Community-Partnered Development of Behavioral Economic Incentives in a Pre-exposure Prophylaxis Intervention for Transgender and Nonbinary Clients in Los Angeles

Community-Partnered Development of Behavioral Economic Incentives in a Pre-exposure Prophylaxis Intervention for Transgender and Nonbinary Clients in Los Angeles | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Community-Partnered Development of Behavioral Economic Incentives in a Pre-exposure Prophylaxis Intervention for Transgender and Nonbinary Clients in Los Angeles Mika Baumgardner, Carrie L. Nacht, Kimberly Ling Murtaugh, Risa Flynn, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7654557/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Background This article describes our community-engaged process of incorporating culturally relevant, non-monetary, chance-based incentives into a transgender and gender nonbinary (TGNB) oriented pre-exposure prophylaxis (PrEP) intervention called PrEP Well . Methods PrEP Well , a single-group longitudinal observational study design, was developed as a community-led, multicomponent HIV prevention intervention that combines peer navigation and fixed monetary incentives for research activities in a TGNB community health center. Recruitment for PrEP Well began in April 2022. We added prize-based behavioral economic incentives to PrEP Well on April 25, 2023. These prizes reflect the TGNB community’s interests through input from a transgender community advisory board, surveys of health center clients, and partnerships with local TGNB-owned businesses. Data are drawn from program administrative records, surveys, and qualitative interviews with program recipients. Comparisons between prize selection were assessed via Chi-square tests. Qualitative interviews were analyzed via inductive thematic analysis. Results Before implementation, survey respondents found additional incentives for participation in PrEP Well were highly acceptable. After the incentives were implemented in PrEP Well , qualitative data from exit interviews highlighted the motivational impact of combining a fun, chance-based incentive model with the empowering ability to choose from a variety of trans affirming non-monetary incentives. Conclusions Our community-partnered approach integrated behavioral economic incentives into a TGNB-oriented PrEP intervention. The participants found the additional community-relevant prize-based incentives to be acceptable and motivating. Future research should explore the immediate and long-term outcomes of this approach, and its scalability with diverse TGNB populations, to promote equity in HIV outcomes. pre-exposure prophylaxis transgender and nonbinary LGBT health HIV behavioral economics economic incentives community-engaged research Figures Figure 1 Background HIV continues to disproportionately affect transgender and gender nonbinary (TGNB) individuals. 1 , 2 Pre-exposure prophylaxis (PrEP) medication is a highly effective method of HIV prevention, 3–8 but TGNB people are underrepresented across the PrEP services continuum. 2 , 9 as well as in research on PrEP uptake and adherence. 10 – 12 TGNB people experience unique barriers to healthcare access, often shaped by stigma, discrimination, lack of culturally competent care, and other socioeconomic and structural challenges. 10 , 13 – 15 Although there is a pressing need to develop and implement culturally competent PrEP interventions tailored to TGNB communities, health services often do not support TGNB needs. A 2022 scoping review revealed that many health interventions grouped TGNB individuals with broader lesbian, gay, bisexual, transgender, and queer (LGBTQ) categories, lacked TGNB input in their design, and did not adequately address intersectional barriers. 16 Several studies have demonstrated that interventions with promising results among broad LGBTQ populations can be ineffective for TGNB recipients. 16 – 18 Interventions are more effective when they elicit feedback from TGNB communities at all levels of design and implementation, 16,19 including interventions targeting HIV prevention and care access in TGNB communities. 19 – 24 Designing incentive systems tailored to TGNB community is key to motivating health behaviors and reducing barriers for the community. Financial incentives have been shown to motivate participation in randomized controlled trials to promote a variety of health behaviors including smoking cessation, substance use abstinence, and adherence to HIV medications. 25 Behavioral economic interventions use incentives designed around decision processes and individual preferences that shape behavior. Studies have shown that chance-based financial incentives can be powerful motivators for HIV prevention and other health related behavioral changes. 26 – 29 Studies suggest that regardless of the financial amount offered, incentives that are fun and focus on the recipient’s ingroup community and identity can lead to long term behavioral change. 27, 30–33 Moreover, one study reported that simply giving participants the ability to make a decision about a hypothetical prize empowered them by increasing feelings of control and joy. 34 Creating an incentive system that uses behavioral economics to engage TGNB individuals with culturally specific and empowering incentives can enhance these perceptions of fun, community identity, and control to sustainably increase HIV prevention behaviors. Several studies applied behavioral economic incentives to motivate HIV-related health behaviors among cisgender people 26 – 29 , 35 , 36 , but there is little comparable work among TGNB populations. Nevertheless, the limited data are promising. One study with HIV-positive transgender women of color that offered unlimited peer health navigation and escalating monetary incentives for behavioral and biomedical milestones reported increases in HIV care participation across up to 3 years of program participation. 37 Another study revealed that chance-based incentives in addition to informational text messages resulted in significant improvements in HIV knowledge compared to a control group that received informational text messages only. Although the sample was mostly Latinx sexual minority men, approximately one-third of the participants were Latinx transgender women ( n = 66). 27 These studies all used monetary incentives and provided limited information about how the incentives were developed for their TGNB recipients. As is largely the case in related areas of research, transgender women have also been the focus of relevant work to date. None of these studies created non-monetary incentives tailored to the needs of the entire TGNB community. In summary, the use of tailored behavioral economic incentives for HIV prevention is understudied with TGNB communities, limiting the design of prevention interventions that support this population. The purpose of this paper is to describe a community-engaged process that involves tailoring a behavioral economic prize-based incentive structure to increase PrEP engagement and adherence among TGNB individuals. Methods Study setting and design We partnered with a TGNB-serving community organization to conduct this study as a component of their ongoing PrEP Well program. PrEP Well is a peer navigation intervention that connects participants with gender-affirming PrEP services at a TGNB-serving organization. 38 The organization is a federally qualified health center in Los Angeles, California that offers many services, including primary health care, HIV testing and treatment, legal and employment services, etc. 39 Full details on the community-led design and implementation of PrEP Well have been described elsewhere. 38 The design of PrEP Well was informed by TGNB community members and staff. 40 Briefly, PrEP Well aimed to bring comprehensive community-led PrEP services onsite to the TGNB-serving organization, where anyone who identifies as TGNB that is 18 years or older can enroll. PrEP Well includes peer-led enrollment and navigation along the PrEP care continuum and 30-day and 90-day follow-up visits. PrEP Well began enrolling participants in August, 2022, and recruitment is still ongoing. PrEP Well provides financial incentives to participants for attending each visit, regardless of their engagement with PrEP ( $ 50 for baseline, $ 75 for 30-day follow-up, $ 100 for 90-day follow-up) to collect data on engagement barriers. The participants expressed a need for additional incentives. Therefore, the current study sought to develop and implement a supplemental behavioral economic incentive system that would motivate participants to increase PrEP engagement and adherence. Development of the behavioral economic prize-based incentive system began in January, 2023, and the system was implemented on April 25, 2023. The demographic data of the participants who received the newly implemented incentives were collected from April 25, 2023 through January 1, 2025 (Table 1 ). Table 1 Demographics of Pre-exposure prophylaxis ( PrEP) Well participants from April 25, 2023 to January 1, 2025, N = 128 Characteristic Total (N = 128) N (%) Assigned sex at birth Female 16 (12.5) Male 110 (85.9) Intersex 2 (1.6) Gender identity Woman 88 (68.8) Man 11 (8.6) Nonbinary 19 (14.8) Nonbinary trans femme 1 (0.8) Genderfluid 1 (0.8) Aliagender 1 (0.8) Two-spirit 1 (0.8) Pharaoh 1 (0.8) None 1 (0.8) Sexual orientation Queer 15 (11.7) Straight 63 (49.2) Bisexual 13 (10.2) Pansexual 22 (17.2) Gay or lesbian 12 (9.4) Questioning 2 (1.6) Omnisexual 1 (0.8) Race/ethnicity a American Indian/Alaskan Native 6 (4.7) Asian 6 (4.7) Black or African American 28 (21.9) Hispanic or Latinx 79 (61.7) Multiracial 23 (18.0) Other Pacific Islander 3 (2.3) White non-Hispanic 79 (61.7) Relationship status Single 84 (65.6) Open relationship 18 (14.1) Dating/casual relationship 13 (10.2) Closed relationship 12 (9.4) Other/prefer not to say 1 (0.8) On PrEP b at enrollment 25 (19.5) Age, mean (SD) c 31.7 (9.8) Total number of spins during PrEP Well , mean (SD) 3.2 (2.1) a Not mutually exclusive b Pre-exposure prophylaxis c Standard deviation We use a descriptive approach drawing from multiple data sources (surveys, project administrative records, interviews) to illustrate the community-engaged design approach (Fig. 1 ). Creating the Prize Wheel and Incentive selection The research team drafted procedures describing how incentives would be implemented in PrEP Well (Table 2 ). The participants could receive up to 3 spins per visit (9 total) over the study duration. After participants spun the wheel, they could browse a catalog of prize options and select their desired prize. Table 2 Pre-exposure prophylaxis ( PrEP) Well behavioral economic incentive structure. Participant behavior Time point Number of spins earned Attended information session about PrEP a Well Baseline 1 spin Welcome to PrEP Well spin Baseline 1 spin Attended initial appointment with PrEP provider 30- or 90-day follow-up 1 spin Filled PrEP prescription at pharmacy 30- or 90-day follow-up 1 spin Attended lab/STI b testing visit 30- or 90-day follow-up 1 spin Urine testing shows PrEP adherence 30- or 90-day follow-up 1 spin Congratulations on finishing PrEP Well program 90 1 spin Discretionary spin for other positive activities or attempts Any 1 spin a Pre-exposure prophylaxis b Sexually transmitted infection To frame the incentive exchange as a fun game with themes of TGNB empowerment, the incentive levels reflect the colors of the transgender pride flag: pink (70% likelihood, average cost $ 0.88, retail value $ 1–6), blue (25% likelihood, average cost $ 5.25, retail value $ 10- $ 30), and silver (5% likelihood, average cost $ 51.43, retail value $ 50–100). The average cost of items reflects significant savings in bulk discount purchases and other cost-saving techniques. Based on behavioral economic theory about the motivational advantages of identity-related incentives, 30,33 we engaged community members to select prizes that would be perceived as fun, valuable, and tailored to the TGNB community. First, we generated a range of prize options with input from TGNB staff of the community organization. The research team included prizes sourced from TGNB-owned businesses to authentically build trust, representation, and resilience with the community through economic empowerment. To engage TGNB-owned businesses, the research team utilized transowned.co, an online directory of verified TGNB-owned businesses. The team contacted businesses to verify they were comfortable being denoted as “Trans Owned” within our study context. Conversations with some TGNB-owned businesses led to referrals to other businesses. We also commissioned a local TGNB artist to create original art and prizes. Additionally, some prizes were purchased through digital storefronts such as Amazon.com. To assess the incentives selected as prizes for PrEP Well participants, we created a visual array survey (i.e., with images of each item to maximize understandability). In February, 2023, we distributed this survey to Focus Groups 1 and 2, two convenience samples composed of clients at two LGBTQ-serving settings to guide incentive selection for PrEP Well participants. There was no incentive for survey takers. We first sought feedback on our incentive procedures from a transgender community advisory board in February, 2023; dinner and small monetary incentives were provided as compensation for participation. Second, we sought feedback from a convenience sample of clients at an LGBTQ youth access center, who were invited to spin the prize wheel and win a prize of their choice in exchange for their participation. At the end of both presentations, board members and youth completed a qualitative feedback survey asking what they thought about PrEP Well , the prize wheel, and the prizes offered. The participants were also invited to participate verbally during these engagements. After implementing the wheel, we totaled how many participants chose each prize, from April 25, 2023 through January 1, 2025. Qualitative interviews All participants in PrEP Well were eligible to participate in exit interviews. The interview methodology was developed for PrEP Well and is described elsewhere, in a currently unpublished manuscript. 41 From September 2023 to August 2024, semi-structured interviews were conducted by the PrEP Well peer navigator, who asked about facilitators, barriers, and suggested improvements for PrEP Well . The interviews were conducted in English or Spanish, transcribed, translated to English if in Spanish, and de-identified. For the current study, we drew on findings related to discussion of the prize-based incentives during exit interviews. Data analysis Upon recruitment, demographic data, including age, gender identity, race/ethnicity, and relationship status, were collected via a Qualtrics survey and univariate summary statistics were reported. After implementing the prize wheel, we conducted bivariate comparisons between prize categories (silver, blue, pink). Specifically, we used a chi-square test to compare the frequency of each prize selected and to test whether there was a statistically significant difference in prize selection compared with an equal distribution, with a significance set at α = 0.05. Qualitative data from exit interviews were analyzed via inductive thematic analytic methods. 41 A subset of transcripts was first open-coded, and an initial codebook was created. This codebook was refined iteratively through double coding by two researchers until acceptable inter-rater reliability (Kappa ≥ .80) was achieved. The remaining transcripts were then coded independently. NVivo software was used to facilitate coding and data management. 43 Results The responses to the pre-implementation prize preference survey generally fall into two groups: older Spanish-speaking adults and younger English-speaking youth, which reflects the diverse perspectives of the community. Overall, both groups demonstrated interest in electronics and fashion items (Table 3 ). Neither group expressed interest in toys. Older Spanish-speaking adults appeared to prefer beauty and personal care items more than younger English speakers, who preferred home goods and franchise merchandise. These data informed the incentive selection for PrEP Well . Table 3 Pre-implementation prize preferences Category Prize Total N Number of selections by Older Spanish speakers (N = 15) Number of selections by Younger English speakers (N = 9) Category proportion of total selections N (row %) N (row %) Electronics and Tech Accessories N = 37 selections Earbuds/Headphones 13 5 (38.5) 8 (61.5) 33.9% Fitness Tracker 1 0 (0.0) 1 (100.0) iPad 10 5 (50.0) 5 (50.0) Phone Case 2 2 (100.0) 0 (0.0) Pop Socket 2 2 (100.0) 0 (0.0) Portable Charger 6 0 (0.0) 6 (100.0) Smart Watch 3 2 (66.7) 1 (33.3) Fashion and Accessories N = 18 selections Baseball Hat 3 1 (33.3) 2 (66.7) 16.5% Fanny Pack 1 0 (0.0) 1 (100) Hoodie/Sweatshirt 5 3 (60.0) 2 (40.0) Necklaces 1 0 (0.0) 1 (100) Rings 3 1 (33.3) 2 (66.7) Socks 5 3 (60.0) 2 (40.0) Home Goods N = 12 selections Crystal Scoop 1 0 (0.0) 1 (100) 11.0% Fan 1 0 (0.0) 1 (100) Mugs 5 1 (20.0) 4 (80.0) Sun Catcher 0 0 (0.0) 0 (0.0) Water Bottle 5 0 (0.0) 5 (100.0) Toys N = 6 selections Fidget Toy 2 0 (0.0) 2 (100.0) 5.5% Mystery Box 3 2 (66.7) 1 (33.3) Squishies 1 0 (0.0) 1 (100) Beauty and Personal Care N = 17 selections Hair Extensions 5 4 (80.0) 1 (20.0) 15.6% Nail Polish 0 0 (0.0) 0 (0.0) Perfume/Cologne 10 9 (90.0) 1 (10.0) Press On Nail Set 2 1 (50.0) 1 (50.0) Brand specific prizes N = 19 selections Batman Brand 3 0 (0.0) 3 (100.0) 17.4% Disney Brand 2 2 (100) 0 (0.0) Dragon Ball Brand 2 0 (0.0) 2 (100) Marvel Brand 2 0 (0.0) 2 (100) Pokémon Brand 2 0 (0.0) 2 (100) Sailor Moon Brand 3 0 (0.0) 2 (100) Star Wars Brand 1 0 (0.0) 1 (100) Studio Ghibli Brand 3 0 (0.0) 3 (100) Transformers Brand 1 0 (0.0) 1 (100) Total selections 109 43 66 100% We also received qualitative feedback during pre-implementation incentive validation activities (Table 4 ). Overall, participants expressed overwhelmingly positive support for the incorporation of the wheel and prize incentives. The participants also suggested several prizes to be added, including electronics, apparel, accessories, beauty and art supplies, spiritual items, and outdoor gear. Table 4 Themes and example quotes illustrating the perceptions of the prize wheel prior to implementation in Pre-exposure prophylaxis ( PrEP) Well Theme Descriptions Illustrative quotations Perceptions of prizes Positive adjectives participants used to describe prizes “Adorb” “Smart” “Fun” Improves accessibility “I like how accessible [the wheel] is.” Anticipated positive effects on participation “[Adding the new incentives] is definitely the way to go. [The wheel and prizes] will be the best way…to get more participants.” “I think [adding the wheel] will help with participation because more people would come if they c[ould] win something.” General positive reception “I feel like the prizes are really good and [are] worth the time to take the program.” Positive perceptions of silver tier “I really like the silver tier prizes cause it’s stuff we would need that we can’t get.” After the pilot, the wheel and prizes were maintained in the ongoing PrEP Well project, and the prize choices were recorded for all participants (Table 5 ). The participants earned an average of 3.2 (standard deviation: 2.1) spins during their participation in PrEP Well. There were a total of 392 spins across all participants, with 58.2% being pink tier spins, 34.2% blue tier spins, and 7.6% silver tier spins. Table 5 Comparison of top prize selections for each category, from April 25, 2023 to January 1, 2025 Prize category Prize Times selected N (row %) Chi Square p-value a Silver N = 30 spins Bluetooth speaker 8 (26.7) 0.6703 Over-the-ear headphones 10 (33,3) Earbuds 12 (40.0) Blue N = 134 spins Portable charger 46 (34.3) < 0.0001 Trans pride or solid color blanket 35 (19.4) Trans pride attire (e.g., t-shirt, bracelet, necklace) 18 (13.4) Stickers 9 (6.7) Stealth Bros Dopp kit 8 (6.0) Estrogen or testosterone necklace 8 (6.0) Mars products (e.g., fanny pack, mug) 6 (4.5) Camping hammock 4 (3.0) Pink N = 228 spins Candle 70 (30.7) < 0.0001 Fidget toys 37 (16.2) Face mask, eye mask, clay mask 32 (14.0) Tucker panties 32 (14.0) Pill organizer 24 (10.5) Mars branded items (e.g., socks, ornament, art prints, pop socket) 14 (6.4) Trans pride shoelaces 12 (5.3) Lava lamp pen 7 (3.1) a Compared to equal distribution of prize options In each tier, participants were free to choose any available prizes and could choose prizes they had selected previously. For the highest likelihood, lowest price tier (pink) and the moderate likelihood, middle price tier (blue), there was significant difference between which prizes were selected ( p < 0.0001), suggesting clear preferences for certain items. These preferences did not necessarily correspond to the cost or retail value of the prizes selected. In the lowest likelihood, highest price tier (silver), there was no significant difference in how often participants selected Bluetooth speakers, over the ear headphones, and earbuds ( p = 0.6703). Originally, apparel items created by a local TGNB-owned business were included in the silver category but they were moved to the blue category because they were not selected when presented in the silver tier. During qualitative exit interviews, participants expressed approval of the prize wheel. The participants emphasized that the wheel represented an external motivation to improve health, which coupled well with internal motivations to improve health (Table 6 ). The participants commented positively about the portable chargers, face masks, tuckers, trans pride shoelaces, fidget keychains, socks, estrogen/testosterone necklaces, and candles. Table 6 Themes and example quotes illustrating the perceptions of the prize wheel after implementation in PrEP Well Theme Descriptions Illustrative quotations Perceptions of wheel Positive perceptions of the prize wheel “[The wheel] turns a stressful time into something fun, something that makes you want to come.” “Nobody does [a prize wheel] in other places.” “Not all of us had the childhood we wanted…so it’s kind of nice when we do get to experience something that’s… just fun and [spinning a prize wheel is] something that you’d do as a kid.” Prize specific feedback Appreciation of trans pride themed items “Our identity is very important to all of us and especially in the world we live in.” Positive perception of portable charger I got the battery charger on my first time. And I still get teared up. It's pretty cool.” Positive perception of blanket “The truth is that even though the [prizes] look very small, they mean a lot because it's really a basic thing. [Winning the blanket] did help me at one point for the cold weather or to cover [my]self with something.” Positive perceptions of noise cancelling headphones “I really liked the earphones because I have social anxiety. So me going home from getting those buds and them being in my ear, ignoring the world, them were like a lifesaver.” “Every time I use [my headphones], I think about [PrEP Well]...[I] see why you should do things like [PrEP Well]. Because good things could come from it.” Discussion This study demonstrated that creating a TGNB-specific incentive system in partnership with the community built trust and increased the acceptability of PrEP Well . Using behavioral economic principles to designate fun components (i.e., a prize wheel), identity affirming prizes, and providing choices with incentive selection led to positive perceptions in PrEP Well exit interviews. The high level of acceptability of the prize-based incentive system reflects the importance of community participation in study design and implementation. The prizes that were integrated with PrEP Well reflected the prize selections from the pre-implementation surveys and incentive validation pilot. This also informed targeted purchasing of inventory so that funds were not spent on non-preferred items. The variety of prizes reflected the range of experiences of the TGNB community, including those that faced significant financial instability. For participants, portable chargers, blankets, and scented candles may have provided additional functional benefits. Providing a range of prizes to choose from created an empowerment opportunity as well as an incentive to participate. Previous research has shown that chance-based incentives alone are not always effective in motivating behavioral change. 28 , 32 , 44 To create effective interventions that lead to sustained behavioral change around HIV prevention behaviors in the TGNB community, public health practitioners should consider creating fun incentive structures that offer participants the opportunity to make choices around gender-affirming incentives. Research has shown that simply giving participants the option to choose from a variety of incentives can restore a sense of internal control and create a more exciting intervention. 34 Our current findings are consistent and provide examples of ways in which future studies may implement behavioral economic principles to improve HIV prevention behaviors in the TGNB community. Our qualitative interviews revealed that the participants appreciated the use of trans empowering colors, trans owned businesses, and gender affirming prizes. Qualitative data highlighted the role of external motivators in shaping health behaviors, as well as the nuanced ways these incentives intersected with participants' personal goals, identities, and community connections. Many participants described struggling with financial insecurity so the addition of prize-based non-monetary incentives to PrEP Well , which already included fixed monetary incentives, created a powerful motivator for participation. While financial incentives can initially attract participants, they may not be as effective for sustained engagement in health-related behaviors. 45 Previous studies have shown that the effectiveness of interventions decreases significantly after incentives are removed. 28 We aimed to address this challenge by offering prize-based incentives that would continue to remind participants about their community after their participation in the intervention ended. One example that reflects these efforts is the tucker panties that were included in the pink tier. These panties can be expensive, difficult to acquire, and vary widely in quality. Through outreach with community partners, we connected with a TGNB-owned small business making high quality tucker panties. These panties were specifically desired by community members and a prize that you would not see in almost any other prize-based interventions. Although the panties became available in January 2024, 8 months after the implementation of the prize-based incentives, they reached the same levels of selection as prizes that were available for the entire duration. Although the fulfillment timeline was longer than engaging with a large retail entity, we were able to reinvest in the local community and the panties remained one of the most popular prizes. The panties are a memorable product that participants can gain added functional benefits from after study participation has concluded, which may subtly remind them of their experiences in PrEP Well and community to positively influence long term PrEP adherence behaviors. As PrEP Well is an ongoing program that continues to evolve based on organizational changes and client preferences, the protocol changed to meet the needs of the community. At one point, our study coordinator noted that some participants felt frustrated to lose spins when they made their best effort to complete a study activity (i.e., completing a doctor visit) but were not able to for reasons out of their control (e.g., delayed insurance authorization). In response, our staff could award a discretionary spin for the participants’ good faith effort. The participants were also allowed to select items from a lower tier category if they preferred it over the higher tier options awarded from their spin. Allowing for this flexibility has led to high levels of acceptability among participants without greatly affecting cost or administrative burden. Limitations This study has several limitations that might hamper its ecological validity. First, the availability of items fluctuates at times due to ordering delays. This was due to the availability of items from vendors, the administrative process of tracking inventory, and the navigation of various institutional procurement processes to pay vendors. Second, because the inventory of items varied, it was not always possible for participants to receive their first-choice prize. Sometimes, a participant would be willing to collect their prize later, when it became available, whereas others would choose a different prize so they could collect it immediately. Furthermore, PrEP Well was conducted at a single TGNB center in Los Angeles, so prize selections may not be generalizable to TGNB individuals elsewhere. However, PrEP Well reached a wide array of ages, racial, ethnic, and TGNB identities with consistent results. Finally, because this was a pilot study, a limited number of participants were included in the analyses. Conclusions Future studies should explore the opportunities for recruitment and sustainment that come from creating behavioral economic based incentive systems that are tailored to the specific needs of the target community. This is especially true for members of the TGNB community, who often face stigma and whose needs are frequently overlooked in healthcare settings. Community-driven approaches foster trust, enhance the effectiveness of health interventions, and empower community members to take greater ownership of their health decisions. Additionally, examining the long-term sustainability of behavioral changes initiated through such interventions is critical to understanding the broader impact on HIV prevention efforts. By continuing to center community partnerships and leveraging behavioral economic principles, future interventions can further refine strategies to reduce HIV disparities among TGNB populations. Abbreviations Pre-exposure prophylaxis (PrEP) Transgender and gender nonbinary (TGNB) Lesbian, gay, bisexual, transgender, and queer (LGBTQ) Declarations Ethics Approval and Consent to Participate: Participants completed written informed consent, and appropriate ethical approval was received by the Institutional Review Board of San Diego State University. All research activities adhered to the Declaration of Helsinki. Consent for Publication: Not applicable. Availability of Data and Materials: The datasets generated and/or analysed during the current study are not publicly available because participants of this study did not give written consent for their data to be shared publicly but are available from the corresponding author on reasonable request. Competing Interests: The authors have no conflicts of interest to disclose. Funding: This study was supported by the California HIV/AIDS Research Program (CHRP) under award number H21IS3484 (PI: Storholm) and P30MH058107-26S5 (MPI: Storholm/Shoptaw). Drs. Storholm, Murtaugh and Ms. Opalo received additional funding from P30MH058107-27S1(MPI: Storholm/Shoptaw). Ms. Nacht received additional support from the National Institute on Drug Abuse T32DA023356 (PIs: Strathdee, Martin). The funders and sponsors did not participate in the conduct of this study; the content of this manuscript does not represent the official views of CHRP or the National Institutes of Health. Authors’ Contributions: MB: conceptualization, formal analysis, writing – original draft. CLN: supervision, writing – original draft. KLM: methodology, funding acquisition, writing – review and editing. RF: supervision, writing – review and editing. CO: investigation, writing – review and editing. ARD: funding acquisition, writing – review and editing. EDS: funding acquisition, writing – review and editing. Acknowledgements: The authors would like to thank our volunteers— Anthony Guevara, Michelle Williams, Sharon Fong, Simrat Kaur, and Tianlun Cai—whose contributions made this work possible, as well as our study participants, members of the community advisory board, community-owned businesses, and the staff of the Los Angeles Trans Wellness Center, especially Mariana Marroquin, for their contributions to the intervention design and data collection for this project. References Stutterheim SE, van Dijk M, Wang H, et al. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS One 2021;16(12):e0260063, doi:10.1371/journal.pone.0260063 Ackerley CG, Poteat T, Kelley CF. Human Immunodeficiency Virus in Transgender Persons. 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Reaching transgender populations in Zambia for HIV prevention and linkage to treatment using community-based service delivery. J Int AIDS Soc 2022;25 Suppl 5(Suppl 5):e25995, doi:10.1002/jia2.25995 Hirshfield S, Contreras J, Luebe RQ, et al. Engagement in HIV Care Among New York City Transgender Women of Color: Findings from the Peer-Led, TWEET Intervention, a SPNS Trans Women of Color Initiative. AIDS Behav 2021;25(Suppl 1):20-30, doi:10.1007/s10461-019-02667-6 Wilson EC, Turner C, Arayasirikul S, et al. HIV Care Engagement Among Trans Women of Color in San Francisco Bay Area Demonstration Projects: Findings from the Brandy Martell Project and TransAccess. AIDS Behav 2021;25(Suppl 1):31-39, doi:10.1007/s10461-019-02697-0 Nemoto T, Iwamoto M, Suico S, et al. Sociocultural Contexts of Access to HIV Primary Care and Participant Experience with an Intervention Project: African American Transgender Women Living with HIV in Alameda County, California. AIDS Behav 2021;25(1):84-95, doi:10.1007/s10461-019-02752-w Loya-Montiel MI, Davis DA, Aguilar-Martínez JM, et al. Making the Link: A Pilot Health Navigation Intervention to Improve Timely Linkage to Care for Men Who have Sex with Men and Transgender Women Recently Diagnosed with HIV in Guatemala City. AIDS Behav 2019;23(4):900-907, doi:10.1007/s10461-018-2328-6 de Walque D. The use of financial incentives to prevent unhealthy behaviors: A review. Soc Sci Med 2020;261(113236, doi:https://doi.org/10.1016/j.socscimed.2020.113236 Linnemayr S, Stecher C, Mukasa B. Behavioral economic incentives to improve adherence to antiretroviral medication. Aids 2017;31(5):719-726, doi:10.1097/qad.0000000000001387 MacCarthy S, Wagner Z, Barreras JL, et al. Brief Report: Using Behavioral Economics to Increase HIV Knowledge and Testing Among Latinx Sexual Minority Men and Transgender Women: A Quasi-Experimental Pilot Study. J Acquir Immune Defic Syndr 2020;85(2):189-194, doi:10.1097/qai.0000000000002433 Roy Paladhi U, Katz DA, Farquhar C, et al. Using Behavioral Economics to Support PrEP Adherence for HIV Prevention. Curr HIV/AIDS Rep 2022;19(5):409-414, doi:10.1007/s11904-022-00624-y Halpern SD, Kohn R, Dornbrand-Lo A, et al. Lottery-based versus fixed incentives to increase clinicians' response to surveys. Health services research 2011;46(5):1663-74, doi:10.1111/j.1475-6773.2011.01264.x Haslam C, Haslam SA, Cruwys T. Social Scaffolding: Supporting the Development of Positive Social Identities and Agency in Communities. In: Social Scaffolding: Applying the Lessons of Contemporary Social Science to Health and Healthcare. (Williams R, Kemp V, Haslam SA, et al. eds.) Cambridge University Press: Cambridge; 2019; pp. 244-256. Groden P, Capellini A, Levine E, et al. The success of behavioral economics in improving patient retention within an intensive primary care practice. BMC Fam Pract 2021;22(1):253, doi:10.1186/s12875-021-01593-8 Kamenica E. Behavioral Economics and Psychology of Incentives. Annu Rev Econom 2012;4(Volume 4, 2012):427-452, doi:https://doi.org/10.1146/annurev-economics-080511-110909 Davis J. Identity Economics: How Our Identities Shape Our Work, Wages, and Well-Being, George A. Akerlof and Rachel E. Kranton, Princeton University Press, vi + 185 pp. Econ Philos 2011;27(331-338, doi:10.1017/S0266267111000253 Rick SI, Pereira B, Burson KA. The benefits of retail therapy: Making purchase decisions reduces residual sadness. J Consum Psychol 2014;24(3):373-380, doi:https://doi.org/10.1016/j.jcps.2013.12.004 Barnabas RV, van Heerden A, McConnell M, et al. Lottery incentives have short-term impact on ART initiation among men: results from a randomized pilot study. J Int AIDS Soc 2020;23(S2):e25519, doi:https://doi.org/10.1002/jia2.25519 Greene B, Bernardo L, Thompson M, et al. Behavioral Economic Strategies to Improve Enrollment Rates in Clinical Research: Embedded Recruitment Pilot Trial. JMIR Form Res 2023;7(e47121, doi:10.2196/47121 Reback CJ, Kisler KA, Fletcher JB. A Novel Adaptation of Peer Health Navigation and Contingency Management for Advancement Along the HIV Care Continuum Among Transgender Women of Color. AIDS Behav 2021;25(Suppl 1):40-51, doi:10.1007/s10461-019-02554-0 Storholm ED, Nacht CL, Opalo C, et al. Preliminary Outcomes from PrEP Well: A Community-led, Multicomponent HIV Prevention Strategy Implemented in a Transgender Community Health Center. J Community Health 2025, doi:10.1007/s10900-025-01468-4 Taylor J. Fundamentals of Community Health Centers. National Health Policy Forum; 2004. Reynolds HE, Nacht CL, Opalo C, et al. “By Us, for Us”: Qualitative Insights to Inform Implementation of Comprehensive Pre-Exposure Prophylaxis Services in a Trans Community Center. Ann LGBTQ Public Popul Health, doi:10.1891/LGBTQ-2023-0038 Nacht CL, Jessup O, Baumgardner M, Wells J, Opalo C, Marroquin M, Flynn R, Dopp AR, Ling Murtaugh K, Storholm ED. Qualitative Client Perspectives on PrEP Well: A Community-led PrEP Implementation Project with Structural Supports at a Transgender and Nonbinary Community Center. AIDS Care, under review. Guest G, MacQueen K, Namey E. Applied Thematic Analysis. Thousand Oaks, California; 2012. Ltd QIP. NVivo. 2020. Thirumurthy H, Ndyabakira A, Marson K, et al. Financial incentives for achieving and maintaining viral suppression among HIV-positive adults in Uganda: a randomised controlled trial. Lancet HIV 2019;6(3):e155-e163, doi:10.1016/s2352-3018(18)30330-8 Linnemayr S, Rice T. Insights From Behavioral Economics to Design More Effective Incentives for Improving Chronic Health Behaviors, With an Application to Adherence to Antiretrovirals. J Acquir Immune Defic Syndr 2016;72(2):e50-2, doi:10.1097/qai.0000000000000972 Additional Declarations No competing interests reported. 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04:18:20","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":137144,"visible":true,"origin":"","legend":"","description":"","filename":"abbb4131dba74ef8af59ef6135e8cedd1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7654557/v1/aac49d3f575bbfe1eb968daf.xml"},{"id":94622622,"identity":"844b61a9-9812-4359-9d98-1d0a70954d84","added_by":"auto","created_at":"2025-10-29 04:18:24","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":150341,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7654557/v1/dc9a5eb21731038678f05ae6.html"},{"id":94622373,"identity":"c8747280-a553-4c19-ac61-b3b54b39b1f5","added_by":"auto","created_at":"2025-10-29 04:18:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":170229,"visible":true,"origin":"","legend":"\u003cp\u003eMulti-step evaluation to community-engaged incentive selection, assessment, and evaluation\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7654557/v1/0110c5afc03ee20ab6c006a6.png"},{"id":94640199,"identity":"8cb0bb5d-8295-4a18-b103-5b2c74a09968","added_by":"auto","created_at":"2025-10-29 07:48:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1142303,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7654557/v1/e8baec98-9fc6-4e0f-8d1b-3ad4458bf368.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Community-Partnered Development of Behavioral Economic Incentives in a Pre-exposure Prophylaxis Intervention for Transgender and Nonbinary Clients in Los Angeles","fulltext":[{"header":"Background","content":"\u003cp\u003eHIV continues to disproportionately affect transgender and gender nonbinary (TGNB) individuals.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Pre-exposure prophylaxis (PrEP) medication is a highly effective method of HIV prevention,\u003csup\u003e3\u0026ndash;8\u003c/sup\u003e but TGNB people are underrepresented across the PrEP services continuum.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e as well as in research on PrEP uptake and adherence.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e TGNB people experience unique barriers to healthcare access, often shaped by stigma, discrimination, lack of culturally competent care, and other socioeconomic and structural challenges.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eAlthough there is a pressing need to develop and implement culturally competent PrEP interventions tailored to TGNB communities, health services often do not support TGNB needs. A 2022 scoping review revealed that many health interventions grouped TGNB individuals with broader lesbian, gay, bisexual, transgender, and queer (LGBTQ) categories, lacked TGNB input in their design, and did not adequately address intersectional barriers.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Several studies have demonstrated that interventions with promising results among broad LGBTQ populations can be ineffective for TGNB recipients.\u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Interventions are more effective when they elicit feedback from TGNB communities at all levels of design and implementation,\u003csup\u003e16,19\u003c/sup\u003e including interventions targeting HIV prevention and care access in TGNB communities.\u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDesigning incentive systems tailored to TGNB community is key to motivating health behaviors and reducing barriers for the community. Financial incentives have been shown to motivate participation in randomized controlled trials to promote a variety of health behaviors including smoking cessation, substance use abstinence, and adherence to HIV medications.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Behavioral economic interventions use incentives designed around decision processes and individual preferences that shape behavior.\u003c/p\u003e\u003cp\u003eStudies have shown that chance-based financial incentives can be powerful motivators for HIV prevention and other health related behavioral changes.\u003csup\u003e\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Studies suggest that regardless of the financial amount offered, incentives that are fun and focus on the recipient\u0026rsquo;s ingroup community and identity can lead to long term behavioral change. \u003csup\u003e27, 30\u0026ndash;33\u003c/sup\u003e Moreover, one study reported that simply giving participants the ability to make a decision about a hypothetical prize empowered them by increasing feelings of control and joy.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eCreating an incentive system that uses behavioral economics to engage TGNB individuals with culturally specific and empowering incentives can enhance these perceptions of fun, community identity, and control to sustainably increase HIV prevention behaviors. Several studies applied behavioral economic incentives to motivate HIV-related health behaviors among cisgender people\u003csup\u003e\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e, but there is little comparable work among TGNB populations. Nevertheless, the limited data are promising.\u003c/p\u003e\u003cp\u003eOne study with HIV-positive transgender women of color that offered unlimited peer health navigation and escalating monetary incentives for behavioral and biomedical milestones reported increases in HIV care participation across up to 3 years of program participation.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e Another study revealed that chance-based incentives in addition to informational text messages resulted in significant improvements in HIV knowledge compared to a control group that received informational text messages only. Although the sample was mostly Latinx sexual minority men, approximately one-third of the participants were Latinx transgender women (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;66).\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThese studies all used monetary incentives and provided limited information about how the incentives were developed for their TGNB recipients. As is largely the case in related areas of research, transgender women have also been the focus of relevant work to date. None of these studies created non-monetary incentives tailored to the needs of the entire TGNB community. In summary, the use of tailored behavioral economic incentives for HIV prevention is understudied with TGNB communities, limiting the design of prevention interventions that support this population. The purpose of this paper is to describe a community-engaged process that involves tailoring a behavioral economic prize-based incentive structure to increase PrEP engagement and adherence among TGNB individuals.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy setting and design\u003c/p\u003e\u003cp\u003eWe partnered with a TGNB-serving community organization to conduct this study as a component of their ongoing \u003cem\u003ePrEP Well\u003c/em\u003e program. \u003cem\u003ePrEP Well\u003c/em\u003e is a peer navigation intervention that connects participants with gender-affirming PrEP services at a TGNB-serving organization.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e The organization is a federally qualified health center in Los Angeles, California that offers many services, including primary health care, HIV testing and treatment, legal and employment services, etc.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Full details on the community-led design and implementation of \u003cem\u003ePrEP Well\u003c/em\u003e have been described elsewhere.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe design of \u003cem\u003ePrEP Well\u003c/em\u003e was informed by TGNB community members and staff.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e Briefly, \u003cem\u003ePrEP Well\u003c/em\u003e aimed to bring comprehensive community-led PrEP services onsite to the TGNB-serving organization, where anyone who identifies as TGNB that is 18 years or older can enroll. \u003cem\u003ePrEP Well\u003c/em\u003e includes peer-led enrollment and navigation along the PrEP care continuum and 30-day and 90-day follow-up visits. \u003cem\u003ePrEP Well\u003c/em\u003e began enrolling participants in August, 2022, and recruitment is still ongoing.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrEP Well\u003c/em\u003e provides financial incentives to participants for attending each visit, regardless of their engagement with PrEP (\u003cspan\u003e$\u003c/span\u003e50 for baseline, \u003cspan\u003e$\u003c/span\u003e75 for 30-day follow-up, \u003cspan\u003e$\u003c/span\u003e100 for 90-day follow-up) to collect data on engagement barriers. The participants expressed a need for additional incentives. Therefore, the current study sought to develop and implement a supplemental behavioral economic incentive system that would motivate participants to increase PrEP engagement and adherence.\u003c/p\u003e\u003cp\u003eDevelopment of the behavioral economic prize-based incentive system began in January, 2023, and the system was implemented on April 25, 2023. The demographic data of the participants who received the newly implemented incentives were collected from April 25, 2023 through January 1, 2025 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics of Pre-exposure prophylaxis (\u003cem\u003ePrEP) Well\u003c/em\u003e participants from April 25, 2023 to January 1, 2025, N\u0026thinsp;=\u0026thinsp;128\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;128)\u003c/p\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssigned sex at birth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16 (12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e110 (85.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntersex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender identity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWoman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e88 (68.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11 (8.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNonbinary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (14.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNonbinary trans femme\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGenderfluid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAliagender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTwo-spirit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharaoh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSexual orientation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQueer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (11.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStraight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63 (49.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBisexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (10.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePansexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (17.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGay or lesbian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12 (9.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuestioning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (1.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOmnisexual\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRace/ethnicity\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmerican Indian/Alaskan Native\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (4.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (4.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack or African American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28 (21.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic or Latinx\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79 (61.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultiracial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23 (18.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther Pacific Islander\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (2.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite non-Hispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79 (61.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e84 (65.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpen relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (14.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDating/casual relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (10.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClosed relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12 (9.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther/prefer not to say\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOn PrEP\u003csup\u003eb\u003c/sup\u003e at enrollment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25 (19.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, mean (SD)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31.7 (9.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal number of spins during \u003cem\u003ePrEP Well\u003c/em\u003e, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.2 (2.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ea\u003c/sup\u003eNot mutually exclusive\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003eb\u003c/sup\u003ePre-exposure prophylaxis\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ec\u003c/sup\u003eStandard deviation\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWe use a descriptive approach drawing from multiple data sources (surveys, project administrative records, interviews) to illustrate the community-engaged design approach (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eCreating the Prize Wheel and Incentive selection\u003c/p\u003e\u003cp\u003eThe research team drafted procedures describing how incentives would be implemented in \u003cem\u003ePrEP Well\u003c/em\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The participants could receive up to 3 spins per visit (9 total) over the study duration. After participants spun the wheel, they could browse a catalog of prize options and select their desired prize.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePre-exposure prophylaxis (\u003cem\u003ePrEP) Well\u003c/em\u003e behavioral economic incentive structure.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant behavior\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTime point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of spins earned\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttended information session about \u003cem\u003ePrEP\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eWell\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBaseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 spin\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWelcome to \u003cem\u003ePrEP Well\u003c/em\u003e spin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBaseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 spin\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttended initial appointment with PrEP provider\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30- or 90-day follow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 spin\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFilled PrEP prescription at pharmacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30- or 90-day follow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 spin\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttended lab/STI\u003csup\u003eb\u003c/sup\u003e testing visit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30- or 90-day follow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 spin\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrine testing shows PrEP adherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30- or 90-day follow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 spin\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCongratulations on finishing \u003cem\u003ePrEP Well\u003c/em\u003e program\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 spin\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiscretionary spin for other positive activities or attempts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAny\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 spin\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003ePre-exposure prophylaxis\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003eb\u003c/sup\u003eSexually transmitted infection\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo frame the incentive exchange as a fun game with themes of TGNB empowerment, the incentive levels reflect the colors of the transgender pride flag: pink (70% likelihood, average cost \u003cspan\u003e$\u003c/span\u003e0.88, retail value \u003cspan\u003e$\u003c/span\u003e1\u0026ndash;6), blue (25% likelihood, average cost \u003cspan\u003e$\u003c/span\u003e5.25, retail value \u003cspan\u003e$\u003c/span\u003e10-\u003cspan\u003e$\u003c/span\u003e30), and silver (5% likelihood, average cost \u003cspan\u003e$\u003c/span\u003e51.43, retail value \u003cspan\u003e$\u003c/span\u003e50\u0026ndash;100). The average cost of items reflects significant savings in bulk discount purchases and other cost-saving techniques. Based on behavioral economic theory about the motivational advantages of identity-related incentives,\u003csup\u003e30,33\u003c/sup\u003e we engaged community members to select prizes that would be perceived as fun, valuable, and tailored to the TGNB community. First, we generated a range of prize options with input from TGNB staff of the community organization. The research team included prizes sourced from TGNB-owned businesses to authentically build trust, representation, and resilience with the community through economic empowerment.\u003c/p\u003e\u003cp\u003eTo engage TGNB-owned businesses, the research team utilized transowned.co, an online directory of verified TGNB-owned businesses. The team contacted businesses to verify they were comfortable being denoted as \u0026ldquo;Trans Owned\u0026rdquo; within our study context. Conversations with some TGNB-owned businesses led to referrals to other businesses. We also commissioned a local TGNB artist to create original art and prizes. Additionally, some prizes were purchased through digital storefronts such as Amazon.com.\u003c/p\u003e\u003cp\u003eTo assess the incentives selected as prizes for \u003cem\u003ePrEP Well\u003c/em\u003e participants, we created a visual array survey (i.e., with images of each item to maximize understandability). In February, 2023, we distributed this survey to Focus Groups 1 and 2, two convenience samples composed of clients at two LGBTQ-serving settings to guide incentive selection for \u003cem\u003ePrEP Well\u003c/em\u003e participants. There was no incentive for survey takers.\u003c/p\u003e\u003cp\u003eWe first sought feedback on our incentive procedures from a transgender community advisory board in February, 2023; dinner and small monetary incentives were provided as compensation for participation. Second, we sought feedback from a convenience sample of clients at an LGBTQ youth access center, who were invited to spin the prize wheel and win a prize of their choice in exchange for their participation. At the end of both presentations, board members and youth completed a qualitative feedback survey asking what they thought about \u003cem\u003ePrEP Well\u003c/em\u003e, the prize wheel, and the prizes offered. The participants were also invited to participate verbally during these engagements. After implementing the wheel, we totaled how many participants chose each prize, from April 25, 2023 through January 1, 2025.\u003c/p\u003e\u003cp\u003eQualitative interviews\u003c/p\u003e\u003cp\u003eAll participants in \u003cem\u003ePrEP Well\u003c/em\u003e were eligible to participate in exit interviews. The interview methodology was developed for \u003cem\u003ePrEP Well\u003c/em\u003e and is described elsewhere, in a currently unpublished manuscript.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eFrom September 2023 to August 2024, semi-structured interviews were conducted by the \u003cem\u003ePrEP Well\u003c/em\u003e peer navigator, who asked about facilitators, barriers, and suggested improvements for \u003cem\u003ePrEP Well\u003c/em\u003e. The interviews were conducted in English or Spanish, transcribed, translated to English if in Spanish, and de-identified. For the current study, we drew on findings related to discussion of the prize-based incentives during exit interviews.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eUpon recruitment, demographic data, including age, gender identity, race/ethnicity, and relationship status, were collected via a Qualtrics survey and univariate summary statistics were reported. After implementing the prize wheel, we conducted bivariate comparisons between prize categories (silver, blue, pink). Specifically, we used a chi-square test to compare the frequency of each prize selected and to test whether there was a statistically significant difference in prize selection compared with an equal distribution, with a significance set at α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eQualitative data from exit interviews were analyzed via inductive thematic analytic methods.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e A subset of transcripts was first open-coded, and an initial codebook was created. This codebook was refined iteratively through double coding by two researchers until acceptable inter-rater reliability (Kappa\u0026thinsp;\u0026ge;\u0026thinsp;.80) was achieved. The remaining transcripts were then coded independently. NVivo software was used to facilitate coding and data management.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe responses to the pre-implementation prize preference survey generally fall into two groups: older Spanish-speaking adults and younger English-speaking youth, which reflects the diverse perspectives of the community. Overall, both groups demonstrated interest in electronics and fashion items (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Neither group expressed interest in toys. Older Spanish-speaking adults appeared to prefer beauty and personal care items more than younger English speakers, who preferred home goods and franchise merchandise. These data informed the incentive selection for \u003cem\u003ePrEP Well\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePre-implementation prize preferences\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePrize\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal N\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNumber of selections by Older Spanish speakers (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNumber of selections by Younger English speakers (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCategory proportion of total selections\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN (row %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN (row %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003eElectronics and Tech Accessories\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;37 selections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEarbuds/Headphones\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (38.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (61.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e33.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFitness Tracker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eiPad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (50.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhone Case\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePop Socket\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePortable Charger\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSmart Watch\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eFashion and Accessories\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;18 selections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBaseball Hat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e16.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFanny Pack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHoodie/Sweatshirt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (40.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNecklaces\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (66.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (40.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eHome Goods\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;12 selections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCrystal Scoop\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e11.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (80.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSun Catcher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWater Bottle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eToys\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;6 selections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFidget Toy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e5.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMystery Box\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSquishies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eBeauty and Personal Care\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;17 selections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHair Extensions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (80.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e15.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNail Polish\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerfume/Cologne\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (90.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (10.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePress On Nail Set\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (50.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eBrand specific prizes\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;19 selections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBatman Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003e17.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDisney Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDragon Ball Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarvel Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePok\u0026eacute;mon Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSailor Moon Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStar Wars Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudio Ghibli Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransformers Brand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal selections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWe also received qualitative feedback during pre-implementation incentive validation activities (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Overall, participants expressed overwhelmingly positive support for the incorporation of the wheel and prize incentives. The participants also suggested several prizes to be added, including electronics, apparel, accessories, beauty and art supplies, spiritual items, and outdoor gear.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and example quotes illustrating the perceptions of the prize wheel prior to implementation in Pre-exposure prophylaxis (\u003cem\u003ePrEP) Well\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescriptions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIllustrative quotations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003ePerceptions of prizes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive adjectives participants used to describe prizes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Adorb\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Smart\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Fun\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImproves accessibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I like how accessible [the wheel] is.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnticipated positive effects on participation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;[Adding the new incentives] is definitely the way to go. [The wheel and prizes] will be the best way\u0026hellip;to get more participants.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think [adding the wheel] will help with participation because more people would come if they c[ould] win something.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeneral positive reception\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I feel like the prizes are really good and [are] worth the time to take the program.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive perceptions of silver tier\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I really like the silver tier prizes cause it\u0026rsquo;s stuff we would need that we can\u0026rsquo;t get.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAfter the pilot, the wheel and prizes were maintained in the ongoing \u003cem\u003ePrEP Well\u003c/em\u003e project, and the prize choices were recorded for all participants (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The participants earned an average of 3.2 (standard deviation: 2.1) spins during their participation in \u003cem\u003ePrEP Well.\u003c/em\u003e There were a total of 392 spins across all participants, with 58.2% being pink tier spins, 34.2% blue tier spins, and 7.6% silver tier spins.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of top prize selections for each category, from April 25, 2023 to January 1, 2025\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrize category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrize\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTimes selected\u003c/p\u003e\u003cp\u003eN (row %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChi Square\u003c/p\u003e\u003cp\u003ep-value\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSilver\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;30 spins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBluetooth speaker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.6703\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOver-the-ear headphones\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (33,3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEarbuds\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (40.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003eBlue\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;134 spins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePortable charger\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (34.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTrans pride or solid color blanket\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (19.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTrans pride attire (e.g., t-shirt, bracelet, necklace)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (13.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStickers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStealth Bros Dopp kit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (6.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEstrogen or testosterone necklace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (6.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMars products (e.g., fanny pack, mug)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (4.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCamping hammock\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (3.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003ePink\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;228 spins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCandle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 (30.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFidget toys\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (16.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFace mask, eye mask, clay mask\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (14.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTucker panties\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (14.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePill organizer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (10.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMars branded items (e.g., socks, ornament, art prints, pop socket)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (6.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTrans pride shoelaces\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (5.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLava lamp pen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (3.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eCompared to equal distribution of prize options\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn each tier, participants were free to choose any available prizes and could choose prizes they had selected previously. For the highest likelihood, lowest price tier (pink) and the moderate likelihood, middle price tier (blue), there was significant difference between which prizes were selected (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), suggesting clear preferences for certain items. These preferences did not necessarily correspond to the cost or retail value of the prizes selected. In the lowest likelihood, highest price tier (silver), there was no significant difference in how often participants selected Bluetooth speakers, over the ear headphones, and earbuds (\u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.6703). Originally, apparel items created by a local TGNB-owned business were included in the silver category but they were moved to the blue category because they were not selected when presented in the silver tier.\u003c/p\u003e\u003cp\u003eDuring qualitative exit interviews, participants expressed approval of the prize wheel. The participants emphasized that the wheel represented an external motivation to improve health, which coupled well with internal motivations to improve health (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The participants commented positively about the portable chargers, face masks, tuckers, trans pride shoelaces, fidget keychains, socks, estrogen/testosterone necklaces, and candles.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and example quotes illustrating the perceptions of the prize wheel after implementation in \u003cem\u003ePrEP Well\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescriptions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIllustrative quotations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceptions of wheel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive perceptions of the prize wheel\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;[The wheel] turns a stressful time into something fun, something that makes you want to come.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Nobody does [a prize wheel] in other places.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Not all of us had the childhood we wanted\u0026hellip;so it\u0026rsquo;s kind of nice when we do get to experience something that\u0026rsquo;s\u0026hellip; just fun and [spinning a prize wheel is] something that you\u0026rsquo;d do as a kid.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003ePrize specific feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAppreciation of trans pride themed items\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Our identity is very important to all of us and especially in the world we live in.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive perception of portable charger\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eI got the battery charger on my first time. And I still get teared up. It's pretty cool.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive perception of blanket\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;The truth is that even though the [prizes] look very small, they mean a lot because it's really a basic thing. [Winning the blanket] did help me at one point for the cold weather or to cover [my]self with something.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive perceptions of noise cancelling headphones\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I really liked the earphones because I have social anxiety. So me going home from getting those buds and them being in my ear, ignoring the world, them were like a lifesaver.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026ldquo;Every time I use [my headphones], I think about [PrEP Well]...[I] see why you should do things like [PrEP Well]. Because good things could come from it.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that creating a TGNB-specific incentive system in partnership with the community built trust and increased the acceptability of \u003cem\u003ePrEP Well\u003c/em\u003e. Using behavioral economic principles to designate fun components (i.e., a prize wheel), identity affirming prizes, and providing choices with incentive selection led to positive perceptions in \u003cem\u003ePrEP Well\u003c/em\u003e exit interviews. The high level of acceptability of the prize-based incentive system reflects the importance of community participation in study design and implementation.\u003c/p\u003e\u003cp\u003eThe prizes that were integrated with \u003cem\u003ePrEP Well\u003c/em\u003e reflected the prize selections from the pre-implementation surveys and incentive validation pilot. This also informed targeted purchasing of inventory so that funds were not spent on non-preferred items. The variety of prizes reflected the range of experiences of the TGNB community, including those that faced significant financial instability. For participants, portable chargers, blankets, and scented candles may have provided additional functional benefits. Providing a range of prizes to choose from created an empowerment opportunity as well as an incentive to participate.\u003c/p\u003e\u003cp\u003ePrevious research has shown that chance-based incentives alone are not always effective in motivating behavioral change.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e To create effective interventions that lead to sustained behavioral change around HIV prevention behaviors in the TGNB community, public health practitioners should consider creating fun incentive structures that offer participants the opportunity to make choices around gender-affirming incentives. Research has shown that simply giving participants the option to choose from a variety of incentives can restore a sense of internal control and create a more exciting intervention.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Our current findings are consistent and provide examples of ways in which future studies may implement behavioral economic principles to improve HIV prevention behaviors in the TGNB community.\u003c/p\u003e\u003cp\u003eOur qualitative interviews revealed that the participants appreciated the use of trans empowering colors, trans owned businesses, and gender affirming prizes. Qualitative data highlighted the role of external motivators in shaping health behaviors, as well as the nuanced ways these incentives intersected with participants' personal goals, identities, and community connections. Many participants described struggling with financial insecurity so the addition of prize-based non-monetary incentives to \u003cem\u003ePrEP Well\u003c/em\u003e, which already included fixed monetary incentives, created a powerful motivator for participation.\u003c/p\u003e\u003cp\u003eWhile financial incentives can initially attract participants, they may not be as effective for sustained engagement in health-related behaviors.\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e Previous studies have shown that the effectiveness of interventions decreases significantly after incentives are removed.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e We aimed to address this challenge by offering prize-based incentives that would continue to remind participants about their community after their participation in the intervention ended.\u003c/p\u003e\u003cp\u003eOne example that reflects these efforts is the tucker panties that were included in the pink tier. These panties can be expensive, difficult to acquire, and vary widely in quality. Through outreach with community partners, we connected with a TGNB-owned small business making high quality tucker panties. These panties were specifically desired by community members and a prize that you would not see in almost any other prize-based interventions.\u003c/p\u003e\u003cp\u003eAlthough the panties became available in January 2024, 8 months after the implementation of the prize-based incentives, they reached the same levels of selection as prizes that were available for the entire duration. Although the fulfillment timeline was longer than engaging with a large retail entity, we were able to reinvest in the local community and the panties remained one of the most popular prizes. The panties are a memorable product that participants can gain added functional benefits from after study participation has concluded, which may subtly remind them of their experiences in \u003cem\u003ePrEP Well\u003c/em\u003e and community to positively influence long term PrEP adherence behaviors.\u003c/p\u003e\u003cp\u003eAs \u003cem\u003ePrEP Well\u003c/em\u003e is an ongoing program that continues to evolve based on organizational changes and client preferences, the protocol changed to meet the needs of the community. At one point, our study coordinator noted that some participants felt frustrated to lose spins when they made their best effort to complete a study activity (i.e., completing a doctor visit) but were not able to for reasons out of their control (e.g., delayed insurance authorization). In response, our staff could award a discretionary spin for the participants\u0026rsquo; good faith effort. The participants were also allowed to select items from a lower tier category if they preferred it over the higher tier options awarded from their spin. Allowing for this flexibility has led to high levels of acceptability among participants without greatly affecting cost or administrative burden.\u003c/p\u003e\u003cp\u003eLimitations\u003c/p\u003e\u003cp\u003eThis study has several limitations that might hamper its ecological validity. First, the availability of items fluctuates at times due to ordering delays. This was due to the availability of items from vendors, the administrative process of tracking inventory, and the navigation of various institutional procurement processes to pay vendors. Second, because the inventory of items varied, it was not always possible for participants to receive their first-choice prize. Sometimes, a participant would be willing to collect their prize later, when it became available, whereas others would choose a different prize so they could collect it immediately.\u003c/p\u003e\u003cp\u003eFurthermore, \u003cem\u003ePrEP Well\u003c/em\u003e was conducted at a single TGNB center in Los Angeles, so prize selections may not be generalizable to TGNB individuals elsewhere. However, \u003cem\u003ePrEP Well\u003c/em\u003e reached a wide array of ages, racial, ethnic, and TGNB identities with consistent results. Finally, because this was a pilot study, a limited number of participants were included in the analyses.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFuture studies should explore the opportunities for recruitment and sustainment that come from creating behavioral economic based incentive systems that are tailored to the specific needs of the target community. This is especially true for members of the TGNB community, who often face stigma and whose needs are frequently overlooked in healthcare settings. Community-driven approaches foster trust, enhance the effectiveness of health interventions, and empower community members to take greater ownership of their health decisions. Additionally, examining the long-term sustainability of behavioral changes initiated through such interventions is critical to understanding the broader impact on HIV prevention efforts. By continuing to center community partnerships and leveraging behavioral economic principles, future interventions can further refine strategies to reduce HIV disparities among TGNB populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePre-exposure prophylaxis (PrEP)\u003c/p\u003e\n\u003cp\u003eTransgender and gender nonbinary (TGNB)\u003c/p\u003e\n\u003cp\u003eLesbian, gay, bisexual, transgender, and queer (LGBTQ)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e Participants completed written informed consent, and appropriate ethical approval was received by the Institutional Review Board of San Diego State University. All research activities adhered to the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analysed during the current study are not publicly available because participants of this study did not give written consent for their data to be shared publicly but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors have no conflicts of interest to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was supported by the California HIV/AIDS Research Program (CHRP) under award number H21IS3484 (PI: Storholm) and P30MH058107-26S5 (MPI: Storholm/Shoptaw). Drs. Storholm, Murtaugh and Ms. Opalo received additional funding from P30MH058107-27S1(MPI: Storholm/Shoptaw). Ms. Nacht received additional support from the National Institute on Drug Abuse T32DA023356 (PIs: Strathdee, Martin).\u0026nbsp;The funders and sponsors did not participate in the conduct of this study; the content of this manuscript does not represent the official views of CHRP or the National Institutes of Health.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u0026nbsp;\u003c/strong\u003eMB: conceptualization, formal analysis, writing \u0026ndash; original draft. CLN: supervision, writing \u0026ndash; original draft. KLM: methodology, funding acquisition, writing \u0026ndash; review and editing. RF: supervision, writing \u0026ndash; review and editing. CO: investigation, writing \u0026ndash; review and editing. ARD: funding acquisition, writing \u0026ndash; review and editing. EDS: funding acquisition, writing \u0026ndash; review and editing.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors would like to thank our volunteers\u0026mdash; Anthony Guevara, Michelle Williams, Sharon Fong, Simrat Kaur, and Tianlun Cai\u0026mdash;whose contributions made this work possible, as well as our study participants, members of the community advisory board, community-owned businesses, and the staff of the Los Angeles Trans Wellness Center, especially Mariana Marroquin, for their contributions to the intervention design and data collection for this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStutterheim SE, van Dijk M, Wang H, et al. The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. 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(Williams R, Kemp V, Haslam SA, et al. eds.) Cambridge University Press: Cambridge; 2019; pp. 244-256.\u003c/li\u003e\n\u003cli\u003eGroden P, Capellini A, Levine E, et al. The success of behavioral economics in improving patient retention within an intensive primary care practice. BMC Fam Pract 2021;22(1):253, doi:10.1186/s12875-021-01593-8\u003c/li\u003e\n\u003cli\u003eKamenica E. Behavioral Economics and Psychology of Incentives. Annu Rev Econom 2012;4(Volume 4, 2012):427-452, doi:https://doi.org/10.1146/annurev-economics-080511-110909\u003c/li\u003e\n\u003cli\u003eDavis J. Identity Economics: How Our Identities Shape Our Work, Wages, and Well-Being, George A. Akerlof and Rachel E. Kranton, Princeton University Press, vi + 185 pp. Econ Philos 2011;27(331-338, doi:10.1017/S0266267111000253\u003c/li\u003e\n\u003cli\u003eRick SI, Pereira B, Burson KA. The benefits of retail therapy: Making purchase decisions reduces residual sadness. 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Preliminary Outcomes from PrEP Well: A Community-led, Multicomponent HIV Prevention Strategy Implemented in a Transgender Community Health Center. J Community Health 2025, doi:10.1007/s10900-025-01468-4\u003c/li\u003e\n\u003cli\u003eTaylor J. Fundamentals of Community Health Centers. National Health Policy Forum; 2004.\u003c/li\u003e\n\u003cli\u003eReynolds HE, Nacht CL, Opalo C, et al. \u0026ldquo;By Us, for Us\u0026rdquo;: Qualitative Insights to Inform Implementation of Comprehensive Pre-Exposure Prophylaxis Services in a Trans Community Center. Ann LGBTQ Public Popul Health, doi:10.1891/LGBTQ-2023-0038\u003c/li\u003e\n\u003cli\u003eNacht CL, Jessup O, Baumgardner M, Wells J, Opalo C, Marroquin M, Flynn R, Dopp AR, Ling Murtaugh K, Storholm ED. Qualitative Client Perspectives on PrEP Well: A Community-led PrEP Implementation Project with Structural Supports at a Transgender and Nonbinary Community Center. AIDS Care, under review.\u003c/li\u003e\n\u003cli\u003eGuest G, MacQueen K, Namey E. Applied Thematic Analysis. Thousand Oaks, California; 2012.\u003c/li\u003e\n\u003cli\u003eLtd QIP. NVivo. 2020.\u003c/li\u003e\n\u003cli\u003eThirumurthy H, Ndyabakira A, Marson K, et al. Financial incentives for achieving and maintaining viral suppression among HIV-positive adults in Uganda: a randomised controlled trial. Lancet HIV 2019;6(3):e155-e163, doi:10.1016/s2352-3018(18)30330-8\u003c/li\u003e\n\u003cli\u003eLinnemayr S, Rice T. Insights From Behavioral Economics to Design More Effective Incentives for Improving Chronic Health Behaviors, With an Application to Adherence to Antiretrovirals. J Acquir Immune Defic Syndr 2016;72(2):e50-2, doi:10.1097/qai.0000000000000972\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pre-exposure prophylaxis, transgender and nonbinary, LGBT health, HIV, behavioral economics, economic incentives, community-engaged research","lastPublishedDoi":"10.21203/rs.3.rs-7654557/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7654557/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThis article describes our community-engaged process of incorporating culturally relevant, non-monetary, chance-based incentives into a transgender and gender nonbinary (TGNB) oriented pre-exposure prophylaxis (PrEP) intervention called \u003cem\u003ePrEP Well\u003c/em\u003e.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e\u003cem\u003ePrEP Well\u003c/em\u003e, a single-group longitudinal observational study design, was developed as a community-led, multicomponent HIV prevention intervention that combines peer navigation and fixed monetary incentives for research activities in a TGNB community health center. Recruitment for \u003cem\u003ePrEP Well\u003c/em\u003e began in April 2022. We added prize-based behavioral economic incentives to \u003cem\u003ePrEP Well\u003c/em\u003e on April 25, 2023. These prizes reflect the TGNB community\u0026rsquo;s interests through input from a transgender community advisory board, surveys of health center clients, and partnerships with local TGNB-owned businesses. Data are drawn from program administrative records, surveys, and qualitative interviews with program recipients. Comparisons between prize selection were assessed via Chi-square tests. Qualitative interviews were analyzed via inductive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eBefore implementation, survey respondents found additional incentives for participation in \u003cem\u003ePrEP Well\u003c/em\u003e were highly acceptable. After the incentives were implemented in \u003cem\u003ePrEP Well\u003c/em\u003e, qualitative data from exit interviews highlighted the motivational impact of combining a fun, chance-based incentive model with the empowering ability to choose from a variety of trans affirming non-monetary incentives.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eOur community-partnered approach integrated behavioral economic incentives into a TGNB-oriented PrEP intervention. The participants found the additional community-relevant prize-based incentives to be acceptable and motivating. Future research should explore the immediate and long-term outcomes of this approach, and its scalability with diverse TGNB populations, to promote equity in HIV outcomes.\u003c/p\u003e","manuscriptTitle":"Community-Partnered Development of Behavioral Economic Incentives in a Pre-exposure Prophylaxis Intervention for Transgender and Nonbinary Clients in Los Angeles","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 04:01:19","doi":"10.21203/rs.3.rs-7654557/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-05T01:23:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-28T07:27:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-25T03:49:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-23T21:04:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T18:13:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-19T18:52:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124583536292660078696179498725417962188","date":"2025-12-16T16:01:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185825680542675834360999667442870678830","date":"2025-12-15T20:22:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66340410176619650870038427648414290074","date":"2025-12-15T16:58:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333497537654211463320673874379671275711","date":"2025-12-14T14:05:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173229608010363240778198552411032425998","date":"2025-12-12T12:25:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-14T04:57:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-01T06:56:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-30T06:24:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-29T06:38:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-09-29T00:48:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bec1965c-377f-45e8-9623-7f2e4bfc0966","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T23:23:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 04:01:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7654557","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7654557","identity":"rs-7654557","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}