Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)

Graduate Group


First Advisor

Alison M. Buttenheim


Financial incentives directed to patients for health-related behavior change are promising interventions to improve health. Understanding stakeholders’ perceptions of the acceptability of financial incentives is essential for implementation. The proposed inquiry is a qualitative study that addresses two aims: 1) Explore nurse practitioners’ perceptions of the acceptability of financial incentives for health-related behavior change in primary and specialty care, and 2) Characterize how nurse practitioners’ perceptions of the effectiveness of financial incentives for health-related behavior change shape perceptions of acceptability, including the benefits and burdens. This inquiry uses an abductive approach to anchor analytic claims and develop a coherent explanation that best fits the data. Using purposive sampling with snowball techniques, a sample of 30 NPs was recruited from Penn Medicine. Participants reviewed 3 vignettes on financial incentive programs developed from clinical studies in the NIH Research Portfolio Online Reporting Tool, then participated in semi-structured interviews to explore their perceptions of financial incentive acceptability. The abductive analysis generated 5 themes, each of which included subthemes. In Facilitating Health Outcomes, participants identified needing more tools to help their patients, favoring incentives for health promotion and preventative care, making a difference amidst major financial challenges, and spurring engagement and accountability for health. In Compromising Relational Norms, participants expressed concern that incentives could erode trust within the nurse practitioner-patient relationship, shift care delivery to a transactional exchange, push patients toward decisions not aligned with their wishes, and cause harm. Participants suggested that education should not be divorced from incentive interventions and implicit messages matter in their Firm Provisos. Implementation Preferences revealed preferences for third party administrators and specifics related to the timing of the incentive offer. Lastly, participants highlighted that Demonstrable Effectiveness is Important when considering incentives’ acceptability. Participants often equated effectiveness with sustainability, associated effectiveness with perceived ethicality, and identified research data as a mitigator of ambivalence. The findings suggest that incentives’ complexity is not limited to their specific design features but also inclusive of embedded ethical considerations. Modifying design features alone may not impact acceptability. These insights generate future directions for investigation within behavioral economics, implementation science, bioethics, and nursing.


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