Do financial incentives improve children’s long-term adherence to medication in asthma?

This editorial commentary focuses on a recent study investigating the effect of financial incentives on children’s adherence to their asthma medication (1). We aim to discuss this new study in the context of contemporary practice.

Elements of asthma treatment and adherence

Adherence to maintenance inhaled corticosteroids is the cornerstone of asthma management in children (2). Adherence in this case involves not only the patient taking the prescribed dose (number of actuations and frequency) but also using the correct inhaler technique (2).

Correct inhaler technique is recognized as a fundamental aspect of medication adherence and has been shown to be inadequateparticularly in children (3). Satisfactory inhaler technique is essential to ensure adequate deposition of the drug in the lungs (its site of action), rather than being deposited in the oropharynx or upper airway which is often the case if incorrect technique is used. These two elements (administering the prescribed dose and using correct inhaler technique) are mutually exclusive and therefore must both be targeted with regards asthma self-management education to ensure optimal adherence to treatment and therefore maximize patient outcomes.

The above elements pertain to all patients with asthma (adults and children), though in children there are added challenges. First, younger children are reliant on their parents/carers to deliver the management plan (i.e., the parents/carers administer the inhalers at the prescribed frequency). In addition, it can be difficult for parents/carers to persuade younger children to tolerate inhaling medication without resistance. Older children and adolescents take on more responsibility for this but that has also proven to be a difficult transition (4). With regards inhaler technique, younger children find the action of deep inhalation and breath hold difficult and therefore alternative strategies such as tidal breathing techniques are often used; the latter have variable effectiveness (5).

There have been several strategies implemented in recent years to tackle required aspects of adherence with varying success. These have included: addressing negative perceptions of inhaled steroid use (for example, by using a shared decision making model), providing support through motivational interviews, improving inhaler technique training with physical demonstration and ‘teach-back’, use of electronic inhaler monitoring devices (EIMDs) which can provide valuable feedback with regards adherence and lastly, directly observed therapy (DOT) which can provide the basis for definitive feedback on both inhaler frequency and technique (6).

Inhaler attachments to monitor frequency of inhaler use are feasible in children, however, they do not consistently lead to improvements in clinical outcomes (7). Some of these devices can monitor inhalation flow rates which can provide some quasi/proxy evidence of inhaler technique and thereby drug deposition, but their effectiveness is yet to be proven.

The one intervention which marries the monitoring of both medication frequency and inhaler technique is the use of video directly observed therapy (vDOT) (8). This is where a patient (or carer in case of a young child) records a video of themselves (the patient) using their inhaler for each actuation using their smart phone and uploads this onto a secure cloud-based platform. A trained healthcare professional asynchronously reviews these videos and assesses the inhaler technique. Using vDOT offers the healthcare professional the opportunity to provide near real time feedback (if resources are available) or, the videos can be reviewed, and feedback given, on a weekly or biweekly basis.

There is growing evidence of improved inhaler technique and frequency of inhaler use with subsequent improvement in clinical outcomes using vDOT. It has been successfully used to assess and optimize treatment for children with poorly controlled asthma and prevent the need for escalation to more expensive medications (e.g., biological therapies) (9,10).

Use of financial incentives

In 2007, the King’s Fund (11) published a systematic review of the use of financial incentives across all aspects of healthcare. They found that such incentives had been used across a wide range of healthcare activities including smoking cessation, weight loss, adherence to tuberculosis medications, abstaining from illicit drug use, attendance at clinics and take-up of immunisations. They found that financial incentives were successful in the short term when targeting simple behaviour change such as improved attendance at a clinic or engagement with a treatment programme. However, in the longer term, particularly once the intervention had ceased, patients tended to relapse into former unhealthy behavioural patterns (12).

While financial rewards are a feasible and distinctive means of providing an incentive to follow medical advice in chronic illness (including asthma) (13), there is still uncertainty on whether financial incentives improve adherence to asthma medication in children and adolescents in both the short term (while incentives are being given) and in the longer term (when incentives are discontinued).

A recent systematic review of financial incentives in asthma management (14) found three pilot or feasibility studies on the impact on children (15-17). One demonstrated a significant difference in adherence (frequency of medication use) while patients received the financial incentive compared to without (n=20, 80% versus 33%) (16). Another pilot study (n=12) showed an improvement from median baseline adherence (frequency of medication use) of 19% to 50% following an eight-week programme which included monetary incentives (17). The third was a feasibility study which recruited 10 patients, offering monetary incentives for increased inhaler usage; mean adherence at baseline (53%) did not significantly change by the end of the study (51%) (15). None of these studies had longer term follow up data to assess sustained impact of the financial incentives.

In a separate more recent randomized controlled trial of adolescents with asthma, participants were randomized to either electronic medication monitoring (EMM) with reminders (control) or EMM + $1 per day for perfect medication adherence (intervention). Adherence declined in both groups (80% to 64% in the control group and 90% to 58% in the financially incentivised group) with no significant difference in the rate of decline between these two groups. There was also no significant change in the slope of decline following payment discontinuation for the financially incentivised group with no (18).

New paper contribution

The paper, “Tailored Adherence Incentives for Childhood Asthma Medications: A Randomized Clinical Trial”, published by Kenyon et al. in JAMA Pediatrics (1), is a well-designed study to determine the effect of financial incentives added to a remote mobile intervention (see below) on the frequency of inhaler use in children with high-risk asthma (in this case, mainly non-Hispanic Black children, 5–12 years of age,living in an urban area in the USA).

All children in the study (intervention and control arms) had their frequency of inhaler use monitored by using a device attached to the inhaler which could sense each time the inhaler was actuated (but without any measurement of flow rate) (Propeller Health). This sensor was linked to an online platform named ‘Way to Health’, which participants could access via their smartphone. This online platform allowed participants to gain feedback on frequency of inhaler use (vs. that prescribed) and provided daily reminders on when to use the inhaler via text message.

The authors specifically aimed to investigate whether there was an improvement in the frequency of use of inhaled steroids in children using the reminder messages and feedback alone and with the addition of a financial incentive. This was done by designing a 3-armed study: (I) daily text message + weekly adherence feedback + financial incentive; (II) daily text message + weekly adherence feedback; and (III) control (still had electronic monitoring via the Propeller Health device but could not access feedback). The financial incentive was up to a maximum of 1 US dollar per day ($0.25 per puff for children prescribed 4 daily doses and $0.50 per puff for children prescribed 2 daily doses).

The experimental phase lasted for 3 months, followed by a 3-month active observation phase during which the interventions ceased but adherence monitoring continued. There was then follow up for 1 year post randomisation to collect clinical data.

The study outcome measures were:

• Adherence to inhaled corticosteroid (ICS) (observed to prescribed ratio) during the experimental phase;
• Adherence to ICS (observed to prescribed ratio) during the observation phase;
• Clinical: asthma-related health care use (i.e., number of exacerbations) and difference in children’s Asthma Control Test (cACT) score.

There were 106 children randomized into the study, with a total of 99 participants included in the statistical analyses, i.e., 40 active control, 38 in the full intervention and 21 hybrid intervention). The results showed that patients enrolled in the full intervention arm (i.e., including financial incentive) had 15% [95% confidence interval (CI): 2–29%]; higher adherence during the experimental phase when compared with the active control. Adherence with the full intervention exceeded 60% at one month post initiation of the intervention while the other two treatment modalities returned equivalent figures of less than 50%. However, during the post intervention observation phase, when the reminders and the financial incentives ceased, there was no significant difference in adherence between the two intervention groups or when compared with the control group. At this stage the difference in adherence data between participants in the full intervention group when compared with participants in the active control was −6% (95% CI: −21% to 8%).

There were no statistically significant differences in any of the clinical measures in the year following randomisation (hospital admissions, emergency department visits, courses of oral steroids) or change in cACT score from baseline to the end of the study between the study groups.

Discussion

This new study adds to our knowledge within the field of adherence to asthma medication in children. From a methodological perspective, the active control group (monitoring only) allowed the researchers to establish a baseline (while controlling for the Hawthorne effect) to compare the effect of the two levels of intervention. The authors, however, highlight the fact that the active control group had adherence monitoring in place as a limitation of their study. This latter intervention alone has been shown to improve adherence in previous research (7). The hybrid intervention (reminders and feedback but no financial incentive) was a useful approach to isolate the impact of the financial incentives used within the full intervention.

The results are consistent with recent work in this area, demonstrating that reminders and feedback can improve adherence (19,20) and that financial incentives, even modest, can improve adherence (16,17). As was the case in previous studies, however, the improvements are short lived and only occur while the intervention is taking place. In fact, during the observation period (when the interventions had ceased), there was a sharp decline in adherence within the financially incentivized (intervention) group to the point where adherence appeared better within the control group. While it would be inaccurate to infer this means the intervention is harmful in the longer term, it does illustrate the fickle nature of financial incentives.

Currently it seems that effective adherence interventions in childhood asthma do not have a sustained effect, with asthma control lapsing once the intervention has been withdrawn (inhaler usage declines and technique deteriorates). This means that the adherence interventions will need to be reapplied intermittently and that this latter frequency is likely to differ for different interventions. The continuous or indeed intermittent implementation of a financial incentive may not be feasible or acceptable to funders. If a child or young person continues having acute asthma attacks, a biologic may have to be started with the therapy administrated by the healthcare provider.

Future directions

It is clear from this commentary that additional research is required in this specific area of incentives. Since their impact is not long-lasting, aspects that need further consideration include: the size of the incentive, positive or negative incentives, the duration of the incentives and how frequently they need to be repeated and who would fund incentives in the longer term. Furthermore, research studies to date have largely focused on improving use of ICS inhalers. This is particularly pertinent since recent changes to Global Initiative for Asthma (GINA) guidance have focused on moving towards anti-inflammatory and reliever therapy/maintenance and reliever therapy (AIR/MART) regimes of combination inhalers (inhaled corticosteroid/long-acting beta agonist) (21). While a personalized asthma action plan, for those on MART (not AIR alone) should still recommend regular twice daily inhaled steroids as maintenance therapy, the flexibility around multiple doses of the combination inhaler may in the future lead to a fundamental shift in prescribing practice and with that what will be considered appropriate frequency of inhaler use. The authors of the paper at the centre of this review acknowledge this change in practice and consider that the immediate therapeutic feedback a patient receives from a combination inhaler (i.e., they find it easier to breathe) compared with a steroid only inhaler, may in itself improve adherence, an effect which has been shown in adult studies (22) but not yet in children’s asthma. In the face of the changing climate of AIR/MART, what will optimal care of asthma in children look like? This may need to be re-defined and this redefinition will shape future clinical trials on adherence to asthma management plans in children.

It is likely that inhaler use will be central to the care of the majority of children with asthma for many years to come. As most studies to date have only considered frequency of inhaler use in determination of adherence, future research studies should specifically include an evaluation of inhaler technique (as part of a comprehensive assessment of medication adherence) and also focus on approaches which result in sustained improvements to adherence rather than short term solutions. Aspects of the timing of interventions e.g., duration of interventions and intervals between repetitions of interventions which have a short-term impact, should also form part of future research.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Pediatrics. The article has undergone external peer review.

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0100/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0100/coif). Following their research work at Queen’s University Belfast, M.D.S. and J.Mc.E. are involved in the commercialisation of vDOT in the UK. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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