Using Digital Health, Financial Incentives, and Community Health Worker Support to Change Health Behavior

University of Pennsylvania

Status: Completed

Conditions: Diabetes Mellitus

Treatments: Behavioral: Digital health monitoring with financial incentives; Other: Usual Care; Behavioral: IMPaCT Community Health Worker

Study type: Interventional

Funder types: Other

Identifiers

NCT03939793

20191985

Details and patient eligibility

About

This randomized controlled trial tests how digital health monitoring with financial incentives (DFI) and community health worker (CHW) support may affect how a person manages their diabetes. Participants will be randomized to one of three arms: 1) DFI intervention, 2) hybrid DFI/CHW intervention, or 3) usual care. Investigators hypothesize that compared to usual care and DFI alone, the hybrid intervention will lead to more glucose self-monitoring and greater improvements in glycosylated hemoglobin.

Full description

Low-income Americans struggle to stay healthy in the face of real-life challenges such as housing insecurity or trauma. Two interventions show promise for promoting behavior change and improving health outcomes: digital health interventions coupled with financial incentives (DFI) and community health workers (CHWs). Yet, these interventions have limitations; DFI interventions have low uptake and high attrition among vulnerable populations, while CHW interventions are relatively resource intensive.

Investigators propose a 24-week randomized trial of a hybrid DFI/CHW intervention among a population of 150 low-income patients with diabetes. Participants will be randomized to one of three arms: 1) DFI intervention, 2) hybrid DFI/CHW intervention, 3) usual care. Participants assigned to DFI will receive a free wireless glucometer and be eligible for a lottery incentive if they use their glucometer. Participants assigned to the hybrid DFI/CHW intervention will receive the same glucometer and incentives. If they exhibit low adherence to self-monitoring or poor glucose control, they will also receive support from a CHW who would help patients to address underlying socioeconomic barriers and cope with setbacks. Investigators hypothesize that compared to usual care and DFI alone, the hybrid intervention will lead to more glucose self-monitoring and greater improvements in glycosylated hemoglobin.

Enrollment: 150 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Penn Medicine patients diagnosed with diabetes mellitus.
• Glycosylated hemoglobin >=9% within the past 6 months.
• Requires insulin.
• Uninsured/publicly insured.
• Residents of high-poverty ZIP codes in West/Southwest Philadelphia.
• Have access to a cellphone with unlimited text message capabilities.

Exclusion criteria

• Already have a continuous glucose monitor.
• Previously enrolled in the study.
• Currently have an outpatient CHW.
• Unwilling/unable to provide informed consent.
• In another study that asks participants to monitor their blood sugar.

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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150 participants in 3 patient groups, including a placebo group

Usual Clinical Support

Placebo Comparator group

Description:

Participants will continue with their usual diabetes care provided by their clinic. Participants will receive a free wireless glucometer on the day of enrollment if they do not already have one.

Treatment:

Other: Usual Care

DFI Alone

Active Comparator group

Description:

Participants will receive a free wireless glucometer on the day of enrollment if they don't already have one. To encourage habit formation, for the first 6 weeks of the trial, participants will be eligible for a daily lottery incentive for every day that they use their glucometer. Investigators will use an approach similar to what we have used in prior DFI trials: the lottery will provide infrequent large payoffs (a 1 in 100 chance of a US$50 reward) and more frequent small payoffs (an 18 in 100 chance of a US $5 reward). Participants who draw the winning lottery number, but did not check their glucose the day prior will receive an automated text or e-mail message informing them what earnings they would have won had they used their glucometer. After 6 weeks, investigators will terminate the lottery but continue to monitor patients' adherence to glucose self-monitoring.

Treatment:

Behavioral: Digital health monitoring with financial incentives

Hybrid DFI CHW

Experimental group

Description:

Participants in the hybrid intervention will receive a wireless glucometer if they don't already have one and financial incentives just as in the DFI intervention. However, any individuals who have low adherence (no self-monitoring) or elevated glucose readings (\>300 mg/dL) for \>30% of days over any 2 week period in the first 12 weeks of the study will be assigned to receive ongoing community health worker (CHW) support for the duration of the 24-week study period.

Treatment:

Behavioral: IMPaCT Community Health Worker

Behavioral: Digital health monitoring with financial incentives