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Getting More Food-Allergic Young Adults To Carry Their Epinephrine: A Behavioral Economics Approach

Study Shows Effectiveness of Financial Incentives

As one of the estimated 2.5% of Americans with a food allergy, deciding my next meal, snack, or even beverage is no simple task. Remembering to carry emergency epinephrine is also no walk in the park. Young adults like me are particularly vulnerable to error related to their food allergies and likely to engage in risky behavior. And despite the risk of death by anaphylaxis, few individuals with severe food allergies carry their emergency epinephrine on a daily basis. A new study by LDI Senior Fellow Carolyn Cannuscio and colleagues, including Senior Fellows Rosemary Frasso, David Grande, and Zachary Meisel, examines how a behavioral economics intervention can encourage young adults to carry their epinephrine auto-injectors.

The study randomized 33 young adults (aged 18-30) with severe food allergies into two groups: one received text message reminders, and the other received text message reminders plus a financial incentive. Over 49 days participants were prompted by text message to send a photograph of their auto-injector, with a daily code word, at 10 randomly selected check-in times. Members of the control group received the text messages and $20 at the completion of the study, no matter their ‘success’ at carrying epinephrine; members of the intervention group received $10 (up to $100 total) for every time they checked in with evidence of having  epinephrine on hand.

Members of the intervention group provided evidence of carrying their auto-injector at 57% of check-ins, compared to 27% for the control group. Successful individual check-ins for the intervention group ranged from 22% to 72%, while for the control group it was 13% to 40%. 





Below is an example of the text messages sent, which also included allergen facts to educate participants. 

Participants reported favorable perceptions of the text messaging and that taking part in the study made them more aware of carrying their auto-injectors. In addition, one participant remarked that the messages “made me feel like I was part of a community knowing you were sending the same messages to a bunch of different people”.

This study makes clear that financial incentives together with text messaging are more successful than text messaging alone in encouraging young people to carry their epinephrine.

This is in line with other studies (and here) showing that financial incentives can boost medication adherence. But the potentially unsustainable nature of financial incentives makes other options worth exploring. Cannuscio and colleagues note:

The study raises the question of whether text messaging alone, with cognitively tested message framing, could foster adherence to safer food allergy management practices. Messages that include performance feedback--modeled on the automatic messaging and feedback supplied by popular activity tracking devices--might be a highly feasible, relatively low-cost intervention model.

The authors also recommend expanding access to epinephrine by having auto-injectors available in schools, restaurants, transportation hubs, and other social areas. The effectiveness of having stock epinephrine available in schools led to the signing of the School Access to Emergency Epinephrine Act in 2013.

Getting food-allergic young people to carry their epinephrine auto-injector is challenging, but this research suggests that simple behavioral economics strategies can boost the likelihood that they have epinephrine on hand when emergency strikes. 

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