Patients’ reactions to being offered financial incentives to increase colorectal screening: A qualitative analysis

Abstract

Purpose:

To explore financial incentives as an intervention to improve colorectal cancer screening (CRCS) adherence among traditionally disadvantaged patients who have never been screened or are overdue for screening.

Approach:

We used qualitative methods to describe patients’ attitudes towards the offer of incentives, plans for future screening, and additional barriers and facilitators to CRCS.

Setting:

Kaiser Permanente Washington (KPWA).

Participants:

KPWA patients who were due or overdue for CRCS.

Method:

We conducted semi-structured qualitative interviews with 37 patients who were randomized to one of two incentives (guaranteed $10 or a lottery for $50) to complete CRCS. Interview transcripts were analyzed using a qualitative content approach.

Results:

Patients generally had positive attitudes towards both types of incentives, however, half did not recall the incentive offer at the time of the interview. Among those who recalled the offer, 95% were screened compared to only 25% among those who did not remember the offer. Most screeners stated that staying healthy was their primary motivator for screening, but many suggested that the incentive helped them prioritize and complete screening.

Conclusions:

Incentives to complete CRCS may help motivate patients who would like to screen but have previously procrastinated. Future studies should ensure that the incentive offer is noticeable and shorten the deadline for completion of FIT screening.

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 towards 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 towards the offer of incentives, plans for future screening, and additional barriers and facilitators to any CRCS testing.

Approach

Study population and setting

We conducted semi-structured telephone interviews with a subset of participants who were part of a three-arm randomized controlled trial to test two types of financial incentives for completion of CRCS within six months. Trial details are described elsewhere¹⁶ (ClinicalTrials.gov: NCT00697047).

Briefly, the trial focused on populations that were less likely to be current for CRCS, including people of color, those of Hispanic or Latino ethnicity, and those who have Medicaid coverage.^17,18 The trial also aimed to evaluate whether financial incentives increased CRCS uptake and decreased CRCS disparities. Letters were mailed to 10,000 subjects, aged 50 to 75 years who were members of Kaiser Permanente Washington (KPWA; formerly Group Health), an integrated healthcare delivery system who were due for CRCS. We enrolled those who returned the survey and did not report the following: a colonoscopy in the last 9 years, a prior CRC diagnosis, or a first-degree blood relative with CRC diagnosed before age 60.

Participants (N = 838) were randomized to one of three arms: (Group 1) mailed interventions only; (Group 2) mailed interventions plus guaranteed $10 upon completion of screening; or (Group 3) mailed interventions plus a 1 in 10 chance of receiving $50 upon completion of screening. We interviewed participants randomized to Group 2 (Guaranteed Incentive of $10) and Group 3 (Probabilistic Incentive of a 1 in 10 chance of winning $50 cash).

All participants received up to three mailings. The first mailing included an educational brochure with information on CRCS options (at-home fecal testing with a FIT kit, flexible sigmoidoscopy, and colonoscopy) and the benefits and risks of each test. The second mailing included a FIT kit with wordless pictographic instructions and a postage paid return envelope. A third mailing included a reminder to complete screening if the participant had not done so. For participants in the Guaranteed Incentive and Probabilistic Incentive groups, each mailing included details about their randomized incentive group. These participants also received a reminder letter informing them that they needed to complete screening within five months to be eligible for the financial incentive. This follow-up period was chosen to allow individuals enough time to schedule and complete a colonoscopy if that screening method was chosen.

Qualitative Study Eligibility and Recruitment

The qualitative study began interview recruitment in September 2017, while enrollment was still active in the larger trial. Interview recruitment ended in December 2017. We used the trial database and electronic health record (EHR) to identify, on a bi-weekly basis, trial participants who were randomized to the Guaranteed Incentive group or the Probabilistic Incentive group and spoke English (i.e., no flag for ‘translator services needed’ in the EHR). We interviewed both those who had and who had not completed screening after study mailings. For those who completed screening, invitation letters were mailed two to eight weeks after FIT mailing. For those who did not complete screening (non-responders to study FIT or other CRCS test), invitation letters were sent eight weeks after FIT mailing to allow enough time to ensure screening status had not changed. To understand the unique perspectives of underserved populations where screening disparities exist, we used purposive sampling to recruit trial participants based on Medicaid insurance coverage and race and ethnicity.

We used a two-stage invitation process to recruit potential participants. First, we mailed invitation letters and information sheets with a $2 pre-incentive that described the qualitative study with a telephone number to ask questions or opt-out. Second, if potential participants did not opt-out, the interviewer (KK) made up to four call attempts, leaving up to three messages. After confirming interest, the interviewer obtained oral informed consent and either conducted the 15–20 minute interview in the same call or scheduled an interview time. Upon completion, interview participants received $40 as compensation for their time.

Interview Guide

The interviewer (KK) used a semi-structured interview guide with 10 questions and probes to encourage in-depth exploration¹⁹ (Appendix A). The interview guide was developed by the study team, including those with expertise in CRCS interventions (BG, SV), use of financial incentives in cancer screening (JK), and qualitative methods (LAS, KK). Topics and questions were informed by behavioral economic theory^20,21 and guided by gaps in the literature regarding patient perceptions of being offered a monetary incentive for CRCS and the extent to which incentives influenced patients’ decision-making about CRCS. Questions included the following: 1) previous experiences with CRCS, 2) reaction to being offered money to complete screening, 3) the influence of receiving money to complete screening, 4) future screening plans, and 5) other questions relevant to the impact of the incentive, such as type of test completed. After interview enrollment began, some participants (n=16) did not recall the offer of a financial incentive. Among those 16 participants, questions in the guide were revised accordingly (i.e., prefaces to questions and probes were added such as: “if you had been offered an incentive…”).

Analyses

All interviews were audio-recorded and professionally transcribed. We used a directed qualitative content analysis approach²² 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, four trained coders (LAS, KK, CD, LJ) independently reviewed four 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 one of the four coders. Five transcripts, in addition to the initial four concurrently analyzed, were coded by at least two 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 two 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.

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%)

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 two 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 four 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, seven 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).

Cost was also mentioned as a reason for choosing FIT over colonoscopy. Several participants noted that they might choose a colonoscopy if offered for free, but others with poor colonoscopy experiences in the past said no amount of money would prompt them to complete a colonoscopy.

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 six 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, three-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 three 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.

SO WHAT?

What is already known on this topic?

Colorectal cancer screening rates lag in traditionally disadvantaged groups including people of color and those with Medicaid insurance. Financial incentives are a promising approach to improve screening rates among these groups.

What does this article add?

Financial incentives were well-received and almost all participants who recalled the incentive offer went on to be screened. Many participants reported that they already intended to be screened, but the incentives helped them prioritize screening and complete it earlier.

What are the implications for health promotion practice or research?

Financial incentives are a promising approach to increasing screening among motivated patients who have previously procrastinated. Future studies should ensure that incentives are offered in a noticeable way and should consider adding a due date in order to receive the incentive to further encourage timely screening.

Abbreviations:

KPWA

Kaiser Permanente Washington

EHR

electronic health record

CRCS

colorectal cancer screening

Appendix A. Semi-structured Interview Guide

Introduction and Verbal Informed Consent

“We recently sent you a letter inviting you to participate in a phone interview about the views and experiences of patients previously contacted about colon cancer screening as part of the Smart Options for Screening (SOS) study.

We would like to hear more about your thoughts and opinions around colon cancer screening. We hope these interviews will help improve the SOS colon cancer screening program.

Doing this interview is up to you. If you decide to participate, you may end the call or skip questions you do not want to answer. You may also leave the study at any time. Your name and other personal information will be kept confidential and will not be shared with your health care team. Whether or not you participate will not affect your care or health benefits. If you are an employee of Kaiser Permanente, your decision will not affect your employment.

We would like to record this phone call to make sure we have listed your answers correctly and you may request that the recorder be turned off at any time during the call. We will send the recording to a transcription company via secure website. They will listen to the recording, write down what you said and securely transfer the files back to us. A study team member will delete your name and any names you mention before sharing the written copy with the study researchers. No study reports will include your name or any information that identifies you. We will destroy the audio recording before the end of the study. Is this okay with you?”

[IF NO to consent, end call and thank participant for their time; If YES, continue with interview]

Previous Experiences with Colorectal Cancer Screening

QUESTIONS

• 1Are you familiar with any screening tests that might help detect colon cancer early? What have you heard?

  [Use probes sparingly on this question, as this is not the focus of the interview.]

  Probes: Are you familiar with a stool test (FIT kit) that screens (or tests) for colon cancer? How did you hear about it?

  Probes: What have you heard about colonoscopies? What have you heard about flexible sigmoidoscopies?

• 2Could you tell me about the last time you considered completing a screening test for colon cancer?

  Probes: What kinds of questions/ concerns did you have when making your decision? What kind of information did you want?

  (DO NOT INTRODUCE INCENTIVES HERE UNLESS THE PATIENT BRINGS THEM UP, THEN FOLLOW UP)

• 3Could you tell me about the last time you can remember getting a stool test kit in the mail?

  Probes: What did you do first? What did you think about it? Did you talk to anyone about it (family/friends/ health provider)? What did you do with the stool kit in the end? What made you (do it, wait, not do it)? What were the most important factors that influenced your decision? Was the timing convenient when you received the mailed test? Why or why not (other health issues/ too busy)?

  (DO NOT INTRODUCE INCENTIVES HERE UNLESS THE PATIENT BRINGS THEM UP, THEN FOLLOW UP)

Reaction to Incentive Offer

• 4Do you recall getting a study letter in the mail that said you would be eligible for an incentive of [($10) OR (being entered into a raffle with a one in ten chance of receiving $50)] if you completed a colon cancer screening test? [IF NEEDED: There was also a blue pamphlet enclosed describing the different options for colon cancer screening.]

  Probes: What was your initial reaction to getting a letter about being [(offered money) OR (entered into a raffle for money)]? How did you feel about this offer (of money)? Did you trust that you would really receive the money? Have you ever been in a similar situation where you were offered money for a health behavior or medical procedure?

  IF RESPONDENT DOESN’T REMEMBER LETTER OR INCENTIVE OFFER: If you had been offered money to complete colon cancer screening, do you think it would change your decision to (screen, not screen)? If you had been offered a gift card instead of (cash OR chance to receive cash) would that make a difference? Can you think of anything else that would have been a more influential incentive?

Influence of Incentive Offer

• 5FOR RESPONDENTS THAT REMEMBER INCENTIVE OFFER: Did the opportunity to receive money influence your decision to complete screening for colon cancer? Why or why not?

  Probes: How did you feel about the idea of [(receiving money) OR (being entered into a raffle for money)] for completing the screening? What did you think about the amount of money that was offered? Did the offer of money help you prioritize getting screened over other things you had to do?

  If you had been offered (OTHER INCENTIVE), would that have changed your decision to (screen, not screen)? If you had been offered a gift card instead of (cash OR chance to receive cash) would that make a difference? Can you think of anything else that would have been a more influential incentive?

• 6FOR NON-COMPLETERS: Do you plan to get screened in the next year?

  Probes: Can you tell me more about why or why not? If you were offered a different amount of money or a different type of incentive would that change your mind? What would help you to do colon cancer screening tests and repeat them over time?

• 7FOR COMPLETERS: How did you decide between having a colonoscopy and doing the stool test?

  Probes: Did one seem easier than the other (less invasive/messy/embarrassing)? Did you think that one test was better than another? Was cost a factor?

  (DO NOT INTRODUCE INCENTIVES HERE UNLESS THE PATIENT BRINGS THEM UP, THEN FOLLOW UP)

• 8FOR COMPLETERS: How did the offer of money (or a chance for money) impact your decision between getting a colonoscopy and completing the stool test?

  Probes: Without the offer of money, would you have made a different choice? Why or why not? If a different amount of money were offered, would you have chosen a different type of colon cancer screening?

Plans for future screening

• 9FOR COMPLETERS: Now that you have completed screening, do you plan to continue recommended screening in the future?

  Probes: Can you tell me more about why or why not? What would make you decide not to keep doing screening tests after you had done one (or done a few)? What would motivate you to continue to be screened for colon cancer screening over time? Would you do it again if you were not offered money or if you were offered less (or more) money?

• 10Is there anything else you would like to share?

Closing

Thank you so much for talking with me today. I will be mailing you $40 today as a thank you. I’m turning off the recorder now. Thanks again for taking the time to share your opinions today!