Hypertension affects over 70 million Americans, is responsible for one-sixth of deaths, and costs more than $70 billion annually. It disproportionately affects African-Americans and is poorly controlled in all populations, particularly Latinos, due to lack of symptoms, low awareness, inadequate treatment, and poor adherence. Monetary incentives to patients have induced short-term improvements in health and health-related behaviors, including weight loss and smoking cessation, but improvements are seldom maintained after incentives are removed. Incentives have not been tested in a chronic disease such as hypertension, but existing research suggests that even if such incentives stimulate better blood pressure (BP) control, the effect is unlikely to persist after incentives are withdrawn. Additional strategies are needed so that patients internalize motivation to maintain BP control. This pilot study will develop and test in a randomized trial a novel intervention to improve BP control based on behavioral economics and social psychology.
Specific Aims are to: 1) develop an intervention that combines a behavioral economic component, using monetary incentives that incorporate linear payments in proportion to BP improvement and chance lotteries to boost motivation to reach subgoals, and a social psychological component, using identity and motivational labeling techniques, to sustain BP control after incentives are removed;2) implement the intervention in a randomized trial in two community clinics in Los Angeles among hypertensive subjects who are principally Latino and African-American;3) assess the effects of the intervention on BP over a 6-month period, and determine whether reductions in BP for the first 6 months are sustained for an additional 6 months;and 4) assess acceptability of the intervention to the study population. We will randomly assign 262 subjects with uncontrolled hypertension to a control group, which will receive educational materials and a home BP monitor, or to an intervention group, which additionally will receive: 1) payments tied to amount of improvement in BP from baseline, and 2) a personalized intervention to internalize motivation for BP control. Study staff will measure BP monthly in both groups. Intervention subjects who improve BP control will receive monthly payments for 6 months, after which payments will cease. At the time of monthly BP measurements, study staff will administer to intervention subjects identity-relevant procedures to promote attribution of their BP control behaviors to intrinsic motivations relating to their responsibilities, relationships, and/or activities important to them. BP also will be measured 3 and 6 months after termination of payments, to determine whether impact on BP control is sustained. Co-primary outcomes will be 1) change in and 2) normalization of BP;secondary outcomes will include acceptability of the intervention and subjects'views regarding its impact. If successful, future work will seek to isolate the separate impact of monetary incentives and of interventions to internalize motivations to control BP, will assess the dose required to achieve these effects, and will test impact of the intervention's components upon other populations.
Despite unequivocal proof that tight control of blood pressure with antihypertensive medication can prevent hypertensive complications-including strokes, myocardial infarcts, heart failure, end-stage renal disease, and death- blood pressure remains uncontrolled in the majority of individuals with hypertension. We propose a novel patient-centered intervention that combines monetary incentives and a social psychological intervention to help patients sustain blood pressure control once incentives are no longer offered by strengthening intrinsic motivation to control blood pressure among two vulnerable populations: African Americans, who suffer disproportionately from hypertension, and Mexican Americans, who have the lowest hypertension control rates of any demographic group in the United States. If the intervention is successful, it could be adapted as a set of tools to apply in clinical practice to improve outcomes of a range of chronic diseases, by maximizing the motivation of patients to optimize their treatment.
| Mogler, Braden K; Shu, Suzanne B; Fox, Craig R et al. (2013) Using insights from behavioral economics and social psychology to help patients manage chronic diseases. J Gen Intern Med 28:711-8 |
