Randomised controlled trial of alternative messages to increase enrolment in a healthy food programme among individuals with diabetes

A Gopalan, J Paramanund, P A Shaw, D Patel, J Friedman, C Brophy, A M Buttenheim, A B Troxel, D A Asch, K G Volpp, A Gopalan, J Paramanund, P A Shaw, D Patel, J Friedman, C Brophy, A M Buttenheim, A B Troxel, D A Asch, K G Volpp

Abstract

Objectives: We compared the effectiveness of diabetes-focused messaging strategies at increasing enrolment in a healthy food programme among adults with diabetes.

Methods: Vitality is a multifaceted wellness benefit available to members of Discovery Health, a South Africa-based health insurer. One of the largest Vitality programmes is HealthyFood (HF), an incentive-based programme designed to encourage healthier diets by providing up to 25% cashback on healthy food purchases. We randomised adults with type 2 diabetes to 1 of 5 arms: (1) control, (2) a diabetes-specific message, (3) a message with a recommendation of HF written from the perspective of a HF member with diabetes, (4) a message containing a physician's recommendation of HF, or (5) the diabetes-specific message from arm 2 paired with an 'enhanced active choice'(EAC). In an EAC, readers are asked to make an immediate choice (in this case, to enrol or not enrol); the pros and cons associated with the preferred and non-preferred options are highlighted. HF enrolment was assessed 1 month following the first emailed message.

Results: We randomised 3906 members. After excluding those who enrolled in HF or departed from the Vitality programme before the first intervention email, 3665 (94%) were included in a modified intent-to-treat analysis. All 4 experimental arms had significantly higher HF enrolment rates compared with control (p<0.0001 for all comparisons). When comparing experimental arms, the diabetes-specific message with the EAC had a significantly higher enrolment rate (12.6%) than the diabetes-specific message alone (7.6%, p=0.0016).

Conclusions: Messages focused on diabetes were effective at increasing enrolment in a healthy food programme. The addition of a framed active choice to a message significantly raised enrolment rates in this population. These findings suggest that simple, low-cost interventions can enhance enrolment in health promoting programmes and also be pragmatically tested within those programmes.

Trial registration number: NCT02462057.

Keywords: DIABETES & ENDOCRINOLOGY; NUTRITION & DIETETICS; active choice; health promotion; messaging.

Conflict of interest statement

PAS, ABT and KGV have received research funding from the Vitality Institute. JP and DP are employees of Discovery Vitality, and CB is an employee of Vitality USA. Given these relationships, these three individuals were not involved in data analysis but provided only operational support and expertise. DAA and KGV are both principals at the behavioural economics consulting firm, VAL Health. KGV also has received consulting income from CVS Caremark and research funding from Humana, CVS Caremark, Discovery (South Africa), Hawaii Medical Services Association and Merck. ABT serves on the scientific advisory board of VAL.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Figures

Figure 1
Figure 1
Participant enrolment, allocation, follow-up and analysis. HF, HealthyFood.
Figure 2
Figure 2
Enrolment in HealthyFood programme by study arm. Note: Vertical error bars depict 95% Clopper and Pearson confidence intervals.

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