Research In Practice Blog
Tailored Adherence Incentives for Childhood Asthma Medications: A Randomized Clinical Trial
Urban racial and ethnic minority children are disproportionately affected by asthma. In fact, they are three times more likely to be hospitalized and five times more likely to die from asthma compared to their non-minority peers. While many factors contribute to these disparities, low adherence to preventative asthma medications is well-documented, and there is potential for improvement.
A research team from the Children’s Hospital of Philadelphia, which includes Clinical Futures' Core Faculty Members Drs. Chén C. Kenyon, Victoria Miller, Tyra Bryant-Stephens, Joseph Zorc, and Chris Feudtner, conducted a study recently published in JAMA Pediatrics. The study, Tailored Adherence Incentives for Childhood Asthma Medications (TAICAM), investigated how technology and financial incentives can assist families in managing high-risk asthma.
The team examined the impact of an intervention that used mobile health technology and financial incentives to generate a “habit loop” (cue-routine-reward) to promote adherence to inhaled asthma preventive medications among a high-risk group of predominantly racially minoritized children with asthma.
The primary goal of this approach was to enhance the evidence regarding effective methods to engage children with high-risk asthma and their families with effective strategies for improving their child’s asthma control. Additionally, it aimed to understand the dynamic effects of financial incentives on childhood adherence to asthma medication.
Study Design and Findings
The TAICAM trial was a three-arm randomized clinical trial conducted from September 2019 to June 2022 at Children’s Hospital of Philadelphia. This trial aimed to evaluate a multi-component mobile health intervention designed to improve medication adherence among children. The intervention was developed and refined through an iterative pilot process.
A detailed study protocol for the trial was published previously. The trial included 106 participants, children aged 5 to 12 years who were prescribed an inhaled asthma maintenance medication, which could be either an inhaled corticosteroid (ICS) or an ICS combined with a long-acting beta-agonist (ICS-LABA). Participants were randomly assigned to one of three experimental conditions in a 2:1:2 ratio. This design aimed to obtain preliminary estimates of the marginal effects of the intervention components on adherence and utilization outcomes, in preparation for a planned multicenter study. The results are reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines.
The TAICAM research team utilized the electronic health record system to review daily inpatient and emergency department census reports, and asthma registry reports to identify potential participants. Eligible children were those who had experienced at least two asthma exacerbations requiring systemic steroids in the prior year. Written informed consent was obtained from all caregivers, and children aged 8 years and older provided their own assent. Demographics, including race and ethnicity, were reported by the participants to assess the generalizability and representativeness of the study population.
Researchers monitored inhaled medication use with electronic inhaler sensors over a 7-month period. Families who completed a 1-month run-in phase were randomized into one of three groups for a 3-month experimental phase:
- The full intervention group received daily text message reminders about their medication, weekly feedback on adherence, and gain-framed financial incentives of up to $1 per day.
- The hybrid intervention group received daily text message reminders and weekly feedback but no financial incentives.
- The active control group received no reminders, feedback, or incentives.
Following the experimental phase, medication adherence monitoring continued for another 3-month observation period, during which all groups reverted to active control conditions.
Researchers observed higher medication adherence in the full intervention condition than active controls, but only while financial incentives were delivered. While there may be benefits of short-term improvements in adherence with financial incentive-enhanced asthma adherence interventions, researchers observed no evidence that this intervention strategy enhances enduring medication use habits.
Researchers also noted the following challenges of the TACIAM study that limited enduring adherence:
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Setting up a technological feedback loop that mimics a habit loop consisting of cues, behavior, and reward: For a habit, whether good or bad, to be effectively "programmed," the reward must follow the cued behavior closely enough to serve as reinforcement. While this technology can facilitate such a process, everything must work seamlessly.
For instance, participants must keep Bluetooth on continuously, with the sensor close enough to the smartphone to transmit data. Additionally, the smartphone must be connected to Wi-Fi or use cellular data to send the information to the server. Text messages should be enabled, and the caregiver must be near the child to receive the reinforcing text message that will then be communicated to the child.
Researchers also aim to avoid overwhelming caregivers with too many text messages. As a result, they made pragmatic design choices that deviated from optimal behavioral science practices, such as limiting reminders to one text message per day and sending weekly performance feedback and weekly incentives to the participant’s Clincard. These choices likely contributed to the lack of enduring effects. - Lack of connection of the behavior that you are boosting with an external incentive to internal incentives/motivations that children care about: There is often a disconnect between the behaviors we encourage through external incentives and the internal motivations that matter to children. For example, suppose a child really wants to walk upstairs at school or play basketball with their friends without getting out of breath. Now suppose an intervention successfully connects the dots between more frequent use of a preventative inhaler and improvements in these specific symptoms for this child. In that case, the child would be more motivated to take their medication once the external incentives are removed.
Implications:
Despite considerable challenges, including various structural and contextual barriers to adherence, financial incentives demonstrate real-world potential, but the effect is time limited. While there may be some benefit in offering financial rewards to children to improve adherence during active disease periods, the lack of evidence for lasting behavior change should urge caution for those hoping that simply pairing technology with financial incentives may foster habit formation. This is especially important for populations that face various challenges opposing the desired behaviors, including medication access and trust.
Actionable Insights:
- Research: The authors established a need for further research to (1) narrow proximity of cued behaviors with positive reinforcement and (2) bridge external rewards with more personalized internal motivation.
- Advocacy/Policy: In the interim, the authors highlight the potential value of treatment strategies that provide symptom relief (a form of positive reinforcement) alongside symptom prevention – or so called SMART (single maintenance and reliever therapy), which is another evidence-based, guideline-endorsed therapy. However, this guideline-concordant approach is often not thwarted by pharmacy benefit managers that limit access to SMART-compatible medications by requiring prior authorizations for a second inhaler at school or a second home or not covering the medications at all. While many Medicaid formularies – including PA Medicaid’s common formulary – now allow access to these medications, coverage among private insurers is spotty at best – an area that is ripe for advocacy and potential policy intervention/regulation.
Additional Information and Resources:
JAMA Pediatrics Editorial- “Financial Incentives to Promote Sustained Improvements in Child Health”
Wright DR, Malik FS, Shah SK. Financial Incentives to Promote Sustained Improvements in Child Health. JAMA Pediatr. Published online March 17, 2025. doi:10.1001/jamapediatrics.2025.0020
Study authors from Clinical Futures: Chén C Kenyon, Victoria Miller, Tyra Bryant-Stephens, Joseph Zorc, Chris Feudtner