank JT, Gilkey MB. Anticipated regret and health behavior: a meta-analysis. Health Psychol. 2016;35(11):1264–75. Scholar
  67. 67.
    Amankwaa I, Boateng D, Quansah DY, Akuoko CP, Evans C. Effectiveness of short message services and voice call interventions for antiretroviral therapy adherence and other outcomes: a systematic review and meta-analysis. PLoS One. 2018;13(9):e0204091. Scholar
  68. 68.
    AlGhurair SA, Hughes CA, Simpson SH, Guirguis LM. A systematic review of patient self-reported barriers of adherence to antihypertensive medications using the world health organization multidimensional adherence model. J Clin Hypertens (Greenwich). 2012;14(12):877–86. Scholar
  69. 69.
    Conn VS, Ruppar TM, Enriquez M, Cooper P. Medication adherence interventions that target subjects with adherence problems: systematic review and meta-analysis. Res Soc Adm Pharm. 2016;12(2):218–46. Scholar
  70. 70.
    Carrera M, Royer H, Stehr M, Sydnor J. Can financial incentives help people trying to establish new habits? Experimental evidence with new gym members. J Health Econ. 2018;58:202–14. Scholar
  71. 71.
    Loewenstein G, Price J, Volpp K. Habit formation in children: evidence from incentives for healthy eating. J Health Econ. 2016;45:47–54. Scholar
  72. 72.
    Strohacker K, Galarraga O, Williams DM. The impact of incentives on exercise behavior: a systematic review of randomized controlled trials. Ann Behav Med. 2014;48(1):92–9. Scholar
  73. 73.
    Kulendran M, King D, Schmidtke KA, Curtis C, Gately P, Darzi A, et al. The use of commitment techniques to support weight loss maintenance in obese adolescents. Psychol Health. 2016;31(11):1332–41. Scholar
  74. 74.
    Lesser LI, Thompson CA, Luft HS. Association between monetary deposits and weight loss in online commitment contracts. Am J Health Promot. 2018;32(1):198–204. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.School of Public Health, Faculty of Health and Medical SciencesThe University of AdelaideAdelaideAustralia
  2. 2.Adelaide Nursing School, Faculty of Health and Medical SciencesThe University of AdelaideAdelaideAustralia
  3. 3.Discipline of General PracticeAdelaide Medical School, The University of AdelaideAdelaideAustralia
  4. 4.College of Medicine and Public HealthFlinders UniversityAdelaideAustralia

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