Association for Behavior Analysis International

Behavioral economics is becoming an increasingly well-known field, particularly in the area of promoting healthy choices. Contingency management, which involves delivering immediate incentives (usually money) contingent on objective evidence of the desired target behavior (e.g., drug abstinence), is a behavioral economic intervention that is not only successful, but also has recently received widespread support. In the current symposium, a series of talks will address recent advances in the area of incentive-based interventions as they have been applied to a variety of health behaviors (smoking and cocaine abstinence, as well as participation in cardiac rehabilitation programs), as well as under a variety of conditions (group versus individual contingencies, deposit contracts, etc).

Cardiac rehabilitation is a program of structured exercise and education that is standard of care following a serious cardiac event and significantly reduces morbidity and mortality following such events. Patient populations differ significantly in how likely they are to attend, with low-income patients having some of the lowest participation rates. In the current study we are testing the effectiveness of using contingency management to increase cardiac rehabilitation participation among low-income patients, specifically those enrolled in Medicaid or other state-supported insurance. Patients agreeing to participate are randomized into a usual care or an incentive condition. Those in the incentive condition earn financial incentives on an escalating schedule for completing each of the 36 prescribed exercise sessions. Those in the usual care condition do not earn incentives but are compensated for completing study measures. Thus far 74 patients have been randomized in this study. Currently those in the incentive group are 5-7 times more likely to complete the cardiac rehabilitation program than those in the usual care condition. These initial results demonstrate that incentives substantially increase participation in cardiac rehabilitation among low-income patients and may be an important tool for addressing disparities in health care access.

Previous research has shown that Internet-based group contingency management (CM) can promote comparable rates of smoking cessation relative to individual contingencies (Meredith et al., 2011; Meredith & Dallery, 2013). Although previous group CM studies enrolled groups of smokers with no pre-existing relationships, Christakis and Fowler (2008) found that smoking abstinence can be influenced by the abstinence of one's friend, spouse, sibling, close neighbor, or coworker. Thus, the aim of the current study was to explore the feasibility and preliminary efficacy of a group CM intervention that was developed for pairs of smokers with a pre-existing relationship (e.g., friends). Six pairs of smokers participated in a multiple-baseline design. During a two-week intervention, participants could earn monetary rewards that increased for meeting successive abstinence goals ($1.50, $1.75, $2.00, etc.) plus a bonus when both members were abstinent ($3.00). Recruitment was challenging with approximately 50% of interested applicants unable to identify a partner. Preliminary results showed that pairs of participants either did very well together (both abstained) or very poorly (both smoked), with no groups showing a split pattern. Thus, although social support of a familiar partner may have been helpful in some cases, it may have been harmful in others.

Positive reinforcement of cocaine abstinence has established efficacy, but low acceptance for reasons including complexity and an individual format in community treatment programs, which rely primarily on group treatments. The primary purpose of this pilot study was to examine the efficacy of positive reinforcement for cocaine abstinence using Individual (I) or Interdependent Group (G) contingencies in comparison to a standard care non-contingent condition (S). Thirty-three adult opiate-dependent patients at a community-based methadone maintenance treatment program who screened positive for cocaine use via urinalysis participated. Eleven were block randomized to each group. A between-group comparison and within group ABA reversal design indicated that the percent of cocaine abstinent urine tests increased in both contingent groups, but group contingencies resulted in the largest increase in percent cocaine abstinence (G=17%; I=11%; S=3%) during treatment. The maximum duration of abstinence was higher for individual contingencies, but this group also showed the greatest decrease in abstinence when the contingencies ended (G= -12%; I = -20%; S = -13%). This preliminary work suggests that group contingencies may have similar efficacy to individual contingencies, while having potential advantages including reduced implementation complexity, consistent treatment format, and potential for better maintenance.