title: Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial.
abstract: BACKGROUND
  Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy.
  
  
  METHODS
  In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493.
  
  
  RESULTS
  Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12·1, 95% CI 3·7-39·9; p<0·0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14·0, 4·2-46·2; p<0·0001). These differences remained significant with sensitivity analyses.
  
  
  CONCLUSIONS
  Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown.
  
  
  BACKGROUND
  National Institute for Health Research (RP-PG-0707-10149).
authors.affiliation: Centre for Mental Health, Imperial College London, London, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: Weaver
authors.affiliation: King's College London National Addiction Centre, King's College London Institute of Psychiatry, King's College London, London, UK.
authors.forename: Nicola
authors.initials: N
authors.lastname: Metrebian
authors.affiliation: King's Clinical Trials Unit, Department of Biostatistics, King's College London Institute of Psychiatry, King's College London, London, UK.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hellier
authors.affiliation: Research Department of Clinical Educational and Health Psychology, University College London, London, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Pilling
authors.affiliation: King's College London National Addiction Centre, King's College London Institute of Psychiatry, King's College London, London, UK.
authors.forename: Vikki
authors.initials: V
authors.lastname: Charles
authors.affiliation: Research Department of Clinical Educational and Health Psychology, University College London, London, UK.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Little
authors.affiliation: Centre for Mental Health, Imperial College London, London, UK.
authors.forename: Dilkushi
authors.initials: D
authors.lastname: Poovendran
authors.affiliation: South London & Maudsley NHS Foundation Trust, London, UK.
authors.forename: Luke
authors.initials: L
authors.lastname: Mitcheson
authors.affiliation: Camden and Islington NHS Foundation Trust, London, UK.
authors.forename: Frank
authors.initials: F
authors.lastname: Ryan
authors.affiliation: Central & North West London NHS Foundation Trust, London, UK.
authors.forename: Owen
authors.initials: O
authors.lastname: Bowden-Jones
authors.affiliation: Camden and Islington NHS Foundation Trust, London, UK.
authors.forename: John
authors.initials: J
authors.lastname: Dunn
authors.affiliation: Sussex NHS Foundation Trust, Worthing, UK.
authors.forename: Anthony
authors.initials: A
authors.lastname: Glasper
authors.affiliation: South London & Maudsley NHS Foundation Trust, London, UK.
authors.forename: Emily
authors.initials: E
authors.lastname: Finch
authors.affiliation: King's College London National Addiction Centre, King's College London Institute of Psychiatry, King's College London, London, UK; South London & Maudsley NHS Foundation Trust, London, UK. Electronic address: john.strang@kcl.ac.uk.
authors.forename: John
authors.initials: J
authors.lastname: Strang
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006509:Hepatitis B / Q000517:prevention & control* / Q000523:psychology; D017325:Hepatitis B Vaccines / Q000008:administration & dosage*; D006556:Heroin Dependence / Q000523:psychology / Q000534:rehabilitation*; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D009042:Motivation; D058850:Opiate Substitution Treatment / Q000523:psychology; D014611:Vaccination / Q000379:methods; D055815:Young Adult
chemical_list: D017325:Hepatitis B Vaccines