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Published in final edited form as: Soc Sci Med. 2026 Feb 9;395:119068. doi: 10.1016/j.socscimed.2026.119068 Search in PMC Search in PubMed View in NLM Catalog Add to search Unconditional cash transfers to improve health behaviors among primary care patients: a qualitative sub-study of a randomized clinical trial Laura A Gibson Laura A Gibson a Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Med, Phila, PA, USA b Penn Leonard Davis Institute of Health Economics, University of Pennsylvania, Phila, PA, USA Find articles by Laura A Gibson a, b, 1 , Aaron Richterman Aaron Richterman a Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Med, Phila, PA, USA b Penn Leonard Davis Institute of Health Economics, University of Pennsylvania, Phila, PA, USA c Department of Medicine, University of Pennsylvania Perelman School of Med, Phila, PA, USA Find articles by Aaron Richterman a, b, c, *, 1 , Aaliyah Randall Aaliyah Randall a Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Med, Phila, PA, USA Find articles by Aaliyah Randall a , Jonathan Muruako Jonathan Muruako a Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Med, Phila, PA, USA Find articles by Jonathan Muruako a , Beth Uzwiak Beth Uzwiak d Story Research, Phila, PA, USA Find articles by Beth Uzwiak d , Eva Fabian Eva Fabian a Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Med, Phila, PA, USA Find articles by Eva Fabian a , Harsha Thirumurthy Harsha Thirumurthy a Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Med, Phila, PA, USA b Penn Leonard Davis Institute of Health Economics, University of Pennsylvania, Phila, PA, USA Find articles by Harsha Thirumurthy a, b , Christina A Roberto Christina A Roberto a Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Med, Phila, PA, USA b Penn Leonard Davis Institute of Health Economics, University of Pennsylvania, Phila, PA, USA Find articles by Christina A Roberto a, b Author information Article notes Copyright and License information a Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Med, Phila, PA, USA b Penn Leonard Davis Institute of Health Economics, University of Pennsylvania, Phila, PA, USA c Department of Medicine, University of Pennsylvania Perelman School of Med, Phila, PA, USA d Story Research, Phila, PA, USA 1 co-first authors. * Corresponding author. Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA. [email protected] (A. Richterman). Issue date 2026 Apr. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ). PMC Copyright notice PMCID: PMC13095333 NIHMSID: NIHMS2163945 PMID: 41691989 The publisher's version of this article is available at Soc Sci Med Abstract Unconditional cash transfers are a popular poverty reduction approach and may influence behavioral risk factors for chronic disease outcomes through economic and psychological pathways. Few studies have used qualitative interviews to identify the mechanisms through which cash transfers delivered in a health care context might influence the health of people living with chronic diseases in the United States. We conducted a pilot randomized controlled trial to identify pathways through which unconditional cash transfers may influence health and assess the acceptability and feasibility of such an intervention among low-income patients receiving treatment for hypertension or diabetes. Inclusion criteria were: ≥1 visit at the Penn Family Care clinic within the six months prior to study start, ≥18 years of age, Pennsylvania Medicaid beneficiary, diagnosis of pre-diabetes or diabetes, and/or hypertension, prescribed ≥1 oral medication for diabetes or hypertension, and no plans to leave the Philadelphia metro area. Participants were randomized to either the standard of care or an unconditional cash transfer intervention, and completed an assessment at enrollment and after 12 weeks of study participation. We enrolled 100 participants from 3/2023–8/2023 and 93 attended the follow-up visit. Thirty-four participants (selected randomly) completed qualitative interviews. The interviews and survey data revealed that cash transfers were primarily used to address basic needs. We identified potential pathways through which cash transfers may improve health, including temporary reductions in stress and anxiety, changes in diet and physical activity, improved medication adherence, and increased healthcare seeking behavior. The intervention itself was viewed as highly acceptable. Participants in the control group were disappointed not to receive the intervention, but felt the process was fair because all participants were economically vulnerable. These findings suggest unconditional cash transfers may improve health for patients with chronic diseases through a variety of pathways that should be measured in future trials. Keywords: Social determinants of health, Poverty, Cash transfers, Basic income, Chronic disease management 1. Introduction Poverty is a fundamental cause of poor health ( Phelan and Link, 2013 ). Some pathways linking poverty to adverse health outcomes are well established, such as financial constraints leading to food insecurity and unemployment. Other pathways, including psychological factors like mental bandwidth and future orientation, are less well understood. These psychological pathways may contribute to unhealthy modifiable behaviors such as smoking, poor dietary choices, physical inactivity, and lack of medication adherence ( Dean et al., 2019 ; Park et al., 2015 ; Schroeder, 2007 ). Because of the many pathways linking poverty to health, health disparities by socioeconomic status have persisted or worsened despite significant biomedical advances ( Mokdad et al., 2018 ; Phelan and Link, 2013 ). This persistence suggests that more robust poverty-alleviation policies and interventions are necessary to close the health gaps between higher and lower income populations. Cash transfer programs, which provide money to low-income individuals or households, are a popular poverty reduction approach, having been implemented by hundreds of countries worldwide ( The World Bank, 2018 ). Interest in unconditional cash transfers that have no behavioral conditionalities (i.e., “no strings attached”) has increased recently, including in several cities in the United States (US) and especially following the COVID-19 pandemic ( Gentilini, 2022 ). Much of the evidence supporting the use of cash transfers comes from low- and middle-income countries, where extreme poverty rates are high and social protection programs are often limited in scope. In these settings, cash transfer programs have been shown to improve outcomes like economic autonomy, school attendance, nutrition, health-service use, health disparities, and health outcomes like mortality ( Bastagli et al., 2016 ; Bidzha et al., 2024 ; Cavalcanti et al., 2025 ; Owusu-Addo et al., 2018 ; Richterman et al., 2023 , 2025 ; Richterman and Thirumurthy, 2022 ). In the US, over 100 ongoing pilots of unconditional cash transfers—commonly referred to as “guaranteed income” programs— are currently underway in cities nationwide. Additionally, several randomized trials are evaluating the effects of unconditional cash transfers in specific populations, such as women with newborn infants ( Gennetian et al., 2022 ; Neighly et al., 2022 ; Stanford Basic Income Lab, 2024 ). However, evidence of the effects of these programs remains preliminary, and relatively little is known about their impact on health behaviors and rigorously measured health outcomes compared to other domains (e.g., economic well-being) ( Neighly et al., 2022 ). Chronic diseases are a leading cause of premature death and diminished quality of life in the US. For that reason, we developed a pilot randomized controlled trial of unconditional cash transfers among low-income adults being treated for hypertension or diabetes at a family medicine clinic in Philadelphia to explore the pathways through which unconditional cash transfers might improve health. We hypothesized that people living with chronic diseases like hypertension or diabetes may especially benefit from unconditional cash transfers, as these payments could facilitate engagement in key health behaviors like medication adherence, healthy dietary intake, and physical activity, which are needed to successfully manage these conditions. Further, these payments could reduce stress responses in the body triggered by poverty that exacerbate these chronic illnesses and hinder their management. Few studies have evaluated the delivery of cash transfers through the healthcare system ( Doherty et al., 2023 ; McConnell et al., 2024 ). As such, we were also interested in assessing the feasibility of this approach as well as the acceptability of conducting a randomized controlled trial in which control group participants were aware that an intervention group was receiving cash. Given the pilot nature of the trial and the small sample size, we decided a priori not to conduct statistical comparisons between the study arms ( Freedland, 2020 ). Instead, we provide a descriptive summary of the quantitative data and focus this paper on our qualitative interviews with participants in both the treatment and control groups. 2. Methods 2.1. Participants We recruited patients with Pennsylvania Medicaid being treated for hypertension or diabetes at a family medicine clinic in Philadelphia ( NCT05838027 ). Inclusion criteria were: 1) ≥1 visit at the Penn Family Care clinic within the six months prior to study start, 2) ≥18 years of age, 3) Pennsylvania Medicaid beneficiary, 4) diagnosis of pre-diabetes or diabetes, and/or hypertension, 5) prescribed ≥1 oral medication for diabetes or hypertension, and 6) no plans to leave the Philadelphia metro area in the next 6 months. We generated a list of potentially eligible patients based on the first five inclusion criteria using the electronic health record. We contacted these potentially eligible patients using the online health portal, sending them information about the study and a link to an online interest form. Study staff contacted interested patients by telephone to provide additional details about the study and confirm eligibility, and then scheduled a baseline visit during which participants were consented and enrolled. Our reporting followed the Consolidated Standards of Reporting Trials (CONSORT) and Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. The study was approved by the University of Pennsylvania Institutional Review Board, and all participants provided written informed consent. 2.2. Study procedures At the baseline visit, consenting participants completed a self-administered survey questionnaire and the psychomotor vigilance task (a computer-based cognitive measure of mental bandwidth) ( Schilbach et al., 2016 ; Schofield, 2021 ). Study staff measured participants’ height, weight, and blood pressure. After this baseline assessment, participants were randomized using a permuted block technique with block size of four to either usual care or the unconditional cash transfer intervention. After completing the baseline visit, participants were scheduled for a follow-up in-person study visit about 12 weeks later that included all elements of the baseline assessment. For the unconditional cash transfer group, this follow-up assessment also included survey questions about how the cash transfers were spent, and a quantitative measure of intervention acceptability (the Acceptability of Intervention Measure) ( Weiner et al., 2017 ). We randomly selected 35 participants (25 intervention, 10 control) for in-depth interviews conducted after the follow-up visit and before the intervention concluded. We planned to interview additional participants if needed to reach thematic saturation ( Vasileiou et al., 2018 ), but this was not necessary. These interviews were conducted in English over the phone by a study team member (BU) who was not otherwise involved in study activities or clinical care for any participants. Interviews were conducted using a semi-structured guide with open-ended questions about acceptability and feasibility of the unconditional cash transfer intervention, and perceived effects and mechanisms of effects of the unconditional cash transfers (intervention group only). We also assessed among all participants the acceptability of using randomization to evaluate the effects of an unconditional cash transfer, thus necessitating inclusion of control group participants in our interview sample. Interviews were audio-recorded and transcribed verbatim by a professional company. All participants were compensated $25 for completing the baseline visit and $50 for the follow-up visit. Participants completing the interview received an additional $35. 2.3. Unconditional cash transfer intervention The unconditional cash transfer group received $125 on the day of enrollment and every two weeks thereafter for a total of $1000 over 14 weeks. This transfer amount was chosen based on available funding and to be in the range of guaranteed income pilots being conducted in the United States ( Neighly et al., 2022 ; Stanford Basic Income Lab, 2024 ). During the consent process, participants were informed about potential impacts of the unconditional cash transfer on means-tested governmental benefits. We obtained a waiver from the Pennsylvania Department of Human Services such that the intervention would not count as income for any state programs (e.g., Medicaid, Supplemental Nutrition Assistance Program, utility assistance programs). The cash transfers were delivered using a rechargeable debit card (Greenphire ClinCard) that was also used for compensation for study activities. Participants were notified via text message after each payment. 2.4. Primary outcomes Our primary outcome was a set of qualitative themes identifying the mechanisms through which cash transfers may influence health and the acceptability of using randomization to study cash transfers. We also provide descriptive data from the surveys on how the cash transfers were used and perceptions of acceptability of the intervention. As this was a pilot trial that was not statistically powered to detect intervention effects, we did not conduct formal statistical testing to evaluate the comparative effectiveness of unconditional cash transfers with the standard of care ( Freedland, 2020 ). 2.5. Descriptive statistics Baseline characteristics were summarized by group using medians and interquartile ranges (IQR) for continuous variables and frequencies and percentages for categorical variables. Among participants in the cash transfer group, we similarly summarized cash transfer use by spending category. We planned for a sample size of 100 to be large enough to evaluate acceptability and feasibility and reach thematic saturation in the qualitative interviews. We produced descriptive statistics using Stata statistical software, version 17 (StataCorp). 2.6. Qualitative analyses We used an integrated thematic analysis approach to identify themes deductively from a priori domains established based on the expertise of the study team and inductively based on participant responses ( Chun Tie et al., 2019 ). BU led the drafting of the codebook and conducted the qualitative interviews. She holds a PhD in medical anthropology with expertise in qualitative methods including interview data collection and analysis as part of mixed methods studies. BU collaborated with AR, LG, and CR to identify and agree upon emergent codes during the interview process. We used an iterative process to refine and finalize the codebook by discussing the thematically coded data excerpts among the research team to ensure consensus about the coding process and theme meaning. Based on these discussions, revised thematic codes were generated and AR, LG, and CR served as auditors for BU’s analyses. Data memos were prepared by BU and discussed with the study team to guide data analysis, find connections between thematic categories, and identify final themes. All transcripts were coded twice by BU. We used Lumivero NVivo 14 software for qualitative data management and analysis. 3. Results From March 27 to August 4, 2023, we contacted 1131 potentially eligible patients via the health record, with 242 interest form responses, among whom 197 were eligible and 100 were enrolled ( Fig. 1 ). Seventy-one percent of the 1131 potentially eligible patients were female. Compared to potentially eligible patients who were invited but not enrolled, a lower percentage were 60 years of age or older (11% vs 21%) ( Supplementary Table 1 ). Ninety-three participants (93%) attended the follow-up study visit, including 49 (98%) in the cash transfer group, and 44 (88%) in the control group. Fig. 1. Open in a new tab CONSORT study flow diagram. Participants had a median age of 47.8 years (IQR 38 to 54), about three quarters (N = 78, 78%) were female, and a majority (N = 90, 90%) identified as Black ( Table 1 ). Over half (N = 58, 58%) had at least some college education, and the marital status of about three quarters (N = 77, 77%) was single. Among the 50 participants (50%) who reported currently working, the median hours worked per week was 39.5 (IQR 30 to 40.5). Sixty participants (60%) had household incomes below 100% of the Federal Poverty Level, and about half (N = 51, 51%) had children in the household. Over half (N = 55, 55%) the participants had low or very low food security( Coleman-Jensen et al., 2020 ). Table 1. Participant characteristics. Intervention Control N 50 50 Age in years, median (IQR) 49.5 (38–55) range: 26–72 45 (38–53) range: 26–69 Female 41 (82%) 37 (74%) Race Black 45 (90%) 45 (90%) White 2 (4%) 2 (4%) Other/Multiple 1 (2%) 3 (6%) Declined to answer 2 (4%) 0 (0%) Hispanic ethnicity 3 (6%) 0 (0%) Straight/Heterosexual 47 (94%) 42 (84%) Education Less than high school 2 (4%) 4 (8%) Completed high school 15 (30%) 21 (42%) Some college 15 (30%) 11 (22%) Associates/Bachelors degree or greater 18 (36%) 14 (28%) Single Marital status 40 (80%) 37 (74%) Living situation Rent 24 (48%) 32 (64%) Own 15 (30%) 8 (16%) Other 11 (22%) 10 (20%) Number of people in household, median (IQR) 3 (2–4) 3 (1–4) Children in household 24 (48%) 27 (54%) Household Income (% Federal Poverty Level) <50% 9 (18%) 16 (32%) 50–74% 7 (14%) 9 (18%) 75–99% 11 (22%) 8 (16%) 100–132% 9 (28%) 5 (10%) 133%+ 14 (28%) 12 (24%) Work and school No School or Work 23 (46%) 27 (54%) Work 24 (48%) 22 (44%) School and Work 3 (6%) 1 (2%) For those working (n=50) Number of hours worked, median (IQR) 40 (35–46) 36 (20–40) Main income source A Job 27 (54%) 23 (46%) Disability or Social Security 14 (28%) 8 (16%) Family or friends 2 (4%) 9 (18%) Supplemental Nutrition Assistance Program (SNAP) 4 (8%) 6 (12%) Unemployment 2 (4%) 0 (0%) TANF (Cash Assistance/Welfare) 0 (0%) 2 (4%) Veteran Benefits 1 (2%) 1 (2%) Hustling (e.g., petty theft) 0 (0%) 1 (2%) Low or Very Low Food Security ( Coleman-Jensen et al., 2020 ) 23 (46%) 32 (64%) In-crisis or Vulnerable Home Energy Insecurity ( US Department of Health and Human Services, 2019 ) 30 (60%) 27 (54%) Financial Well-Being ,( Consumer Financial Protection Bureau, 2015 ) median (IQR) 43 (35–51) 45 (41–54) Psychomotor Vigilance Task Median reaction time, milliseconds, median (IQR) 352 (334–401) 367 (336402) Minor lapses, median (IQR) 3.5 (1–13) 5 (2–12) Hypertension 40 (80) 42 (84) Prediabetes 10 (20) 14 (28) Diabetes 23 (46) 18 (36) Body Mass Index (BMI) in kg/m 2 , median (IQR) 36.3 (30.9–43.2) 37.7 (32.745.6) Systolic blood pressure in mmHg, median (IQR) 135 (122–144) 132 (119148) Diastolic blood pressure in mmHg, median (IQR) 88 (83–96) 88 (81–94) Health spending over past 30 days, median (IQR) $4.5 (0–25) $3 (0–15) Currently smoke 11 (22) 11 (22) AUDIT-C score, median (IQR) 1 (0–2) 1 (0–2) Open in a new tab Eighty-two (82%) participants had a diagnosis of hypertension, 41 (41%) had diabetes, 24 (24%) had prediabetes, and 32 (32%) had both hypertension and diabetes. Participants had a median body mass index (BMI) of 37 kg/m 2 (IQR 32 to 44), a median systolic blood pressure of 132 mmHg (IQR 121 to 142), and a median diastolic blood pressure of 88 (IQR 83 to 95) mmHg. Over the past 30 days, participants reported spending a median of $0 on health expenditures (IQR $0 to $20), with a maximum of $320. Over one-third of the participants ever smoked tobacco (N = 37, 37%), and about one-fifth currently smoked (N = 22, 22%). Six participants (6%) had a positive screen on the Alcohol Use Disorders Identification Test (AUDIT-C) ( Bradley et al., 2003 ). 3.1. Qualitative interview results Nearly all planned individual interviews were completed (25/25 intervention group, 9/10 control group). Characteristics of participants who were interviewed were similar with those who were not interviewed ( Supplementary Table 1 ). Participants reported primarily using cash transfers on immediate needs, particularly food and bills. This was consistent with survey results from the larger sample ( Table 2 ). In the survey, participants reported using cash transfers mainly on: food (N = 28, 61%), utilities (N = 5, 11%), housing (N = 3, 7%), and transportation (N = 3, 7%). Four participants (8%) reported using some of the cash for savings or investments. Table 2. Cash transfer spending by category. Category Any use Main use Food 39 (81%) 28 (61%) Transportation/Car 27 (56%) 3 (7%) Utilities 25 (52%) 5 (11%) Clothes 24 (50%) - Medications/Medical bills 13 (27%) 1 (2%) Paying down credit cards, student loans 12 (25%) 1 (2%) Rent/Mortgage 11 (23%) 3 (7%) Other (e.g., self-care and gas) 9 (19%) 2 (4%) Childcare/School expenses 6 (13%) 1 (2%) Savings/Investments 4 (8%) 2 (4%) Tobacco/Alcohol/Drugs 4 (8%) - Give away 1 (2%) - Open in a new tab 3.1.1. Theme 1: temporary reductions in stress and anxiety, and increases in wellbeing The most frequently reported impact from receiving the cash transfer was a temporary reduction in stress or anxiety. Although the cash transfers were both limited and temporary, participants explained that payments helped to “take the edge off” ongoing financial strain. As one described: “It’s not a lot of money but it’s enough money to take the load off […] those payments filled in a lot of gaps.” Participants reported putting the transfers towards daily or weekly expenses or paying down a debt, such as an unpaid utility bill. One shared: “It was helpful knowing I can feed the kids that day or that week.” Another said: “It reduced stress. You know, you’re not worrying about what you’re going to do and stretching.” These changes were typically characterized as temporary: “You get ahead of the game for a minute.” Knowing that the payments were coming in, however, reduced everyday experiences of stress and anxiety. “Overall, my anxiety level has definitely decreased,” one participant shared. Another described that receiving payments felt “like a weight was lifted off of me.” Along with reducing stress or anxiety, the payments increased a sense of well-being for some participants. One shared: “I just felt better, I just felt better inside. I just felt better. I feel better getting that hundred, I feel better.” Another concurred: “It made me feel less stressed, you know, and it gave me just a sense of something good. I didn’t wake up thinking about this bill here or there; I woke up thinking I was going to get this little bit of money, so I’ll be able to put something on this bill. It made me feel a little bit less stressed, put a little smile on my face. You know, [gave me] motivation.” 3.1.2. Theme 2: Changes in diet Nearly all participants interviewed in the intervention group described some changes with their diet or eating since enrollment. The most prominent changes were purchasing more food than usual and purchasing food more frequently. A few stocked up on shelf stable food, while others were able to purchase food between paychecks or Supplemental Nutrition Assistance Program payments: “I was able to get food and because, like I said, I buy weekly, I don’t fill my refrigerator up because I don’t get food stamps. So I eat minimally […] if I budget right, it’s not much [the payment], but it will take me to payday.” Some participants reported they bought different or additional foods than usual, including fresh fruit and vegetables: “I think a lot of the times fresh produce could be an issue because it can go bad so quickly and sometimes it gets expensive so a lot of time I will do more foods that are canned things, and I’ve been doing a lot of things with getting additional food like fresh produce that I can take and use all week, which is healthier for me too. So I was able to get more fresh produce and additional things.” 3.1.3. Theme 3: Changes in exercise Participants reported changes in exercise as well. For example, a participant who recently survived a stroke used the transfer to pay for transportation to the gym. She explained how this helped her to improve her physical strength: “I looked at it as the payments benefited for me to get to the gym to work out. To strengthen myself that to point I could walk […] there is a time I’ll be able to walk home or walk to the gym without having a problem or a fear of weakness because I was able to get here and strengthen my myself up.” 3.1.4. Theme 4: Improved medication adherence and healthcare seeking behaviors Some participants reported better engaging in their health through medication adherence, ability to attend follow-up appointments, and general improvements in managing chronic illnesses. Some participants expressed that enrollment in the study itself encouraged them to focus on improving or monitoring their health, while others shared that they used the transfers to pay for transportation to medical appointments and for prescription co-pays. As one participant said, “I have high blood pressure, so it made me monitor my blood pressure a little better and pay attention to what I’m eating.” Participants also shared how they utilized the payments to support the health needs of family members, including children and older adults. Participants reported using the transfers to pay for medical bills, co-pays, and transportation to medical appointments for older adults in their household or family, and for diapers, food, and clothing for children and grandchildren. Of note, while out-of-pocket payments are generally low for Pennsylvania Medicaid recipients, notable costs at the time of the study included: $1 copay for generic medications, $3 for brand name medications, $1 for medical diagnostic testing, $3 per day admitted to the hospital, $0.50 per unit of service for outpatient psychotherapy. Medications to treat hypertension, cancer, diabetes, epilepsy, heart disease, HIV, and psychosis were exempt from copays. Some participants also saw value in the delivery of the cash transfer intervention within the health care context, as this served as a reminder and allowed them to better focus on their health even independent of the cash itself. One participant said, “this study was, like, an enhancer for me to keep myself on record about what’s going on as far as my body.” Another shared, “on the one hand it helps you with little things that you have to do, the payments, then on the other hand it helps you get on track and stay on task [with your health]. I like going to the study.” 3.1.5. Theme 5: Acceptability of the intervention and study design Participants found the unconditional cash transfer intervention to be highly acceptable, indicating that they especially appreciated that they could spend the money however they wished. This was consistent with exceptionally high scores on the Acceptability of Intervention Measure (median score 5 out of 5, IQR 5 to 5) from the survey results. Participants in the control group were disappointed not to receive cash transfers but felt that the process was fair because all participants were economically vulnerable and had a chance to receive the payments. To illustrate this, one participant said, “I think it’s a good way. So that way you know there’s no favoritism. No one is getting selected because they made a bigger impact than the other person.” Transparency was also seen as important: “I don’t have a problem with [randomization] … because they are, they pretty much told me … up front how it was going to be like what you’re telling me now. So I don’t have a problem with it.” More broadly, participants felt that they benefited by participating in the study, independent of the cash intervention. As one said, “I did enjoy sharing my opinions on the surveys because I know the importance of how a survey will impact the community. So I thought that was very helpful.” This was further emphasized by another participant, who shared, “it made me feel like I was doing something, contributing.” 4. Discussion In qualitative analyses of a subset of participants enrolled in a pilot randomized controlled trial of unconditional cash transfers for low-income adults receiving treatment for hypertension or diabetes at a family medicine clinic in Philadelphia, we identified several potential pathways through which unconditional cash transfers may improve health for populations with chronic diseases. These included temporary reductions in stress and anxiety, changes in diet and physical activity, improved medication adherence, and increased healthcare seeking behavior. Additionally, we found that unconditional cash transfers were both acceptable and feasible to recipients within the primary care setting. Our low rates of loss to follow-up — including among participants who did not receive cash transfers— suggest the feasibility of using a trial design to evaluate the efficacy of cash transfers in the primary care setting. This study was among the first in the US to study cash transfers delivered within a healthcare context and specifically targeted at people living with chronic diseases. Our findings provide strong rationale for larger-scale evaluations of unconditional cash transfers that are conducted in the healthcare context and among patients with chronic diseases, and that are powered to detect effects on clinical outcomes. The most frequently reported impact of receiving cash transfers was a temporary reduction in stress or anxiety, suggesting a potential psychological pathway through which the intervention may improve health behaviors and outcomes ( Dean et al., 2019 ; Park et al., 2015 ). This connection between mental health and chronic disease management was further emphasized by participants who described how cash transfers enabled them to better engage with their chronic conditions during the study period. These findings align with evidence from several studies of the general population in the US and globally, which suggest that cash transfers can lead to improvements in mental health ( Agarwal et al., 2024 ; Costello, 2010 ; Haushofer and Shapiro, 2016 ; Miller et al., 2024 ; West and Castro, 2023 ). Participants receiving the cash transfer intervention also described improvements in health behaviors closely linked to chronic disease outcomes, including diet, physical activity, medication adherence, and other healthcare seeking behavior. Whether these changes translate into meaningful improvements in clinical outcomes remains an important question for future research. Recent large-scale studies of unconditional cash transfers in the US have shown mixed results in these domains ( Agarwal et al., 2024 ; Miller et al., 2024 ), though notably, these studies have not specifically targeted people already living with chronic diseases and have instead been conducted among younger individuals without chronic diseases. Consistent with recipients of other cash transfers for low-income people in the United States ( Gennetian et al., 2022 ; The Annie E. Casey Foundation, 2022 ), participants in our study primarily used the cash to meet basic needs and mitigate existing debts. Given the high prevalence of poverty, food insecurity, utility insecurity, and financial hardship in our study population, this finding was expected. Importantly, it also suggests that the cash transfers were not used in ways that could be detrimental to health (e.g., tobacco use). Few participants saved or invested the cash, likely due to the relatively modest size and temporary nature of the payments. A relatively novel finding from this pilot study was that among both intervention and control participants randomization was perceived as an acceptable way to evaluate the uncertain effects of cash transfers within the broader context of scarce resources. Few studies have explored the perspectives of people randomly assigned to receive financial benefits in an investigational social program like this, making it reassuring that participants perceived the study design as fair — provided all participants were economically vulnerable and the process was transparent. Similar viewpoints have been reported among people who did not receive insurance coverage through the Oregon Medicaid experiment ( Allen et al., 2013 ). The importance of transparency in studies of cash transfers has also been identified in low income settings ( Macphail et al., 2013 ). This study had several limitations. As a pilot trial, it was not powered to evaluate the comparative effectiveness of unconditional cash transfers versus the standard of care. However, given the limited prior research on the use of unconditional cash transfers for people with chronic diseases in US healthcare settings, this formative work provides a foundation for future research to address this question. Because this trial was conducted at a single urban clinic, findings may not be generalizable to other settings. Similarly, the study population was engaged in health care and responded to a recruitment message on the electronic health portal and telephone calls and had a lower percentage of people 60 years of age or older who may have experienced more technological barriers. The high percentage of potentially eligible female patients identified through the health portal likely reflects this population’s greater engagement in health care. Consequently, these findings may not generalize to populations that are less engaged in health care or who have technological barriers, which may well experience different (and greater) benefits from an unconditional cash transfer. We did not address whether cash transfers would be preferable to other forms of economic support (e.g., in kind transfers). Finally, social desirability bias may have influenced participants’ responses, as those who received cash transfers were also interviewed about their perceived impacts, though the interviewer was not a person affiliated with the University of Pennsylvania or someone they interacted with during the course of the trial. 5. Conclusions In this pilot randomized controlled trial of unconditional cash transfers for low-income adults receiving treatment for hypertension or diabetes at a family medicine clinic in Philadelphia, we found several potential pathways through which cash transfers may improve health. These included temporary reductions in stress and anxiety, changes in diet and physical activity, improved medication adherence, and increased healthcare seeking behavior. Additionally, we found that unconditional cash transfers were both acceptable and feasible within the primary care context, and that a randomized controlled trial design to evaluate their health effects was acceptable to participants. Our findings provide strong rationale for further evaluations of unconditional cash transfers in health care settings for patients with chronic diseases, particularly in trials powered to assess clinical outcomes. Moreover, they highlight key pathways that should be measured in these evaluations to better understand the mechanisms through which cash transfers may influence health. Supplementary Material 1 NIHMS2163945-supplement-1.doc (219KB, doc) 2 NIHMS2163945-supplement-2.docx (26.8KB, docx) 3 NIHMS2163945-supplement-3.docx (22.8KB, docx) 4 NIHMS2163945-supplement-4.docx (25.7KB, docx) Supplementary data to this article can be found online at https://doi.org/10.1016/j.socscimed.2026.119068 . Funding National Institute of Aging through the Penn Roybal Center (5P30AG034546-14). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Abbreviations: BMI body mass index CONSORT Consolidated Standards of Reporting Trials COREQ Consolidated Criteria for Reporting Qualitative Research IQR interquartile range US United States Footnotes Ethics statement The study was approved by the University of Pennsylvania Institutional Review Board, and all participants provided written informed consent. CRediT authorship contribution statement Laura A. Gibson: Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Aaron Richterman: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Supervision, Writing – original draft, Writing – review & editing. Aaliyah Randall: Data curation, Formal analysis, Visualization, Writing – original draft, Writing – review & editing. Jonathan Muruako: Data curation, Writing – review & editing. Beth Uzwiak: Data curation, Formal analysis, Writing – original draft. Eva Fabian: Data curation, Project administration, Writing – review & editing. Harsha Thirumurthy: Conceptualization, Methodology, Supervision, Writing – review & editing. Christina A. Roberto: Conceptualization, Methodology, Supervision, Writing – review & editing. Conflicts of interest Authors declare no conflicts of interest. Data availability Data will be made available on request. 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Supplementary Materials 1 NIHMS2163945-supplement-1.doc (219KB, doc) 2 NIHMS2163945-supplement-2.docx (26.8KB, docx) 3 NIHMS2163945-supplement-3.docx (22.8KB, docx) 4 NIHMS2163945-supplement-4.docx (25.7KB, docx) Data Availability Statement Data will be made available on request. 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