Incentivising has shown to improve participation in clinical trials. However, ethical concerns suggest that incentives may be coercive, obscure trial risks and encourage individuals to enrol in clinical trials for the wrong reasons. The aim of our study was to develop and pilot a discrete choice experiment (DCE) to explore and identify preferences for incentives. A DCE was designed by including following attributes (and levels) of incentives: value, method, and time involvement. To account for trial benefit and risk, each was included as an attribute with levels low, medium and high. For testing purposes, the DCE was administrated using SurveyMonkey in a population of third level students. A total of 245 students, representative of the general student population, participated in the online DCE. The results provide a template to assess and explore the use of different incentive methods in clinical trials. The template can be used in its current format or adapted to particular scenarios. This pilot study provides a feasible methodology to explore the use of incentives for participation in clinical trials and can be adapted to specific trial requirements to provide information for ethical applications or identify the most favourable incentive for participation in clinical trials.
Keywords: Randomised controlled trial; incentive; discrete choice experiment
According to the 1947 Nuremberg Code, no persuasion or pressure of any kind should be put on clinical trial participants ([
Incentivising the consent procedure has shown to improve recall in participants, particularly in relation to potential serious side effects ([
Incentives are however more questionable when participants find themselves in a dependency relationship with the researcher (or physician), where the risks are particularly high, where the research is degrading, where the participant will only consent if the incentive is relatively large because the participant's aversion to the study is strong and where the aversion is a principled one ([
The use of financial incentives in clinical trials is not well studied and generally less accepted. Hospital- or community-based trials need to take extra care to avoid incentives that may be coercive or unduly influence research participants ([
Ethical committees or institutional research board members often struggle with concepts of reimbursement and incentivisation. While members may agree with reimbursement or compensation for time and inconvenience, they may not agree with payment for participation or compensation for risk ([
Difficulties with research to determine the use of incentives for participation include working with 'example' studies to convey different levels of risk and the need for large samples. Taking some of the limitations into account, we explored alternative options to study choice and gain a better understanding of the elements involved in choice-making ([
DCEs can be used to propose choice sets with hypothetical options in relation to incentives introduced in the context of clinical trials. DCE can disentangle stated preferences, or what an individual says they would do, from observed preferences, what the individuals actually does, and compare these to current practice and standards in clinical trials and health research in general. DCEs involve the generation and analysis of choice data in the context of hypothetical scenarios ([
Our aim was to develop and pilot a discrete choice experiment to explore and measure the use of incentives to recruit patients to clinical trials.
A DCE asks individuals to state their preference of hypothetical alternatives, in this case incentives. Each alternative is described by its attributes or characteristics and responses are used to infer the value placed on each attribute. In stating a preference the individual is assumed to choose the alternative that yields the highest individual benefit (utility) ([
Following best practice in designing DCEs, a qualitative approach was taken to identify attributes and levels in a two-step process. First, international literature on incentives in clinical trials was reviewed to identify all the relevant attributes. For each attribute, potential levels were recorded. This literature review was then used to inform an expert group including experts in trial methodology, health economics, epidemiology, social marketing and statistics. The expert group defined the final research question and identified the most relevant and attainable attributes (Table 1).
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Table 1. DCE attributes and levels.
Attribute Explanation Levels Value The monetary value paid to you to take part in the trial • €0 Method The form in which this payment is made • Cash Time involvement The time commitment that you will need to make to take part in the trial • A single one-hour session Trial benefits The possible advantages to you of taking part in the trial, e.g. access to a new treatment which would not otherwise be available to you • Low• Medium• High Trial risks The possible disadvantages to you of taking part in the trial, e.g. the chance that the intervention will have harmful side effects • Low• Medium• High
1 Denotes reference group.
The decision was made to avoid scenarios to confer risk, as interpretation of scenarios is dependent on the individuals' circumstances (for instance age or gender). A more generalisable approach was taken by introducing the DCE with an introduction to randomised trials. The introduction then includes, 'for this example, you have been asked to participate in a trial comparing two interventions to improve your health'. Full instructions and an example scenario are provided in Figure 1. To convey a level of risk and benefit, each scenario included these as attributes with three levels (low, medium, high). The attributes 'benefits' and 'risks' are inherent to each trial, related for instance to the therapeutic effect or adverse effect of an intervention, and cannot be modified by researchers for the purpose of increasing recruitment. However, risk and benefit of the trial influences the decision-making of any prospective participant, so excluding them from the list of attributes would be likely to increase random or unexplainable utility in data analysis ([
Graph: Figure 1. DCE instructions and example of choice set.
To answer the question 'what preferences encourage people to participate in clinical trials?' a small-scale study was proposed to test each element of the DCE in a particular population. As each population allows different approaches, the focus of the presented DCE was a student population, allowing for online DCEs and electronic invitations through social media platforms (Facebook, WhatsApp, university mailing list).
The final DCE included the following attributes: value, method, time involvement, trial risk, trial benefit (Table 1). Based on these attributes and levels, a total of 243 (3
The surveys were transferred to SurveyMonkey as images and the individual's choice (A or B) was recorded electronically. Additional demographic information (age, gender, discipline, educational background, in receipt of study funding, and previous experience with health research) was also collected. Survey links were distributed through the university's student email system and by sharing the link on Facebook and WhatsApp groups. The survey was live for a seven-day period in respect of the amount of student communication (28 September to 5 October 2017). Ethical approval for the study was obtained from the Social Research Ethics Committee at the University College Cork.
The underlying principle of DCEs is based on the consumer theory of demand, which states that when an individual is faced with different choices, he/she will choose the alternative that provides the highest utility ('happiness') ([
Each scenario is judged as a bundle of characteristics (attributes/level) to be compared with an alternative scenario. No scenario will present the ideal options, but we assume that the individual will choose the choice set that will provide them with the highest benefit (utility). With each choice set having a different combination, the effect of each attribute level on the chance of the choice set being chosen can be estimated with a random effects logistic regression analysis accounting for multiple answers by each individuals (STATA v13). The estimated coefficients represent the preference of each attribute level influencing the choice, compared to the lowest (reference) attribute level. This approach limits the number of comparisons and results in two coefficients for each attribute.
A preference heterogeneity analysis was also performed to investigate the influence of selected demographic characteristics. The variability in preferences is investigated by a comparison of the marginal effect of each personal characteristic on the sample level preferences (for instance, what is the marginal effect of studying science on average preference for an incentive). However, this approach results in a large number of comparisons. The use of a reference category as well as restriction in the number of interactions tested, was therefore applied.
- Gender (reference: Male)
- Discipline (reference: College of Arts, Social sciences and Celtic studies)
- Previous experience in clinical studies (reference: No)
- In receipt of a study grant (reference: No)
All the questions were answered by 245 students, 159 (64.9%) of whom were female (Table 2). Their mean age was 22, ranging between 17 and 55.
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Table 2. Demographic overview of the student population.
N % Total 245 Female 159 64.9 Male 85 34.7 Unknown 1 0.4 Discipline College of Arts, Social Sciences and Celtic Studies 53 21.6 College of Science, Medicine and Nursing 123 50.2 College of Business, Public Policy and Law 33 13.5 College of Engineering and Informatics 26 10.6 Level of study Undergraduate 211 86.1 Postgraduate 34 13.9 Recipient of study grant No 85 34.7 Yes 160 65.3 Previous experience in clinical studies No 206 84.1 Yes 39 15.9
Students prefer an incentive with a higher value and compared to no value, students are 1.9 times more likely to opt for €30 and 5.6 times more likely to choose €60 (Table 3). Students prefer cash compared to vouchers (Odds ratio 0.7) or gifts (odds ratio 0.6). Students prefer a one-off time involvement compared to a 30 minutes per week for 3 months. A shorter duration of time involvement, i.e. daily for 3 weeks versus weekly for 3 months, is also preferred by students.
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Table 3. Preference analysis of the attributes of incentives.
Odds ratio 95% Confidence interval Value €0 Reference €30 1.9 1.5–2.4 €60 5.6 4.5–6.9 Method Cash Reference Voucher 0.7 0.5–0.8 Gift 0.6 0.4–0.7 Time involvement 30 minutes/week for 3 months Reference Single one-hour session 2.6 2.1–3.2 30 minutes/day for 3 weeks 1.8 1.4–2.2
None of the included demographic variables influence the choice of students and no differences between colleges can be observed in relation to value or method of incentive. Engineering and informatics students show a slight preference for a single one-hour session. Level of study, recipients of study grants or previous experiences in clinical studies is not associated with a change in preferences.
A total of 200 out of 245 participants are included in this pilot study; 45 students were excluded as they did not complete the DCE. The largest drop off happened after obtaining the participant information (
The application of a DCE to assess preferences in incentives has shown to be successful. Despite being a small-scale pilot study, this modified DCE provides insights into how people choose incentives in relation to participation in clinical trials.
The DCE was developed to test, in its broadest application, the variation in the use of incentives, depending on the benefits and risks of the study. For this reason, the DCE did not include a scenario, as previous experiences would be determining the interpretation of risk and benefit. However, the use of scenarios with or without including specific benefits and risks may improve the application of understanding preferences in particular populations or for particular studies. This pilot study provides a template for use in specific studies or trials, or broader implementation to determine preferences.
It is the first time a DCE methodology is applied in this context to explore the value of incentives for participation in a clinical trial. In this study setting the risk and benefit at different levels allows participants' own personal interpretation of risk and benefit. Other attributes such as levels of monetary incentives, type of incentives and time commitment were pre-set. These attributes as well as their levels could be changed and adapted to other situations to determine preferences for incentives. Limiting the number of comparisons by predetermining the variables of interest as well as setting up models based on pre-specified hypothesis, will help the interpretation and application of a DCE.
In conclusion, we provide a template to explore and determine preferences for incentives for recruitment of participant to clinical trials. The presented methodology will allow researcher to support ethical applications as well as identify the most appropriate incentives for a proposed trial.
We would like to thank Dr Darren Dahly, statistician at the HRB Clinical Research Facility Cork and School of Public Health, University College Cork for his help as member of the expert team.
By Akke Vellinga; Colum Devine; Min Yun Ho; Colin Clarke; Patrick Leahy; Jane Bourke; Declan Devane; Sinead Duane and Patricia Kearney
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