Patients’ Reactions to Being Offered Financial Incentives to Increase Colorectal Screening: A Qualitative Analysis

Purpose

Colorectal cancer screening (CRCS) is gradually increasing, with 62% of adults aged 50-75 now current for screening. However, rates of CRCS are still well below national targets of 80% screened by 2020. ¹ Moreover, traditionally disadvantaged groups screen at lower rates: low income (47%); Medicaid (60%); uninsured (25%); Black (59%); Asian (52%); American Indian/Alaska Native (48%); and Hispanic (47%). ^2,3 Direct mailing of fecal immunochemical tests (FIT) is an evidence-based strategy for increasing CRCS. ^4,5 Prior studies have found that mailed FIT programs lead to similar increases in CRCS in traditionally disadvantaged and advantaged groups. ^{5 -7} However, disadvantaged groups have lower CRCS rates at baseline and do not catch up.

Major drivers of underscreening include: 1) lack of awareness; 2) negative attitudes toward CRCS tests (e.g., aversion to colonoscopy preparation, associated risks, perceived high costs, handling stool); 3) friend or family member with a prior negative experience; 4) lack of motivation; and 5) procrastination. ^8,9 Lack of motivation and procrastination may be driven by low perceived risk of getting CRC in the future and/or lack of immediate benefits from CRCS. ⁸ Thus, it is important to test novel approaches like financial incentives among traditionally disadvantaged groups, which have the potential to overcome the lack of immediate benefits from CRCS and reduce screening disparities.

In a previous study, we demonstrated that a low-cost, automated intervention of mailed fecal tests with stepped-intensity support led to an increase in fecal testing. ⁷ However, disparities in fecal testing persisted, particularly among people of color and those who had not previously completed screening. To better understand reasons for these disparities, we conducted qualitative interviews with patients who completed CRCS and those who did not (non-screeners). Among non-screeners, we found that avoidance and procrastination (i.e., “out of sight, out of mind”) were one of the top reasons given for not screening. ¹⁰

The reasons for such procrastination can be explained by insights from the field of behavioral economics, which posits that people’s choices are often disproportionately influenced by short-term benefits and costs. ¹¹ In the case of CRCS, benefits that are uncertain or that occur in the distant future (e.g., potential reduced mortality due to earlier identification of precancerous lesions) are believed to have few, if any, immediate benefits. In contrast, CRCS has clear and immediate “costs” or inconveniences for patients. Financial incentives may be an effective way to overcome this imbalance, and thus, increase screening uptake. Such an approach could be particularly effective among individuals who have forgone opportunities to complete screening, for whom there could be a larger imbalance between the perceived immediate benefits and costs of CRCS. Few studies have evaluated the comparative effectiveness of giving patients a financial incentive for completing CRCS, and findings are mixed, particularly among groups with lower screening rates. ^{8,12 -15} None of these studies used qualitative methods to gain an in-depth understanding of patients’ responses to incentives.

To understand how incentives influenced CRCS decision-making among traditionally disadvantaged patients (i.e., those with Medicaid and those from underrepresented racial or ethnic groups), we conducted a qualitative study to describe patients’ attitudes toward the offer of incentives, plans for future screening, and additional barriers and facilitators to any CRCS testing.

Approach

Analyses

All interviews were audio-recorded and professionally transcribed. We used a directed qualitative content analysis approach ²² where themes and categories were derived from the data in the context of pre-determined research questions. ²³ First, an initial coding scheme was created based on our research questions. Next, 4 trained coders (LAS, KK, CD, LJ) independently reviewed 4 transcripts, met to review any disagreements, and iteratively modified the codebook based on emergent themes. Using the final codebook, each transcript was randomly assigned to 1 of the 4 coders. Five transcripts, in addition to the initial 4 concurrently analyzed, were coded by at least 2 coders to test coder agreement. Disagreements were discussed until the pair reached consensus. Finally, the coders worked together to reorganize the coded data into the predetermined coding categories. We then analyzed the qualitative content to explore emergent themes within categories.

Results

We identified 120 eligible participants during our recruitment window. Of these, 66 participants were either not able to be reached by phone or did not respond to phone messages. Another 2 were found to be ineligible, and 15 were not contacted because recruitment was full for their recruitment cell (i.e. to avoid further oversampling of white and non-Medicaid patients). In total, 37 participants were interviewed (Table 1). The majority of participants were female (n = 25) and white (n = 20; race/ethnicity was obtained from the EHR), and the average age was 58 years. At the time of the interview, 24 of the participants (65%) had completed screening (n = 22 FIT test, n = 2 colonoscopy). We present our findings using the structure of our predetermined categories, and within each of the categories we expand on emergent themes. Themes are indicated with bold text. Additional patient quotes can be found in Table 2.

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Table 1.

Interview Participant Characteristics (n = 37).

	n (%)
Sex
Male	12 (32%)
Female	25 (68%)
Age (Mean (SD))	57.9 (7.2)
Race
Non-Hispanic White	20 (54%)
Asian	6 (16%)
American Indian/Alaska Native	4 (11%)
Black/African American	2 (5%)
Native Hawaiian/ Pacific Islander	2 (5%)
Hispanic/Latino	1 (3%)
Race unspecified	1 (3%)
Insurance Status
Private	34 (92%)
Medicaid	3 (8%)
Prior screening status
Non-screener	14 (38%)
Prior Screener	23 (62%)
Incentive group assignment
+Monetary ($10 Cash)	17 (46%)
+Lottery ($50 Lottery)	20 (54%)

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Table 2.

Organization of Qualitative Findings by Predetermined Categories and Emergent Themes.

Categories	Emergent themes	Additional illustrative quotes
Reactions to incentives	Lack of recall of incentive offer	“I don’t remember. I might not have read the whole thing, I might have thought it was just a reminder and not really read it.” (female, 60, non-Medicaid, white, did not screen)“Oh golly—do I remember that? Maybe so. I know they sent me 2 dollars to do the test. Maybe they sent more money afterwards, I can’t recall. To be honest, I can’t remember.” (female, 54, non-Medicaid, white, screened)
	Positive reactions	“I thought—well, that was nice. It was a little bit of an incentive” (female, 60, non-Medicaid, Asian, screened)
	Neutral reaction	“I didn’t even notice the [incentive offer] because I didn’t read the whole thing. I didn’t notice the $10 part till after I was going to complete the test and mail it in. So I read the whole thing and thought oh, that’s cool to get $10, but that was not part of my incentive to do the test” (female, 59, non-Medicaid, Asian, screened)
Impact of incentives on screening adherence among those who recalled the incentive offer	No impact on screening decision	“In this case, for this kind of thing where I’m not going anywhere and doing anything fancy, the offer of a drawing didn’t influence my personal decision here.” (female, 63, non-Medicaid, Other person of color, screened)“The money isn’t my goal. To do the test is my goal.” (female, 50, non-Medicaid, Asian, screened)
	Incentive was a primary motivator	“I consider myself extremely healthy and so I wasn’t expecting to get anything but a negative result. Okay, you pay me $10 and I can do this” (female, 65, Medicaid, white, screened).“Well, I need money, that’s really it. It’s a small amount of money, but it was like I needed money and I knew I needed to do it anyway. That $10 isn’t going to make a huge different to me, but now it’s really ridiculous not to do it.” (female, 50, non-Medicaid, white, screened)“To me, I thought this is like—hey, my chances are pretty good. I think I’ll just go ahead and do this and send it in. I don’t know, it worked well for me. It was an enticement. Otherwise, I could have said oh, I’m just not interested in this.” (female, 73, non-Medicaid, white, screened)
	Incentive helped prioritize screening, but wanted to screened eventually	“I probably would have done it without the money, but I did appreciate the money.” (male, 50, non-Medicaid, Asian, screened)“I knew it was something that needed to be done. I was coming up real close to the anniversary date. Was it an added bonus? Yeah.” (male, 53, non-Medicaid, white, screened)
Intentions to continue screening	Maintaining their health	“I think one test, it doesn’t mean that you are safe. So, like I do the mammogram every year, I would do the colon cancer screen every year, if suggested [by my provider]” (female, 50, non-Medicaid, Asian, screened).
	Incentive will help prioritize	“I would probably continue it anyway, like I said, because there’s no cost. But it gets it going a little sooner is what it amounts to.” (female, 66, non-Medicaid, white, screened)
Barriers to screening among non-completers	Feared costs	“Yeah, cost is always a barrier. I’m going to get it this year, I hope, especially since my insurance has gone up 54%—I don’t even know. I mean my insurance next year is going to be just $60 less than my house payment. So that’s cost prohibitive, you know? I think my insurance is going to cover the colonoscopy this year.” (female, 60, non-Medicaid, white, did not screen)
	Not a high priority	“Well, frankly no one in my family has had any instance of colon cancer, so it seems like a lower priority to me.” (female, 73, non-Medicaid, white, did not screen)

Initial Reactions to Financial Incentives for Completing Screening

Just under half (n = 20) of participants did not recall receiving an offer of a $10 incentive or entry into a lottery (1 in 10 chance of $50) in the introductory study letter. Of the 21 who remembered the incentive offer, most reported a positive initial reaction, stating that they were pleased and surprised by the offer. For example, one participant responded: “I was thinking this is cool. That’s more of a little incentive. It’s not anything that made the decision definitive or not. It wasn’t necessarily like a controlling factor, but it was a nice additional incentive” (female, 51, non-Medicaid, Black/African American). A smaller number of participants who recalled the incentive offer had neutral reactions in that they noticed the offer but did not report an emotional response. For example, one participant responded, “I didn’t care about it one way or the other” (female, 63, non-Medicaid, race unspecified). None of the participants reported having a negative reaction to the incentive, although a few with neutral reactions felt that it was odd to be offered money to get screened. One participant said, “Oh, it is a little bit weird. I think people shouldn’t have to be convinced by money to do something” (female, 50, non-Medicaid, white). Overall, we found that participants were either pleased or felt neutral about the incentives, indicating the offers seemed, at worse, to do no harm in promoting CRCS.

Impact of Financial Incentives on Screening Adherence

Of the 16 participants who did not recall the incentive offer, only 4 were screened. In contrast, 20 of the 21 participants who recalled the financial incentive offer in the study letter were screened prior to the interview. However, most respondents who remembered the incentive offer stated that the incentive had no impact on their screening decision. For example, one said, “It’s my own health, so I think I always make an informed decision. So whatever offer or not offer has no impact on my own decision” (male, 62, non-Medicaid, Asian). Other participants stated that the incentive offer was a primary motivator in their screening decision. One participant stated that “[The study introduction letter] said $10 and I knew I already had to do it. So, it helped to make my decision” (female, 50, non-Medicaid, American Indian/Alaska Native). Others stated that they wanted to be screened either way, but the incentive helped them prioritize screening and motivated them to complete CRCS sooner. “That was definitely an incentive to get it going. I didn’t think about it, but that was one of the incentives to get it done sooner, yes” (female, 66, non-Medicaid, white).

Intentions to Continue Screening with or without a Financial Incentive

Twenty-three of the 24 participants who screened said that they intend to screen again when recommended in the future by their physician. The only participant who said she would not screen again cited her age (73 years) and said that after this round of screening, she will opt to discontinue. Most participants cited maintaining their health as the rationale to continue screening in the future. One participant said, “Just to make sure I maintain a healthy life…If a doctor recommends a colonoscopy or a mammogram or whatever, then I will or I do follow through and make those appointments” (female, 59, non-Medicaid, Asian).

Other participants said that continuing to get an incentive would help them to prioritize continued screening. For example, one participant reported, “Definitely money, if I can continue to—or get like a credit or they say we enter you into a drawing for whatever, to kind of start motivating people to become more aware and get this done, as part of that whole prevention effort, kind of be incentivized somehow—that would help me to do it more readily. But I think I’m going to do it, regardless” (female, 51, non-Medicaid, Black/African American). However, almost all participants reported that with or without an incentive, they intend to continue screening, saying: “Oh yeah, I’d do it again without any incentive” (male, 64, non-Medicaid, white) and “I would do it regardless” (male, 50, non-Medicaid, Black/African American).

Among the 13 non-screeners, 7 stated they planned to be screened within the next year. Most of these participants, including the sole non-screening participant who recalled the incentive offer, said that they had simply forgotten or procrastinated, and the interview was prompting them to complete it soon. Two of the non-screeners said they do not plan on screening. One stated, “I don’t plan on pursuing it unless I start having a physical reason for it” (female, 62, Medicaid, white). Several others were undecided stating that they thought it was a good idea, but not a priority. One stated, “I don’t know. Truthfully, I don’t even think that way because I don’t know how long I’m going to be here. There’s other things going on [with my health]” (female, 59, non-Medicaid, Hispanic). Like the screeners, non-screeners stated that the incentives are nice, but they probably would not change their intention to screen or not in the future.

Barriers to Screening Among Participants Who Did Not Complete CRCS

Participants who were not screened during the study described their perceived barriers to screening. The most common reported barrier was fear of the cost. Some participants shared that they did not know whether they would be charged for FIT tests once completed. One participant stated, “I’m never sure if there was a charge for it or not, and so I still don’t know if you send it in and then you get charged from the hospital or from Group Health who is now Kaiser. So that kind of plays into it because any medical procedure these days seems to be expensive, so you like to know beforehand if there’s going to be a charge” (male, 58, non-Medicaid, white). Another participant described a prior experience with scheduling a colonoscopy saying:

I actually was scheduled to have a colonoscopy last year and I canceled it because it was cost prohibitive. I called my insurance company…I said how much is the test going to be? And they couldn’t answer that question, they said we can’t answer that. And I said, can you give me a range? And they said well, it all depends if they go in, if they find anything—if they find any polyps or anything they have to remove. So, I canceled that procedure simply because they couldn’t tell me how much it was going to be. I only knew that I was going to be responsible for paying whatever it ended up being (female, 50, non-Medicaid, white).

Another common barrier among non-screeners was that screening was not a high priority for them at this time, and thus, put it off until later. One participant said, “It’s just something that was always in the back of the line, so to speak, of things to do…Well, frankly no one in my family has had any instance of colon cancer, so it seems like a lower priority to me” (female, 73, non-Medicaid, white). Another said simply, “Just forgetting. I have no hesitation to do it, I just keep forgetting” (female, 60, non-Medicaid, white). One participant suggested that having an extra incentive for completing it quickly, or a deadline for the incentive might have helped her prioritize the screening. She said,

I did let mine sit. I don’t know if that $10 was enough to—I still had to process and kind of talk it through and wrap my brain around—“you are going to do this,” and then I had a gentle reminder. So, I think if there was a little push to just go on and get it done within a timeframe. So, you’ll get your $10 and get entered into a drawing for a gift card or an additional monetary amount? I probably would have gone on and done it within the deadline (female, 51, non-Medicaid, Black/African American).

Conclusion

Our qualitative study found that financial incentives, both guaranteed $10 and probabilistic lottery for $50, were well received by patients. Almost all participants had a positive response to the incentives and were appreciative of the offer. However, nearly half of the participants interviewed did not recall the incentive offer, regardless of incentive type. Of those that did recall the incentive offer, almost all completed screening, compared to a minority of participants who did not remember the incentive offer.

These findings suggest incentives need to be presented in a way that is highly salient to patients, ²⁴ because, in our study, when incentives were remembered they were largely effective. One effective study used brightly colored paper to alert the patient to the incentive within the FIT kit. ¹⁴ Another approach to making incentives visible to patients would be to advertise or offer them in clinical settings, in addition to mailings. ¹⁴

In our study, most participants did not attribute their screening decisions to the incentive. Instead, similar to other studies, they said that facilitators to screening included wanting to stay healthy for themselves and their families, and having the option of FIT over colonoscopy. ^9,10 However, even if incentives were not a major driver of behavior, they may have acted as a cue to action for those who value screening, but had not yet prioritized it among many other competing demands. In fact, the few participants who reported that the incentive prompted their decision to screen stated that they already wanted to screen, and the incentive offer helped them follow through on their intention. These qualitative findings provide context to the results from our parent, quantitative study, in which financial incentives were found to significantly increase FIT uptake among individuals who reported making decisions based on how easy they were to do as well as among patients with high opt-out defensive processing (e.g., “if I feel healthy I don’t go the doctor”). ¹⁶

Future studies should consider adding and advertising a “due date” to receive an incentive, as several non-screeners in our study stated that they intended to be screened but kept procrastinating. We allowed for 6 months to include time for colonoscopy for those that chose that modality, but this may have been too long for the majority who preferred FIT. Future studies should test the impact of a shorter timeframe for FIT testing. Likewise, another promising option would be to offer larger financial incentives for those who screen more promptly.

Among a small minority of participants, there was concern about the potential cost of screening. These participants indicated that any cash incentive would be small in comparison to potential medical bills. Including and highlighting very clear wording about the potential costs of completing CRCS (or lack thereof) may be helpful.

Previous studies on financial incentives for health behavior change have had mixed results. ^{25 -28} Generally, financial incentives were more effective at changing discrete behaviors rather than ongoing or habitual behaviors, although habitual behaviors can also be impacted by sustained financial incentives. ^27,28 Among studies focused on incentives to increase CRCS, results were also mixed, ^8,12,14,29 but generally smaller incentives of $5 or $10 for FIT test completion were found to be ineffective. ^8,14,15 In contrast to these findings, the quantitative analysis of our trial found that both a guaranteed incentive of $10 and probabilistic incentive of a 1 in 10 chance of winning $50 were effective at increasing FIT testing, but not colonoscopy. ¹⁶ Our qualitative findings help explain the difference found in this trial, in that participants often had strong feelings about colonoscopy based on their own or their loved ones’ prior experiences. Thus, they stated that small financial incentives would not compel them to complete a colonoscopy. One recent study found that $100 cash incentives were effective at increasing colonoscopy uptake, ¹² thus larger incentives may be necessary for patients overdue for screening, but who prefer colonoscopy over FIT.

Our findings should be considered in light of several limitations. First, our sample was drawn from KPWA, so all participants were insured and received usual care that included efforts to increase CRCS, such as routinely handing out FIT kits to overdue patients at visits and annual preventive screening reminders. ³⁰ Barriers, facilitators, and impact of incentives may differ among those without insurance or those without access to an integrated managed care system. Second, in the parent, 3-arm study, we found that financial incentives resulted in a 35% net increase in use of FIT among patients with Medicaid insurance, as compared to an overall increase of 7%. However, in our qualitative study, we only interviewed 3 patients with Medicaid and thus, were not able to look for differences in themes by insurance type. Since the perceptions of Medicaid patients were underrepresented in our study, our findings may not be transferable to this group. Similarly, while we did not find differences in themes by race or ethnicity, larger studies with more diverse populations are needed to explore whether or not there are differences in order to develop interventions to decrease screening disparities. Third, over half of the participants in our study had screened in the past; a study focused solely on never-screeners may find additional barriers or reactions to incentive offers. Lastly, patients in our study were required to return a baseline questionnaire to be eligible. Thus, our findings may not be transferable to individuals who do not respond to mailed surveys and reminder calls. Our qualitative study was not designed to make statistical inferences. Qualitative interviews are helpful in providing rich data on the experiences and perceptions of participants, thus we cannot draw statistical conclusions about causation or relations between variables. It is important that future studies explore the utility of financial incentives for CRCS with a larger group of racially and ethnically diverse Medicaid patients.

In conclusion, financial incentives to complete CRCS were well-received and helpful, especially among participants who were motivated to protect their health but procrastinated in completing CRCS. The majority of non-screeners were not aware of the financial incentive. Future intervention studies should be conducted among more racially, ethnically, and economically diverse populations, and focus on making the offer of the incentive more noticeable with a shortened deadline for FIT completion.