title: Randomised controlled trial of alternative messages to increase enrolment in a healthy food programme among individuals with diabetes.
abstract: We compared the effectiveness of diabetes-focused messaging strategies at increasing enrolment in a healthy food programme among adults with diabetes.
  
  
  
  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.
  
  
  
  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).
  
  
  
  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.
  
  
  
  NCT02462057.
authors.affiliation: Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania, USA.|Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.
authors.forename: A
authors.initials: A
authors.lastname: Gopalan
authors.affiliation: Discovery Vitality, Johannesburg, South Africa.
authors.forename: J
authors.initials: J
authors.lastname: Paramanund
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.|LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: P A
authors.initials: PA
authors.lastname: Shaw
authors.affiliation: Discovery Vitality, Johannesburg, South Africa.
authors.forename: D
authors.initials: D
authors.lastname: Patel
authors.affiliation: LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.|Departments of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: J
authors.initials: J
authors.lastname: Friedman
authors.affiliation: Vitality USA, New York, New York, USA.
authors.forename: C
authors.initials: C
authors.lastname: Brophy
authors.affiliation: LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.|Department of Community and Family Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Buttenheim
authors.affiliation: LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.|Department of Population Health, NYU School of Medicine, New York, New York, USA.
authors.forename: A B
authors.initials: AB
authors.lastname: Troxel
authors.affiliation: Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania, USA.|LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.|Departments of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.|Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: D A
authors.initials: DA
authors.lastname: Asch
authors.affiliation: Corporal Michael J. Cresencz VA Medical Center, Philadelphia, Pennsylvania, USA.|LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.|Departments of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.|Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: K G
authors.initials: KG
authors.lastname: Volpp
mesh_terms: D000328:Adult; D003924:Diabetes Mellitus, Type 2 / Q000178:diet therapy; D000072001:Diet, Healthy; D005260:Female; D006293:Health Promotion; D006801:Humans; D008297:Male; D009042:Motivation; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D018579:Patient Selection; D015397:Program Evaluation; D013019:South Africa / Q000453:epidemiology; D060145:Text Messaging; D061217:Weight Reduction Programs
keywords: DIABETES & ENDOCRINOLOGY; NUTRITION & DIETETICS; active choice; health promotion; messaging