Unconditional cash transfers to improve health behaviors among primary care patients: A qualitative sub-study of a randomized clinical trial

Unconditional cash transfers are a popular poverty reduction approach and may influence behavioral risk factors for chronic disease outcomes through economic and psychological pathways. Few studies have used qualitative interviews to identify the mechanisms through which cash transfers delivered in a health care context might influence the health of people living with chronic diseases in the United States. We conducted a pilot randomized controlled trial to identify pathways through which unconditional cash transfers may influence health and assess the acceptability and feasibility of such an intervention among low-income patients receiving treatment for hypertension or diabetes. Inclusion criteria were: ≥1 visit at the Penn Family Care clinic within the six months prior to study start, ≥18 years of age, Pennsylvania Medicaid beneficiary, diagnosis of pre-diabetes or diabetes, and/or hypertension, prescribed ≥1 oral medication for diabetes or hypertension, and no plans to leave the Philadelphia metro area. Participants were randomized to either the standard of care or an unconditional cash transfer intervention, and completed an assessment at enrollment and after 12 weeks of study participation. We enrolled 100 participants from 3/2023-8/2023 and 93 attended the follow-up visit. Thirty-four participants (selected randomly) completed qualitative interviews. The interviews and survey data revealed that cash transfers were primarily used to address basic needs. We identified potential pathways through which cash transfers may improve health, including temporary reductions in stress and anxiety, changes in diet and physical activity, improved medication adherence, and increased healthcare seeking behavior. The intervention itself was viewed as highly acceptable. Participants in the control group were disappointed not to receive the intervention, but felt the process was fair because all participants were economically vulnerable. These findings suggest unconditional cash transfers may improve health for patients with chronic diseases through a variety of pathways that should be measured in future trials.