Financial Reinforcers for Improving Medication Adherence: Findings from a Meta-analysis

BackgroundIncreasingly, financial reinforcement interventions based on behavioral economic principles are being applied in health care settings, and this study examined the use of financial reinforcers for enhancing adherence to medications.MethodsElectronic databases and bibliographies of relevant references were searched, and a meta-analysis of identified trials was conducted. The variability in effect size and the impact of potential moderators (study design, duration of intervention, magnitude of reinforcement, and frequency of reinforcement) on effect size were examined.ResultsFifteen randomized studies and 6 nonrandomized studies examined the efficacy of financial reinforcement interventions for medication adherence. Financial reinforcers were applied for adherence to medications for tuberculosis, substance abuse, human immunodeficiency virus, hepatitis, schizophrenia, and stroke prevention. Reinforcement interventions significantly improved adherence relative to control conditions with an overall effect size of 0.77 (95% confidence interval, 0.70-0.84; P < .001). Nonrandomized studies had a larger average effect size than randomized studies, but the effect size of randomized studies remained significant at 0.44 (95% confidence interval, 0.35-0.53; P < .001). Interventions that were longer in duration, provided an average reinforcement of $50 or more per week, and reinforced patients at least weekly resulted in larger effect sizes than those that were shorter, provided lower reinforcers, and reinforced patients less frequently.ConclusionThese results demonstrate the efficacy of medication adherence interventions and underscore principles that should be considered in designing future adherence interventions. Financial reinforcement interventions hold potential for improving medication adherence and may lead to benefits for both patients and society.     

Potential sources of reinforcement and punishment in a drug-free treatment clinic: client and staff perceptions

Contingency management interventions are quite successful at initiating abstinence from drugs of abuse. However, these approaches to drug abuse treatment are often criticized because of their perceived cost. One way to reduce the cost of contingency management interventions would be to use nonmonetary sources of reinforcement or punishment. A number of reports have discussed the availability of potential sources of reinforcement in opiate replacement clinics. This report describes the availability of potential sources of reinforcement and punishment available in drug-free treatment programs. Both clients and clinic staff rated a number of items in terms of their potential reinforcing and punishing efficacy. Results suggest that there are several sources of reinforcement and punishment available in drug-free clinics, which could be used in contingency management programs. The results also suggest that the clinic staff perceives potential sources of punishment as more aversive than do the clients.     

Research in general practice for smokers and excessive drinkers in Australia and the UK. III. Dissemination of interventions

This article reviews the main methods of dissemination of interventions to doctors for the benefit of patients who are smokers and excessive drinkers. Firstly, the modes of delivery of interventions are discussed suck as: postal delivery, face-to-face strategies such as an educational facilitator, courier, training workshops, reinforcement contact after training, and teaching in medical school. Secondly, vie examine GPs' delivery of interventions working in association with others such as with: the health visitor, health facilitator, practice nurse, and specialist clinic. Thirdly, we discuss the debate about the public health impact of GP interventions for smokers, which is about rates of recruitment of patients to programs and about the most effective interventions that will continue to be used by GPs. Fourthly, doctors underutilize their opportunities to identify and intervene with smokers and excessive drinkers and we explore many of the barriers to intervention. Finally, there are several new initiatives in general practice that require research including: matching GPs to specific treatments, comparing the uptake and continued use of different levels of interventions, evaluating the most effective ways of delivering interventions to GPs, and the training of doctors in the intervention methods.     

Factors Influencing Nurses' Acceptability of Treatments for Problem Behaviors of Nursing Home Residents

The effect of treatment options, side effect profile, and time to implement treatment on ratings of the acceptability of treatments was evaluated Differential reinforcement (DRO) received the highest acceptability rating for treatment of aggressive behavior. Time-out and medication were equally acceptable as treatments for disruptive behavior. Side effect profile decreased ratings of all treatments except DRO. Time involvement and side effect profile resulted in equivalent ratings for disruptive behavior. The use of the least restrictive intervention for disruptive behavior may be especially difficult due to the low ratings of DRO. These results suggest that the time required to use applied behavior analysis interventions in nursing homes is not an impediment to use of such procedures.     

The use of a psychological intervention to increase adherence during factor administration in a child with haemophilia

Summary. While factor replacement treatments allow children with haemophilia to lead near normal lives, these treatments can be difficult to administer, especially to younger children. The intervenous infusions required by these treatments can be painful and result in children attempting to avoid treatment by exhibiting a range of inappropriate behaviours. Their children’s uncooperative behaviour during prophylaxis was cited by parents as a significant barrier to treatment adherence. This study provides a case illustration of the use of psychological interventions to increase adherence during factor administration. Single‐case methodology was used to demonstrate the effectiveness of the psychological interventions including counterconditioning, distraction, and positive differential reinforcement. The intervention resulted in increased adherence across several months of intervention. Psychological interventions can be effectively used by caregivers and care providers to increase adherence in the treatment of haemophilia.     

Flexural Performance of Cement-Treated Sand Reinforced with Geogrids for Use as Sub-Bases of Pavement and Railway Structures

Cement-treated sand (CTS) exhibits undesirable brittle behavior after the applied stress reaches its peak strength. This research investigates the flexural behavior of CTS that is reinforced with uniaxial geogrid (CTSG). A total of 6% cement content was mixed with sand. Uniaxial geogrids with three different strengths were utilized to create the CTSG samples. The number of reinforcement layers, including single and double reinforcements, was studied. The image processing method was applied to analyze the surface cracks in the specimens. The results show that the geogrid type and the number of reinforcement layers affect the flexural behavior of the CTSG. Geogrid reinforcement changed the behavior of the CTS from a brittle material to a semi-brittle or ductile material because the residual tensile stresses were carried by the geogrids. The high-strength geogrid with a double reinforcement layer proved to be most effective in enhancing the peak strength and toughness with improvement ratios of 1.80 and 11.7, respectively. Single and double reinforcement layers with all geogrid types can reduce surface cracks with average crack reduction ratios of 64% and 83%, respectively. The CTSG can be successfully used as a sub-base layer to increase flexural performance and the lifetime of pavement and railway structures.     

A new experimental method for hiatal reinforcement using connective tissue patch transfer

The closure of a large hiatal hernia still represents a challenge for the surgeon. Mesh reinforcement of a hiatoplasty generally decreases recurrence rate. An artificial mesh is cheaper compared with a biologic one, but has a higher complication rate. Our aim was to introduce a new biologic reinforcement method with less expenses. During organ donation for transplantation, tissue islets from pericardium and fascia lata were cryopreserved in a tissue bank. Later, the grafts were transplanted on the diaphragm of mongrel dogs. After 1, 3, and 6 months, the animals were sacrificed, and the transplanted patches were macroscopically and microscopically examined. There were no macroscopic signs of inflammation, abcedation, or significant adhesion formation. The grafts were well recognizable, with palpable thickening and moderate shrinkage. Microscopically, an organization process with fibrosis, neovascularization, and peritoneal integration could be observed. Reinforcement of a hiatoplasty with connective tissue transfer either with cryopreserved or autologous tissue is a good option. This is a cheap and easy method, which should also be tested in human interventions.     

Quasi-Static and Fatigue Properties of Thermoset Sandwiches with 3D Continuous Fibre Reinforced Polyurethane Foam Core

Innovative materials for substituting metals are required to reduce the mass of moving components. This decreases the CO₂ emissions of overall systems. A thermoset sandwich for high mechanical properties and thermal insulation is presented in this paper. It has an innovative 3D continuous reinforced core, which allows the optimisation of the substance exploitation by wide-ranging possibilities of fibre orientation. This was demonstrated with three sandwich variants. The reference had no core reinforcement and the other two were reinforced with different spacer fabrics. The process chain for the manufacturing consists of Structural Reaction Injection Moulding (SRIM) and Vacuum Assisted Resin Transfer Moulding (VARTM). Significant increases in absolute as well as specific characteristic values were demonstrated by the reinforcement in a compression and bending test. It was also shown that quasi-static characteristic values under fatigue loading are maintained to a greater extent with the core reinforcement. The sandwich material was applied as a floor assembly for a snow groomer. The design was tailor-made for the mechanical, thermal and acoustic requirements. This proved the transferability of the process chain for manufacturing samples to the production of large-volume components with complex geometry.     

Cue-dose training with monetary reinforcement

OBJECTIVE: To assess the feasibility and efficacy of two interventions for improving adherence to antiretroviral therapy regimens in HIV-infected subjects compared with a control intervention. DESIGN: Randomized, controlled, pilot study. SETTING: Department of Veterans Affairs HIV clinic and community-based HIV clinical trials site. PARTICIPANTS: Fifty-five HIV-infected subjects on stable antiretroviral therapy regimens. Subjects were predominantly male (89%) and African American (69%), and had histories of heroin or cocaine use (80%). INTERVENTIONS: Four weekly sessions of either nondirective inquiries about adherence (control group, C), cue-dose training, which consisted of the use of personalized cues for remembering particular dose times, and feedback about medication taking using Medication Event Monitoring System (MEMS) pill bottle caps, which record time of bottle opening (CD group), or cue-dose training combined with cash reinforcement for correctly timed bottle opening (CD+CR). MEASUREMENTS: Opening of the pill bottle within 2 hours before or after a predetermined time was measured by MEMS. RESULTS: Adherence to the medication as documented by MEMS was significantly enhanced during the 4-week training period in the CD+CR group, but not in the CD group, compared with the control group. Improvement was also seen in adherence to antiretroviral drugs that were not the object of training and reinforcement. Eight weeks after training and reinforcement were discontinued, adherence in the cash-reinforced group returned to near-baseline levels. CONCLUSIONS: Cue-dose training with cash reinforcement led to transient improvement in adherence to antiretroviral therapy in a population including mostly African Americans and subjects with histories of drug abuse. However, we were not able to detect any sustained improvement beyond the active training period, and questions concerning the timing and duration of such an intervention require further study. Randomized, controlled clinical studies with objective measures of adherence can be conducted in HIV-infected subjects and should be employed for further evaluation of this and other adherence interventions. This study was supported by grants K20-DA000191-05 (MIR) and VA Merit Review 1241 (MIR), P50-DA09241 (BJR) and a General Clinical Research Center grant (M01RR06192) to the University of Connecticut Health Center, Farmington, Conn.     

Determination of Loss of Reinforcement Due to Corrosion through X-ray Computer Micro-Tomography

X-ray computer scanning tomography (CT scan) is an increasingly more available technique, which has been applied to material sciences for years. Although most of its use is qualitative for gaining insights on material behavior, quantitative analysis for estimations of deterioration rates is possible. This paper describes an unbiased, straightforward method to determine the amount of reinforcement lost to corrosion through the use of X-ray tomography without the need to remove the concrete cover. Other methods of assessment such as gravimetric analysis, half-cell potential, resistivity of mortar cover, corrosion current, and scanning electron microscopy (SEM) are used in the same samples for comparison. While the electrical and electrochemical tests are valuable to describe the state of the samples, those demonstrated poor capacity of determining the stage of corrosion of the reinforcement in terms of amount of material lost. Electron microscopy could determine how much of the reinforcement corroded with high accuracy; however, these results are deficient in representativity, being based on a single plane of the steel. X-ray tomography, while suffering from sample size limitation, could provide quantitative information on the total volume of material lost for each sample with far higher accuracy than indirect techniques, which is significant for the forensic determination of remaining life service of structures.     

An update on obesity: Mental consequences and psychological interventions

Besides physical consequences, obesity has negative psychological effects, thereby lowering human life quality. Major psychological consequences of this disorder includes depression, impaired body image, low self-esteem, eating disorders, stress and poor quality of life, which are correlated with age and gender. Physical interventions, mainly diet control and energy balance, have been widely applied to treat obesity; and some psychological interventions including behavioral therapy, cognitive behavioral therapy and hypnotherapy have showed some effects on obesity treatment. Other psychological therapies, such as relaxation and psychodynamic therapies, are paid less attention. This review aims to update scientific evidence regarding the mental consequences and psychological interventions for obesity.     

Crack smokers' intention to use condoms with loved partners: intervention development using the theory of reasoned action, condom beliefs, and processes of change

Prevalence rates of HIV infection acquired through heterosexual contacts have risen steadily since 1982. Crack cocaine smokers are at particular risk of HIV infection due to heterosexual exposure. HIV risk reduction interventions seeking to increase condom use among drug users have met with minimal success, and there is a need for interventions to be strongly grounded in psychosocial models of behaviour change. This study presents the results of an investigation of predictors of intention to use condoms and related therapy processes among heterosexual drug users. Data were analyzed from 586 crack smokers recruited in Washington, DC, Miami, Florida, and Collier County, Florida who reported having both primary and casual sex partners. Participants responded to items derived from the theory of reasoned action, the theory of planned behaviour and the transtheoretical model of change. Condom use beliefs and therapy processes used to initiate and maintain condom use were assessed. Outcome expectancies and normative beliefs were the strongest predictors of intention to use condoms with a primary sexual partner. In turn, beliefs that condoms inhibit sexual romance and decrease sexual pleasure strongly predicted outcome expectancies. Therapy processes found to be associated with these constructs included: self-liberation, counter conditioning and stimulus control/reinforcement. Results suggest that HIV risk reduction interventions using a group format and targeting condom beliefs related to sexual romance and pleasure will decrease negative outcome expectancies about condom use. Also, reinforcing attempts to use condoms with intimate partners should increase positive outcome expectancies and intention to initiate or maintain condoms with a primary sexual partner.     

Micro-social structural approaches to HIV prevention: a social ecological perspective

To be effective and sustainable, HIV-prevention interventions need to be sufficiently powerful to counteract prevailing social norms and diffuse through the targeted community to provide social reinforcement for behaviour change. Social structural and environmental factors are major influences on HIV-related behaviours yet the dearth of conceptualization and operationalization of these factors impede progress in intervention development. In this paper we propose a social ecological perspective to intervention and highlight relevant theories from social psychology and organizational behaviour literatures. We examine social networks and social settings as micro-structural and environmental influences on HIV risk behaviours, social identities and norms, and as important targets for HIV-prevention intervention. Intervention approaches are proposed that target networks and behavioural settings and provide participants with socially meaningful and rewarding behavioural options that are consistent with valued prosocial identities or roles. Examples are presented on how such an approach has been utilized in prior HIV prevention interventions, including our social network-oriented intervention that trained disadvantaged former and current illicit drug users to conduct peer outreach. We describe how behavioural interventions may enhance or introduce new prosocial identities and social roles, and that network members may confer social approval to reinforce these identities and roles, leading to sustained behavioural risk reduction and changes in risk behaviour norms.     

Evaluation of Hybrid Melamine and Steel Fiber Reinforced Geopolymers Composites

This study investigated the influence of the steel and melamine fibers hybridization on the flexural and compressive strength of a fly ash-based geopolymer. The applied reinforcement reduced the geopolymer brittleness. Currently, there are several types of polymer fibers available on the market. However, the authors did not come across information on the use of melamine fibers in geopolymer composites. Two systems of reinforcement for the composites were investigated in this work. Reinforcement with a single type of fiber and a hybrid system, i.e., two types of fibers. Both systems strengthened the base material. The research results showed the addition of melamine fibers as well as steel fibers increased the compressive and flexural strength in comparison to the plain matrix. In the case of a hybrid system, the achieved results showed a synergistic effect of the introduced fibers, which provided better strength results in relation to composites reinforced with a single type of fiber in the same amount by weight.     

Integrative review of physical activity intervention research with aging adults

This paper reviews randomized, controlled trials (RCTs) that have attempted to increase physical activity behavior by aging adults. A systematic review was necessary because numerous studies target older adults, and previous reviews have addressed a limited range of primary studies. Computerized database, ancestry, and extensive search strategies by authors of research reported in English between 1960 and 2000 located diverse intervention trials. RCTs reporting endurance physical activity or exercise behavioral outcomes for at least five subjects were included. Integrative review methods were used to summarize extant research. Forty-two studies were retrieved. Seventeen RCTs with 6,391 subjects were reviewed. A wide variety of intervention strategies were reported. The most common interventions were self-monitoring, general health education, goal setting, supervised center-based exercise, problem solving, feedback, reinforcement, and relapse prevention education. Few studies individually adapted motivational interventions, used mediated intervention delivery, or integrated multiple theoretical frameworks into the intervention. Links between individual intervention components and effectiveness were not clear. Common methodological weaknesses included small samples, untested outcome measures, and time-limited longitudinal designs. Significant numbers of aging adults increased their physical activity in response to experimental interventions. The amount of increased activity rarely equaled accepted behavior standards to achieve positive health outcomes. Further work is essential to identify successful strategies to increase activity by larger numbers of elders and to accelerate the increase in activity by those who change activity behaviors. Sex and ethnic differences need further investigation. There is a vital need for rigorously designed studies to contribute to this science.     

Lessons Learned from a Randomized Trial of Fixed and Escalating Contingency Management Schedules in Opioid-Dependent Pregnant Women

Background: Contingency management (CM) has shown promise for treating substance use disorders in pregnant women. Methods: A randomized clinical trial compared the relative efficacy of three conditions on the measures of opioid and cocaine abstinence and days retained in treatment. A total of 133 pregnant patients attending treatment for substance use disorders were randomized either to an escalating reinforcement condition, a fixed reinforcement condition, or an attendance control condition. Conditions were compared on drug abstinence rates and days retained in treatment. Results: As expected, the pooled escalating + fixed conditions received a greater total amount of voucher money than the control condition mean [M = 392.40 (SE = 40.47) vs. 219.74 (SE = 39.78)], respectively; p < .001. However, the escalating and fixed conditions did not differ on the outcome variables of drug abstinence and treatment retention. Conclusions: The CM conditions examined in the current study did not emerge as superior to the control condition. The lack of significant differences among study conditions may be attributed, in part, to study sample size. Additionally, methodological issues related to the CM intervention may also have compromised outcomes, including delay in reinforcement following the target behavior and limited contact with the reinforcer. Scientific Significance: This study highlights the importance of key CM implementation features, including immediate reinforcement, and adequate access to the reinforcer. It may also be that the reset feature for missing samples in CM interventions is an essential contingency for promoting behavior change.

Trial registration: ClinicalTrials.gov identifier: NCT00497068.     

Applying Behavior Change Models to Understand Spiritual Mechanisms Underlying Change in Substance Abuse Treatment

Despite increasing attention directed to conceptual and methodological issues surrounding spirituality and despite the centrality of “spiritual transformation” in the recovery literature, there is little systematic evidence to support the role of spiritual change as a necessary condition for substance abuse behavior change. As an explicit conceptualization of mechanisms underlying behavior change is fundamental to effective interventions, this article: 1) briefly reviews relevant behavior change theories to identify key variables underlying change; 2) presents an integrative conceptual framework articulating linkages between program components, behavior change processes, spiritual change mechanisms and substance abuse outcomes; and 3) presents a discussion of how the mechanisms identified in our model can be seen in commonly used substance abuse interventions. Overall, we argue that spiritual transformation at an individual level takes place in a social context involving peer influence, role modeling, and social reinforcement.     

Identification of behaviour change techniques to reduce excessive alcohol consumption

Background Interventions to reduce excessive alcohol consumption have a small but important effect, but a better understanding is needed of their ‘active ingredients’. Aims This study aimed to (i) develop a reliable taxonomy of behaviour change techniques (BCTs) used in interventions to reduce excessive alcohol consumption (not to treat alcohol dependence) and (ii) to assess whether use of specific BCTs in brief interventions might be associated with improved effectiveness. Methods A selection of guidance documents and treatment manuals, identified via expert consultation, were analysed into BCTs by two coders. The resulting taxonomy of BCTs was applied to the Cochrane Review of brief alcohol interventions, and the associations between the BCTs and effectiveness were investigated using meta‐regression. Findings Forty‐two BCTs were identified, 34 from guidance documents and an additional eight from treatment manuals, with average inter‐rater agreement of 80%. Analyses revealed that brief interventions that included the BCT ‘prompt self‐recording’ (P = 0.002) were associated with larger effect sizes. Conclusions It is possible to identify specific behaviour change techniques reliably in manuals and guidelines for interventions to reduce excessive alcohol consumption. In brief interventions, promoting self‐monitoring is associated with improved outcomes. More research is needed to identify other behaviour change techniques or groupings of behaviour change techniques that can produce optimal results in brief interventions and to extend the method to more intensive interventions and treatment of alcohol dependence.