The Impact of Providing Incentives for Attendance at AIDS ...

The Impact of Providing Incentivesfor Attendance at AIDS Prevention SessionsSHERRY DEREN, PhDRICHARD STEPHENS, PhDW. REES DAVIS, PhDTHOMAS E. FEUCHT, PhDSTEPHANIE TORTU, PhDDr. Deren is Director and Principal Investigator, Dr. Davis is aProject Director, and Dr. Tortu is Co-Investigator and ProjectDirector, all at the Institute for AIDS Research, NationalDevelopment and Research Institutes, Inc., New York City. Dr.Stephens is a Professor, Department of Sociology at the Universityof Akron, Akron, OH. Dr. Feucht is an Associate Professor ofSociology at Cleveland State University, Cleveland, OH.This research was supported by grants R18DA05746,R18DA05754, and U01DA07286 from the National Institute onDrug Abuse.Tearsheet requests to Sherry Deren, PhD, NDRI, 11 Beach St.,New York, NY, 10013; tel. 212-966-8700, ext. 521.Synopsis ....................................The research literature on AIDS prevention effortscontains many reports on the impact of interventionsessions. Little information is available, however, onthe success of various strategies to recruit clients toattend these sessions.An assessment of the comparative impact of moneyand other types of incentives on group attendance intwo AIDS risk reduction projects, in the Harlem areaof New York City and in Cleveland, OH, wasundertaken. In both projects, injecting drug users andthe sex partners of injecting drug users wererecruited to participate in group sessions that focusedon the reduction of AIDS risk behaviors. Data ongroup attendance were analyzed for 838 people in theNew York project and 1,168 in the Ohio project.After the projects were underway, attendanceincentives at both were changed from money to foodcoupons or gift certificates. Results indicated that anonmonetary incentive was associated with a significantdecline in group attendance. Concerns regardingpaying monetary incentives to injecting drug usersare discussed.INJECTING DRUG USERS (IDUs) and their sex partnersaccount for approximately one-third of all reportedAIDS cases (1), and they currently constitute one ofthe fastest growing risk groups. Extensive efforts areunderway to reduce HIV transmission among thesegroups. National projects have been funded to recruitand engage IDUs and their sexual partners in avariety of AIDS intervention programs. There havebeen many reports on the impact of interventions onbehavior change (2-5), and further research toidentify successful interventions continues.Little has been reported specifically on the successof various strategies to recruit clients to attend AIDSrisk reduction meetings, although some anecdotalreports have indicated difficulties in achieving highattendance rates at prevention sessions. There isalmost no published literature on the types of reinforcementor incentive that could be used toincrease attendance at these interventions.Positive reinforcement for specific behaviors hasbeen used in other health-related areas, includingdrug treatment settings (6,7), and incentives or"enablers" have been used to enhance compliancewith tuberculosis treatment regimens (8-11).An examination of the impact of various incentiveson involvement in HIV prevention interventionprograms is needed, especially among hard-to-reachpopulations such as IDUs. As successful programsare identified, knowledge of variables related toincreasing attendance and completion of preventionprograms will be critical.In this paper we examine the comparative impactof money and other types of incentives (food couponsand gift certificates) on group attendance in twoAIDS risk reduction projects, conducted in theHarlem area of New York City and in Cleveland,OH. Findings from two different geographic areascan provide information as to the generalizability ofthe impact of incentives on attendance. In addition, adiscussion of some of the ethical issues and concernsposed by providing monetary incentives to IDUs isprovided.Methods and SubjectsBoth the Harlem AIDS Project (HAP) and theCleveland project were among the AIDS outreachresearch and demonstration projects funded by the548 Public Health Reports

National Institute on Drug Abuse (NIDA) in 63locations throughout the United States beginning in1987. HAP operated in the community from 1989through 1991, and the Cleveland project operatedfrom 1989 until 1992. IDUs and the sex partners ofIDUs (not necessarily partners of the IDUs in thegroups) were recruited to participate in both AIDSrisk reduction intervention projects. Baseline and6-month followup interviews were conducted.Participants in both projects were administered theAIDS Initial Assessment Interview (AIA), whichcollected data on many topics, including demographics,drug use, needle use behaviors, and sexualbehaviors. Test-retest reliabilities for risky sexualbehaviors and use of injected drugs ranged from .66to .86, according to a 1991 personal communicationfrom NOVA Research of Bethesda, MD. Cashincentives for attendance were used initially in bothprojects. Then, because of changes in NIDA policy,different incentives were used in both projects. Thisprovided the opportunity for examining the impact ofincentives on attendance.The Harlem AIDS project. For the Harlem project,IDUs and the sexual partners of IDUs were recruitedfrom the streets and from the obstetricalgynecologicalclinics of Harlem Hospital. Clientswere brought to one of three field sites in the Harlemcommunity to be interviewed and then were assignedto attend a standard AIDS education group session(usually within 1-2 days of the interview). Thissession included discussion of modes of transmissionand methods of prevention. The format was composedof didactic presentation, discussion, and anAIDS film. After this session, they were randomlyassigned either to the standard intervention condition(after which they attended no additional sessions), orto an enhanced intervention condition, (after whichthey were asked to attend two additional sessions).The enhanced intervention program was designedto teach specific behavioral skills needed to practicerisk reduction, including needle cleaning, condomuse, and the negotiation skills necessary to practicethese risk reduction behaviors. Deren and coworkersprovide more detail on the content of the groupsession (3).At the outset, clients were given a $15 moneyorder for an initial interview and a $10 money orderfor attendance at each group session. Providingmoney to clients for the interview was perceived aspayment for their time spent in participation in theresearch aspects of the study and was continuedthroughout the project. Money orders were usedinstead of cash as a security precaution, so as not tokeep cash at the field site. When money orderpayment for attendance at group sessions was nolonger permitted, clients were given a $10 foodcoupon, redeemable at local supermarkets.Client recruitment began in two research sites inHarlem in May 1989. A policy change regardingincentives occurred in September 1989. Followupinterviewing began in December 1989, with recruitmentcontinuing through December 1990. A total of1,770 clients were recruited at three research sites.For the purposes of this paper, the recruitment periodof May 1, 1989, through December 1, 1989, wasselected. Since followup interviewing began inDecember, focusing on this time period eliminatesany changes that may have come from adding afollowup component, such as longer delays betweenscheduled groups, as well as any changes due toinclement winter weather.The Cleveland project. The Cleveland projectconsisted of outreach into the drug-using neighborhoodsby project workers. All clients were brought tosites where they were interviewed and then given astandard intervention session assignment. The clientwas given $10 for agreeing to be interviewed,although the payment was made at the end of thestandard intervention. Thus, unlike the New Yorkproject, all clients who were interviewed were assignedto a standard intervention session conductedon the same day. The standard intervention consistedof viewing of an AIDS education film, a brief reviewof fundamental knowledge about AIDS, the risks ofcontracting AIDS through needle use and risksinvolving sexual behavior. Clients were taught how tobleach needles and properly use condoms.Upon completion of the standard interventionsession, clients were randomly assigned either to thestandard intervention group (after which they attendedno additional sessions) or to an enhancedintervention group. The enhanced intervention condi-July-August 1994, Vol. 109, No. 4 549

Table 1. Sociodemographic characteristics, by percentages,of clients recruited in two time periods with differentincentives to New York AIDS prevention projectTime 1 Time 2(5/1-8/31/89) (9/1-12/1/89)Characteristic Money orders Food coupons Significance'N .............. 498 340 ...Sex:Male ............. 58 55 NSFemale .......... 42 45...Age (mean years).. 37.7 36.4 P < .05Ethnicity:Afrcan American. . 93 83 P < .001Hispanic ......... 5 13 ...Other ............ 2 4 ...Target population:IDUs ............. 80 80 NSSex partners ofIDUs ........... 20 20 NSEmployed .......... 10 7 NSHigh schoolgraduate ......... 53 55 NSResidence:Own home ....... 31 25 P

clients interviewed from May 1 to December 1 attendedat least one group session. The impact ofchanging incentives from money orders to foodcoupons for group attendance is shown in table 3.There was a significant difference in attendance withthe changed incentive. During the period when the incentivewas the money order, 83 percent of all clientswho were interviewed returned for at least one groupsession; when food coupons were used, 66 percent ofclients returned for at least one session (P < .001).Of the 635 clients who attended group sessions,288 (45 percent) were randomly assigned to thestandard intervention and 347 (55 percent) assignedto the enhanced intervention condition. Comparisonsof client characteristics for those assigned to theenhanced and standard conditions indicates similarityof client characteristics and risk behaviors. Table 3provides information on the relationship between theincentive used and attendance at the enhancedsessions. When money orders were used, 74 percentof those assigned to enhanced groups completed bothsessions; when food coupons were used, 58 percentattended both enhanced sessions (P < .01). Analysesby age, ethnicity, and residential status indicated thatthese variables had no significant impact on theresults, that is, attendance declined with food couponsacross all categories.Data were examined to see if there were any interactionsbetween client characteristics and incentive ongroup attendance. No significant differences werefound for any client characteristics except forethnicity. When money orders were used, 83 percentof African Americans returned for at least one group,compared with 78 percent of Hispanics (not significant).When food coupons were used, however, 69percent of African Americans returned for at leastone group, compared to 42 percent of Hispanics(P < .001). Thus, although there was a reduction inattendance for both groups of clients when theincentive changed from money orders to foodcoupons, the greatest reduction, by almost half,occurred in the Hispanic sample.Table 2. AIDS-related risk behaviors, by percentages, ofclients recruited in two time periods with different incentivesto New York AIDS prevention projectTime 1 Time 2money foodBehavior orders coupons Significance'Injected drug use (IDUs only):2Heroin ........................ 39 43 NSCocaine ...................... 43 48 NSSpeedball ..................... 38 43 NSNoninjected drug use:2Alcohol ....................... 43 42 NSCrack ......................... 50 53 NSCocaine ...................... 24 18 P < .05Heroin ........................ 16 19 NSCondom use (percent of timeused):Single sex partner ............. 17 17 NSMultiple sex partners .......... 35 36 NS' Chi-square tests were used for all significance tests involving categoricaldata; t tests were used for comparisons of means.2Mean monthly frequency.Table 3. Attendance at standard and enhanced groupsessions by incentive, New York AIDS prevention projectMoney ordersFood couponsAttendance Number Percent Number Percent Significance'Cleveland project. A total of 1,168 clients wererecruited from April 25, 1989, through November 30,1990. Of the total, 957 were recruited when theincentive was cash, and 211 participated after theincentive was changed to a supermarket gift certificate.Demographic characteristics of the groups arepresented in table 4. As in the New York sample, amajority of the Cleveland sample were male (73percent) and injecting drug users (69 percent).There were significant differences in the demographiccharacteristics of clients recruited in Cleve-Interviewed ....... 498 ... 340 ... ...Returned for session1 .......... 411 83 224 66 P < .001Assigned toenhanced ....... 232 ... 115 ... ...Number of sessionsattendedby those assignedtoenhanced: P < .010 sessions ..... 37 16 26 23 ...1 session ...... 23 10 22 19 ...2 sessions ..... 72 74 67 58 ...1 Chi-square tests were used for all significance tests.land during the two periods. Generally, thoserecruited after the incentive changed from cash to agift certificate were significantly more likely to befemale, younger, sex partners, less likely to be highschool graduates, more likely to be living in someoneelse's home and to have their children living withthem. There were no significant differences inethnicity of the two samples (at least 85 percentAfrican American) or in the percent employed.Selected risk-related behaviors summarized in table 5indicate that there were no significant differences inthe two groups in terms of baseline level of drug useor condom use.Overall, 48 percent of the 688 clients assigned tothe enhanced group attended at least one session. TheJuly-August 1994, Vol. 109, No. 4 551

Table 4. Sociodemographic characteristics, by percentages,of clients recruited in two time periods with differentincentives, Cleveland AIDS prevention projectTime 1(4/25/89- Time 29/19/90) (9/20-11/30/90)Characteristic cash gift certificate Significance'Number ............ 957 211 ...Sex: Male ............. 75 65 P

drug addiction are available) than the harm caused bypeople becoming infected and spreading the virus thatleads to AIDS (for which there is not likely to beeffective vaccines or curative treatments for manyyears).2. Concern that because funds are limited forpublic health and AIDS prevention, the moneyavailable should be used only for prevention andtreatment efforts. These economic considerations,regarding the costs of using public health money forincentives, is an important concern, and may requirecost-benefit analyses. However, the costs of providinghealth care to AIDS patients, the costs to society ofproviding care to children orphaned by AIDS in theirfamilies, and the loss to society of the potentialproductivity of people are likely to exceed substantiallythe costs associated with providing incentives toattend intervention sessions.3. Concern that other groups do not seem to needincentives and therefore (a) it is unfair to providethem only to some groups or (b) it is demeaning topay people to receive information or services that canbe helpful to them. The belief that some high-riskgroups may be more motivated to attend interventionsesssions without incentives does not necessarilyindicate that it is therefore inappropriate to useincentives for people or groups who may be lessmotivated. Drug use and poverty, particularly amongmembers of inner city minority communities, mayresult in distrust of the larger mainstream society, andthus may make it very difficult to obtain adequatelevels of participation in programs. Furthermore,AIDS itself calls for a certain level of response.Although efforts to motivate or empower people toseek their own health services can be undertaken, theconsequences of HIV infection, in terms of thelikelihood of AIDS diagnosis and the possibility oftransmission, may indicate that timely preventionefforts are the priority.Further discussion and research on the advantagesand disadvantages of using incentives for AIDSprevention interventions are needed. Research toidentify methods of maximizing attendance and toexamine alternative enablers or incentives is needed.In addition, research regarding such variables as thecharacteristics of subjects and the demographiccharacteristics and activities of project recruiters canbe helpful in increasing attendance. These issues areof urgent concern, so that study of the efficacy ofalternative interventions can be undertaken withrecruitment of the widest variety of persons. This willbecome even more pressing as successful interventionefforts are found and methods of maximizing theTable 5. AIDS-related risk behaviors, by percentages, ofclients recruited in two time periods with different incentives,Cleveland AIDS prevention projectTime 1 Time 2Money Foodorders, coupons,Behavior cash gift certificates Significance'Injected drug use (IDUsonly):2Heroin ................. 20 18 NSCocaine ................ 27 29 NSSpeedball .............. 14 11 NSNoninjected drug use:2Alcohol ................. 42 45 NSCrack .................. 33 34 NSCocaine ................ 20 17 NSHeroin ................. 7 6 NSCondom use (percent oftime used):Single sex partner ...... 18 11 NSMultiple sex partnerṡ... 26 24 NS'Chi-square tests were used for all significance tests involving categoricaldata; t tests were used for comparisons of means.2Mean monthly frequency.Table 6. Attendance at standard and enhanced groupsessions by incentive, Cleveland AIDS prevention projectCashGift certificatesAttendance Number Percent Number Percent Significance'Interviewed ....... 957 ... 211Assigned toenhanced ....... 553 ... 135 ... ...Number of sessionsattendedby those assignedtoenhanced: P

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