The Mixed Nature of Incentives for Community Health Workers: Lessons from a Qualitative Study in Two Districts in India

Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. 

Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdaspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household’s financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. 

In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. 

Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. 

The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW.

Full article at:   http://goo.gl/wyuobV

By:  Enisha Sarin,^1,* Sarah Smith Lunsford,² Ankur Sooden,¹ Sanjay Rai,¹ and Nigel Livesley¹

¹University Research Co., LLC, New Delhi, India

²EnCompass LLC, Bethesda, MD, USA

Edited by: Chikaikeo Ogbonna, University of Jos, Nigeria

Reviewed by: Luret Albert Lar, University of Jos, Nigeria; Emmanuel Nwabueze Aguwa, University of Nigeria Nsukka, Nigeria; Afolaranmi Olumide Tolulope, University of Jos, Nigeria

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Tracking and Locating Itinerant Subjects with a Rechargeable Incentive Card: Results of a Randomized Trial

ABSTARCT

Background: High attrition among research participants undermines the validity and generalizability of field research. This study contrasted two incentivizing methods-money orders (MOs) or rechargeable incentive cards (RICs)-with regard to rates of participants' study engagement and follow-up contact over a 6-month period.

METHODS:

Substance abusers (N = 303) in Los Angeles, California were recruited and randomized to either an MO (control) or RIC (experimental) condition. All participants were asked to call the researchers at the beginning of each calendar month for the ensuing 5 months to update their locator information, even if nothing had changed. Each call resulted in a $10 payment, issued immediately via the RIC system or by MO by mail. Research staff located and interviewed all participants at Month 6. Contact logs assessed level of effort required to locate participants and conduct follow-up interviews.

RESULTS:

Relative to controls, RIC participants, especially those with low ability to defer gratification, initiated more monthly calls. Six-month follow-up rates did not differ between RIC (75%) and controls (79%), though the RIC condition was associated with an average staff time savings of 39.8 minutes per study participant.

DISCUSSION:

For longitudinal public health research involving itinerant study participants, the RIC method produces a modest benefit in study engagement and reduced staff time devoted to participant tracking and payments. However, the overall cost-effectiveness of this approach will depend on the pricing model of the card-issuing vendor (which in turns depends on the scale of the project, with per-unit costs falling for larger projects).

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By:  Farabee D1, Hawken A2, Calhoun S3, Veliz R1, Grossman J1, Zhang Y2.

• 1 Department of Psychiatry and Biobehavioral Sciences, UCLA , Los Angeles , California , USA.
• 2 School of Public Policy, Pepperdine University , Malibu , California , USA.
• 3 Department of Criminology, Law and Society, UC Irvine , Irvine , California , USA.
• Subst Use Misuse. 2016 Mar 23:1-6.  

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Conditional Cash Transfers & Uptake Of & Retention in Prevention of Mother-To-Child HIV Transmission Care

BACKGROUND:

Novel strategies are needed to increase retention in and uptake of prevention of mother-to-child HIV transmission (PMTCT) services in sub-Saharan Africa. We aimed to determine whether small, increasing cash payments, which were conditional on attendance at scheduled clinic visits and receipt of proposed services can increase the proportions of HIV-infected pregnant women who accept available PMTCT services and remain in care.

METHODS:

In this randomised controlled trial, we recruited newly diagnosed HIV-infected women, who were 32 or less weeks pregnant, from 89 antenatal care clinics in Kinshasa, Democratic Republic of Congo, and randomly assigned (1:1) them to either the intervention group or the control group using computer-based randomisation with varying block sizes of four, six, and eight. The intervention group received compensation on the condition that they attended scheduled clinic visits and accepted offered PMTCT services (US$5, plus US$1 increment at every subsequent visit), whereas the control group received usual care. Outcomes assessed included retention in care at 6 weeks' post partum and uptake of PMTCT services, measured by attendance of all scheduled clinic visits and acceptance of proposed services up to 6 weeks' post partum. Analyses were by intention to treat. This trial is registered with ClinicalTrials.org, number NCT01838005.

FINDINGS:

Between April 18, 2013, and Aug 30, 2014, 612 potential participants were identified, 545 were screened, and 433 were enrolled and randomly assigned; 217 to the control group and 216 to the intervention group. At 6 weeks' post partum, 174 participants in the intervention group (81%) and 157 in the control group (72%) were retained in care (risk ratio [RR] 1·11; 95% CI 1·00-1·24). 146 participants in the intervention group (68%) and 116 in the control group (54%) attended all clinic visits and accepted proposed services (RR 1·26; 95% CI 1·08-1·48). Results were similar after adjustment for marital status, age, and education.

INTERPRETATION:

Among women with newly diagnosed HIV, small, incremental cash incentives resulted in increased retention along the PMTCT cascade and uptake of available services. The cost-effectiveness of these incentives and their effect on HIV-free survival warrant further investigation.

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By:  Yotebieng M1, Thirumurthy H2, Moracco KE3, Kawende B4, Chalachala JL4, Wenzi LK4, Ravelomanana NL5, Edmonds A5, Thompson D5, Okitolonda EW4,Behets F6.

• 1The Ohio State University, College of Public Health, Division of Epidemiology, Columbus, OH, USA; The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA. Electronic address: yotebieng.2@osu.edu.
• 2The University of North Carolina at Chapel Hill, Department of Health Policy and Management, Chapel Hill, NC, USA.
• 3The University of North Carolina at Chapel Hill, Department of Health Behavior, Chapel Hill, NC, USA.
• 4The University of Kinshasa, School of Public Health, Kinshasa, Democratic Republic of Congo.
• 5The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA.
• 6The University of North Carolina at Chapel Hill, Department of Epidemiology, Chapel Hill, NC, USA; The University of North Carolina at Chapel Hill, Department of Social Medicine, Chapel Hill, NC, USA. 
• Lancet HIV. 2016 Feb;3(2):e85-93. doi: 10.1016/S2352-3018(15)00247-7.

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Combination Social Protection for Reducing HIV-Risk Behavior amongst Adolescents in South Africa

BACKGROUND:

Social protection (i.e. cash transfers, free schools, parental support) has potential for adolescent HIV-prevention. We aimed to identify which social protection interventions are most effective and whether combined social protection has greater effects in South Africa.

METHODS:

In this prospective longitudinal study, we interviewed 3516 adolescents aged 10-18 between 2009 and 2012. We sampled all homes with a resident adolescent in randomly-selected census areas in four urban and rural sites in two South African provinces. We measured household receipt of fourteen social protection interventions and incidence of HIV-risk behaviors. Using gender-disaggregated multivariate logistic regression and marginal-effects analyses, we assessed respective contributions of interventions and potential combination effects.

RESULTS:

Child-focused grants, free schooling, school feeding, teacher support, and parental monitoring were independently associated with reduced HIV-risk behavior incidence (OR 0.10-0.69). Strong effects of combination social protection were shown, with cumulative reductions in HIV-risk behaviors. For example, girls' predicted past-year incidence of economically-driven sex dropped from 11% with no interventions, to 2% amongst those with a child grant, free school and good parental monitoring. Similarly, girls' incidence of unprotected/casual sex or multiple-partners dropped from 15% with no interventions to 10% with either parental monitoring or school feeding, and to 7% with both interventions.

CONCLUSION:

In real-world, high-epidemic conditions, 'combination social protection' shows strong HIV-prevention effects for adolescents and may maximize prevention efforts.This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Full PDF article at:  http://goo.gl/ojMVoi  Abstract:  http://goo.gl/fXkGhX

By:  Cluver LD1, Orkin MF, Yakubovich AR, Sherr L.

• 1Centre for Evidence-Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK 2Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa 3DST-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa 4University College London, London, UK. 

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Using Peer-Referral Chains with Incentives to Promote HIV Testing and Identify Undiagnosed HIV Infections among Crack Users in San Salvador

In El Salvador, crack users are at high risk for HIV but they are not targeted by efforts to promote early HIV diagnosis. 

We evaluated the promise of peer-referral chains with incentives to increase HIV testing and identify undiagnosed HIV infections among networks of crack users in San Salvador. For 14 months, we offered HIV testing in communities with a high prevalence of crack use. For the following 14 months, we promoted chains in which crack users from these communities referred their peers to HIV testing and received a small monetary incentive. We recorded the monthly numbers of HIV testers, and their crack use, sexual risk behaviors and test results. 

After launching the referral chains, the monthly numbers of HIV testers increased significantly (Z = 6.90, p < .001) and decayed more slowly (Z = 5.93, p < .001), and the total number of crack-using testers increased nearly fourfold. Testers in the peer-referral period reported fewer HIV risk behaviors, but a similar percentage (~5 %) tested HIV positive in both periods. More women than men received an HIV-positive diagnosis throughout the study (χ²(1, N = 799) = 4.23, p = .040). 

Peer-referral chains with incentives can potentially increase HIV testing among networks of crack users while retaining a focus on high-risk individuals.

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By:   Glasman LR1, Dickson-Gomez J2, Lechuga J3, Tarima S4, Bodnar G5, de Mendoza LR6.

• 1Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 N Summit Ave., Milwaukee, WI, USA. lglasman@mcw.edu.
• 2Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 N Summit Ave., Milwaukee, WI, USA.
• 3Department of Psychology, University of Texas, El Paso, TX, USA.
• 4Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA.
• 5Departamento de Investigación, Fundación Antidrogas de El Salvador (FUNDASALVA), Santa Tecla, El Salvador.
• 6Department of Psychology, Universidad Centroamericana José Simeón Cañas, San Salvador, El Salvador. 

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Development of Immunity Following Financial Incentives for Hepatitis B Vaccination among People Who Inject Drugs

BACKGROUND:

People who inject drugs (PWID) are at risk of hepatitis B virus (HBV) but have low rates of vaccination completion. The provision of modest financial incentives increases vaccination schedule completion, but their association with serological protection has yet to be determined.

OBJECTIVE:

To investigate factors associated with vaccine-induced immunity among a sample of PWID randomly allocated to receive AUD$30 cash following receipt of doses two and three ('incentive condition') or standard care ('control condition') using an accelerated 3-dose (0,7,21 days) HBV vaccination schedule.

STUDY DESIGN:

A randomised controlled trial among PWID attending two inner-city health services and a field site in Sydney, Australia, assessing vaccine-induced immunity measured by hepatitis B surface antibodies (HBsAb≥10mIU/ml) at 12 weeks. The cost of the financial incentives and the provision of the vaccine program are also reported.

RESULTS:

Just over three-quarters of participants - 107/139 (77%) - completed the vaccination schedule and 79/139 (57%) were HBsAb≥10mIU/ml at 12 weeks. Vaccine series completion was the only variable significantly associated with vaccine-induced immunity in univariate analysis (62% vs 41%, p<0.035) but was not significant in multivariate analysis. There was no statistically discernible association between group allocation and series completion (62% vs 53%). The mean costs were AUD$150.5, (95% confidence interval [CI]: 142.7-158.3) and AUD$76.9 (95% CI: 72.6-81.3) for the intervention and control groups respectively.

CONCLUSION:

Despite increasing HBV vaccination completion, provision of financial incentives was not associated with enhanced serological protection. Further research into factors which affect response rates and the optimal vaccination regimen and incentive schemes for this population are needed.

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By:   Day CA1, Shanahan M2, Wand H3, Topp L4, Haber PS5, Rodgers C6, Deacon R7, Walsh N8, Kaldor J3, van Beek I6, Maher L3; Hepatitis Acceptability Group Vaccine Incentives Trial (HAVIT) Study Group.

• 1Discipline of Addiction Medicine, Central Clinical School (C39), Sydney Medical School, University of Sydney, NSW 2006, Australia. Electronic address: carolyn.day@sydney.edu.au.
• 2National Drug and Alcohol Research Centre, University of New South Wales, NSW 2052, Australia.
• 3The Kirby Institute, UNSW Australia, Sydney, NSW 2052, Australia.
• 4Cancer Council NSW, Woolloomooloo, NSW 2010, Australia.
• 5Discipline of Addiction Medicine, Central Clinical School (C39), Sydney Medical School, University of Sydney, NSW 2006, Australia; Drug Health Services, Royal Prince Alfred Hospital, Missenden Road, Camperdown,NSW 2050, Australia.
• 6Kirketon Road Centre, South Eastern Sydney Local Health District, Kings Cross, NSW 1340 Australia.
• 7Discipline of Addiction Medicine, Central Clinical School (C39), Sydney Medical School, University of Sydney, NSW 2006, Australia.
• 8Department of Epidemiology and Preventive Medicine, Monash University, 89 Commercial Road, Melbourne, Victoria 3004, Australia. 

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Social Protection: Potential for Improving HIV Outcomes among Adolescents

Introduction

Advances in biomedical technologies provide potential for adolescent HIV prevention and HIV-positive survival. The UNAIDS 90–90–90 treatment targets provide a new roadmap for ending the HIV epidemic, principally through antiretroviral treatment, HIV testing and viral suppression among people with HIV. However, while imperative, HIV treatment and testing will not be sufficient to address the epidemic among adolescents in Southern and Eastern Africa. In particular, use of condoms and adherence to antiretroviral therapy (ART) remain haphazard, with evidence that social and structural deprivation is negatively impacting adolescents’ capacity to protect themselves and others. This paper examines the evidence for and potential of interventions addressing these structural deprivations.

Discussion

New evidence is emerging around social protection interventions, including cash transfers, parenting support and educational support (“cash, care and classroom”). These interventions have the potential to reduce the social and economic drivers of HIV risk, improve utilization of prevention technologies and improve adherence to ART for adolescent populations in the hyper-endemic settings of Southern and Eastern Africa. Studies show that the integration of social and economic interventions has high acceptability and reach and that it holds powerful potential for improved HIV, health and development outcomes.

Conclusions

Social protection is a largely untapped means of reducing HIV-risk behaviours and increasing uptake of and adherence to biomedical prevention and treatment technologies. There is now sufficient evidence to include social protection programming as a key strategy not only to mitigate the negative impacts of the HIV epidemic among families, but also to contribute to HIV prevention among adolescents and potentially to remove social and economic barriers to accessing treatment. We urge a further research and programming agenda: to actively combine programmes that increase availability of biomedical solutions with social protection policies that can boost their utilization.

Below:  Impacts of cash and care provision on HIV-risk behaviour among adolescents in South Africa (marginal effects models, controlling for covariates) 

Full article at:    http://goo.gl/6TM8hV

By:   Lucie D Cluver,§,1,2 Rebecca J Hodes,3,4 Lorraine Sherr,5 F Mark Orkin,6 Franziska Meinck,1 Patricia Lim Ah Ken,7Natalia E Winder-Rossi,8 Jason Wolfe,9 and Marissa Vicari10

¹Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford, Oxford, UK

²Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

³AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town, Cape Town, South Africa

⁴Department of Historical Studies, University of Cape Town, Cape Town, South Africa

⁵Health Psychology Unit, Department of Infection & Population Health, University College London, London, UK

⁶School of Clinical Medicine and DST-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa

⁷HIV and AIDS Section, UNICEF, New York, USA

⁸UNICEF Regional Office for Eastern and Southern Africa, Nairobi, Kenya

⁹Office of HIV/AIDS, Bureau for Global Health, US Agency for International Development, Washington, DC, USA

¹⁰Collaborative Initiative for Paediatric HIV Education and Research (CIPHER), International AIDS Society, Geneva, Switzerland

^§Corresponding author: Lucie D Cluver, Centre for Evidence-Based Interventions, Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford OX1 2ER, UK. Tel: +44(0)1865 270325. (Email: ku.ca.xo.ips@revulC.eicuL)

 

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Financial Incentives to Improve Progression through the HIV Treatment Cascade

We reviewed recent literature on conditional and unconditional financial incentives for their impact on improving movement through the HIV care cascade and HIV prevention.

Concepts from behavioral economics may help improve engagement in HIV care by addressing upstream structural risk factors for HIV, such as poverty, or providing conditional rewards for immediate, measurable outcomes related to HIV care. Incentives have been shown to increase uptake of HIV testing. Yet, few studies to date focus on linkage to care: 

• one large USA-based randomized trial failed to show an effect of incentives; 
• and a smaller trial showed improved linkage to care among drug users, but no difference in virologic suppression. 
• Several small USA-based studies have shown an impact of financial incentives on antiretroviral therapy adherence, but without durability beyond the incentive period. 
• HIV prevention has the most robust evidence for decreasing HIV risk-taking behavior among adolescents and may serve as a model for research on the care cascade.

Financial incentives show promise for improving engagement in HIV testing, care, and prevention. Understanding the durability, scalability, ease of implementation, and cost-effectiveness of these different approaches will be critical for maximizing the impact of incentives in curtailing the HIV epidemic.

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By: Bassett IV1, Wilson D, Taaffe J, Freedberg KA.

• 1aDivision of Infectious Diseases bDivision of General Internal Medicine cMedical Practice Evaluation Center, Massachusetts General Hospital dHarvard Center for AIDS Research, Harvard University, Boston, Massachusetts eGlobal AIDS Program, World Bank, Washington, District of Columbia fDepartment of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.

Effectiveness of Conditional Cash Transfers to Increase Retention in Care & Adherence to PMTCT Services: A Randomized Controlled Trial

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Effectiveness of Conditional Cash Transfers to Increase Retention in Care and Adherence to PMTCT Services

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