CEIs Can Help Change COVID-19 and HIV Behavioral Outcomes
By: Sai Srihaas Potu
There are many different reasons why people do things. Sometimes people are motivated to act because of internal desires and wishes, but at other times, behaviors are driven by a desire for external rewards. According to one theory of human motivation, actions are often inspired by a desire to gain outside reinforcement. The incentive theory is one of the major theories of motivation and suggests that behavior is motivated by a desire for reinforcement or incentives.
The incentive theory began to emerge during the 1940s and 1950s, building on the earlier drive theories established by psychologists such as Clark Hull. How exactly does this theory account for human behaviors? Rather than focusing on more intrinsic forces behind motivation, the incentive theory proposes that people are pulled toward behaviors that lead to rewards and pushed away from actions that might lead to negative consequences.
Not all incentives are created equal and the rewards that you find motivating might not be enough to inspire another person to act. Physiological, social, and cognitive factors can all play a role in what incentives you find motivating. In recent years, behavioral economists have come up with new methodologies based on the incentive theory in order to foster better decisions.
Behavioral economics (BE) has been used to study several health behaviors such as smoking and drug use, but there is little knowledge of how these insights relate to HIV prevention and care. Behavioral economic interventions can complement psychological frameworks for reducing HIV risk by introducing unique theoretical understandings about the conditions under which risky decisions are amenable to intervention.
People commonly fail to act in their self-interest and behave in ways they later regret such as overeating or smoking. Behavioral economists study why and in what circumstances individuals display such decision-making errors or biases. Insights from behavioral economics have been applied to study several diseases and health behaviors, but to date, none have explored HIV. BE is grounded in traditional economics but enriches this framework with insights from psychology. It also shares some characteristics with existing health behavior theories. Like social-cognitive theory, it starts from the premise that expectations of future events and outcomes are important determinants of behavior.
For three decades, psychological science has been the foundation for public health efforts to prevent human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) cases. In the absence of biomedical interventions, especially in the early phases of HIV/AIDS, public health programs relied on psychological theories of behavior change to design strategies for reducing HIV risk behaviors.
Despite these successes, the number of new HIV infections has continued to rise in the past decade, revealing limitations to psychological approaches to HIV prevention. In 2009 alone, there were an estimated 2.6 million new HIV infections globally, primarily in settings characterized by poverty. An estimated 56,000 new infections occurred annually in the United States since 2006, with ethnic minority populations disproportionately at risk for infections.
HIV prevention research has recently become energized by insights from behavioral economics. As a hybrid of economics and psychology, behavioral economics introduces unique theoretical understandings about the conditions under which risky decisions are made. A notable contribution of behavioral economics to HIV prevention is the emergence of conditional economic incentive (CEI) programs for changing HIV-related behavioral outcomes. Similar to contingency management (CM) programs developed by psychologists for treating individual-level substance use problems, CEIs operate as policy and structural-level interventions by providing financial rewards to individuals who engage in behaviors that facilitate positive health outcomes.
CEI is a demand-side intervention that provides economic incentives to an individual contingent upon achievement of a behavioral goal. The premise of CEI is consistent with contingency management programs used frequently in substance use treatments that modify behaviors through operant reinforcements, such as conditional cash or vouchers, in exchange for reducing drug or alcohol use. In this way, CEI programs capitalize on behavioral economic and behavioral psychology principles.
Subsequently, CEI principles can also help target the COVID-19 pandemic. Since the first described cases of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were identified in the Hubei region of China in December 2019, coronavirus has been spreading rapidly across countries. On March 11th, 2020, the World Health Organization (WHO) finally declared the SARS-CoV-2 a pandemic due to the increasing number of cases around the world. This has resulted in high rates of emergency visits, hospitalizations, and intensive care unit admissions.
The same principles that governed the ideologies of CEI programs can be used to help control the spread of the COVID-19 pandemic. By having economic incentives, the public will likely make better decisions which will ultimately help them stay safe. Though there are limitations to this principle, the government needs to start thinking about its implementation in order to stop the rapid spread of the pandemic.
CEI programs offer a promising addition to our current arsenal of HIV and COVID-19 prevention strategies. However, questions remain regarding the necessary conditions to optimize intervention effects. In summary, behavioral economic interventions can be viewed as a valuable addition to, but not a replacement of, existing psychological approaches to HIV and COVID-19 prevention.
Concepts and methods from each disciplinary approach offer unique perspectives – with psychology emphasizing the supply of prevention programs and behavioral economics emphasizing the demand for prevention service incentives to motivate user uptake and engagement. Even as new biomedical approaches arise, there remains a continued public health need to modify demand-side behaviors. Ultimately, with the way life is running right now, CEI might be the best option in order to foster better decisions and keep the public safe.
1. Dutra L, Stathopoulou G, Basden SL, Leyro TM, Powers MB, Otto MW. A meta-analytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry. 2008.
2. Giuffrida A, Torgerson DJ. Should we pay the patient? Review of financial incentives to enhance patient compliance. BMJ. 1997.
3. Haug NA, Sorensen JL. Contingency management interventions for HIV-related behaviors. Current HIV/AIDS Reports. 2006.
4. Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction. 2006.