PAYING ADOLESCENTS FOR HEALTH

SCREENINGS WORKS
MARTIN HALLA
GERALD J. PRUCKNER
THOMAS SCHOBER

ABSTRACT
With regard to their future health, adolescents are at a critical stage. Previous evaluations
have shown that health screenings, counseling, and other intervention programs during
this phase of life are important, particularly for those with a low socioeconomic back-
ground. Unfortunately, adolescents tend to have little interest in preventive programs.
We designed a field experiment to evaluate the effectiveness of financial incentives to pro-
mote participation in health screenings. Our study comprises more than 10,000 partici-
pants, observed via high-quality administrative data from Austria. The treatment group
received a €40 shopping voucher if they participated in an age-specific health screening.
On average, the financial incentive increased the likelihood of participation by 280 percent.
Treatment effects are comparably larger for children in families with a higher socioeco-
nomic status, and of parents with a revealed preference for secondary health prevention.

K E Y W O R D S : health screenings, financial incentives, adolescence, early intervention,

secondary prevention
J E L C L A S S I F I C A T I O N : H51, H75, I12, I14, I18, J13

I. Introduction
Adolescence and puberty are marked by important physiological and psychological changes.
Particularly during these turbulent periods, young people face choices with potential conse-
quences for their future health and human capital. A healthy lifestyle, positive social influ-
ences, and educational achievements affect current health, schooling, and family life, but
they also co-determine adult outcomes (Van den Berg et al. 2014). In high-income countries,
the vast majority of adolescents are healthy by traditional medical standards, but they face a
number of significant threats to their health in this phase of life. This age group is at partic-
ular risk of starting smoking tobacco, alcohol, and drug abuse, experiencing self-harm and
interpersonal violence, and engaging in unprotected or nonconsensual sex. These behaviors
have an impact on the trajectory of life and contribute to adult morbidity and mortality.

Martin Halla, Johannes Kepler University Linz; IZA; Christian Doppler Laboratory Aging, Health, and the
Labor Market; and GÖG, Austrian Public Health Institute. Gerald J. Pruckner, Johannes Kepler University
Linz and Christian Doppler Laboratory Aging, Health, and the Labor Market. Thomas Schober (correspond-
ing author, [email protected]), Johannes Kepler University Linz; Christian Doppler Laboratory Ag-
ing, Health, and the Labor Market; and Auckland University of Technology.

Electronically published September 19, 2022.

American Journal of Health Economics, volume 8, number 4, fall 2022.

© 2022 American Society of Health Economists. Published by The University of Chicago Press for the
American Society of Health Economists. https://doi.org/10.1086/721571
 Paying Adolescents for Health Screenings Works // H A L L A ET AL.

Longitudinal studies demonstrate that this period is also an age of opportunity that can
help adolescents to break early patterns that may lead to ill health and social disadvantage
(Richter 2006). Interventions such as guidance on a healthy lifestyle, support from family
and school, and access to supportive services are recommended to promote adolescents’
well-being. Medical advice in the field of primary prevention and the early recognition of
potential health deficits are important instruments of health promotion at this age. More-
over, the use of medical counseling and participation in secondary health screenings may
generate benefits for adult well-being, and even the next generation of children. Hendren
and Sprung-Keyser (2020) demonstrate that direct investments in low-income children’s
health have historically had the highest return among a large number of US tax and expen-
diture policies.1
The American Academy of Pediatrics (AAP) currently recommends an annual preven-
tive visit for adolescents and young adults through age 21 (AAP 2021). While there is a wide
variation in estimated preventive visit rates for the US (ranging from 25 to 81 percent; see
Online Appendix Table A.1) and other countries (see Online Appendix Table A.2), it is clear
that a significant share of adolescents do not follow AAP’s recommendation. Those with low
socioeconomic background are less likely to receive a preventive care visit in the United
States (Yu et al. 2001; Irwin et al. 2009) and abroad (see, for instance, for Germany, Hagen
and Strauch 2011).
One possibility to increase participation in health screening exams is offering financial
incentives. To evaluate this strategy, we performed a field experiment with more than 10,000
adolescents observed using high-quality administrative data from Austria. Our randomized
controlled trial was conducted in cooperation with an Austrian statutory health insurance
provider.2 The screening examination itself, referred to as the Health Check Junior (HCJ),
is free of charge. It comprises a detailed anamnesis, including a general health check and ex-
tensive medical advice on age-specific health risks and lifestyle issues. This setup has several
methodological advantages. First, we could draw our participants from a well-defined and
accessible subject pool. Second, we have access to administrative records, which allow us
to observe participants before and after treatment. Thus, we have precise information on
outcomes, and we are able to generate rich control and stratification variables. Third, the
health screenings are offered in a standard outpatient setting by contracted primary-care
physicians. We were able to measure our outcome variable, screening participation, without
any extra effort and free of error.
The treatment group was offered a €40 shopping voucher for participation in an age-
specific health screening program. The control group received an equivalent invitation, but
without a financial incentive. Our results revealed a statistically significant treatment effect
of 6.7 percentage points (pp). Relative to the low participation of 2.4 percent in the control
group, the treatment effect represents an increase of 280 percent. We find evidence for

1 Importantly, the return to health policies (captured by the so-called marginal value of public funds) is
constant across all ages (Hendren and Sprung-Keyser 2020), and does not diminish with age as previously
assumed (Heckman 2006).
2 Our partner, the Social Insurance Institution for Businesses (Sozialversicherungsanstalt der gewerblichen
Wirtschaft), provides compulsory health insurance for all self-employed people and their relatives.

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substantial treatment effect heterogeneity. The incentive was found to work significantly
better for children in families with a higher socioeconomic status (SES), and of parents
with a revealed preference for secondary health prevention.
Our findings add to a small body of literature. To date, there are only a handful of studies
on financial incentives for health screenings of adolescents. Evidence is available for specific
programs, such as treatment for latent tuberculosis infection (Kominski et al. 2007), HPV
vaccination (Mantzari, Vogt, and Marteau 2015), glucose monitoring adherence and glyc-
emic control (Wong et al. 2017), and HIV testing (Kranzer et al. 2018).3 There is comparably
more evidence for children (below the age of five)4 and adults,5 which demonstrates the ef-
fectiveness of financial incentives for secondary prevention.
The remainder of this paper proceeds as follows. Section II outlines the relevant institu-
tional background. Section III describes our experimental design and the collected data. Sec-
tion IV presents our estimated treatment effects, and Section V concludes the paper.

II. Institutional Setting

In this section, we briefly describe the relevant institutional setting. First, we provide gen-
eral information on the Austrian health-care system. Second, we discuss existing health
screening programs and introduce the new program for adolescents.

A . AUSTRIAN HEA LTH-CAR E SYS TEM

Austria has a Bismarckian-type health-care system with almost universal access to high-
quality medical services. Depending on occupation and place of residence, individuals are

3 Among these studies, only Mantzari, Vogt, and Marteau (2015) examine responses by SES. The authors
do not find evidence that the impact of financial incentives on HPV vaccination rates varies by social dep-
rivation (proxied by respondents’ postcode). Comparably more evidence is available based on observational
studies on large-scale policy initiatives. These find that low SES families are less aware of and participate less
in financially incentivized programs (see, e.g., Spence et al. 2010; Owen et al. 2020).
4 The majority of these studies are from low- and middle-income countries. Recent meta-analyses con-
clude that financial incentives are effective in increasing the use of preventive services (Lagarde, Haines,
and Palmer 2007; Bassani et al. 2013). Evidence from high-income countries is rare. One recent exception
is an evaluation of an Austrian developmental screening program for children at the ages of 2, 3, and 4 years
(Halla, Pruckner, and Schober 2016). A financial incentive of €185 increased the likelihood of participating
in all three examinations by about 46 percent. A smaller number of studies have tested financial incentives
for primary intervention. In particular, there is evidence on the effectiveness of financial incentives for the
consumption of fruits and vegetables at lunchtime in primary schools (Just and Price 2013; Belot, James,
and Nolen 2016; Loewenstein, Price, and Volpp 2016).
5 Evidence for adults is from high-income countries and available for chlamydia testing (Dolan and
Rudisill 2014), colorectal cancer screening (Gupta et al. 2016; Mehta et al. 2019), and fecal occult blood tests
(Kullgren et al. 2014). There are also a number of studies on financial incentives in the promotion of primary
prevention, such as breastfeeding (Relton et al. 2018), exercise (Charness and Gneezy 2009; Royer, Stehr,
and Sydnor 2015), nutrition (Mochon et al. 2017), smoking cessation (Volpp et al. 2009), weight loss (Volpp
et al. 2008; Jeffery 2012; Cawley and Price 2013), and comprehensive workplace wellness programs (Jones,
Molitor, and Reif 2019).

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assigned to one (out of 18) particular health insurance fund. Insurance is mandatory and
there is no choice regarding the insurance fund or package. All health insurance funds cover
almost all medical expenses, including medication, in the inpatient and outpatient sector.
The outpatient expenditures are funded by social security payments. Expenditures for hos-
pitalization are cofinanced by social security contributions and tax revenues from different
federal levels. Patients usually pay a prescription charge for medication, and a small deduct-
ible per day for hospitalization. Our study focuses on children of self-employed persons.
This group is insured with the Social Insurance Institution for Businesses (Sozialversi-
cherungsanstalt der gewerblichen Wirtschaft, SVA).6

B . E X I S T I N G H E A L T H S CR E E N I N G P R O G R A M S

Traditionally, the Austrian health-care system has offered two structured and nationwide
health screening programs. First, the so-called Mother-Child-Pass Examination Program
(MCPEP) has been advocated for pregnant mothers and their newborns. Over time, the
aim and scope of this program have expanded, and it now lasts until the 5th year of the
child’s life (Halla, Pruckner, and Schober 2016). Second, insurants beyond 18 years old
are offered a general health screening (Hackl et al. 2015). In both programs, screening ex-
aminations are conducted by primary-care physicians and fully covered by health insur-
ance funds. Until 2016, there was no screening program available for the 6- to 17-year
age group.7 Regardless, this age group also has very good access to primary care. Children
and adolescents can use the services of general practitioners and pediatricians at any time
without copayments. Whether and to what extent these services are used for preventive
purposes is, however, not documented.

C. NE W PR O G R A M : H E A LT H C H E C K JUN IO R
On October 1, 2016, the SVA introduced a nationwide health screening program for chil-
dren and young people between 6 and 17 years of age. The HCJ program closes the gap be-
tween the aforementioned nationwide screening programs. The medical examinations are
also conducted by primary-care physicians (general practitioners or pediatricians) and are
fully funded by the SVA.8 It distinguishes between a track for younger (6–11 years) and older
(12–17 years) participants, and the two tracks differ in content to account for age.
The aim of HCJ is to identify health risks in young people at an early stage, strengthen
health awareness, implement preventive measures in the event of unhealthy lifestyles, and

6 SVA merged after our sample period. As of January 1, 2020, the SVA and the Social Insurance Institution
for Farmers (Sozialversicherungsanstalt der Bauern, SVB) have been merged into the Social Insurance Insti-
tution for the Self-Employed (Sozialversicherungsanstalt der Selbständigen, SVS). In contrast to most other
Austrian health insurance funds, the SVA/SVS charges a 20 percent copayment for outpatient medical treat-
ment. Minors are exempt from this payment. There are no further important peculiarities.
7 The exception to this are school health checks during compulsory education. They include the child’s
medical history as reported by the parents and a physical examination by a school doctor with a focus on
the development status of the child or adolescent. However, the examinations are not centrally organized
and the data are not collected in a structured way.
8 In 2020, the honorarium for physicians amounts to €80.70 per HCJ examination.

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provide support in important developmental phases such as school enrollment or puberty.

The primary-care physician determines the health status of children and adolescents and
addresses the most relevant lifestyle issues for these age groups, such as nutrition, exercise,
media consumption, and substance abuse.9 Until now, the SVA (SVS) is the only health in-
surance fund that offers a screening program for this age group.

III. Field Experiment

Our randomized controlled trial was implemented during the pilot phase of HCJ. From
2013 until September 2016, the program was offered only in the federal states Burgenland
and Vienna.10 These two federal states comprise about one-quarter of the Austrian popu-
lation. In an attempt to test the effectiveness of a financial incentive for participation in this
new health screening program, the experiment was conducted in collaboration with the
SVA.

A . S A MP L E D E F IN I T I O N
The SVA register provided us with a well-defined and accessible subject pool. For our trial,
we selected all families with at least one child between 9 and 17 years of age.11 The principal
insured parent must have lived in the federal state of Vienna or Burgenland and have been
insured with the SVA at least from 2012 to 2014. Another inclusion criterion was positive
health-care expenditures in either 2012 or 2013. Conversely, families with a child whose
two-year health-care expenditures (2012 and 2013) were above the 98th percentile of
€8,378 were excluded. This provided us with a sample of 10,727 adolescents.

B . R A N D O MI Z A T I O N
Although program participation is basically a joint decision between parents and children,
depending on the age of the child, we reached out directly to those concerned. All adoles-
cents in our subject pool received an age-specific invitation letter via mail.12 This letter in-
troduced the new HCJ program and encouraged them to participate. It included an age-
appropriate explanation of the rationale for secondary prevention:

The great thing about preventive health screenings is that you don’t see the doctor
when you are sick, but before, when you are still healthy. This way you can help your
body not to get sick in the first place.

We randomly assigned approximately 38 percent of all children to the treatment group

(N 5 4,103), and 62 percent to the control group (N 5 6,624). The control group was
motivated only by the provided information. For the treatment group, the letter included

9 The medical examination form (translated from German) is included in Online Appendix Figure A.1.
10 In the meantime, the screening program has been extended to cover the whole of Austria.
11 We did not include children between 6 and 8 years since our focus is on puberty/adolescence.
12 The letters (translated into English) sent to young (9–11 years) and older (12–17 years) subjects are
included in Online Appendix Figures A.2 and A.3.

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additional information on the financial incentive. This group was offered a €40 shopping
voucher if they participated in HCJ. The wording of the additional text included in the let-
ter (translated into English) is as follows:

For participating in HCJ, you will receive a shopping voucher worth €40 for
Mariahilfer Strasse in Vienna as a thank you. The SVA will send you this voucher
as soon as you have completed the medical check-up.

The rationale for using a shopping voucher as a financial incentive (rather than cash) is
threefold. First, our partner in this experiment, SVA, had a strict preference for shopping
vouchers (over cash). Second, since the experiment addresses children and adolescents who
may not have their own bank account, it is easier to organize a financial incentive by means
of a shopping voucher. Third, shopping vouchers can be sent without much bureaucratic
effort, so that no bank transfers are necessary. The Mariahilfer Strasse is the largest shop-
ping street (about 1.8 kilometers) in the city of Vienna. It hosts hundreds of shops including
flagship stores, boutiques, and supermarkets. It caters to a wide range of consumers. Thus,
the shopping voucher can be used to purchase all kinds of products, and should be a close
substitute to cash.
In families with multiple children, all children were assigned to the same group. The
SVA distributed the letters via mail around June 1, 2014. This was the first information
campaign addressing insurance holders. Contracted physicians were informed about the
pilot phase of HCJ in the first quarter of 2014. They received detailed information about
the intention and content of the program, as well as their reimbursement, but not about
our subsequent intervention.

C . P R E D E T E R MI N E D V A R I A B L E S
One particular strength of our field experiment is that we can observe our subjects before
and after treatment via high-quality register data. The adolescents were typically coinsured
with the principal insured parent, who can also be observed in the register. Information
about father and mother is available, if both parents are self-employed, or if one parent
is coinsured with their spouse. For the 10,727 adolescents in the sample, we observed
4,485 principal and 2,604 coinsured mothers, and 7,321 principal and 582 coinsured fa-
thers.13 We can link these data to other administrative records, most importantly to the
Austrian Social Security Database. These data include administrative records to verify pen-
sion claims and provide information on earnings (Zweimüller et al. 2009).
We use information on the adolescent’s sex, age, and place of residence to generate ba-
sic demographic control variables. In further specifications, we additionally control for
the socioeconomic background of their family, and the principal insured parent’s health
screening behavior. The former is captured with different indicators, such as migration
background, parental education, and earnings. The latter is based on information on past
participation in general health screening for adults. We also used this information to ex-
plore treatment effect heterogeneity.

13 If both parents are self-employed, we define the mother as the principal parent.

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Table 1 provides an overview of all predetermined variables used. Adolescents are on

average 12.8 years old, roughly half of them are female, and 87 percent live in Vienna.
About a quarter of principal insured parents have foreign citizenship. This means that
the proportion of those with a migration background is significantly higher than the 19 per-
cent in the Austrian population (Statistics Austria 2021b).
The principal insured parent’s annual median income between 2012 and 2014 amounted
to €20,746 for fathers, and €11,727 for mothers. We use this sex-specific income to dif-
ferentiate between adolescents with low- and high-income parents. The income levels cor-
respond to the 30th percentile of the income distribution of the large group of employees in
Austria (Statistics Austria 2021a). Thus, the households in our sample have a relatively lower
SES compared with the Austrian population. One-fifth of principal insured parents partic-
ipated in the general health screening for adults in either 2012 or 2013.

TABLE 1. Average predetermined characteristics of treatment and control

group

Control Treated Difference p-value

(1) (2) (3) (4)
Individual characteristics
Age 12.9 12.8 0.1 0.255
Female 0.49 0.50 20.01 0.471
Lives in Vienna 0.88 0.87 0.01 0.225
Principal insured parent’s characteristics
Foreign citizenship 0.26 0.25 0.01 0.311
1
General health check participation 0.20 0.19 0.00 0.913
High income2 0.53 0.52 0.01 0.471
Mother’s education
Compulsory education 0.11 0.12 20.01 0.322
Vocational/lower sec. educ. 0.26 0.24 0.02 0.071
Upper sec./tertiary educ. 0.39 0.38 0.01 0.173
Missing information 0.24 0.26 20.02 0.009
Health at birth
Gestation (completed weeks) 39.6 39.6 0.0 0.812
Birth weight (grams) 3,344 3,343 1 0.927
Apgar score (5 min. after birth) 9.8 9.8 0.0 0.236
Missing information 0.15 0.16 20.01 0.351
Note: This table reports average characteristics for individuals in the control (column 1) and
treatment (column 2) group. Column 3 shows the difference between the two group averages.
Column 4 presents the p-value of the respective t-test. 1Refers to the years 2012 and 2013.
2
We use the sex-specific principal insured parent’s median income in the sample to differen-
tiate between adolescents with low- and high-income parents.

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In line with our randomization, we see that all adolescents’ and their parents’ character-
istics are balanced across control and treatment group. Thus, there are no significant differ-
ences. This also holds true for adolescents’ health at birth. For the majority (about 85 percent)
of observations, we obtain information on gestation, birth weight, and the Apgar score.14

IV. Estimation Results

To examine the effect of the treatment voucheri on the likelihood of screening participa-
tion HCJi, we estimate a simple linear probability model,

HCJi 5 b
voucheri 1 g
femalei 1 d
agei 1 h
Viennai 1 ei (1),

where we control for subject’s sex (femalei), age (agei), and place of residence (Viennai) in
the baseline specification. In further specifications, we also control for the principal in-
sured parent’s income and health screening behavior, and the mother’s level of education.
The error term is denoted by εi. We calculate standard errors clustered at the family level.
Our sample comprises 5,103 families with one child, 2,155 with two children, and 419 with
three or more children.

A . A V E R A G E TR E A T M E N T E F F E C T S
The estimation results are summarized in Table 2. Column 1 shows the unconditional treat-
ment effect. The financial incentive of a €40 shopping voucher increases the average treated
subject’s likelihood of participation by 6.7 pp. The effect is statistically (p 2 value < 0:01)
and economically significant. Given the participation rate of 2.4 percent in the control
group, the estimated coefficient represents an increase of 280 percent. As expected, due
to randomization, the impact of the shopping voucher on HCJ participation does not de-
pend on the inclusion of controls. In column 2, we control for the subject’s age, sex, and
place of residence. In columns 3 to 6, we additionally stepwise control for the principal in-
sured parent’s income, their health screening behavior, and the mother’s educational at-
tainment. The estimated treatment effects remain unchanged.15
Figure 1 illustrates the development of HCJ participation over time in the treatment and
control groups. Participation is found to have increased continuously in both groups after
receipt of the invitation letters as of June 1, 2014 (the dotted vertical line). However, the gra-
dient in the treatment group is comparatively steeper. The participation rate among the
treatment group is around 8 percent after one year. The equivalent rate for the control group
amounts to less than 2 percent. A small number of adolescents had already participated in
HCJ before our intervention. This participation was initiated by contracted physicians, who
had known about HGJ since the first quarter of 2014.

14 This information is provided in the Austrian Birth Register. Not all adolescents can be linked to this
data source, most notably because births outside Austria are not recorded in this register.
15 The estimation output reveals a higher HCJ participation for females (1.2 pp) and for adolescents who
live in Vienna (1.6 pp), while the participation rate decreases by 0.3 pp with each year of age. We also find a
significant and positive impact on participation if the principal insured parent earns an income above the
median (1.4 pp), and if they themselves had participated in a general preventive health check in 2012 or
2013 (2.7 pp). The mother’s level of education is ceteris paribus not statistically significant.

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TABLE 2. Estimated impact of the shopping voucher on health screening

participation

(1) (2) (3) (4) (5)

a a a a
Shopping voucher (€40) 0.067 0.067 0.067 0.067 0.067a
(0.006) (0.006) (0.006) (0.006) (0.006)
Female 0.012a 0.012a 0.012a 0.012a
(0.004) (0.004) (0.004) (0.004)
Age 20.003a 20.004a 20.004a 20.003a
(0.001) (0.001) (0.001) (0.001)
Lives in Vienna 0.012c 0.012c 0.016b 0.016b
(0.007) (0.007) (0.007) (0.007)
High income of principal insured parent 0.017a 0.017a 0.014a
(0.005) (0.005) (0.005)
Health check participation of principal insured parent 0.028a 0.027a
(0.007) (0.007)
Mother’s level of education (Base: Missing)
Compulsory 20.011
(0.007)
Vocational/lower sec. 0.002
(0.006)
Upper sec./tertiary 0.009
(0.006)
Constant 0.024a 0.051a 0.044a 0.035a 0.032b
(0.002) (0.013) (0.013) (0.013) (0.015)
Note: This table summarizes estimation results of the effect of shopping vouchers on adolescents’
health check participation. Each column reports coefficients from a regression of a binary indica-
tor for health check participation on a binary indicator for the offered shopping voucher and
varying control variables. The number of observations is 10,727. Standard errors in parentheses
are clustered at the family level. ap < 0.01, bp < 0.05, cp < 0.10.

Since we have no information on who would open the letter, our treatment effect (of be-
ing mailed the letter) differs from a treatment effect of knowing about the financial incentive.
The final responses can be observed, whereas the intermediate stages, such as opening and
reading the mail piece remain concealed. Marketing literature deals with opening rates in
direct mailing. Feld et al. (2013) analyze 700 mail campaigns based on a unique commercial
direct mail panel from GfK (Growth from Knowledge Society for Consumer Research) in-
cluding 3,000 representative German households. Panel participants collected the received
mail pieces and sent GfK all letters they did not want to keep (opened or unopened) and a
list of pieces they chose to keep. The authors find an opening rate—the ratio of opening
to total recipients—of almost 90 percent, a result consistent with previous evidence (e.g.,

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FIGURE 1. Group-specific cumulative participation rate over time. This figure

illustrates the cumulative share of participating adolescents in the treatment
and control groups over time. The vertical line indicates June 1, 2014, the day
from which the invitation letters were sent out. A color version of this figure is
available online.

Stone and Jacobs 2008). We expect that the opening rate in our experiment is also very high.
The sender is not a more or less well-known firm but the individual’s statutory health in-
surance fund. This institution communicates all matters by mail, and in the vast majority of
cases, the letters contain important information about the recipient’s health insurance.

B . T R EA T M E N T E F FE C T H E T E R O G E N E I T Y
To test whether the shopping voucher has a different impact across subgroups, we repeated
our analysis using subsamples. We consider three dimensions: basic demographic charac-
teristics, socioeconomic background, and parental health screening behavior. Figure 2
shows point estimates and corresponding 95 percent confidence intervals based on several
sample splits. The p-values reported next to the bars indicate the statistical significance of
the difference between these two estimated coefficients.16
First, we consider the sample splits by subject’s sex. Female subjects are somewhat
more responsive (7.3 vs. 6.1 pp), but the difference is not statistically significant. Second,
we are interested in the adolescents’ socioeconomic backgrounds. We see two main chan-
nels. On the one hand, households with a lower socioeconomic background could be more
responsive due to an income effect. On the other hand, attention and interest towards

16 These p-values are based on estimations using the full sample with interactions between the respective
group indicator and all other covariates. Online Appendix Table A.3 includes detailed estimation output for
these (and other) split-sample analyses.

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FIGURE 2. Estimated impact of the shopping voucher in various subsamples.

The figure summarizes estimation results of the effect of shopping vouchers
on adolescents’ health check participation. We split the sample according to
sex of child, principal insured parent’s citizenship, mother’s level of education,
principal insured parent’s income, and their general health check participation.
Online Appendix Table A.3 includes detailed estimation output. Next to the bars,
we report p-values based on estimations using the full sample with interactions
between the respective group indicator and all other covariates. A color version
of this figure is available online.

preventive health care may require a certain level of health literacy, which can be expected
to be lower in households with a lower socioeconomic background. We use three different
indicators for the socioeconomic background: citizenship, educational attainment, and
earnings. Generally, we measure these indicators for the principal insured parent.17 How-
ever, because of the higher number of missing data entries for fathers’ educational attain-
ment, we use maternal education in our baseline specification. Adolescents with a foreign
principal insured parent respond comparably less (4.9 vs. 7.2 pp). The difference is signif-
icant at the 8 percent level only. Existing language barriers and lack of knowledge about the
health-care system in general may explain their lower health literacy.18 Responsiveness in-
creases with mother’s educational attainment. Children of mothers with upper secondary

17 We obtain equivalent results if we use the father’s or mother’s (instead of the principal insured parent’s)
characteristics (see Online Appendix Table A.3).
18 The fact that foreign-born mothers are less responsive to monetary incentives is supported by the re-
sults of the aforementioned study on participation in a nationwide developmental screening program for
preschoolers in Austria (Halla, Pruckner, and Schober 2016). The authors find that foreign-born mothers
react significantly less to the financial incentive than their Austria-born counterparts and mention a lack
of language proficiency and institutional knowledge as plausible explanations for this finding.

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or tertiary education show the highest treatment effect (8.1 pp), and those with mothers
with compulsory schooling show the lowest (2.9 pp). An equivalent pattern is present
for children of a principal insured parent with a low (5.6 pp) versus high (7.7 pp) income.
Thus, across all indicators, we find consistent evidence for stronger treatment effects
among adolescents with a higher SES.19 This is in line with the idea that awareness/pref-
erence for secondary prevention compensates for any income effect. Notably, the social
gradient in the effectiveness of the financial incentive is less pronounced in terms of rela-
tive treatment effects (measured in percent), since baseline participation rates tend to be
lower among households with lower socioeconomic backgrounds (see column 2 of Online
Appendix Table A.3).
Third, interesting results emerge with regard to differentiation as to whether the parents
themselves attend health screenings. The voucher effect for adolescents whose principal in-
sured parent attended a general health check in the past runs up to 10.1 pp. In comparison,
the treatment increases participation by only 5.9 pp for children whose main insured parent
did not participate in this program. Again, we obtain equivalent results based on father’s or
mother’s characteristics (see Online Appendix Table A.3). This substantial gradient under-
lines the importance of awareness/preference for secondary prevention within the house-
hold for the effectiveness of the financial incentive.
In summary, the analysis of treatment heterogeneity suggests that the financial incen-
tive is comparably less effective among adolescents from households with a stronger base-
line resistance to secondary prevention.

V. Conclusions
We performed a large-scale field experiment to evaluate the effectiveness of financial in-
centives in promoting health screening examinations among adolescents. A €40 shopping
voucher increases participation from 2.4 percent to 9.1 percent. Thus, the financial incen-
tive almost quadruples participation relative to a personalized invitation, which provides
information only. Our finding adds to the existing evidence documenting the effectiveness
of financial incentives for secondary prevention among other age groups.
We do not find support for the hypothesis that financial incentives have a stronger im-
pact for families with a lower SES, who are likely to benefit more from early intervention.
Rather, our results indicate that the financial incentive is more effective among children
from families with a higher SES, and those with a revealed preference for own (adult)
health screenings. Thus, any income effect seems of minor importance relative to the higher
health awareness and health literacy more present among families with a higher SES. It is
well known that parents tend to pass on their health behavior to their children. Our finding
suggests that financial incentives for secondary prevention are not able to resolve any pre-
existing social gradient, but rather amplify differences.20

19 This result is, for example, in contrast to Just and Price (2013) who find that the impact of incentives for
healthy eating is higher in lower-income schools.
20 Jones, Molitor, and Reif (2019) document an equivalent selection pattern for adults in the context of a
comprehensive workplace wellness program in the United States.

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We conclude that financial incentives help to increase participation in health screening

exams among adolescents and could have a positive influence on subsequent health (behav-
ior). Unfortunately, the tool is comparably less effective in engaging those groups who would
benefit the most. A further downside is that substantial financial incentives within public
health care would shift costs onto lower-income and probably unhealthier insurance holders
if these groups continue to participate at lower rates. However, a comprehensive incidence
analysis must also take the different contribution rates of socioeconomic groups into account.
The economic efficiency-based argument for early intervention, resting on the simple
comparison between the costs of intervention (today) and the costs of nonintervention
(later), is intuitive, and proponents assume that early intervention is more cost-effective
than later remediation (Conti and Heckman 2013). Likewise, we expect the studied health
screening examinations among adolescents to be cost-effective. However, it is hard to
gauge actual cost savings, since there are no credible estimates for this type of screening
available in the literature.

ACKNOWLEDGEMENTS
We would like to thank the Social Insurance Institution for the Self-Employed
(Sozialversicherungsanstalt der Selbständigen, SVS) for support in planning and executing
the experiment. In particular, we want to thank Michael Müller.

FUNDING INFORMATION
We gratefully acknowledge financial support from the Austrian Federal Ministry of
Education, Science, and Research (BMBWF) and the National Foundation for Research,
Technology, and Development.

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