Ishita Ghai

All Publications

• Impact of behavioral economics to improve antihypertensive therapy adherence, a pilot randomized controlled trial in Los Angeles. Scientific reports Linnemayr, S., Ghai, I., Palimaru, A., Barajas, D., Vallejo, R., Blyler, C. A., Morales, E. M., De Guzman, M., Joung, S. Y., Ungar, S., Ebinger, J. E. 2025; 15 (1): 38452

  Abstract

  Routinized pill-taking can enhance medication adherence but is difficult to achieve. In this pilot randomized controlled trial we assess the feasibility, acceptability, and preliminary efficacy of a novel behavioral economics-based approach to medication-adherence. We enrolled 60 hypertensive adults, who all received information on pill-routinization and selected an existing behavioral routine ('anchor') to assist with routinization of pill-taking. Participants were randomized into 3 groups: 1)'Control' receiving usual care (n = 20); 2)'Messages' receiving daily text messages (n = 20); and 3)'Incentives' receiving both text messages and rewards for medication adherence (n = 20). Interventions lasted 3 months, followed by a 6-month post-intervention period during which we assessed medication-adherence and conducted standardized assessments of acceptability. The study demonstrated high feasibility and acceptability, with 90% of participants willing to refer others to the study. Mean adherence during the extended follow-up period (months 7-9) was numerically higher in both intervention arms than the control arm (Control 75%, Messages 84%, and Incentives 77%) though this pilot study was not powered to detect a statistically significant difference (P = 0.73). While this pilot study was under-powered to detect between-group differences, the novel behavioral economics habit formation approach was feasible, acceptable, and yielded promising results, warranting completion of a fully-powered trial. Registration: URL:  https://www.clinicaltrials.gov ; Unique identifier: NCT04029883; registered 23/07/2019.

  View details for DOI 10.1038/s41598-025-94805-5

  View details for PubMedID 41188444

  View details for PubMedCentralID PMC12586644

• Measuring Primary Care Productivity in the Era of Interprofessional Team Care: Stakeholder, Scoping Review, and Implementation Perspectives. The Milbank quarterly Rubenstein, L. V., Newberry, S. J., Ghai, I., Motala, A., Curtis, I., Shekelle, P. G., Wagner, T. H., Tran, L. D., Fihn, S. D., Nelson, K. M. 2025

  Abstract

  Policy Points The economics and outcomes of modern primary care are substantially driven by investment in interprofessional clinical team members aimed at delivering complex, population health-oriented care. Neither interprofessional primary care team investment nor the work products expected in return are well represented in current commonly used productivity metrics. Stakeholder perspective-guided scoping review followed by expert panel input on measure development showed the feasibility of applying economic methods for assessing primary care productivity relative to multiple high-value products.CONTEXT: Current primary care productivity measures do not account for investment in interprofessional primary care teams in relation to primary care goals and thus are insufficient for assessing and improving primary care efficiency and productivity. We explored alternative productivity measurement methods.METHODS: We conducted a scoping review of English language literature between 2008 and 2023 to identify articles that assessed primary care practice productivity and efficiency. We reviewed the full texts of articles to assess their analytic models including inputs, outputs, and context measures. Using scoping review results to inform content, we conducted a modified Delphi expert panel to discuss potential use cases, analytic approaches, and data elements for new primary care productivity measures. Panelists anonymously voted on recommendations for guiding near-term measure development and testing.FINDINGS: Evidence review identified 25 included studies. The majority (76%, 19/25) used an economic model-based productivity calculation, predominantly estimated using data envelopment analysis (DEA), with stochastic frontier analysis accounting for most of the remainder. Primary care staffing was the most common input, included in 84% of the 19 economic model studies. As outputs, over half (53%) of studies included measures of quality of care, whereas the same proportion included numbers of clinical activities. No studies used patient-reported experiences of care. Expert panelists recommended that initial measure development focus on primary care practice efficiency improvement, building the measure on routinely collected health system data, accounting for the clinical team's full-time equivalent staffing, and incorporating quality of care. Panelists endorsed DEA while also acknowledging that other approaches had potential.CONCLUSIONS: We identified measurement approaches that aligned with both economic and foundational primary care principles but none that were implemented for routine use. Opportunities exist to develop metrics that accurately reflect primary care structures, goals, and values.

  View details for DOI 10.1111/1468-0009.70044

  View details for PubMedID 40782372

• Increased Knowledge Mediates the Effect of Game Changers for Cervical Cancer Prevention on Diffusion of Cervical Cancer Screening Advocacy Among Social Network Members in a Pilot Trial. International journal of behavioral medicine Ghai, I., Wagner, G. J., Matovu, J. K., Juncker, M., Namisango, E., Bouskill, K., Nakami, S., Beyeza-Kashesya, J., Luyirika, E., Wanyenze, R. K. 2024; 31 (5): 753-763

  Abstract

  Game Changers for Cervical Cancer Prevention (GC-CCP), a peer-led, group advocacy training intervention, increased cervical cancer (CC) prevention advocacy not only among intervention recipients, but also their social network members (referred to as "alters") who were targeted with advocacy in a pilot randomized controlled trial. We examined mediators and moderators of this effect on alter advocacy, to understand how and for whom the intervention had such an effect.Forty women (index participants) who had recently screened for CC enrolled and were randomly assigned to receive the GC-CCP intervention (n = 20) or the wait-list control (n = 20). Up to three alters from each participant (n = 103) were surveyed at baseline and month 6. Measures of CC-related cognitive constructs (knowledge, enacted stigma, and risk management self-efficacy), as well as extent of advocacy received from index participants, were assessed as mediators of the intervention effect on alter advocacy using multivariate regression analyses. Alter characteristics were examined as moderators.Increased CC-related knowledge partially mediated the intervention effect on increased alter engagement in CC prevention advocacy; those with greater gains in knowledge reported greater engagement in advocacy. No moderators of the intervention effect were identified.The effect of GC-CCP on alter CC prevention advocacy is enhanced by increased alter knowledge pertaining to CC prevention, causes, and treatment and suggests this may be key for diffusion of intervention effects on increased CC prevention advocacy throughout a social network.NCT04960748 (registered on clinicaltrials.gov , 7/14/2021).

  View details for DOI 10.1007/s12529-023-10217-7

  View details for PubMedID 37656308

  View details for PubMedCentralID PMC10904666

• Barriers and facilitators of habit building for long-term adherence to antihypertensive therapy among people with hypertensive disorders in Los Angeles, California: a qualitative study. BMJ open Ghai, I., Palimaru, A., Ebinger, J. E., Barajas, D., Vallejo, R., Morales, M., Linnemayr, S. 2024; 14 (7): e079401

  Abstract

  The aim of this study was to a) explore barriers and facilitators associated with medication-taking habit formation, and b) elicit feedback on the components of an intervention designed to help form strong habits for long-term medication adherence.The study design was qualitative; we conducted semistructured interviews between September 2021 and February 2022.The interviews were conducted online, with 27 participants recruited at the Cedars-Sinai Medical Center in Los Angeles, California.A purposive sample of 20 patients who were over 18 years of age, had been diagnosed with hypertensive disorder (or reported high blood pressure; >140/90 mm Hg) and who were prescribed antihypertensive therapy at the time of recruitment, along with seven providers were interviewed.Contextual factors included frequent changes to prescription for regimen adjustment, and polypharmacy. Forgetfulness, perceived need for medication, and routine disruptions were identified as possible barriers to habit formation. Facilitators of habit formation included identification of stable routines for anchoring, planning, use of external reminders (including visual reminders) and pillboxes for prescription management, and extrinsic motivation for forming habits. Interestingly, experiencing medication side effects was identified as a possible barrier and a possible facilitator of habit formation. Feedback on study components included increasing text size, and visual appeal of the habit leaflet; and imparting variation in text message content and adjusting their frequency to once a day. Patients generally favoured the use of conditional financial incentives to support habit formation.The study sheds light on some key considerations concerning the contextual factors for habit formation among people with hypertension. As such, future studies may evaluate the generalisability of our findings, consider the role of visual reminders in habit formation and sustenance, and explore possible disruptions to habits.NCT04029883.

  View details for DOI 10.1136/bmjopen-2023-079401

  View details for PubMedID 38991671

  View details for PubMedCentralID PMC11243207

• Assessing and Improving Productivity in Primary Care: Proof of Concept Results for a Novel Value-Based Metric. Journal of general internal medicine Tran, L. D., Wagner, T. H., Shekelle, P., Nelson, K. M., Fihn, S. D., Newberry, S., Ghai, I., Curtis, I., Rubenstein, L. V. 2024

  View details for DOI 10.1007/s11606-024-08710-0

  View details for PubMedID 38926317

  View details for PubMedCentralID 7295229

• INcentives and ReMINDers to Improve Long-Term Medication Adherence (INMIND): impact of a pilot randomized controlled trial in a large HIV clinic in Uganda. Journal of the International AIDS Society Linnemayr, S., Odiit, M., Mukasa, B., Ghai, I., Stecher, C. 2024; 27 (6): e26306

  Abstract

  Habits are a common strategy for successfully countering medication non-adherence, yet existing interventions do not support participants during the long habit formation period, resulting in high attrition. We test a novel intervention combining text messages and incentives with anchoring to support antiretroviral therapy (ART) pill-taking habits.In a randomized, parallel controlled trial, a sample of 155 participants 18 years and older who initiated ART within 3 months were recruited at Mildmay Uganda between October 2021 and April 2022. All participants were educated on the anchoring strategy and chose an anchor, that is existing routines, to pair with pill-taking. Participants were randomized to either usual care (C = 49), daily text message reminders to follow their anchoring plan (Messages group; T1 = 49) or messages and incentives conditional on pill-taking in line with their anchor (Incentives group; T2 = 57). Assessments occurred at baseline, month 3 (end of intervention) and month 9 (end of observation period). The primary outcomes are electronically measured mean adherence and pill-taking consistent with participants' anchor time.The primary outcome of pill-taking in line with the anchoring plan was higher in the Incentives group during the 3-month intervention (12.2 p.p. [95% CI: 2.2 22.2; p = .02]), and remained significantly higher after the incentives were withdrawn (months 4-6 (14.2 p.p. [95% CI 1.1 27.2; p = .03]); months 7-9 (14.1 p.p. [95% CI -0.2 28.5; p = .05])). Mean adherence was higher in both treatment groups relative to the control group during the intervention (T1 vs. C, p = .06; T2 vs. C, p = .06) but not post-intervention.The promising approach of using incentives to support habit formation among ART treatment initiators needs to be evaluated in a fully powered study to further our understanding of the habit formation process and to evaluate its cost-effectiveness.

  View details for DOI 10.1002/jia2.26306

  View details for PubMedID 38923298

  View details for PubMedCentralID PMC11197960

• Food Insecurity During the COVID-19 Pandemic: A Longitudinal Mixed-Methods Study from a Cohort of HIV Clients in Uganda. AIDS and behavior MacCarthy, S., Wagner, Z., Saya, U., Ghai, I., Karamagi, Y., Odiit, M., Mukasa, B., Linnemayr, S. 2023; 27 (7): 2216-2225

  Abstract

  The COVID-19 pandemic threatens the food security of people in low-income countries. This is important for people living with HIV (PLWH) because HIV medication should be taken with food to avoid side-effects. We used survey data (n = 314) and qualitative interviews (n = 95) to longitudinally explore how the pandemic impacted food insecurity among PLWH in Kampala, Uganda. Prior to March 2020, 19.7% of respondents were food insecure. Our regression models estimate that food insecurity rose by 9.1 percentage points in our first round of surveys (June-September 2020; p < 0.05; t = 2.17), increasing to 17.2 percentage points in the second round of surveys (July-November 2021; p < 0.05; t = 2.32). Qualitative interviews reveal that employment loss and deteriorating support systems led to reduced meals and purchasing of cheaper foods. Respondents reported continuing to take their HIV medication even in the presence of food insecurity. Strategies for ensuring that PLWH have enough food should be prioritized so that the millions of PLWH in sub-Saharan Africa can take their medication without experiencing uncomfortable side-effects.Clinical Trials Registration Number NCT03494777.

  View details for DOI 10.1007/s10461-022-03953-6

  View details for PubMedID 36629972

  View details for PubMedCentralID PMC9838483

• Behavioural Economics to Improve Antihypertensive Therapy Adherence (BETA): protocol for a pilot randomised controlled trial in Los Angeles. BMJ open Ebinger, J. E., Ghai, I., Barajas, D., Vallejo, R., Blyler, C. A., Morales, M., Garcia, N., Joung, S., Palimaru, A., Linnemayr, S. 2023; 13 (1): e066101

  Abstract

  Non-adherence to antihypertensive therapy is one of the major barriers to reducing the risk of cardiovascular disease. Several interventions have targeted higher medication adherence, yet most do not result in sustained adherence. Routinisation has emerged as a potential method for mitigating this problem, but requires high motivation during the relatively long habit formation phase. This pilot randomised controlled trial aims to test the feasibility, acceptability, and preliminary efficacy of behavioural economics-based incentives and text messages to support the routinisation of the medication-taking behaviour for promoting long-term medication adherence.This study will recruit and randomly assign 60 adult patients seeking care for hypertension at the Cedars-Sinai Medical Center in Los Angeles to one of the three groups, Control (n=20), Messages (n=20) and Incentives (n=20) in a 1:1:1 ratio. All participants will receive information about the importance of routinisation and will select an existing behavioural routine ('anchor') to which they will tie their pill-taking to, and the corresponding time. Additionally, participants in the Messages group will receive daily text messages reminding them of the importance of routines, while those in the Incentives group will receive daily text messages and conditional prize drawings. The interventions will be delivered over three months. Participants will be followed for six months post-intervention to measure behavioural persistence. Surveys will be administered at baseline, month-3 and month-9 visits. Primary outcomes include: (1) electronically measured mean medication adherence during the intervention period and (2) post-intervention period; and (3) mean timely medication adherence based around the time of the participants' anchor during the intervention period, and (4) post-intervention period.The study was approved by the Cedars-Sinai Institutional Review Board (Study ID: Pro00057764). Findings will be published in scientific peer-reviewed journals.NCT04029883.

  View details for DOI 10.1136/bmjopen-2022-066101

  View details for PubMedID 36697048

  View details for PubMedCentralID PMC9884869

• Incentives and Reminders to Improve Long-term Medication Adherence (INMIND): Protocol for a Pilot Randomized Controlled Trial. JMIR research protocols Stecher, C., Ghai, I., Lunkuse, L., Wabukala, P., Odiit, M., Nakanwagi, A., Linnemayr, S. 2022; 11 (10): e42216

  Abstract

  Nonadherence to antiretroviral therapy (ART) among people living with HIV is a crucial barrier to attaining viral suppression globally. Existing behavioral interventions have successfully increased ART adherence, but typically show only short-term impact that dissipates after the interventions are withdrawn.This study aims to test the feasibility, acceptability, and preliminary efficacy of a novel intervention that uses SMS text messages and conditional incentives to support ART initiators in establishing pill-taking habits.A sample of 150 participants aged ≥18 years who have initiated ART in the preceding 3 months will be recruited from Mildmay Uganda in Kampala, Uganda. All (150/150, 100%) participants will be educated on the anchoring strategy and will choose an existing routine to pair with their daily ART adherence from a set of 3 suggested routines: getting dressed in the morning, eating breakfast, or eating dinner. Then, participants will be randomized to receive either usual care (control group: 50/150, 33.3%) or 1 of the 2 interventions delivered over 3 months: daily SMS text message reminders to follow their chosen anchoring plan (messages group; treatment group 1: 50/150, 33.3%) or daily SMS text messages and incentives conditional on taking their ART medication around the time of their chosen anchor (incentives group; treatment group 2: 50/150, 33.3%). Long-term ART adherence will be evaluated for 6 months after the intervention, and survey assessments will be conducted at baseline, 3 months, and 9 months. Outcomes include feasibility and acceptability measures and intervention efficacy outcomes defined by electronically measured mean medication adherence during the intervention and during the 6 months after the intervention, along with a measure of routine ART adherence based on taking medications around the time of participants' anchor during the intervention and during the 6 months after intervention.As of February 18, 2022, recruitment was completed. A total of 150 participants were recruited, and data collection is expected to end in December of 2022. Final results are expected to be submitted for publication by April 2023.This study is the first to use behavioral economics-based interventions in combination with the anchoring strategy to improve long-term ART adherence among treatment initiators. We hypothesize that the combination of SMS text message reminders and incentives will increase participants' use of their anchoring strategy, and thus medication adherence will be better maintained after the intervention ends in our intervention groups relative to the control group that uses only the anchoring strategy. Results of this pilot study will help to refine this combined intervention approach for testing at scale and broaden our understanding of the habit formation process.ClinicalTrials.gov NCT05131165; https://clinicaltrials.gov/ct2/show/NCT05131165.DERR1-10.2196/42216.

  View details for DOI 10.2196/42216

  View details for PubMedID 36315224

  View details for PubMedCentralID PMC9664328

• Estimation of Potential Savings Associated With Switching Medication Formulation. JAMA health forum Desai, S. M., Wang, J., Ananthakrishnan, U. M., Ghai, I., Mehrotra, A., Bhargava, H. K. 2022; 3 (2): e214823

  Abstract

  This cross-sectional study describes the price differences between capsule and tablet or ointment and cream forms of prescription drugs for insured patients.

  View details for DOI 10.1001/jamahealthforum.2021.4823

  View details for PubMedID 35977272

  View details for PubMedCentralID PMC8903120