Methods for increasing adolescent epinephrine auto-injector carrying


In a recent study, the use of text messages alongside financial incentives increased epinephrine auto-injector carrying among adolescents.

While text messages alone do not increase the carrying of epinephrine auto-injectors (EAIs) among adolescents with food allergies, text messages alongside small financial incentives lead to a significant increase in EAI carrying, according to a recent study.

Immunoglobulin E-mediated food allergies have been estimated to be in 4% to 8% of children in the United States, leading to reactions which can range from mild to severe. Anaphylaxis may occur in some cases, which can be life-threatening but is treatable with immediate epinephrine administration.

Without a universal cure for food allergies, self-management is needed to protect individuals. Adolescents are at the greatest risk of anaphylaxis, in large part because of failure to adhere to prevention strategies. One of these strategies is consistently carrying EAIs, but there are few interventions for increasing EAI carrying in adolescents.

Multiple chronic conditions have shown promising results after the implementation of behavioral economics approaches. Investigators hypothesized that 2 approaches could be implemented to increase EAI carrying.

The first approach tested was text message reminders to carry epinephrine, and the second was the combination of text message reminders and financial incentives. Investigators developed 2 interventions to test these hypotheses.

The interventions were based on 5 principles: availability heuristic, feedback, incentives, loss aversion, and present bias. In the text only intervention, the first 2 principles were employed, while all 5 principles were employed in the text and financial incentive intervention. A cohort multiple randomized controlled design was used to test both interventions.

After the base cohort, follow-ups occurred over a 2-year period at baseline, midway, and end of the study period. During follow-ups, participants reported their knowledge, attitude, and behaviors toward food allergies.

Inclusion criteria included having a food allergy, having a prescription for an EAI, being aged 15 to 19 years old, being proficient in English, and having a phone capable of sending and receiving photos. Carrying EAIs consistently was measured as the primary outcome of the study. Patients would send photos of their EAI next to a code word for that day to confirm they were carrying.

Participants had a mean age of 16 years and were primarily non-Hispanic White. Tree nuts and peanuts were the most common food allergies, and many participants had more than 1 food allergy.

In the text only intervention group, 28% of reports were positive for carrying an EAI, compared to 38% of the control group. In the text and financial intervention group, 45% of reports were positive for carrying an EAI, compared to 23% in the control group. The sensitivity analysis including late responses showed an even larger difference.

While text messages were given an average score on being informative, financial incentives were described as highly motivating. This indicates increased effectiveness of a combined approach using text messaging and financial incentives.


Dupuis R, Feuerstein-Simon R, Brown-Whitehorn TF, et al. Food allergy management for adolescents using behavioral incentives: arandomized trial. Pediatrics. 2023;151(2). doi:10.1542/peds.2022-058876

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