The idea of paying people to engage in pro-health behaviors and whether it is an effective, sustainable, and cost-effective tool for promoting individual and public health are controversial areas, but according to an international group of researchers writing in this week's PLoS Medicine: "When incentives are used to encourage utilization of, or compliance with, established means of producing individual or public health benefits and when it is likely that recipients are already favorably disposed to these goals, then traditional concerns about the provision of incentives in research may be misplaced, and even misguided."
Writing on behalf of the Ethics Working Group of the HIV Prevention Trials Network, the authors, led by Alex John London from the Philosophy Department and Center for Ethics and Policy at Carnegie Mellon University in Pittsburgh, USA, examine ethical issues raised when research is aimed at evaluating whether providing incentives—usually in the form of cash payments, gift cards, vouchers, prizes, or other material benefits—encourages recipients to use or adhere to a health intervention, care plan, or behavior modification activity.
Current research ethics guidelines do not distinguish the provision of incentives for the purpose of increasing recruitment into research studies from the use of incentives as part of a health intervention whose efficacy is being evaluated in a study. London and colleagues argue that: "some common concerns about using incentives to increase participation in research, such as that attractive incentives will undermine participant autonomy, are misplaced when incentives are used to overcome economic obstacles or a lack of effective motivation, and when recipients are incentivized to engage in health-related behaviors or practices with which they are already familiar and which they regard as beneficial or worthwhile."
The authors argue that Research Ethics Committees (established bodies responsible for approving the ethical conduct of trials) should require researchers to provide an evidence-based rationale for predicting that the provision of an incentive will encourage the intended health behavior and not adversely affect the willingness of participants or community members to engage in that behavior.
The authors also recommend: "Research Ethics Committees should ensure, as far as possible, that the use of incentives to promote healthy behavior could be sustained in the context where research is conducted and would not represent an unreasonable use of scarce health resources."
Funding: This work was conducted with support from the HIV Prevention Trials Network (HPTN) under award number U01 AI068619 from the National Institute of Allergy and Infectious Diseases (NIAID), the National Institute on Drug Abuse (NIDA,) and the National Institute of Mental Health (NIMH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the HPTN, NIAID, or NIMH. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: AJL, DAB, and AB are members of the Ethics Working Group of the HIV Prevention Trials Network, which currently sponsors two clinical trials involving financial incentives for health.
Citation: London AJ, Borasky DA Jr, Bhan A, for the Ethics Working Group of the HIV Prevention Trials Network (2012) Improving Ethical Review of Research Involving Incentives for Health Promotion. PLoS Med 9(3): e1001193. doi:10.1371/journal.pmed.1001193
Alex John London
Philosophy Department and Center for Ethics and Policy
Carnegie Mellon University
United States of America
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