Elsevier

Academic Pediatrics

Volume 22, Issue 2, March 2022, Pages 203-209
Academic Pediatrics

Promoting Healthy Childhood Behaviors With Financial Incentives: A Narrative Review of Key Considerations and Design Features for Future Research

https://doi.org/10.1016/j.acap.2021.08.010Get rights and content

Abstract

In the last decade, there has been a robust increase in research using financial incentives to promote healthy behaviors as behavioral economics and new monitoring technologies have been applied to health behaviors. Most studies of financial incentives on health behaviors have focused on adults, yet many unhealthy adult behaviors have roots in childhood and adolescence. The use of financial incentives is an attractive but controversial strategy in childhood. In this review, we first propose 5 general considerations in designing and applying incentive interventions to children. These include: 1) the potential impact of incentives on intrinsic motivation, 2) ethical concerns about incentives promoting undue influence, 3) the importance of child neurodevelopmental stage, 4) how incentive interventions may influence health disparities, and 5) how to finance effective programs. We then highlight empirical findings from randomized trials investigating key design features of financial incentive interventions, including framing (loss vs gain), timing (immediate vs delayed), and magnitude (incentive size) effects on a range of childhood behaviors from healthy eating to adherence to glycemic control in type 1 diabetes. Though the current research base on these subjects in children is limited, we found no evidence suggesting that loss-framed incentives perform better than gain-framed incentives in children and isolated studies from healthy food choice experiments support the use of immediate, small incentives versus delayed, larger incentives. Future research on childhood incentives should compare the effectiveness of gain versus loss-framing and focus on which intervention characteristics lead to sustained behavior change and habit formation.

Section snippets

Potential Effects on Intrinsic Motivation

One of the primary critiques of financial incentives to promote health behaviors relates to the potential effects on intrinsic motivation. The motivational crowding theory suggests that providing external rewards to incentivize behavior can potentially decrease intrinsic motivation by “crowding out” existing intrinsic motivation or preventing it from developing.10 While there is no clear consensus on how and when incentives may crowd out intrinsic motivation, several researchers have

Framing: Gain and Loss-Framed Incentives

Behavioral economists have built on the foundational work on positive and negative reinforcement8,9,34,35 by exploring the differential framing of financial incentives. Individuals tend to overly weight the impacts of losses compared to gains. Implementing loss-framed incentives for health behaviors has been effective in increasing physical activity and smoking cessation rates in adult populations,36,37 but there is less evidence in children.

Two randomized clinical trials seeking to improve

Future Research

While the use of financial incentives to promote childhood health behaviors is not new, knowledge of what approaches are most effective at what developmental stage remains poorly understood. The quantity of experimental studies in children is limited and distributed across a range of behaviors, yet several early observations are emerging. While there is robust evidence for loss-framing in adults, it is not clear that this approach is effective in children. Also, evidence from several primary

Acknowledgments

Financial statement: This work was supported by the National Institutes of Health award grant no. K23HL136842 to C.C.K and K08CA226390 to B.P.J.

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  • The authors have no conflict of interest to disclose.

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    These authors contributed equally.

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