Acceptability of financial incentives and penalties for encouraging uptake of healthy behaviours: focus groups
Giles et al. BMC Public Health
Acceptability of financial incentives and penalties for encouraging uptake of healthy behaviours: focus groups
Emma L Giles 0
Falko F Sniehotta 0
Jean Adams 0
0 Institute of Health and Society, Newcastle University , Baddiley-Clark Building, Newcastle upon Tyne, Tyne and Wear NE2 4AX , UK
Background: There is evidence that financial incentive interventions, which include both financial rewards and also penalties, are effective in encouraging healthy behaviours. However, concerns about the acceptability of such interventions remain. We report on focus groups with a cross-section of adults from North East England exploring their acceptance of financial incentive interventions for encouraging healthy behaviours amongst adults. Such information should help guide the design and development of acceptable, and effective, financial incentive interventions. Methods: Eight focus groups with a total of 74 adults were conducted between November 2013 and January 2014 in Newcastle upon Tyne, UK. Focus groups lasted approximately 60 minutes and explored factors that made financial incentives acceptable and unacceptable to participants, together with discussions on preferred formats for financial incentives. Verbatim transcripts were thematically coded and analysed in Nvivo 10. Results: Participants largely distrusted health promoting financial incentives, with a concern that individuals may abuse such schemes. There was, however, evidence that health promoting financial incentives may be more acceptable if they are fair to all recipients and members of the public; if they are closely monitored and evaluated; if they are shown to be effective and cost-effective; and if clear health education is provided alongside health promoting financial incentives. There was also a preference for positive rewards rather than negative penalties, and for shopping vouchers rather than cash incentives. Conclusions: This qualitative empirical research has highlighted clear suggestions on how to design health promoting financial incentives to maximise acceptability to the general public. It will also be important to determine the acceptability of health promoting financial incentives in a range of stakeholders, and in particular, those who fund such schemes, and policy-makers who are likely to be involved with the design, implementation and evaluation of health promoting financial incentive schemes.
Qualitative focus groups; Acceptability; Financial incentives; Healthy behaviours
Poor engagement in health promoting behaviours is a
key determinant of morbidity and mortality worldwide
and results in substantial social, healthcare and
economic costs . Despite consistent efforts to encourage
uptake of healthy behaviours, unhealthy behaviours
remain common [2,3]. Developing effective methods to
encourage uptake of healthy behaviours will result in
substantial benefits to society as a whole.
Providing financial incentives to encourage healthy
behaviours is one method of encouraging uptake of
healthy behaviours. Health promoting financial incentives
(HPFI) have been defined as cash or cash-like rewards or
penalties, provided contingent on performance, or
nonperformance, of healthy behaviours . This includes
deposit contracts where individuals deposit their own
money in advance and receive this back if they
successfully change their behaviour, but forfeit the money if not
. Reviews in this area have found that HPFI can be
effective in encouraging individuals to participate in
healthpromoting behaviours, although evidence is mixed in terms
of effect size [6-16]. In particular, a recent systematic review
of the effectiveness of HPFIs found that financial incentives
were around 1.5 to 2.5 times more effective for promoting
healthy behaviours than no intervention or usual care .
However, not only do financial incentives need to be
effective and cost-effective, but they also need to be
acceptable to potential recipients and wider society if
they are to become a frequently used mechanism for
achieving healthy behaviour change.
We recently conducted a systematic review bringing
together both empirical and scholarly writing on the
acceptability of HPFI . The majority of the included
papers were scholarly pieces rather than empirical
evidence, and most of this scholarly writing appeared to
lack an empirical evidence base. Where empirical
evidence exists it is largely in the form of survey data rather
than qualitative data providing detailed opinions on the
acceptability of HPFI [18-27]. Thus, most of the debate
within the literature on the acceptability of financial
incentives appears to be unsubstantiated and represent
the opinions of authors, rather than being underpinned
by evidence. That said, the papers included in our
systematic review argued that HPFI are acceptable under
certain circumstances and that these are not
substantially different from the circumstances under which most
other public health interventions would be considered
acceptable . Health promoting financial incentives
have been argued to be more acceptable when they are
effective and cost effective [28,29]; when they provide
an initial stimulus for behaviour change [30,31]; when
they help to remove some of the financial barriers that
individuals face when changing their health behaviours
[32-34]; and when they foster behaviour change that
can benefit wider society . There is, nonetheless, a
body of opinion that views HPFI as unacceptable
under any circumstances. Reasons for this include
concerns that some individuals may take-up an unhealthy
behaviour in order to be eligible for HPFI, known as
‘gaming the system’ [36,37]; that HPFI can lower a
person’s intrinsic motivation to change their behaviour
[38,39]; that incentives can be coercive and force an
individual to do something that they would not
ordinarily do [32,40] and that HPFI schemes can be
difficult to administer, implement and monitor [41-43].
That said, the debate on this topic is not necessarily
evidence-based and is often contradictory .
Our review identified few previous qualitative studies
on acceptability of HPFI. Those that have been
conducted were restricted to alcohol, drug, and smoking
cessation practitioners, managers and service providers,
[21,20] pregnant women  and Maori, Pacific Islanders
and low income groups . Thus, growing, but still
limited qualitative research on acceptability of HPFI has
been conducted with a cross-section of participants, with
limited research having been carried out in the United
Kingdom (UK) [19,27,30,45-48].
We therefore conducted qualitative focus groups with
members of the public to gain an in-depth insight into
the factors related to acceptability of HPFI and preferred
formats of HPFI.
A qualitative methodology was adopted in order to
provide in-depth empirical evidence on the
acceptability of HPFI. Focus groups were chosen as they allow
for a detailed discussion on the topic  and
provided a forum for participants to reflect on their
opinions towards HPFI based on the views of others
. Thematic analysis was undertaken on the data
collected, with further details on the methodological
approach provided below.
Participants and recruitment
Focus group participants were recruited using a variety
of methods. Members of two local databases of
individuals, who had expressed an interest in taking part in
research, were contacted (by database owners) with study
information. As the contents of the databases were
classed as confidential information by the list owners,
we do not have information on how many people were
approached or their characteristics. Eighty six individuals
responded positively – mostly aged over 50 years,
reflecting the make-up of the databases as a whole.
Younger individuals were recruited through notices
placed in newsletters, and on the staff websites of large,
local employers. Again, we do not know how many
individuals these invitations reached and so cannot calculate
response rates. This resulted in 54 positive responses.
The total available pool of participants was therefore
140, based on the number of responses to the
recruitment notices. Potential participants were informed in
advance that they would be assessed for eligibility and
that this would determine whether or not they would be
able to participate in the focus groups.
As is usually the case with qualitative research, we did
not aim to recruit a representative sample; rather we
aimed to conduct discussions with a cross-section of
individuals. Aside from the age of the participants
and their home postcode (to determine their social
classification) we did not collect information on other
socio-demographic, or health behaviour, characteristics
of the sample.
A stratified sampling approach was used,  so that
four of the eight focus groups contained ‘older’
participants (60 years or older) and four groups contained
‘younger’ participants (18–59 years). Within both the
‘younger’ and ‘older’ groups, further stratification based
on affluence (social classification) was undertaken.
Affluence of individuals was assessed using the ABC1C2DE
classification of participant’s home postcodes. Post codes
in ABC1 areas were classified as ‘affluent’, and post codes
in C2DE areas were classified as ‘less affluent’ [51,52].
Thus two focus groups were ‘younger affluent’; two
‘younger less affluent’; two ‘older affluent’; and two ‘older
less affluent’. Homogeneous focus groups were
conducted to ensure that participants had shared
connections which would help to promote an atmosphere of
discussion and dialogue. This would also help
participants to relate and connect to each other . Having
homogeneous groups helps to make the environment
non-threatening so that participants are more likely to
communicate their true attitudes and opinions [54,55].
We planned to conduct eight focus groups with around
8–12 participants per group. This number of individuals
per group is large enough to generate discussion, but
not too large that it impedes reticent group members
from contributing . We invited 12 eligible
participants to each focus group hoping that at least eight
would attend, selecting them on a first-come-first-served
basis. Details of individuals who expressed an interest in
taking part, but who were not invited to a focus group
were kept on record in preparation for a separate phase
of work, involving individual interviews. Only a minority
of participants who were contacted declined to take part
in the focus groups, usually because they were unable to
attend on the chosen day or time. Focus groups
continued until data saturation was reached – the point at
which no new topics were being discussed.
Focus groups were held in an accessible University
teaching room, located close to the centre of a city in
North East England. This location was chosen to be
convenient for the majority of participants.
Information sheets and consent forms were either
emailed or posted to participants at least one week in
advance of sessions, with email or telephone reminders
made the day before. This was the only contact between
the researcher and participants prior to data collection.
The focus groups lasted approximately 60 minutes and
were audio-recorded, with written consent being
provided before each session commenced. At the end of
each session, participants were provided with a verbal
summary of the discussion and a written debriefing
sheet, containing summary information of the research
and the contact details of the researchers. As is routine,
participants received £20 in high street shopping
vouchers to remunerate them for their time, and were
offered reimbursement of their travel expenses. This
may have biased the sample towards those attracted by
financial incentives. However, in practice, many of the
participants had forgotten that they would receive a
voucher for their time by the time that they attended the
focus group. All data was held on password protected
computers at the University. To preserve anonymity and
confidentiality consent forms were stored separately
from the audio recordings, and identifiers were assigned
to the codes rather than naming individuals. Ethical
approval was granted by Newcastle University Faculty of
Medical Sciences Ethics Committee before data
A topic guide was developed for the sessions (see
Additional file 1: appendix 1). This ensured that all
topics of interest were covered during each focus group,
but allowed for flexibility should new topics of relevance
be raised by participants . The researcher did not
know why participants chose to take part in the research
and did not ask in order to maintain objectivity
throughout data collection and analysis. The four main
discussion themes were: 1) whether participants had personally
encountered financial rewards or penalties, 2) questions
regarding the acceptability of incentives, 3) questions
regarding the unacceptability of financial incentives,
and 4) cross-cutting themes. Discussion was led by the
same primary moderator (ELG) in all eight focus groups,
and the moderator was careful not to influence
discussions by giving their opinion. All researchers remained
objective throughout data collection and analysis. A
second moderator was present in all focus group sessions,
who took written notes to ensure all key topics were
Focus group audio recordings were transcribed verbatim
by an external company and checked by the primary
moderator (ELG) for accuracy. Transcripts were then
uploaded into NVivo 10 and subjected to thematic
analysis [57-59]. The thematic analysis involved using the
themes generated from our acceptability systematic
review  as a starting point for coding, but with the
additional option of coding words and paragraphs as
new codes (nodes) should novel data emerge . This
approach was taken because we had some grounding in
the likely themes that would arise in the focus groups,
but we were unaware if additional themes would be
discussed. The initial themes were: 1) the nature of fair
exchange, 2) design and delivery, 3) effectiveness and
cost-effectiveness, 4) recipients, and 5) impact on
individuals and wider society . Thus, the process of
coding was a combination of inductive and deductive
The first stage of the thematic coding was undertaken
by one researcher (ELG) and involved close reading of
the transcripts with words or phrases coded into one or
more of the a priori themes, or coded as new nodes.
Next, transcripts were re-read by ELG and all codes
were checked for completeness. The third stage
involved one researcher (ELG) reflecting on the thematic
codes within each theme to ensure words and phrases
had been assigned to the most relevant element. The
final stage involved a ‘step back’ from the data, and
the final themes were reflected upon in light of the
research question, in order to determine a narrative.
This final stage was undertaken by one researcher
(ELG) and verified by a second (JA).Throughout data
collection, analysis and write-up we considered the
consolidated criteria for reporting qualitative studies
(COREQ) checklist [60,61]. Transcripts were not returned
to participants for correction. However, at the end of
each focus group the researcher summarised the main
themes that were discussed and gave participants an
opportunity to correct the summary and change their
Eight focus groups were conducted, involving a total of
74 individuals. Each group comprised between seven
and 12 individuals. In total, 39 men and 35 women took
part, 38 were ‘less affluent’ and 36 ‘affluent’ with 37
‘older’ and 37 ‘younger’ participants. Overall, the
majority of participants expressed a very negative opinion
towards HPFI, compared to a minority who indicated that
they thought HPFI were a useful catalyst for behaviour
change. Those who would accept a HPFI personally,
mostly said this was because they would particularly
value the money received. Most participants had not
personally received a HPFI and did not have knowledge
of them in practice.
Largely, focus group discussions centred on the five
original themes identified in our systematic review.
There was some discussion of other topics which were
coded as new themes. These are discussed below in turn,
illustrated by verbatim quotations which clearly
represent the theme.
The nature of fair exchange
Fundamentally, most participants thought that HPFI
were unfair. In particular, they thought it was unfair to
reward ‘bad behaviour’ whilst not providing any such
reward to those who follow healthy lifestyle
recommendations of their own accord.
“…it’s unfair to the healthy ones…” [Focus Group 5,
Younger, More Affluent]
…”people being rewarded because you made a bad
choice, and now you made a good choice, what’s my
reward for making the right choice” [Focus Group 7,
Younger, Less Affluent]
Offering HPFI was considered particularly unfair to
those who had found it difficult to change their
behaviour without the use of incentives but had, nevertheless,
managed to do so.
“…you can always argue for all the people that have
struggled with giving up smoking or struggled with
weight loss and have managed to do that without the
incentives… you could see it as a bit like well I’ve done
it this way, why shouldn’t everybody” [Focus Group 8,
Younger, Less Affluent]
It was generally assumed that the costs of HPFI would
be met by public ‘tax payers’ money, and it is likely that
this would indeed be the case for any large-scale scheme
in the UK. Some participants felt it would be unfair to
use such money in a way that would only benefit a
minority. Additionally, many participants regarded HPFI
as a practice which was always considered unfair and
“It’s unfair to everybody if it’s coming out of everybody’s
pocket.” [Focus Group 5, Younger, More Affluent]
“Bribery is never going to be the answer … it does feel a
bit like bribery” [Focus Group 3, Older, Less Affluent]
Design and delivery of incentive schemes
During discussions about the design and delivery of HPFI
schemes, most participants discussed HPFI in terms that
we have labelled as: ‘framing’ (e.g. as a reward for engaging
in a healthy behaviour, compared to a reward for giving up
an unhealthy behaviour); ‘administration and evaluation’
(who administers and evaluates the scheme and how),
‘funding sources’ (who funds the incentive scheme), and
‘design features’ (e.g. cash vs. shopping vouchers). This is in
contrast to how we have previously conceptualised HPFI,
in terms of the: direction of the incentive (reward or
penalty); form (cash, shopping voucher or deposit);
magnitude (incentive amount); certainty (whether the incentive is
guaranteed or not); target (whether trying to change a
behaviour is rewarded or just successful behaviour change);
frequency (whether a reward is given for all behavioural
instances or just some); immediacy (how soon the reward
is provided); schedule (whether the same amount of
incentive is provided each time); and recipient (who receives
the incentive) . This could partly be due to individuals
being unable to ‘picture’ how HPFI schemes should be
designed, due to the fact that few had personal
experience of them. Some refused to answer questions on what
HPFI schemes should look like because they
fundamentally disagreed with the concept.
Where the framing of incentives was discussed
participants said that it was preferable to reward people
for making healthy choices and for showing long-term
commitment to behaviour change. There was however
some concern that HPFI would be stigmatising if
participants received vouchers that were identifiable to
the schemes, thus there was a preference for ‘anonymous’
“I think er you know it’s the whole notion of giving up
something. It needs to be as if you’re making a
different choice so you’re not going to spend money
on cigarettes you’re going to spend it on the gym.”
[Focus Group 7, Younger, Less Affluent]
“I agree that they need help but the help has to be
done in a way that the incentive is not just about cash
it’s also about them making a commitment to change
their lives.” [Focus Group 7, Younger, Less Affluent]
Where the incentive format was discussed most
participants expressed a preference for reward schemes rather
than penalties or deposit contracts. Often the rationale
for preferring a reward format was related to
accessibility issues. There was an opinion that deposit and penalty
schemes would not be ‘open to all’, particularly if
individuals had to find the money up-front in order to
“I think because of the current climate at the minute
as well people wouldn’t be able to afford to put money
up front.” [Focus Group 4, Older, Less Affluent]
Largely, penalty schemes were disliked, for the same
reason that deposit schemes were disliked: that they may
not be available to all individuals, particularly those on
lower incomes. Participants also wondered where
deposited monies would go if they were not returned to
individuals, preferring that money went to charity, rather
than be divided between participants who had been
successful at changing their behaviour. Schemes offering
lottery tickets as rewards tended to be disliked by
participants as they felt that individuals need a
guaranteed reward should they be successful in changing their
“And I think a lot of the people you maybe want to
help here won’t have the money to put up front.”
[Focus Group 3, Older, Less Affluent]
“I do think that if there’s going to be a charge or some
sort of penalty it’s gonna penalise people who are
worse off, I’m not keen on that at all.” [Focus Group 7,
Younger, Less Affluent]
“…secondly if somebody’s gonna be penalised where
would that money be going?” [Focus Group 6,
Younger, More Affluent]
Similarly the preferred format of HPFI was vouchers
rather than cash. Cash was argued to be open to abuse,
such that recipients may spend cash rewards on the very
behaviour that they were trying to change e.g. cigarettes.
Whilst focus group participants reported that they
would personally prefer to receive cash if they were to
take part in a HPFI scheme, they were less trusting that
other people would spend cash wisely and so preferred
vouchers. A small number of individuals expressed a
consistent preference for cash over vouchers because
they felt cash could be used more flexibly than vouchers.
“…like you say … [with] cash incentives though … [it
does make you] think ‘oh well I know that’s, that’s
what I should be doing with this money but I’ll just go
and spend it on a packet of cigarettes or something.”
[Focus Group 6, Younger, More Affluent]
“Probably cash myself… But vouchers for other people.”
[Focus Group 6, Younger, More Affluent]
In terms of the magnitude of incentives many
participants were either unwilling or unable to provide a
specific amount that they felt was acceptable for rewarding
behaviour change. A rationale for providing ‘large’
incentives was that people would not find ‘small’ incentives
sufficiently rewarding. Conversely, the rationale behind
‘small’ incentives was that it would help to make HPFI
schemes more affordable, whilst also limiting abuse of
the system. However, participants were unwilling to be
more specific concerning what they meant by ‘large’ and
“And money won’t, won’t make them change their
lifestyle not, not unless you’re talking about large sums
of money.” [Focus Group 1, Older, More Affluent]
“Yeah so however much erm I suppose money was
dangled I suppose obviously there is a certain amount
where it gets beyond and you think ‘oh right actually
it really is worth it’.” [Focus Group 6, Younger,
“I think the higher the incentive as well the more abuse
that’ll happen.” [Focus Group 4, Older, Less Affluent]
Whilst it was agreed that individuals enrolled in the
same behaviour change programme should all be
provided with the same magnitude of incentive, it was
suggested that HPFI could be tailored to individuals, such
as asking individuals what type of reward they would
prefer e.g. £50 in cash, £50 in vouchers, or a £50 gift.
However, there was no discussion of how pragmatic or
feasible such tailoring would be. Participants also said
that HPFI schemes need to be convenient for people to
enrol in and that they should correspond with the
behaviour in terms of how long they are given to people,
e.g. a short time for ‘simple’ behaviours, and a long
time for ‘complex’ behaviours.
“It depends how long the programme is and so on and
events you know what behaviour you’re expecting people
to change I mean ‘cause it’s related it’s got to be related
to [it].” [Focus Group 6, Younger, More Affluent]
“Just personally I think if you’re gonna pay everyone
that smokes just for example everyone who smokes a
tenner [£10] not to smoke, I think you need to pay
everybody that tenner [£10] a month ‘cause I think
otherwise you’re gonna have people maybe wonder
why they should bother if they only get a fiver [£5] and
some others getting twenty quid [£20].” [Focus Group 4,
Older, Less Affluent]
“It depends on what you have to do for it as well,
that’s the thing if it’s gonna be a massive inconvenience
so a big effort then you’re less inclined to do it I would
think.” [Focus Group 7, Younger, Less Affluent]
There was limited discussion on whether HPFI schemes
should target outcome behaviours (e.g. stopping smoking)
and/or process behaviours (e.g. attending smoking
cessation clinics). Targeting process as well as outcome
behaviours was argued to be preferable by some participants,
to reward those individuals who genuinely tried to
change their behaviours, but could not meet outcome
“You’ve got to be able to measure whatever you’re
doing and sometimes people will make great efforts
and yet don’t show any improvement.” [Focus Group 5,
Younger, More Affluent]
Lastly, two of the most discussed issues were the
matter of administration and monitoring of HPFI schemes,
and objectively verifying that recipients had changed
their behaviour(s). Many participants said that HPFI
schemes would need extensive and objective monitoring
in order to confirm individuals were eligible to earn an
“Who’s going to monitor these things though…”
[Focus Group 6, Younger, More Affluent]
“I think you need to be able to prove that you have
achieved it.” [Focus Group 7, Younger, Less Affluent]
“I don’t think it would have to be up to the
individual to report I think there’d have to be some
sort of testing or weighing.” [Focus Group 4, Older,
Effectiveness and cost effectiveness
One of the reasons why focus group participants found
HPFI unacceptable may be partly related to them
questioning the effectiveness of such schemes. Many
participants questioned how effective HPFI schemes were,
compared to discussing how effective and cost-effective
they thought they were. Participants particularly
wondered if HPFI would have a long-lasting effect on
behaviour change, and whether behaviour would be maintained
once incentives were withdrawn.
“I would want to know if there is any research which
has actually, good research which has actually proved
evidence that any of these kind of these initiatives
work.” [Focus Group 3, Older, Less Affluent]
“While you’re on your scheme you [are] possibly doing
it. Whether it knocks on to actually a lifestyle change
or a long term change I’m not convinced.” [Focus
Group 7, Younger, Less Affluent]
Some individuals were more pragmatic in their
approach, and indicated that if HPFI could be shown to be
effective and cost-effective over the long term, then it
would be worth using them, even if they disagreed with
them in principle.
“I’ve been thinking about it and I would have said no,
but I, I just think if, if nothing else works it’s worth
giving it a try.” [Focus Group 1, Older, More Affluent]
“If it is efficacious, then of course the payment comes
out in the balance doesn’t it?” [Focus Group 5,
Younger, More Affluent]
“To see the efficacy of it, because I take a more
pragmatic view than some of the other people here…
That it all depends whether it works or not.” [Focus
Group 5, Younger, More Affluent]
There was also a lot of discussion concerning who
would fund HPFI schemes. Many participants suggested
that National Health Service (NHS) money could be
used to fund HPFI, but only if over the long-term,
money was saved through reduced expenditure on
health care. This also led to discussion over whether
the UK could afford to fund HPFI under the ‘current
“The gentleman mentioned limited funding available,
it’s probably not the best time to start giving people
things for stuff like that.” [Focus Group 5, Younger,
“If they made a clear case that say they’d save
money in the long run on certain things like if you
managed to stop people smoking by giving them
financial incentives and therefore the burden on
the NHS was lessened.” [Focus Group 6, Younger,
HPFI were said by some to be reactive rather than
proactive, in that they do not address the underlying
causes of unhealthy behaviours.
“… incentives [are like] a bit of an Elastoplast in that
it covers over but it doesn’t really get to the root of
what causes it in the first place.” [Focus Group 3,
Older, Less Affluent]
“I think there’s a big difference in giving breastfeeding
mothers money to breastfeed ‘cause that’s got
nothing to do with addiction.” [Focus Group 3,
Older, Less Affluent]
Participants did not think HPFI should be made
available to those who they thought would ‘waste’ the
money. Conversely, they felt it was important that HPFI
did not inadvertently discriminate against certain social
groups who may not be able to engage in the target
“But you’ve then got a runt of people who really no
matter what you do for them, they’re always going to
live badly and they’re always going to take what they
can and, and give nothing back.” [Focus Group 2,
Older, More Affluent]
“But there’s something about paying someone to
stop drinking that I think’s quite, I don’t know
what the right word is it’s quite unsettling I think.”
[Focus Group 4, Older, Less Affluent]
Impact on individuals and wider society
Some of the participants discussed an opinion that
healthy behaviours are rewarding in themselves. For
example quitting smoking results in better health and
more disposable cash, even if a financial incentive is not
provided. Participants were also concerned that if
individuals were unsuccessful in changing their behaviours,
and so did not receive an incentive, that they could
become disillusioned and perhaps less likely to try to
change their behaviour in future.
“The fact that you’ve stopped smoking and you are not
buying cigarettes should be a financial incentive to
stop.” [Focus Group 3, Older, Less Affluent]
“You’re already healthy you’re leading such a
marvellous life, that [is] its own reward in itself.”
[Focus Group 6, Younger, More Affluent]
“It’s a funny one, because with the best will in the
world people want to do it. And that just reinforces
failure and if you know, if you can’t do it then you
don’t get your incentive you know that’s a double
failure isn’t it.” [Focus Group 3, Older, Less Affluent]
However, HPFI were also felt by some participants to
be a positive influence on individuals and wider society,
when they were seen as an ‘added bonus’ and an initial
catalyst for change, helping people to feel rewarded for
their efforts; coming back to the need for HPFI schemes
to be effective and cost-effective.
“Yeah, as well as getting you going you actually feel
‘well I’m getting a pat on the back someone’s
recognising my effort’.” [Focus Group 6, Younger,
“I think it can encourage people to change and if you
just start that little bit that you know if they’ve had
that incentive it might continue.” [Focus Group 1,
Older, More Affluent]
Additionally, some participants felt that HPFI were
not appropriate for certain behaviours, such as
encouraging healthy patterns of alcohol consumption.
Many focus group participants indicated that they would
prefer education and peer support to HPFI. Participants
felt these would be a more appropriate way to spend
public money to encourage uptake of healthy
behaviours. This was a particularly strong theme that was not
identified in our previous review .
“And it comes back to the point that people have made
about education and I just think at that point it’s got to
be somewhere where you think is it easier to put this
money into changing people’s habits on a short term
[basis] or is it better channelling that money into
educating people and teaching people new types
of habits?” [Focus Group 6, Younger, More Affluent]
“I think it would need to be accompanied by some sort of
support with it.” [Focus Group 4, Older, Less Affluent]
“…a sense of belonging to a group or support, is quite
important.” [Focus Group 8, Younger, Less Affluent]
This is one of only a few qualitative studies on
acceptability of HPFI [19,20,22,27,30,33,45-48,62-66] and one
of only a limited number of empirical research studies
on this topic including UK participants. In a
crosssection of the public we found a range of views on the
acceptability of HPFI which mostly reflected the themes
we developed in a systematic review on this topic .
The results did not indicate that certain groups favoured
(or not) incentives, e.g. older respondents having a more
favourable attitude. These themes focused on: the nature
of fair exchange, whereby incentives have to be fair to
those who are already healthy, and fair in the sense of
not discriminating against societal groups; that HPFI
need to be shown to be effective and cost-effective
before they are implemented wholesale; that certain
individuals, such as pregnant women and low-income groups,
are viewed as more acceptable recipients of HPFI; that
HPFI can have positive impacts on individuals and wider
society; and that HPFI should be designed and delivered
in a way which is less open to abuse (e.g. vouchers rather
than cash), and be tailored to individuals. The discussions
also identified a range of possible methods for maximising
the acceptability of HPFI in practice. These include
providing reassurances that HPFI schemes will be monitored
and evaluated; that they are effective and cost-effective;
and that education and behaviour change support is
provided alongside HPFI.
Comparison to previous findings
Previous qualitative work on the acceptability of HPFI
has reported similar findings in terms of monitoring
and evaluation of HPFI schemes being important to
recipients of HPFI. In interviews with pregnant women,
Mantzari, Vogt and Marteau  found that vouchers
were reported to help such women to stop smoking, but
it was the monitoring of their behaviours in particular
that facilitated and motivated women to quit smoking.
Indeed, the robust monitoring of behaviours for those in
the intervention group was said to have improved their
chances of stopping smoking and thus attaining vouchers.
This monitoring was not provided for the control group
and so was stated as a reason for why fewer women in this
group may have successfully stopped smoking, and
therefore did not qualify for the vouchers. The monitoring was
important in terms of effectiveness, but also in terms of it
being a motivational experience and an important
component of the intervention.
The issue of tailoring HPFI has been raised in previous
qualitative findings . Cameron and Ritter reported
that alcohol and drug managers, practitioners and policy
makers in Australia particularly advocated tailoring of
incentives to better the particular circumstances of
individuals . Similarly our participants indicated that
HPFI need to be tailored to individual preferences, such
that one person may prefer £50 in cash, another, a £50
prize, and a third to place £50 in a deposit scheme. In
addition, practitioners in Cameron and Ritter’s study
expressed concerns about the use of monetary rewards,
given that they could be open to abuse, and that HPFI
were not an intervention approach that should be used
on its own; rather HPFI should form part of a wider
treatment plan. These issues were also discussed in our
However, many of our focus group participants did
not support the use of HPFI for behaviour change at
all. Reasons, such as the potential for ‘gaming the
system’, spending the cash on unhealthy behaviours
(e.g. cigarettes) and HPFI being unfair to already healthy
individuals, were particularly cited as contributing to the
unacceptability of HPFI. This is in opposition to previous
work, which suggests that HPFI were largely supported
when offered for healthy eating behaviours, although
‘gaming the system’ issues have been mentioned in previous
literature [29,67]. The difference here may be in part due to
the very different population samples – a cross-sectional
UK sample vs. a Maori and Pacific Islanders sample. It
could also be that the focus groups with Maori and Pacific
Islanders specifically focused on the use of HPFI for
healthy eating, whereas our focus groups considered HPFI
for healthy behaviours in general, and participants may
not have been able to fully think through the pros and
cons of HPFI for particular behaviours . Additionally,
support for HPFI was seen in focus groups with welfare
service users in Australia, who indicated that HPFI for
quitting smoking was acceptable to them, provided that
individuals did not resort to deception to receive the
money . However, this positive endorsement was
not reflected in the views from staff focus groups and
interviews, where staff preferred non-cash HPFI rewards
. This reflects our findings that monitoring is
considered particularly important.
Whilst there are contradictions to previous literature,
our focus groups did identify findings that concur with
previous research findings. In particular, our focus group
participants argued that financial incentives could be
discriminatory to certain individuals who are unable to
change their behaviours in order to fulfil the criteria
needed to obtain the outcome-based incentives .
Additionally, there was agreement that shopping vouchers
are preferable over cash incentives; partly to overcome
issues of ‘gaming the system’ and using the cash to fund
unhealthy behaviours (e.g. buy cigarettes), which has been
argued previously in the literature . There was also
a view that certain groups of individuals (and certain
behaviours) were inappropriate targets for health
promoting financial incentives, such as those with alcohol
or drug issues. This viewpoint appears to be a common
finding in relation to the acceptability of incentives
[37,42,65]. Whilst the focus group participants were
largely against financial incentives, there is evidence to
suggest that as effectiveness of incentives increase,
acceptability increases [47,62] and so this viewpoint may
have been different had the focus group participants
been provided with evidence of effectiveness.
Whilst there is limited qualitative evidence on the
acceptability of HPFI in a UK context to-date, some of the
findings that have been found in prior empirical studies
are reflected in our findings.
Strengths and limitations
We are confident that data saturation was reached, as
few new topics emerged in the final few focus groups.
Additionally, both the focus groups and the
acceptability review found similar issues around the
acceptability of HPFI, pertaining to: 1) the nature of fair
exchange, 2) design and delivery, 3) effectiveness and
cost-effectiveness, 4) recipients, and 5) impact on
individuals and wider society. The focus groups found two
additional themes which the acceptability review  did
not, namely that HPFI schemes need to be monitored
and evaluated, and that education is preferred over and
above HPFI. Even though the acceptability review
findings shaped the discussion guide for the focus groups,
since new findings did emerge we are confident that
the nature of the topic guide did not overly shape the
That said, given that the main themes arising from both
the acceptability review and the focus groups were similar,
we are confident that we have found empirical evidence
which offers support for many of the arguments for and
against HPFI purported in the literature. In particular, this
empirical evidence supports many of the arguments we
found in the scholarly writings in our acceptability review,
although these original scholarly pieces tended to be based
on opinion rather than evidence [36,42,70].
As is typical with qualitative research, we did not aim to
recruit a ‘representative’ sample or generate generalizable
results. However, the similarity of results from our
systematic review and these focus groups gives credence to our
As a stratified approach to sampling was adopted, the
views expressed on acceptability of HPFI are unlikely to
be restricted to any particular population group. Indeed,
we found that most participants – whether younger,
older, affluent, or less affluent – did not view the use of
HPFI as acceptable and that there were no strong
differences in opinion between the groups. As we did not
collect data on participant characteristics, aside from their
age and home postcode, we are unable to detail the
health behaviours of the participants (e.g. whether or
not they smoked). Such characteristics may influence
attitudes towards HPFI. For example, smokers who
may be entitled to receive HPFI view incentives more
favourably than non-smokers .
Focus group participants were not as forthcoming
when asked to explain why they held certain opinions
on HPFI, as they were when they were asked what those
opinions were. This may because of the nature of group
discussions, where participants may not feel comfortable
explaining their views in front of others .
Additionally, participants were unsure of how effective HPFI
schemes were and spent a great deal of time discussing
this, possibly due to having limited knowledge and
experience of such schemes. Their lack of knowledge on
the effectiveness of HPFI may have contributed to their
negative stance on HPFI for health promoting
behaviours. In particular, participants often concluded that if
HPFI schemes were ineffective then there is no reason
to discuss acceptability. We did not provide information
on effectiveness because we did not want to unduly
influence the discussions. However, presenting evidence of
effectiveness upfront, alongside providing examples
where HPFI schemes have been used to good effect, may
have helped reassure participants about their
effectiveness and limit the focus they had on this issue. This may
have provided more space for participants to fully
explain the reasons behind their opinions and led to more
favourable attitudes towards HPFI. A relationship
between stated effectiveness and acceptability of HPFI has
been demonstrated in quantitative research  and it
would be interesting and useful to confirm and explore
this relationship using qualitative methods.
Interpretation of findings
The majority of participants held an unfavourable
attitude towards HPFI. Mainly this negativity appeared to
centre on the issue of trust, in that participants felt they
could not trust other people to report behaviour change
truthfully or use the money that they received as part of
a HPFI scheme wisely. This seemed to influence which
groups were considered ‘deserving’ or not of HPFI, e.g.
vulnerable groups such as pregnant women were trusted
to receive HPFI, but drug users were not. Ultimately, the
majority of participants said that they could trust
themselves not to abuse cash rewards, but that they could not
trust other people. A variety of safeguards were therefore
suggested to avoid abuse (e.g. objective monitoring and use
of shopping vouchers instead of cash rewards). It could
well be that careful consideration needs to be given to how
the ‘target group’ for HPFI is defined. This may mean
widening the definition of the ‘target group’ beyond those who
might participate, to the public in general who all stand to
benefit from improved population health. This may help to
ensure ‘buy-in’ from across the population including those
who are likely to fund any HPFI scheme through taxation.
Despite the majority view that HPFI were not
acceptable, some participants were pragmatic, suggesting that
if HPFI schemes were found to be effective and
costeffective in changing behaviours that they should be
implemented. This concern for evidence of effectiveness
and cost-effectiveness was common and suggests that
implementation of a HPFI scheme should be
accompanied by strong evidence of effectiveness and
costeffectiveness - as well as effective communication of
this evidence to relevant stakeholders.
Participants also expressed a strong preference for
alternative methods of behaviour change, particularly
education and peer support. This reflects perhaps a need for
greater feedback when individuals engage in behaviour
change, with peer support providing verbal reassurance
and positive motivation for individuals. The request for
further education may mean that the way in which
information is currently provided to individuals in behaviour
change programmes (e.g. leaflets) is not recognised as
education and may need to be re-designed in a way that
ensures individuals recognise it as a form of educational
help. Education and peer support may need to be built
into any future HPFI scheme.
Implications for policy, practice and research
Similar qualitative work is required in other stakeholder
groups, in particular with policy-makers, given that these
individuals will likely be involved in the design,
implementation and evaluation of HPFI schemes in practice.
How policy-makers view HPFI, how they would design
HPFI schemes, and which recipients they would deem
acceptable recipients, are key areas to explore in future
research. Additionally, future research could explore
the acceptability of financial incentives in members
of the public for process as well as outcome behaviours
(e.g. attending smoking cessation sessions vs. stopping
smoking); and how individuals define ‘fairness’ in relation
to HPFI. Lastly, future research could explore the
potential for private sector companies to fund health
promoting interventions in a UK context .
This qualitative empirical research has highlighted
clear suggestions for how to design HPFI schemes, such
that: positive rewards rather than negative penalties
should be used; shopping vouchers should be provided
rather than cash; HPFI have to be fairly implemented;
HPFI schemes need to be closely monitored and
evaluated; and education has to be clearly provided alongside
The evidence from qualitative focus groups with
members of the public suggests that HPFI may be acceptable
if schemes are closely monitored and evaluated; are
proven to be effective and cost-effective; are delivered
alongside education on how to change healthy
behaviours and why; and are tailored to individuals. There was
limited discussion on what HPFI schemes should look
like, particularly because focus group participants wanted
evidence of HPFI effectiveness and cost-effectiveness
before they would discuss the acceptability of HPFI schemes.
Overall, the majority of the focus group participants did
not support the use of HPFI, although some were
pragmatic, again saying that if HPFI are shown to be effective
and cost-effective then they should be considered as a valid
behaviour change intervention. If HPFI are to be used,
more support was given for targeting vulnerable groups
such as pregnant women and low-income groups. More
research is needed into determining acceptability of HPFI
in a wider range of stakeholders, particularly policymakers,
who will be involved in designing and delivering HPFI
JA contributed to conception and design, data analysis and interpretation,
drafting and approval of the manuscript. EM and FFS contributed to
conception and design, data interpretation, and editing and approval of the
manuscript. ELG contributed to data collection and analysis, drafting and
approval of the manuscript. All authors agree to be accountable for all
aspects of the work. All authors read and approved the final manuscript.
This work is produced under the terms of a Career Development research
training Fellowship issued by the NIHR to JA (Grant number: CDF-2011-04-001).
The views expressed are those of the authors and not necessarily those of the
NHS, The National Institute for Health Research or the Department of Health. ELG
is funded in part, and FFS is fully funded by Fuse: the Centre for Translational
Research in Public Health, a UKCRC Public Health Research Centre of Excellence.
At the time of conducting this research, JA was also funded in part by Fuse. JA
is currently funded in part by the Centre for Diet & Activity Research (CEDAR).
Funding for Fuse and CEDAR from the British Heart Foundation, Cancer Research
UK, Economic and Social Research Council, Medical Research Council, the
National Institute for Health Research, under the auspices of the UK
Clinical Research Collaboration, is gratefully acknowledged. No funding
bodies played any role in the design, writing or decision to publish this
We would like to thank the Institute for Ageing and Health and the Institute
of Neuroscience at Newcastle University, for allowing us to send recruitment
notices to their databases of research volunteers. We would also like to
thank Newcastle University, Newcastle City Council and Nexus for allowing
us to place recruitment notices on their internal noticeboards and to email
their employees our research details. Thank you to the second moderators
who helped to run and monitor the focus groups: Majid Althaqafy, Melissa
Girling, Karen Heslop, Dominika Kwasnicka, Mary Webster and Heather Yoeli.
1. Swann C , Carmona C , Ryan M , Raynor M , Baris E , Dunsdon S , et al. Health systems and health-related behaviour change: a review of primary and secondary evidence . National Institute for Health and Clinical Excellence 2010 .
2. Department of Health. Our healthier nation: a contract for health . London: Her Majesty's Stationery Office ; 1998 .
3. Department of Health. Choosing health: making healthier choices easier . London: Her Majesty's Stationery Office ; 2004 .
4. Giles EL , Robalino S , McColl E , Sniehotta FF , Adams J. The effectiveness of financial incentives for health behaviour change: Systematic review and meta-analysis . PLOS ONE . 2014 ; 9 : 1 - 16 .
5. Adams J , Giles EL , McColl E , Sniehotta FF . Carrots, sticks and health behaviours: a framework for documenting the complexity of financial incentive interventions to change health behaviours . Health Psychol Rev . 2014 ; 8 ( 3 ): 286 - 95 .
6. Bains N , Pickett W , Hoey J. The use and impact of incentives in population based smoking cessation programs, a review . Am J Health Promot . 1998 ; 12 : 307 - 20 .
7. Christianson J , Leatherman S , Sutherland K. Financial incentives, healthcare providers and quality improvements: a review of the evidence . Health Foundation . 2007 .
8. Hardeman W , Griffin S , Johnston M , Kinmonth AL , Wareham NJ . Interventions to prevent weight gain: a systematic review of psychological models and behaviour change methods . Int J Obesity . 2000 ; 24 : 131 - 43 .
9. Jepson R , Clegg A , Forbes C , Lewis R , Sowden A , Kleijnen J. The determinants of screening uptake and interventions for increasing uptake: a systematic review . Health Technol Assess . 2000 ; 4 ( 14 ): 1 - 133 . i-vii.
10. Kane RL , Johnson P , Town RJ , Butler M. A structured review of the effect of economic incentives on consumers' preventive behavior . Am J Prev Med . 2004 ; 27 ( 4 ): 327 - 52 .
11. Sutherland K , Leatherman S , Christianson J. Paying the patient, does it work? The Health Foundation . 2008 .
12. Scott A , Sivey P , Ait Ouakrim D , Willenberg L , Naccarella L , Furler J , et al. The effect of financial incentives on the quality of health care provided by primary care physicians (Review) . Cochrane Database Syst Rev . 2011 ; 9:CD008451 . doi:10.1002/14651858.CD008451.pub2.
13. Jochelson K. Paying the patient: improving health using financial incentives . Kings Fund . 2007 .
14. Kavanagh JTA , Oakley A , Harden A. A scoping review of the evidence for incentive schemes to encourage positive health and other social behaviors in young people . London: Institute of Education, University of London; 2005 .
15. Kavanagh JSC , Thomas J. Incentives to improve smoking, physical activity, dietary and weight management behaviours: a scoping review of the research evidence . London: Institute of Education, University of London; 2009 .
16. Müller-Riemenschneider F , Reinhold T , Nocon M , Willich SN . Long-term effectiveness of interventions promoting physical activity: A systematic review . Prev Med . 2008 ; 47 : 354 - 68 .
17. Giles EL , Robalino S , Adams J , Sniehotta FF , McColl E : Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods , Year: 2015 , doi:10.10.16/j. ypmed. 2014 .12.029
18. Arterburn D , Westbrook EO , Wiese CJ , Ludman EJ , Grossman DC , Fishman PA , et al. Insurance coverage and incentives for weight loss among adults with metabolic syndrome . Obesity . 2008 ; 16 : 70 - 6 .
19. Bonevski B , Bryant J , Lynagh M , Paul C. Money as motivation to quit: A survey of a non-random Australian sample of socially disadvantaged smokers' views of the acceptability of cash incentives . Prev Med . 2012 ; 55 : 122 - 6 .
20. Bonevski B , Bryant J , Paul C. Encouraging smoking cessation among disadvantaged groups: A qualitative study of the financial aspects of cessation . Drug Alcohol Rev . 2011 ; 30 : 411 - 8 .
21. Cameron J , Ritter A. Contingency management: perspectives of Australian service providers . Drug Alcohol Rev . 2007 ; 26 : 183 - 9 .
22. Ducharme LJ , Knudsen HK , Abraham AJ , Roman PM . Counselor attitudes toward the use of motivational incentives in addiction treatment . Am J Addict . 2010 ; 19 : 496 - 503 .
23. Kim A , Kamyab K , Zhu J , Volpp K. Why are financial incentives not effective at influencing some smokers to quit? Results of a process evaluation of a worksite trial assessing the efficacy of financial incentives for smoking cessation . J Occup Environ Med . 2011 ; 53 : 62 - 7 .
24. London AJ , Borasky Jr DA , Bhan A , Ethics Working Group of the H.I. V Prevention Trials Network. Improving ethical review of research involving incentives for health promotion . PLoS Med . 2012 ; 9 : e1001193 .
25. Luyten J , Vandevelde A , Van Damme P , Beutels P. Vaccination policy and ethical challenges posed by herd immunity, suboptimal uptake and subgroup targeting . Public Health Ethics . 2011 ; 4 : 280 - 91 .
26. Mantzari E , Vogt F , Marteau TM . The effectiveness of financial incentives for smoking cessation during pregnancy: is it from being paid or from the extra aid ? BMC Pregnancy Childbirth . 2012 ; 12 : 24 .
27. Mhurchu CN , Eyles H , Dixon R , Matoe L , Teevale T , Meagher-Lundberg P. Economic incentives to promote healthier food purchases: exploring acceptability and key factors for success . Health Promot Int . 2012 ; 27 : 331 - 41 .
28. Schmidt H. Bonuses as incentives and rewards for health responsibility: a good thing ? J Med Philos . 2008 ; 33 : 198 - 220 .
29. Marteau T , Ashcroft R , Oliver A. Using financial incentives to achieve healthy behaviour . BMJ . 2009 ; 338 : 983 - 5 .
30. Eunson J , Murray L. The acceptability of carrotts . Ipsos Mori ; 2012 .
31. Lynagh M , Sanson-Fisher R , Bonevski B. What's good for the goose is good for the gander . Guiding principles for the use of financial incentives in health behaviour change . Int J Behav Med . 2013 ; 20 : 114 - 20 .
32. Madison KM , Volpp K , Halpern SD . The law, policy, and ethics of employers' use of financial incentives to improve health . J Law Med Ethics . 2011 ; 39 : 450 - 68 .
33. Parke H , Ashcroft R , Brown R , Marteau TM , Seale C. Financial incentives to encourage healthy behaviour: an analysis of UK media coverage . Health Expect . 2011 ; 16 : 292 - 304 .
34. Mitchell MS , Goodman JM , Alter DA , John LK , Oh PI , Pakosh MT , et al. Financial incentives for exercise adherence in adults: systematic review and meta-analysis . Am J Prev Med . 2013 ; 45 : 658 - 67 .
35. Ashcroft RE , Marteau T , Oliver A. Payment to look after health: incentive mechanisms require deeper understanding . BMJ . 2008 ; 337 :a1135.
36. Malone SW , Jason L. Using incentives, lotteries, and competitions in work-site smoking cessation interventions . Drug Alcohol Abuse Rev . 1990 ; 1 : 313 - 37 .
37. Oliver A , Bauld L. A consideration of user financial incentives to address health inequalities . J Health Politics Policy Law . 2012 ; 37 : 201 - 26 .
38. Ashcroft RE . Personal financial incentives in health promotion: where do they fit in an ethic of autonomy . Health Expect . 2011 ; 14 : 191 - 200 .
39. Donatelle RJ , Hudson D , Dobie S , Goodall A , Hunsberger M , Oswald K. Incentives in smoking cessation: status of the field and implications for research and practice with pregnant smokers . Nicotine Tob Res . 2004 ; 6 : S163 - 79 .
40. Grant RW . The ethics of incentives: historical origins and contemporary understandings . Econ Philos . 2002 ; 18 : 111 - 39 .
41. Popay J. Should disadvantaged people be paid to take care of their health? No BMJ . 2008 ; 337 : 141 .
42. Petry NM . Contingency management treatments: controversies and challenges . Addict . 2010 ; 105 : 1507 - 9 .
43. Cookson R. Should disadvantaged people be paid to take care of their health? Yes . BMJ . 2008 ; 337 : 141 .
44. Moller AC , McFadden H , Hedeker D , Spring B. Financial motivation undermines maintenance in an intensive diet and activity intervention . J Obesity . 2012 ; 37 ( 5 ): 819 - 27 .
45. Lynagh M , Bonevski B , Symonds I , Sanson-Fisher RW . Paying women to quit smoking during pregnancy? Acceptability among pregnant women . Nicotine Tob Res . 2011 ; 13 : 102 - 1036 .
46. Promberger M , Brown RC , Ashcroft RE , Marteau TM . Acceptability of financial incentives to improve health outcomes in UK and US samples . J Med Ethics . 2011 ; 37 : 682 - 7 .
47. Promberger M , Dolan P , Marteau TM. “ Pay them if it works”: Discrete choice experiments on the acceptability of financial incentives to change health related behaviour . Soc Sci Med . 2012 ; 75 ( 12 ): 2509 - 14 .
48. Priebe S , Sinclair J , Burton A , Marougka S , Larsen J , Firn M , et al. Acceptability of offering financial incentives to achieve medication adherence in patients with severe mental illness: a focus group study . J Med Ethics . 2010 ; 36 ( 8 ): 463 - 8 .
49. Flick U. An introduction to qualitative research . London: SAGE Publications Ltd ; 2004 .
50. Gale NK , Heath G , Cameron E , Rashid S , Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research . BMC Med Res Methodol . 2013 ; 13 : 1 - 8 .
51. Ipsos Media CT . Social grade a classification tool bite sized thought piece . Ipsos Mori ; 2009 .
52. Lee J , Park DH , Han I. The effect of negative online consumer reviews on product attitude: An information processing view . Electron Commer Res Appl . 2008 ; 7 : 341 - 52 .
53. Gomez B , Jones JPIII . Research methods in geography: A critical introduction . West Sussex: John Wiley & Sons; 2010 .
54. Krueger RA , Casey MA . Focus groups a practical guide for applied research . 4th ed. London: SAGE Publications Ltd; 2009 .
55. Rea LM , Parker RA . Designing and conducting survey research: A comprehensive guide . 3rd ed. San Francisco: John Wiley & Sons; 2012 .
56. Carlsen B , Glenton C. What about N? A methodological study of sample-size reporting in focus group studies . BMC Med Res Methodol . 2011 ; 11 : 1 - 10 .
57. Bryman A. Social research methods . 2nd ed. Oxford: Oxford University Press ; 2004 .
58. Strauss AL . Qualitative analysis for social scientists . Cambridge : Cambridge University Press ; 2003 .
59. Barnett-Page E , Thomas J. Methods for the synthesis of qualitative research: a critical review . BMC Med Res Methodol . 2009 ; 9 : 1 - 11 .
60. Braun V , Clarke V. Using thematic analysis in psychology . Qual Res Psychol . 2006 ; 3 : 77 - 101 .
61. Tong A , Sainsbury P , Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups . Int J Qual Health Care . 2007 ; 19 : 349 - 57 .
62. Volpp KG , Pauly MV , Loewenstein G , Bangsberg D. P4P4P: an agenda for research on pay-for-performance for patients . Health Aff . 2009 ; 28 : 206 - 14 .
63. Hoddinott P , Morgan H, MacLennan G , Sewel K , Thomson G , Bauld L , et al. Public acceptability of financial incentives for smoking cessation in pregnancy and breast feeding: a survey of the British public . BMJ Open . 2014 ; 4 : 9 .
64. Meads DM , McCabe C , Camidge DC , Hill KM , House AO , Hulme CT. A contingent valuation survey of user financial incentives for health behaviour change . Value Health . 2013 ; 16 ( 3 ): A11 .
65. Parke H , Ashcroft R , Brown R , Marteau TM , Seale C. Financial incentives to encourage healthy behaviour: An analysis of UK media coverage . Health Expectations . 2013 ; 16 : 292 - 304 .
66. Raiff BR , Jarvis BP , Turturici M , Dallery J. Acceptability of an internet-based contingency management intervention for smoking cessation: Views of smokers, nonsmokers, and healthcare professionals . Exp Clin Psychopharm . 2013 ; 21 : 204 - 13 .
67. Aveyard P , Bauld L. Incentives for promoting smoking cessation: what we still do not know . Cochrane Database Syst Rev . 2011 ; 8:ED000027 . doi:10.1002/14651858.ED000027.
68. Mitchell MS , Faulkner GE. On supplementing “foot in the door” incentives for eHealth program engagement . J Med Internet Res . 2014 ; 16 :e179.
69. Schmidt H , Voigt K , Wikler D. Carrots , Sticks, and Health Care Reform - Problems with Wellness Incentives . New England J Med . 2010 ; 362 :e3.
70. Pearson SD , Lieber SR . Financial penalties for the unhealthy? Ethical guidelines for holding employees responsible for their health . Health Aff . 2009 ; 28 : 845 - 52 .
71. Smithson J. Focus Groups . In: Alasuutari PBL, Brannen J, editors. The SAGE handbook of social research methods . London: SAGE Publications Ltd ; 2008 .
72. Ni Mhurchu C , Aston L , Jebb S. Effects of worksite health promotion interventions on employee diets: a systematic review . BMC Public Health . 2010 ; 10 : 62 .