Background Novel strategies are urgently needed to reduce gaps in the tuberculosis (TB) cascade of care. While patient centered interventions like cash transfers are increasingly recognized as a crucial approach for improving TB outcomes, data to support acceptable incentive intervention design that maximizes their utility are limited. We assessed attitudes and perceptions as well as willingness-to-accept (WTA) varying incentive structures for completing TB diagnostic evaluation among patients in Uganda.
Methods We surveyed 177 adult patients undergoing TB evaluation at 10 community health centers in Uganda between September 2018 and March 2019. We collected household sociodemographic information and assessed attitudes and perceptions of incentives. We conducted a willingness-to-accept experiment assessing willingness to complete TB diagnostic evaluation in exchange for incentives ranging in value from 500 Ugandan Shillings (USh) to 25,000USh (~$0.15-6.75USD). We compared associations between willingness-to-accept and patient characteristics using ordered logistic regression.
Results Participants’ willingness to return to the health center to complete TB diagnostic evaluation increased proportionally with incentive amount. The median participant had a WTA amount between 2,000 and 5,000 USh. Cash (52%) and transportation vouchers (34%) were the most popular incentive types. Half of respondents preferred unconditional incentives, but for a multi-day evaluation 84% preferred conditioning the incentive upon clinic return. In multivariate models we found the pairwise difference between the third income quartile and the reference (lowest) income quartile (aOR=2.38, 95%CI: 1.20-4.69; p=0.01), younger age, and difficulty returning to the health center to be significantly associated with willingness to accept higher incentive thresholds.
Conclusions In Uganda, incentives such as cash transfers or transportation vouchers are an acceptable intervention for facilitating adherence to TB diagnostic evaluation. Household income is associated with preferred incentive structure and amount, especially for those at the cusp of the poverty threshold, who are more likely to prefer unconditional and higher valued incentives. Targeted and context-specific socioeconomic supports for at-risk patients are needed to optimize outcomes.