Food Allergy Management for Adolescents Using Behavioral Incentives: A Randomized Trial

To determine if the use of 2 behavioral economics-informed interventions (text message nudges alone or with modest monetary rewards) will increase the frequency in which adolescents with food allergies carry epinephrine auto-injectors (EAIs).

The base cohort 1 included 31 adolescents. All participants met the following inclusion criteria: (1) have a diagnosis of 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 can send and receive photos. Participants’ characteristics were similar across all 3 study groups.

A cohort multiple randomized controlled trial design was used. For Intervention 1, participants were randomly assigned to receive Intervention 1 (text message nudges) or usual care (control group). For Intervention 2 (text message nudges and financial incentives), the control group from Intervention 1 was randomly assigned to continue usual care (control group) or receive Intervention 2. Nudges included information, facts, or tips about food allergies or requested feedback relevant to food allergies from participants. These were randomly timed and included about 30 messages over a 10-week period. The financial incentive included a virtual account for each participant that held $100. This amount decreased by $10 each time a participant failed to demonstrate self-carrying of their EAI at random checkpoints. All groups had weekly random check-ins where they had 30 minutes to respond to a text message with a picture of their EAI next to a codeword. Patients were followed for 2 years.

The primary endpoint was consistency of epinephrine-carrying measured as a proportion of checkpoints at which participants demonstrated carrying their epinephrine as previously described. At the start of the study, all participants self-reported consistently carrying an EAI. The Intervention 1 group (text message nudges) carried their EAI 28% of the time versus 38% for the control group (P = .06). The Intervention 2 group (text message nudges and financial incentives) carried their EAI 45% of the time versus 23% of the time in the control group (P = .02). When late responses were included (>30 minutes), the difference was 52% of epinephrine carrying in Intervention 2 group versus 32% in the control group. Participants in both intervention groups reported, on average, that financial incentives were highly motivating.

In adolescents with food allergies, frequent text message nudges were unsuccessful in promoting EAI-carrying, but nudges combined with financial incentives improved EAI-carrying.

Adolescence is a challenging time in life where patients are often expected to become more autonomous in their medical care. As this study emphasizes, although all participants self-reported consistently carrying an EAI, only roughly 1/4 to less than 1/2 of patients were found to consistently carry their EAIs. As delayed administration of epinephrine is a risk factor for fatal anaphylaxis, it is imperative to continue to research ways to promote consistency of carrying EAIs in this vulnerable population.