Video Abstract

Video Abstract

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OBJECTIVE

We sought to evaluate the use of behavioral economics approaches to promote the carrying of epinephrine auto-injectors (EAIs) among adolescents with food allergies. We hypothesized that adolescents who receive frequent text message nudges (Intervention 1) or frequent text message nudges plus modest financial incentives (Intervention 2) would be more likely to carry their epinephrine than members of the usual care control group.

METHODS

We recruited 131 adolescents ages 15 to 19 with a food allergy and a current prescription for epinephrine to participate in a cohort multiple randomized controlled trial. Participants were randomly assigned to participate in Intervention 1, Intervention 2, or to receive usual care. The primary outcome was consistency of epinephrine-carrying, measured as the proportion of checkpoints at which a participant could successfully demonstrate they were carrying their EAI, with photo-documentation of the device.

RESULTS

During Intervention 1, participants who received the intervention carried their EAI 28% of the time versus 38% for control group participants (P = .06). During Intervention 2, participations who received the intervention carried their EAI 45% of the time versus 23% for control group participants (P = .002).

CONCLUSIONS

Text message nudges alone were unsuccessful at promoting EAI-carrying but text message nudges combined with modest financial incentives almost doubled EAI-carriage rates among those who received the intervention compared with the control group. However, even with the intervention, adolescents with food allergies carried their EAI <50% of the time. Alternative strategies for making EAIs accessible to adolescents at all times should be implemented.

What’s Known on This Subject:

Adolescence is the period of highest risk of death from anaphylaxis for children with food allergies. Yet, there is a lack of adherence to preventive strategies, including the carrying of potentially life-saving epinephrine auto-injectors (EAIs), and few evidence-based interventions exist.

Although text message nudges alone did not promote EAI-carrying, text message nudges combined with modest financial incentives almost doubled EAI carriage rates compared with usual care. However, at any given point in time, only 54% of adolescents carried their EAI.

In the United States, an estimated 4% to 8% of children have immunoglobulin E-mediated food allergies.13  Allergic reactions can be mild or severe, including anaphylaxis, a potentially life-threatening condition that is treatable with the prompt administration of epinephrine.4  Inpatient hospital stays and emergency department visits make up ∼60% of the total direct medical costs of food allergies in children.5  No universal cure exists for food allergies, leaving those affected by them to practice careful self-management, which includes preventive measures (ie, avoidance of potentially allergenic foods) and emergency response (ie, administration of epinephrine during anaphylaxis).6

Adolescence is the period with the highest risk of death from anaphylaxis.79  This higher risk results in part from a lack of adherence to prevention strategies, such as the consistent carrying of epinephrine auto-injectors (EAIs), because of increased independence from parents and greater risk-taking behaviors.1012  One study found that, among college students with food allergies with a history of anaphylactic symptoms, only approximately one-third reported ever carrying an EAI; only one-half of them carried it with them at all times.13  Multiple studies have identified barriers and facilitators to carrying and using epinephrine, including characteristics of EAI devices (eg, bulkiness, ease of use) and the social environment (eg, ability to carry epinephrine in a backpack at school but difficulty when socializing outside of school).12,14,15  Yet few interventions exist to improve epinephrine carriage rates; most interventions that have been implemented are purely educational.16,17

The use of behavioral economics approaches to promote disease management offers promising results across multiple chronic conditions.1821  These same concepts can be applied to promote safe food allergy management practices.22  Behavioral economics acknowledges that individuals typically have bounded rationality, meaning that they often do not behave perfectly rationally but do so in predictable ways on the basis of mental shortcuts or heuristics.23  Based on a pilot intervention with promising results for nudge approaches to improve epinephrine-carrying among young adults,22  we experimentally evaluated 2 behavioral economics interventions to promote epinephrine-carrying among adolescents. Using a cohort multiple randomized controlled trial design,24  we hypothesized that:

1. Adolescents with food allergies who receive frequent text message nudges (Intervention 1) would be more likely to carry their epinephrine than members of the usual care control group.

2. Adolescents with food allergies who receive frequent text message nudges plus financial incentives (Intervention 2) would be more likely to carry their epinephrine than members of the usual care control group.

Informed by our pilot study that employed text message nudges and modest financial incentives,22  we developed 2 sequential interventions on the basis of 5 principles of behavioral economics to promote consistent epinephrine-carrying among adolescents with food allergies.

#### Principle 1: Availability Heuristic

The availability heuristic refers to the ease with which examples about a certain topic come to mind.25  It offers a way to overcome patients’ limited bandwidth to attend to healthy behaviors, such as consistent epinephrine-carrying, by nudging patients. In this study, nudges were text message prompts to increase the salience of food allergy management among adolescents. Text message-based interventions have been successfully employed among youth, including to manage diabetes and asthma.26  Working with a convenience sample of adolescents and young adults with food allergies who were not part of this study, we piloted and cognitively tested a bank of text message nudges in cognitive interviews.27  Messages provided information, facts, or tips about food allergies or requested feedback from participants (eg, “What is the most important advice you would give a friend with food allergies?”).

#### Principle 2: Feedback

Providing feedback about a certain behavior allows individuals to learn.25  We provided automated feedback to participants when they succeeded or failed to document they were carrying their EAIs.

Incentives are a cornerstone of behavioral economics.25  In our pilot study, we found that modest financial incentives (approximately $100) were a successful motivator for carrying epinephrine among young adults.22 #### Principle 4: Loss Aversion Loss aversion refers to individuals’ tendency to be more effectively motivated by the threat of losing something of value than by the gain of something of equivalent value.28 #### Principle 5: Present Bias Present bias refers to individuals’ tendency to focus on the present rather than the future.28,29 In the case of food allergy management, the benefits of consistently carrying epinephrine may not be immediately apparent given (hopefully) rare use in emergency situations. Intervention 1 tested the use of nudges (Principle 1) and feedback (Principle 2) to promote epinephrine-carrying by sending intervention group participants intermittent, randomly timed (∼30 over a 10-week period, primarily outside of regular school hours) text messages. Intervention 2 used all 5 principles, including the nudges and feedback components from Intervention 1 with the addition of financial incentives (Principle 3), which were designed by leveraging the loss aversion principle (Principle 4) and with information about the incentive for carrying epinephrine provided immediately (Principle 5). At the beginning of the second intervention period, intervention group participants were notified that$100 was placed in a virtual account for them and that they would lose $10 every time they failed to successfully demonstrate they were carrying their EAI at each of the 10 random checkpoints. This study used a cohort multiple randomized controlled trial design to test the 2 interventions to promote epinephrine-carrying and characterize food allergy management behaviors.24 The base cohort was followed for a period of 2 years during which they were asked to fill out 3 surveys (at baseline, midway, and at the end of the study period) about their food allergy knowledge, attitudes, and behaviors. During recurring text-based assessments to monitor adverse events, participants were also asked about the incidence of food allergic reactions. At enrollment, participants self-reported their age, sex, and race/ethnicity to assess sample representativeness and generalizability of findings. All participants were part of the base cohort. Within the base cohort, participants were randomly assigned to participate in Intervention 1 (text message nudges), Intervention 2 (text message nudges and financial incentives), or to receive usual care (Fig 1). During Intervention 1, the control group consisted of participants who were (1) randomly assigned to receive usual care and (2) randomly assigned to later participate in Intervention 2. During Intervention 2, the control group consisted of only participants randomly assigned to receive usual care throughout the entire study period. Participants randomly assigned to participate in Intervention 1 were followed during Intervention 2 to assess the long-term effects of the intervention on epinephrine-carrying but were excluded from the primary analysis for Intervention 2 to avoid confounding the comparison with any potential carryover effects of Intervention 1. FIGURE 1 Study intervention flow. FIGURE 1 Study intervention flow. Close modal We worked with the Children’s Hospital of Philadelphia (CHOP) Recruitment Enhancement Core to send out emails or letters to >2500 patients on the basis of the following search criteria: (1) ages 15 to 19, (2) epinephrine prescription, (3) seen by an allergy specialist at any CHOP location within the last 36 months, and (4) had 1 of the following International Classification of Diseases codes for food allergy (T78.0–T78.2, T78.40, T78.49, Z91.018). We also recruited patients by phone, by posting physical and online flyers, and by publishing the trial on Penn Medicine’s trial portal. Recruitment began in June 2018 and ended in February 2019. To participate in the study, participants had to meet the following inclusion criteria: (1) have a food allergy, (2) have a current prescription for an EAI, (3) be between 15 and 19 years of age, (4) be fluent in English, and (5) have a cellphone that could send and receive photos. The study coordinator recruited 131 participants for the base cohort. Participants were then randomly assigned by the study biostatistician to receive Intervention 1 (n = 26), Intervention 2 (n = 54), or usual care (n = 51; Supplemental Fig 1). Given the relatively small sample size, we used permutated block randomization and stratified by sex to ensure a balance between groups.30 With 25 participants per group, we estimated 80% power to detect a 23% difference in the proportion of successful checkpoints (our primary outcome) between each intervention group and the control group, a smaller difference than we found in our pilot study.22 We obtained informed consent from all participants aged 18 and older and parental consent and participant assent for those <18 years of age. Consent was obtained during a phone call with the study coordinator, and participants were asked to sign the consent form electronically. Participants received$20 for completing each of the 3 surveys and \$20 for participating in a debrief interview after the study was over.

The administration of the interventions was fully automated by using the Way to Health platform.31  After participants enrolled in the study, they registered their cellphone numbers with the platform to receive all study surveys and interventions by text message.

The primary endpoint was consistency of epinephrine-carrying, measured as the proportion of checkpoints at which a participant could successfully demonstrate they were carrying their epinephrine. Checkpoints occurred for all participants (intervention and control) once per week at a random time during both intervention periods and included a text message with a request to share a photograph of their EAI next to a code word of the day to ensure they were taking the photo in real time. For example:

Are you carrying your epinephrine now? If not, text “no” in response. If yes, text a photo of your epinephrine auto-injector next to the written code word “computer”.

Participants were classified as having successfully demonstrated they were carrying their EAI if they replied to the checkpoint message with a photo of their EAI and the code word of the day within 30 minutes of receiving the message (Fig 2). This assessment method was successfully employed in the pilot study.22

FIGURE 2

Example of a successful checkpoint photograph.

FIGURE 2

Example of a successful checkpoint photograph.

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We initially planned to measure the primary outcome as the proportion of 10 checkpoints during which participants were carrying their EAIs. Early technical glitches with the study platform during Intervention 1 led to a failure to reach multiple study participants; 12 checkpoint attempts were made from which 9 yielded usable data. Thus, for Intervention 1, the primary outcome was the proportion of 9 checkpoints during which participants carried their EAIs. During Intervention 2, all 10 checkpoints worked as planned.

We also collected process data, using a mix of open- and close-ended questions, during the midway and exit surveys to evaluate whether participants found the text message nudges useful and informative, assess the frequency at which text message nudges were sent, and understand how motivating the financial incentives were for participants who received them.

All data were analyzed in RStudio version 1.3.959. To assess the effectiveness of the interventions as measured by the primary endpoint and test hypotheses 1 and 2, we used a 2-sided Wilcoxon rank test (at a 0.05 significance level) to determine between-group differences in the proportion of successful checkpoints for each intervention.32

Analyses were conducted by using complete case analysis with missing data treated as a failure to document epinephrine-carrying, following the intention-to-treat principle.33  We conducted a sensitivity analysis that counted successful responses to checkpoints even if they were late (ie, outside the 30-minute window, per our predefined criteria).

This study was approved by the Institutional Review Boards of the University of Pennsylvania and the CHOP.

Cohort participants identified primarily as non-Hispanic white, with a mean age of 16 years. The most common food allergies were to tree nuts and peanuts, and more than two-thirds of participants were allergic to >1 food. All participants self-reported consistently carrying their EAIs; only one-half had ever been treated with an injection of epinephrine. Participants’ characteristics were similar across all 3 study groups (Table 1).

TABLE 1

Participant Demographic Characteristics, Overall and by Intervention Group

CharacteristicCohort (n = 131)Intervention 1Intervention 2
Intervention Group
1: Text Messages
Only (n = 26)
Control Group 1 (n = 105)Intervention Group
2: Text Messages and Financial Incentives (n = 54)
Control Group 2 (n = 51)
Sex, n (%)a
Female 65 (50) 13 (50) 52 (50) 27 (50) 25 (49)
Male 65 (50) 13 (50) 52 (50) 27 (50) 25 (49)
Decline to answer 1 (1) 0 (0) 1 (1) 0 (0) 1 (2)
Age, mean (SD) 16 (1) 16 (2) 17 (1) 17 (1) 16 (1)
Race, n (%)a
American Indian or Alaskan Native 1 (1) 0 (0) 1 (1) 0 (0) 1 (2)
Asian 5 (4) 2 (8) 3 (3) 2 (4) 1 (2)
Black 15 (12) 5 (19) 10 (10) 4 (7) 6 (12)
White 104 (79) 19 (73) 85 (81) 45 (83) 40 (78)
Other 5 (4) 0 (0) 5 (5) 3 (6) 2 (4)
Decline 1 (1) 0 (0) 1 (1) 0 (0) 1 (2)
Ethnicity, n (%)
Hispanic 3 (2) 0 (0) 3 (3) 1 (2) 2 (4)
Decline to answer 1 (1) 0 (0) 1 (1) 0 (0) 1 (2)
9 9 (7) 0 (0) 9 (9) 3 (6) 6 (12)
10 36 (28) 11 (42) 25 (24) 10 (19) 15 (30)
11 30 (23) 4 (15) 26 (25) 14 (26) 12 (24)
12 22 (17) 3 (12) 19 (18) 10 (19) 9 (18)
College Freshman 28 (21) 6 (23) 22 (21) 14 (26) 8 (16)
College Sophomore 6 (5) 2 (8) 4 (4) 3 (6) 1 (2)
Allergic to, n (%)b
Peanut 79 (70) 15 (71) 64 (70) 30 (65) 34 (74)
Tree nuts 84 (74) 14 (67) 70 (76) 39 (85) 31 (67)
Soy 8 (7) 1 (5) 7 (8) 4 (9) 3 (7)
Wheat 3 (3) 1 (5) 2 (2) 0 (0) 2 (4)
Milk 18 (16) 5 (24) 13 (14) 6 (13) 7 (15)
Egg 18 (16) 3 (14) 15 (16) 8 (17) 7 (15)
Fish 11 (10) 2 (10) 9 (10) 6 (13) 3 (7)
Shellfish 20 (18) 6 (29) 14 (15) 6 (13) 8 (17)
Sesame 26 (23) 3 (14) 23 (25) 11 (24) 12 (26)
Other 21 (19) 7 (33) 14 (15) 10 (22) 4 (9)
Multiple allergies, n (%) 82 (73) 14 (67) 68 (74) 35 (76) 33 (72)
Age at diagnosis, mean (SD)c 4 (4) 4 (3) 3 (4) 4 (4) 3 (3)
Ever used EAI, n (%)c 59 (52) 9 (43) 50 (54) 25 (54) 25 (54)
Ever had an allergic reaction, n (%)c 81 (73) 13 (62) 68 (74) 36 (78) 32 (70)
Consistency of EAI carrying (1–10), mean (SD)c 8 (3) 8 (2) 8 (3) 8 (3) 8 (3)
CharacteristicCohort (n = 131)Intervention 1Intervention 2
Intervention Group
1: Text Messages
Only (n = 26)
Control Group 1 (n = 105)Intervention Group
2: Text Messages and Financial Incentives (n = 54)
Control Group 2 (n = 51)
Sex, n (%)a
Female 65 (50) 13 (50) 52 (50) 27 (50) 25 (49)
Male 65 (50) 13 (50) 52 (50) 27 (50) 25 (49)
Decline to answer 1 (1) 0 (0) 1 (1) 0 (0) 1 (2)
Age, mean (SD) 16 (1) 16 (2) 17 (1) 17 (1) 16 (1)
Race, n (%)a
American Indian or Alaskan Native 1 (1) 0 (0) 1 (1) 0 (0) 1 (2)
Asian 5 (4) 2 (8) 3 (3) 2 (4) 1 (2)
Black 15 (12) 5 (19) 10 (10) 4 (7) 6 (12)
White 104 (79) 19 (73) 85 (81) 45 (83) 40 (78)
Other 5 (4) 0 (0) 5 (5) 3 (6) 2 (4)
Decline 1 (1) 0 (0) 1 (1) 0 (0) 1 (2)
Ethnicity, n (%)
Hispanic 3 (2) 0 (0) 3 (3) 1 (2) 2 (4)
Decline to answer 1 (1) 0 (0) 1 (1) 0 (0) 1 (2)
9 9 (7) 0 (0) 9 (9) 3 (6) 6 (12)
10 36 (28) 11 (42) 25 (24) 10 (19) 15 (30)
11 30 (23) 4 (15) 26 (25) 14 (26) 12 (24)
12 22 (17) 3 (12) 19 (18) 10 (19) 9 (18)
College Freshman 28 (21) 6 (23) 22 (21) 14 (26) 8 (16)
College Sophomore 6 (5) 2 (8) 4 (4) 3 (6) 1 (2)
Allergic to, n (%)b
Peanut 79 (70) 15 (71) 64 (70) 30 (65) 34 (74)
Tree nuts 84 (74) 14 (67) 70 (76) 39 (85) 31 (67)
Soy 8 (7) 1 (5) 7 (8) 4 (9) 3 (7)
Wheat 3 (3) 1 (5) 2 (2) 0 (0) 2 (4)
Milk 18 (16) 5 (24) 13 (14) 6 (13) 7 (15)
Egg 18 (16) 3 (14) 15 (16) 8 (17) 7 (15)
Fish 11 (10) 2 (10) 9 (10) 6 (13) 3 (7)
Shellfish 20 (18) 6 (29) 14 (15) 6 (13) 8 (17)
Sesame 26 (23) 3 (14) 23 (25) 11 (24) 12 (26)
Other 21 (19) 7 (33) 14 (15) 10 (22) 4 (9)
Multiple allergies, n (%) 82 (73) 14 (67) 68 (74) 35 (76) 33 (72)
Age at diagnosis, mean (SD)c 4 (4) 4 (3) 3 (4) 4 (4) 3 (3)
Ever used EAI, n (%)c 59 (52) 9 (43) 50 (54) 25 (54) 25 (54)
Ever had an allergic reaction, n (%)c 81 (73) 13 (62) 68 (74) 36 (78) 32 (70)
Consistency of EAI carrying (1–10), mean (SD)c 8 (3) 8 (2) 8 (3) 8 (3) 8 (3)

SD, standard deviation.

a

Percentages may not add up to 100% because of rounding.

b

Numbers do not sum to group totals and percentages do not add up to 100% because participants could report multiple allergies.

c

Cohort: n = 113, intervention group 1: n = 21, control group 1: n = 92, intervention group 2: n = 46, control group 2: n = 46.

The proportion of participants who successfully documented they were carrying their EAI at each individual checkpoint is presented in Figure 3. During Intervention 1 (text message nudges), participants who received the intervention carried their EAI 28% of the time versus 38% for control group participants (P = .06). During Intervention 2 (text message nudges and financial incentives), participants who received the intervention carried their EAIs 45% of the time versus 23% for control group participants (P = .002). This difference was even larger in the sensitivity analysis that allowed for late responses (52% vs 32%) (Table 2).

FIGURE 3

Proportion of participants who carried their epinephrine auto-injector at each individual checkpoint.

FIGURE 3

Proportion of participants who carried their epinephrine auto-injector at each individual checkpoint.

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TABLE 2

Proportion of Checkpoints at Which Participants Successfully Demonstrated They Were Carrying Their EAIs

Study GroupResponse TimeCarrying Epinephrine, %P
Intervention 1: text message nudges only
Intervention group 1 (n = 26) On time (primary outcome) 28 .06
Control group 1 (n = 105) 38
Intervention group 1 (n = 26) On time and late (sensitivity analysis) 38 .015
Control group 1 (n = 105) 53
Intervention 2: text message nudges and financial incentives
Intervention group 2 (n = 54) On time (primary outcome) 45 .002
Control group 2 (n = 51) 23
Intervention group 2 (n = 54) On time and late (sensitivity analysis) 52 .003
Control group 2 (n = 51) 32
Study GroupResponse TimeCarrying Epinephrine, %P
Intervention 1: text message nudges only
Intervention group 1 (n = 26) On time (primary outcome) 28 .06
Control group 1 (n = 105) 38
Intervention group 1 (n = 26) On time and late (sensitivity analysis) 38 .015
Control group 1 (n = 105) 53
Intervention 2: text message nudges and financial incentives
Intervention group 2 (n = 54) On time (primary outcome) 45 .002
Control group 2 (n = 51) 23
Intervention group 2 (n = 54) On time and late (sensitivity analysis) 52 .003
Control group 2 (n = 51) 32

Participants in both intervention groups had, on average, neutral ratings for how informative the text messages were (5.67 and 5.43, respectively, on a scale from 1 to 10) and reported that the frequency at which text message nudges were sent was “just right” (72.2% and 76.3% of respondents, respectively). In contrast to their perceptions of the usefulness of the text messages, Intervention 2 participants reported, on average, that the financial incentives were highly motivating (7.71 on a scale from 1 to 10).

This study evaluated the effectiveness of 2 behavioral economics-informed interventions to promote epinephrine-carrying among adolescents with food allergies. Our results indicate that frequent text message nudges were unsuccessful in promoting EAI-carrying, but nudges combined with modest financial incentives increased EAI-carrying. Data for Intervention 2 are consistent with those of our pilot study among young adults with food allergies. In our pilot study, we found that participants who received text messages combined with financial incentives carried their EAIs twice as often as control group participants who received text messages only (54% vs 27% of the time, P = .023).22  The results from these 2 studies provide important evidence that interventions, especially those using financial incentives, can be effective in promoting a potentially life-saving behavior. The use of text message nudges alone, however, may simply not be enough to promote epinephrine-carrying. In fact, intervention participants were neutral about how informative the text message nudges were, suggesting that these were not perceived as beneficial.

Our findings suggest that individuals with food allergies may overestimate how consistently they carry their EAIs. Participants rated the statement “I carry my epinephrine auto-injector everywhere that I go” as an 8, on average, on a scale from 1 (completely disagree) to 10 (completely agree). Yet when we documented actual EAI carriage rates with photographic evidence, we found they carried their EAIs, at most, 53% of the time. Despite the success of the text message nudge plus financial incentives intervention, even during that intervention, adolescents and young adults with food allergies still carried their EAIs ~50% of the time.22  Other work has revealed that the primary reason for not using an EAI after an allergic reaction is that the device was not available.34

Given the unpredictability and potential severity of food allergy reactions, epinephrine, the first line of defense for anaphylaxis, should be accessible at all times and promptly administered when an allergic reaction begins. In fact, time to administration is a contributing factor to death from anaphylaxis.7,8  Given that these and others’ results suggest that consistent EAI carrying may be difficult for most adolescents, a multilevel approach to safe food allergy management is needed. This may include more individually targeted interventions, especially when combined with improvements to EAI devices.35  Moving beyond the individual, EAIs should be universally accessible in public places, schools, recreation centers, and restaurants. Epinephrine is a safe, low-risk medicine that could be made available in the same way that automated external defibrillators are.36  Some EAIs are designed to provide verbal instructions during use, like automated external defibrillators, and are associated with lower rates of error during administration.37  A comparison of different models for supplying epinephrine in schools found that having undesignated stock epinephrine, without requiring individuals to also carry their own EAIs, was the most cost-effective.38

Our study provides important information on a unique way to promote EAI-carrying. Most previous interventions among adolescents with food allergies are information-based interventions,39,40  with an emphasis on training individuals with food allergies and their families how to use EAIs.16  One such study among adolescents found that a mobile health decision support tool led to better symptom recognition and treatment selection for anaphylaxis, although it did not address access to epinephrine in cases when it would be the treatment of choice.41  We found only 1 other behavioral intervention to promote safer food allergy management that goes beyond information provision.40  This study assessed whether periodic checkpoints with school nurses influenced students’ epinephrine-carrying behavior.42  Checkpoints were not associated with more consistent epinephrine-carrying but were associated with carrying unexpired epinephrine.

The interventions evaluated in this study are simple and scalable. Although a text message-only intervention is inexpensive, our data currently do not support its implementation. The provision of modest financial incentives was successful and could be a beneficial strategy at an individual level. Future studies should explore whether smaller incentive amounts, nonfinancial incentives, or different incentive schemes (eg, lottery) are similarly effective. These could offer a lower-cost way of supporting adolescents in managing food allergies to organizations invested in this type of work, including insurance companies and advocacy organizations. In this study, we also could not determine if financial incentives alone, without text message nudges, would be successful as a stand-alone intervention to encourage EAI-carrying.

This study has several limitations. We had a small sample size that decreased over time. The study population was fairly homogenous and primarily included adolescents followed by allergy specialists, who are more likely to be more engaged in the management of their food allergies. Therefore, our results may not be generalizable to all adolescents with food allergies. It is possible that those adolescents not followed by an allergy specialist would more greatly benefit from interventions that increase the salience of food allergies.

The use of text message nudges combined with modest financial incentives was associated with higher rates of epinephrine-carrying among adolescents with food allergies in this randomized controlled trial. Despite this success and the replication of the results from our pilot study, adolescents still carried their life-saving medications ~50% of the time. Alternative strategies that emphasize making EAIs available in a variety of settings, rather than relying on each individual to remember, may be necessary to increase the safety of adolescents with food allergies.

Kate Kearns and Caleb Epstein contributed to the study but not by authorship.

This trial has been registered at www.clinicaltrials.gov (identifier NCT03284372).

Ms Dupuis contributed to data collection, conducted data analyses, interpreted the data, and wrote the first draft of the manuscript; Ms Feuerstein-Simon and Ms Luna Marti contributed to data collection, conducted data analyses, interpreted the data, and provided substantive input on the manuscript; Drs Cannuscio, Brown-Whitehorn, Mollen, and Spergel contributed to the study design and analysis plan, secured funding for the study, contributed to data collection, interpreted the data, and provided substantive input on the manuscript; Drs Meisel, Troxel, and Volpp contributed to the study design and analysis plan, secured funding for the study, interpreted the data, and provided substantive input on the manuscript; Drs Block, Gortmaker, and Kenney interpreted the data and provided substantive input on the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

The funder had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

FUNDING: Research reported in this publication was supported by the National Institute of Child Health & Human Development under award number R21HD088941. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH).

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest related to this article to disclose.

EAI

epinephrine auto-injector

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