title: The effect of out-of-pocket costs and financial rewards in a discrete choice experiment: an application to lifestyle programs.
abstract: BACKGROUND
  Both out-of-pocket costs and financial rewards can be used to influence health related behavior. However, it is unclear which of these two has a larger effect on health related behavior. The aim of this study was to explore the possible difference in effect size between out-of-pocket costs and financial rewards on the willingness of diabetes mellitus type 2 (DM2) patients to participate in a lifestyle program.
  
  
  METHODS
  A discrete choice experiment (DCE) questionnaire was sent to 767 DM2 patients in a geographically defined area (De Leidsche Rijn, Utrecht) in The Netherlands and completed by 206 of them. The questionnaire comprised of 18 choice tasks of which 9 contained a financial reward for lifestyle program completion, while the other 9 included out-of-pocket costs for program participation. In a second version of the questionnaire, the order of out-of-pocket cost and financial reward choice tasks was counterbalanced to reduce bias with respect to the position (first or second) of the two types of choice tasks. Panel-mixed-multinomial-logit models were used for data analysis.
  
  
  RESULTS
  Increasing out-of-pocket costs were associated with a decreasing willingness to participate in a lifestyle program and, contrary to our expectations, increasing financial rewards were also associated with a decreasing willingness to participate in a lifestyle program. In addition, this willingness to participate changed to the same extent for both increasing out-of-pocket costs and increasing financial rewards.
  
  
  CONCLUSIONS
  As expected, increasing out-of-pocket costs may prevent people from deciding to participate in a lifestyle program. However, offering a financial reward to persuade people to participate in a lifestyle program, may result in decreasing willingness to participate in a lifestyle program as well.
authors.affiliation: National Institute for Public Health and the Environment, Centre for Prevention and Health Services Research, PO Box 1 (Internal postal code: 101), 3720 BA Bilthoven, The Netherlands. j.o.p.wanders@umcutrecht.nl.
authors.forename: Johanna O P
authors.initials: JO
authors.lastname: Wanders
authors.forename: Jorien
authors.initials: J
authors.lastname: Veldwijk
authors.forename: G Ardine
authors.initials: GA
authors.lastname: de Wit
authors.forename: Huberta E
authors.initials: HE
authors.lastname: Hart
authors.forename: Paul F
authors.initials: PF
authors.lastname: van Gils
authors.forename: Mattijs S
authors.initials: MS
authors.lastname: Lambooij
mesh_terms: D000328:Adult; D000368:Aged; D002755:Choice Behavior; D003924:Diabetes Mellitus, Type 2 / Q000191:economics* / Q000628:therapy; D005260:Female; D005102:Health Expenditures; D006801:Humans; D008019:Life Style; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010342:Patient Acceptance of Health Care; D012201:Reward; D011795:Surveys and Questionnaires