POP - FOFFARNUS,M.(2013) - Monetary Incentivies to Reinforce and Achievement in a Job-skills Program for Homeless (Pop!!)

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MONETARY INCENTIVES TO REINFORCE ENGAGEMENT AND ACHIEVEMENT IN A JOB-SKILLS TRAINING PROGRAM FOR

HOMELESS, UNEMPLOYED ADULTS

MIKHAIL N. K OFFARNUS, CONRAD J. W ONG, MICHAEL FINGERHOOD,

D ACE S. SVIKIS, GEORGE E. BIGELOW , AND K ENNETH SILVERMAN JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE

The current study examined whether monetary incentives could increase engagement andachievement in a job-skills training program for unemployed, homeless, alcohol-dependent adults.Participants (n ¼ 124) were randomized to a no-reinforcement group (n ¼ 39), during whichaccess to the training program was provided but no incentiveswere given; a training reinforcementgroup (n ¼ 42), during which incentives were contingent on attendance and performance; or anabstinence and training reinforcement group (n ¼ 43), during which incentives werecontingent onattendance and performance, but access was granted only if participants demonstrated abstinencefrom alcohol. abstinence and training reinforcement and training reinforcement participants

advanced further in training and attended more hours than no-reinforcement participants.Monetary incentives were effective in promoting engagement and achievement in a job-skillstraining program for individuals who often do not take advantage of training programs.

Key words: therapeutic workplace, homeless, alcohol abuse, job-skills training, poverty,monetary incentives

In a recent analysis of major social andbehavioral risk factors, poverty (


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beneficial effect (Magura, Staines, Blankertz, &Madison, 2004). More intensive interventions toaddress poverty that include an educational or training component are effective for those who

participate regularly, but most low-incomeindividuals do not participate regularly in suchinterventions and therefore receive no measurablebenefit (Bos et al., 2002; Hamilton, 2002).

Monetary incentives have been shown tofunction as effective reinforcers to promote a

wide variety of positive health-related behaviors when they are delivered contingent on verificationof that behavior. For example, incentives have beenshown to promote abstinence from alcohol and

other drugs (Higgins, Silverman, & Heil, 2008;Silverman, Kaminski, Higgins, & Brady, 2011),medication adherence (Rounsaville, Rosen, &Carroll, 2008), weight loss (Volpp et al., 2008),and use of preventive dental care (Riccioet al., 2010). Preliminary evidence suggests thatincentives may also be effective in promoting attendance in a job-skills training program (Silver-man, Chutuape, Bigelow, & Stitzer, 1996). Deliv-

ering a portion or all of an employee’s pay based on work output is also known to increase productivity,provided that the performance pay is deliveredcontingent on the desired behavior (Bucklin &Dickinson, 2001; Koffarnus, DeFulio, Sigurdsson,& Silverman, 2013).

The delivery of monetary incentives contin-gent on desirable health behavior is rooted in a firm basic science foundation on the effects of reinforcement (Catania, 2007). The benefits of

attending a job-skills training program (e.g.,increased chance of employment, reduction inpoverty), as with the consequences of many positive health behaviors, are often delayed.Delayed outcomes exert relatively little controlover behavior (Bickel & Marsch, 2001). Imme-diately available reinforcers, such as monetary incentives, can much more readily promotepositive behavior than delayed health gains.

This is especially true for people of low socioeconomic status or alcohol-dependentadults, because these populations undervalue

delayed outcomes to a greater extent (Bobova,Finn, Rickert, & Lucas, 2009; Green, Myerson,Lichtman, Rosen, & Fry, 1996; Mitchell, Fields,D’Esposito, & Boettiger, 2005; Petry, 2001).

Given the large impact of poverty on quality-adjusted life years and the staggering medicalcosts of the problematic health outcomesassociated with poverty, monetary incentives topromote attendance and performance in pro-grams that reduce the incidence of unemploy-ment or underemployment could be justified.

The current study extends previous work onmonetary incentives for positive health behaviorsand performance pay for workplace productivity

by examining the use of monetary incentives topromote engagement and performance in a job-skills training program for homeless, unem-ployed, alcohol-dependent adults. The currentstudy used the therapeutic workplace model thatprovides access to job-skills training contingenton desirable behaviors such as drug abstinence(Silverman, 2004; Silverman, DeFulio, &Sigurdsson, 2012). Based on the interests and

skills of participants in the early therapeutic workplace research (Silverman, Chutuape, Svikis,Bigelow, & Stitzer, 1995), the therapeutic

workplace was designed to teach participantsskills that would be useful in office jobs,including typing and computer use. Importantly,our early research showed that participants foundthe therapeutic workplace typing and keypadtraining to be “interesting,” “enjoyable,” “chal-lenging,” and “helpful” (Silverman et al., 1996).

This report describes a secondary analysis of data collected during a randomized controlled clinicaltrial that evaluated the effectiveness of thetherapeutic workplace in promoting abstinencefrom alcohol in homeless, alcohol-dependentadults (Koffarnus et al., 2011). We invited allparticipants to attend and receive training to learnbasic computer skills, and we examined the effectsof the different payment contingencies on engage-

ment and acquisition of job skills in the job-skillstraining program. The unique design of this study allowed us to control payment contingencies and

INCENTIVES FOR JOB-SKILLS TRAINING 583


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manipulate whether participants received paymentor experienced the more typical situation of unpaid

job-skills training, isolating the payment contin-gencies for analysis. We expected that the groups

who received incentives for attendance and goodperformance on the training programs wouldattend more hours and would progress further onthe training programs than the group who did notreceive the monetary incentives.

METHOD

The primary outcome variable of this ran-domized clinical trial to promote alcohol absti-

nence was alcohol use. That outcome anddetailed methodology that met the ConsolidatedStandards of Reporting Trials (CONSORT)criteria for complete clinical trial descriptionhave been reported elsewhere, and portions of ithave been reproduced here for reference (Kof-farnus et al., 2011).

Setting and Participant Selection

The Johns Hopkins Institutional Review Board approved this study. All sessions wereconducted at the Center for Learning and Health,a treatment-research unit at the Johns HopkinsBayview campus. We enrolled participants fromDecember 2001 to October 2005. Study inclu-sion criteria required that participants werehomeless, were unemployed, were at least 18 yearsof age, and met DSM-IV criteria for alcoholdependence. Participant characteristics by study

group are shown in Table 1.

Design and Description of Study Groups

We randomly assigned eligible participants toone of three experimental groups after stratifying on a number of key alcohol- and drug-usevariables: the no-reinforcement (n ¼ 39), train-ing reinforcement (n ¼ 42), or abstinence andtraining reinforcement (n ¼ 43) groups. Note

that in our previous report on this study (Koffarnus et al., 2011), we referred to groupsas “unpaid” instead of “no reinforcement,” “paid”

instead of “training reinforcement,” and “contin-gent paid” instead of “abstinence and training reinforcement.” We invited participants assignedto the no-reinforcement group to receive training

independent of their breath sample results, andthey did not earn monetary vouchers for their participation in the workplace. This condition issimilar to typical training programs for low-income and unemployed adults (Bos et al., 2002;Hamilton, 2002). Participants in the training reinforcement group could earn an hourly wagein vouchers for attending the workplace andadditional productivity pay for performance onthe training programs. These participants were

allowed to work and earn vouchers independentof whether their breath samples were positive for alcohol. Participants in the abstinence andtraining reinforcement group received training and payment similar to participants in thetraining reinforcement group, but access to the

workplace and the opportunity to earn voucher pay was contingent on the alcohol content of their breath samples. An abstinence and training

reinforcement participant who provided analcohol-positive (0.004 g/dl) breath sample was not permitted access to the workplace onthat day and received a temporary decrease in pay on subsequent days (see below).

Therapeutic Workplace and Training Programs

All participants were invited to receive training in a specialized program called the therapeutic

workplace for 4 hr every weekday throughout a

26-week intervention period, and were requiredto provide breath samples under observation that

were tested for alcohol (see Koffarnus et al., 2011,for a description of breath sample collection andobtained results). The therapeutic workplacetraining program is delivered via a web-basedapplication that allows staff to administer andelectronically monitor treatment and training for each trainee. Aspects of the treatment most

relevant to the keyboard training are describedbelow in detail. Other details of the web-basedtherapeutic workplace treatment are described

584 MIKHAIL N. KOFFARNUS et al.


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in detail elsewhere (Silverman et al., 2005,2007).

In the workplace, participants were taughtkeyboard skills using two computer-based train-ing programs (see Dillon, Wong, Sylvest, Crone-Todd, & Silverman, 2004, for a detaileddescription of the training programs). Onetraining program, typing, taught participants tobecome proficient at using a standard QWERTY keyboard. Trainees were presented with a series of characters, and were required to key an identicalstring of characters. Characters that matched the

criterion characters were considered correct, withmismatched characters or omissions consideredincorrect. After 1 min of keying (a timing), thenumber of incorrect and correct characters weredisplayed on the participant’s screen along withany earnings for those characters. Participantscould then initiate another 1-min timing. Theprogram was arranged in a series of steps, witheach step focusing on a small number of new

characters that hadn’t previously been trained.These steps were intermixed with additional stepsthat focused on proficiency, and required trainees

to key previously learned characters at increasedrates. A second program, keypad, was similar to

the typing program but was designed to trainrapid entering of characters on a numeric keypad.Trainees worked on the training programs for 2 hr in the morning (10:00 a.m. to 12:00 p.m.) andfor 2 hr in the afternoon (1:00 p.m. to 3:00 p.m.).

Monetary Incentives

Participants in the abstinence and training reinforcement and training reinforcement groupscould earn an hourly wage as well as pay for

performance on the training programs. Allearnings were paid in monetary vouchers that

were automatically added to each participant’svoucher account and displayed on the partic-ipant’s computer screen. Voucher earnings wereexchangeable for goods and services in thecommunity that were purchased for participantsby staff (e.g., gift cards, rent, utility payments).

Base pay. Hourly base pay began at an initial

low rate of $1.00 per hour and increased by $0.10to a maximum of $5.00 per hour for each day a participant arrived on time (i.e., 10:00 a.m.) and

Table 1

Participant Characteristics by Study Group

Abstinence andtraining reinforcement

(n ¼ 43)

Training reinforcement

(n ¼ 42)

No reinforcement

(n ¼ 39)

p value

(Fisher ’s exact test)

p value

(F test) Age, mean (SD) 42.0 (8.5) 45.2 (8.0) 43.0 (7.6) .19Gender, % male 79.1 81.0 82.1 .96Race, % .06

White 62.8 42.9 43.6Black 37.2 50.0 56.4Other 0 7.1 0

Married, % 0 0 2.6 .31High school diploma or GED, % 65.1 59.5 61.5 .87Usually unemployed past 3 years

prior to intake, %93.0 97.6 92.3 .85

DSM IV diagnosis, % Alcohol dependence 100 100 100

Cocaine dependence 34.9 33.3 35.9 .97Opioid dependence 20.9 11.9 28.2 .19 WRAT3

Grade level reading, mean (SD ) 8.7 (4.0) 8.7 (3.9) 8.4 (4.2) .92Grade levels spelling, mean (SD ) 6.8 (3.8) 6.8 (3.7) 7.3 (4.0) .80

Note. Adapted from Koffarnus et al. (2011).



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completed a work shift (3.5 of 4 hr inattendance). The base pay rate was reset to$1.00 per hour if the participant failed tocomplete a work shift, or arrived late to the

workplace (training reinforcement and absti-nence and training reinforcement groups). Basepay was also reset for abstinence and training reinforcement participants if a breath sample waspositive or missed. Once the base pay hourly rate

was reset, it increased again by $0.10 per hour for each day the participant met the attendance andabstinence requirements. After 9 consecutivedays of meeting each of the requirements, basepay was restored to the value in place before the

reset. Productivity pay was not affected by a reset.To allow for some flexibility, participants startedtraining with credits of 5 late-not-reset days and 5personal days. In addition, participants earned 1late-not-reset day for every 10 completed work shifts and 1 personal day for every five completed

work shifts. Participants could use late-not-resetor personal days to prevent a reset for being late or failing to work a complete work shift,

respectively.Productivity pay. Training reinforcement andabstinence and training reinforcement partici-pants were able to earn additional voucher pay for performance on the training programs. First,participants could earn and lose voucher money for correct and incorrect characters, respectively.Second, participants could earn bonuses for eachstep they passed. On most steps, participantsearned $0.03 for every 10 correct characters and

lost $0.01 for every incorrect character. Thebonuses began at $1.00 and increased in value astrainees progressed through the program.

Outcome Measures

Participants were invited to attend thetherapeutic workplace for a 26-week period,but due to the differential occurrence of holidaysand other closings during individual participants’

enrollment in the trial, this 26-week periodcontained different numbers of work days for individual participants. The number of days the

therapeutic workplace was open for any partici-pant ranged from 108 to 131 days. Because many of the outcome variables were biased by totalavailable training time, all analyses for all

participants were restricted to the first 108 daysof possible attendance.

As a measure of obtained skills, steps achievedon the typing and keypad programs were a primary outcome measure, as was the total stepsachieved across both keying programs. Totalcumulative hours attended was a measure of engagement, and number of steps completed per hour was a rate measure of skill attainment.

Amount of time on task was measured by

calculating the number of 1-min timings per hour that were initiated while in the workplace. Keying speed was measured in two ways: characters typedper timing initiated as a measure of speed whileon task, and characters typed per minute in the

workplace as a measure of overall productivity inthe workplace. Keying accuracy was also exam-ined by calculating the percentage correct (correctcharacters keyed divided by the sum of correct

and incorrect characters keyed) on the typing andkeypad programs individually, as well as an overallcombined accuracy.

Data Analysis

Categorical participant characteristics werecompared with Fisher ’s exact tests, and continu-ous variables were compared with one-way

ANOVAs. Levene’s median test was used todetermine whether group variances were suffi-

ciently similar to conduct one-way ANOVAs for each outcome measure. For the outcomes thatpassed Levene’s median test, one-way ANOVAs

were conducted to look for a group effect, andsignificant results were followed with Tukey ’sposthoc tests on all group pairings. For the measuresthat did not pass Levene’s median test and theordinal steps achieved measures, nonparametricKruskal-Wallis ANOVAs were conducted, and

significant results were followed with Dunn’s posthoc tests on all group pairings. Levene’s mediantests, Fisher ’s exact tests, and one-way ANOVAs



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were carried out in SPSS 17.02, and Kruskal- Wallis ANOVAs were conducted in Prism 5.03.For all inferential statistical tests, a was set to0.05. For each outcome measure we also

calculated the probabilistic index [P ð X > Y Þ],or the probability that a randomly selectedindividual from an experimental (abstinenceand training reinforcement or training reinforce-ment) group showed greater performance than a random individual from the control (no-rein-forcement) group as a measure of effect size(Acion, Peterson, Temple, & Arndt, 2006). Thismeasure ranges from 0 (experimental groupuniversally lower performance than control) to

1 (experimental group universally greater perfor-

mance), with.5 indicating no difference betweenthe groups.

RESULTS

Overall productivity, as measured by stepscompleted on the training programs, wassignificantly higher in the abstinence and training reinforcement and training reinforcement groupsthan in the no-reinforcement group (Table 2).This was true for the typing and keypad programsindividually, as well as for the overall total stepscompleted (Figure 1, top). The abstinence andtraining reinforcement and training reinforce-

ment groups did not differ from one another on

Table 2

Group Means or Medians for Each Outcome Measure and the Results of Anovas and Post Hoc Tests Comparing

Study Groups

Group means or mediansa ANOVA resultsa P ð X > NoV oucher Þb

Abstinence andtraining

reinforcementTraining

reinforcementNo

reinforcement F or H df p value

Abstinence andtraining

reinforcementTraining

reinforcement

Overall steps achievedc

91

88

10.5 13.4 2 .001 .71 .70Typing steps achievedc 49 48 9 12.2 2 .002 .70 .69Keypad steps achievedc 42 42 3 17.9 2


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any of these measures. The abstinence andtraining reinforcement and training reinforce-

ment groups also attended the workplace for a significantly longer total duration than the no-reinforcement group (Table 2, Figure 1, bottom).

Although the abstinence and training reinforce-ment group attended somewhat less than thetraining reinforcement group, this difference wasnot significant. The rate of step completion whilein the workplace did not differ as a functionof group.

Certain aspects of training performance weregreatest in the abstinence and training reinforce-ment group (Table 2). The number of 1-min

timings initiated per hour in the workplace wassignificantly greater in the abstinence andtraining reinforcement group compared to theno-reinforcement group, with the training

reinforcement group initiating an intermediatenumber of timings (Figure 2, top). Groupassignment did not affect typing speed whileon task, as shown by the similar number of characters typed per 1-min timing initiated in thethree groups. Likely as a result of the greater number of initiated timings, overall charactersper minute in the workplace was significantly greater in the abstinence and training reinforce-ment group compared to the no-reinforcement

Figure 1. Total steps achieved (top) and total hoursattended (bottom) for each of the three groups. Individualpoints represent individual participants, and horizontal barsindicate the median values for the group. Asterisks indicatesignificant differences between groups with Dunn’s post hoctests ( p


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group, with the training reinforcement groupkeying at an intermediate rate. Payment contin-gencies also affected accuracy. The abstinence andtraining reinforcement group tended to have

somewhat higher rates of accuracy than the no-reinforcement group, and this trend was signifi-cant for overall accuracy (Figure 2, bottom)and typing accuracy. The training reinforcementgroup had intermediate accuracy rates that werenot statistically different from either of theother groups.

DISCUSSION

Overall, the results confirm the benefit of payment contingencies in increasing achieve-ment in a job-skills training program, engage-ment in a job-skills training program, andperformance quality while on task in a job-skillstraining program. This is most clearly evidencedby the overall achievement of the two groups whoreceived paid training, in that the abstinence andtraining reinforcement and training reinforce-

ment groups completed a median of 91 and 88steps, respectively, and the no-reinforcementgroup completed just 10.5 (Table 2, Figure 1,top). In addition, rate of timing initiation, keying speed, and accuracy were higher in the abstinenceand training reinforcement group than in the no-reinforcement group. The training reinforcementgroup had intermediate values for each of thesemeasures, which may have been due to the greater alcohol use in this group compared to the

abstinence and training reinforcement group(Koffarnus et al., 2011). These results confirmand expand on a growing literature demonstrat-ing the effectiveness of monetary incentives toreinforce a wide range of desirable behaviors (seeHiggins et al., 2008, for a review). Much of the

work in this area has focused on reinforcing abstinence in substance users. Although wefocused on abstinence from alcohol in the current

study (see Koffarnus et al., 2011), the currentstudy demonstrates that monetary incentives areeffective at increasing other desirable behaviors

such as job-skills training performance either inconjunction with (abstinence and training reinforcement group) or independent of (training reinforcement group) abstinence contingencies.

Governments increasingly have supported theuse of monetary incentives as a way to promotehealthy behavior patterns among citizens (Riccioet al., 2010). Given the seriousness of poverty as a public health problem, arranging an incentiveprogram to promote attendance and performancein job-skills training programs may be an effective

way of addressing poverty. Incentives deliveredcontingent on attendance and performance in

job-skills or educational programs would not only

work to alleviate poverty by delivering monetary vouchers to people who could benefit from them,but would have the additional benefit of promoting attendance, performance, and skillacquisition in the training program. Therefore,such an intervention has the potential to addressboth short-term poverty through incentivesdelivered in the context of the intervention andlong-term poverty by addressing one of the major

underlying causes of poverty: lack of sufficienteducation or job skills to gain and maintainemployment.

The current study is limited by the relatively narrow focus of the job-skills training (i.e., totyping and keypad training) and by the fact that

we did not show whether training producedchanges in the employability or employment of participants. It will be important to determine if incentives can be used to promote engagement

and progress in a more comprehensive educationand training program and if that training improves the employment of participants. Italso remains to be seen whether incentives andtraining can produce meaningful changes in thelives of low-income unemployed adults by promoting employment and reducing poverty.

Monetary incentives may not be necessary for all individuals in poverty who could benefit from

job-skills training. In the current experiment, a subset of individuals in the no-reinforcementgroup attended the workplace regularly and made



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substantial progress on the training programseven though they received no monetary incen-tives for doing so (see Figure 1, top). Theseindividuals may be sufficiently motivated by

other factors alone (e.g., skill acquisition).However, participants in the no-reinforcementgroup who chose to attend regularly were few innumber, and this experiment makes clear theneed for an additional motivational factor topromote engagement and performance in themajority of this sample of homeless, unemployed,alcohol-dependent adults. For individuals inpoverty, monetary incentives effectively servethis purpose.

Intensive capital investment programs topromote employment in low-income populationshave attempted to provide basic and job-skillstraining to establish skills that individuals willneed to succeed in the workplace (Boset al., 2002; Hamilton, 2002). These programshave been relatively ineffective, in part becauseeligible individuals fail to attend the programssufficiently to acquire needed skills (Bos

et al., 2002; Hamilton, 2002). This study showsthat monetary incentives for both attendance andperformance on training programs can be highly effective in engaging low-income, unemployedindividuals in training and increasing their skillacquisition. The use of incentives in adulteducation programs could be a critical compo-nent in an intervention to reduce poverty andimprove health in low-income, unemployedpopulations.

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Received June 25, 2012 Final acceptance March 8, 2013

Action Editor, Jennifer Zarcone

http://www.mdrc.org/toward-reduced-poverty-across-generationshttp://www.mdrc.org/toward-reduced-poverty-across-generationshttp://www.mdrc.org/toward-reduced-poverty-across-generationshttp://www.mdrc.org/toward-reduced-poverty-across-generations

Documents

POP - FOFFARNUS,M.(2013) - Monetary Incentivies to Reinforce and Achievement in a Job-skills Program for Homeless (Pop!!)