Are text messages with financial incentives more effective?

According to a research study on Text Messages with Financial Incentives to Help Men With Obesity Lose Weight, the answer is yes. 

Researchers enrolled 585 men with a body mass index (BMI) of 30 or higher and randomly assigned them to three groups: one received behavioral-focused text messages combined with financial incentives, another received the same text messages without incentives, and the third was a control group placed on a waiting list. All participants received weight management information and a pedometer at the start of the trial, which lasted 12 months.

At the end of the year, the results showed that men who received both text messages and financial incentives lost an average of 5.7 kilograms compared to 3 kilograms for the text-only group and just 1.5 kilograms for the control group. The study concluded, “Compared with the control group, the mean percent weight change was significantly greater in the text messaging with financial incentive group… but was not significantly greater in the text messaging alone group.”

In other words, while text messaging alone provided a modest benefit, the addition of financial incentives significantly increased weight loss. Without incentives, the texts alone encouraged some weight loss, but not enough to cross that clinical threshold.

So, why did the financial incentives have such a powerful impact? 

Behavioral economics suggests loss aversion as the explanation. People are generally more motivated to avoid losing something they already have than to gain something new. In this study, participants lost monetary rewards if they failed to meet weight loss targets. The authors noted that “the financial incentive consisted of a monetary reward that was lost if weight loss targets were not met.” That simple framework turned long-term health goals into immediate, tangible consequences.

The intervention’s simplicity also made it scalable. Participants were given inexpensive pedometers and text messages, which could be read privately and acted upon at any time. The texts had a behavioral context with specific tips and prompts designed to fit into daily life. The texts are also a low-barrier, low-cost intervention well-suited for men, who are less likely to engage with healthcare providers about their weight.

What the results show is that although educational or motivational messaging has some use, it's the combination of repeated digital prods with actual stakes that seems to produce lasting behavior change. 

And yet, even with the extremely minimal setup, the financial incentive group lowered their weight to a degree that is itself demonstrated to reduce the risk of chronic diseases such as type 2 diabetes, hypertension, and cardiovascular disease. However, we must be careful not to get overly excited about the results. While the financial incentive group did lose weight statistically, it was described by the authors as "modest." 

Additionally, only 73% of participants were at follow-up at 12 months, so nearly a quarter were not. That level of attrition is to be anticipated in long-term behavioral research, but it does suggest that even minimal-effort interventions have difficulty with long-term adherence.

Text message-based interventions

Text messaging is a cost-effective way of contacting people who might otherwise never pass through a clinic door. However, health information, especially when it comes to sensitive subjects, like obesity, must be protected according to data privacy legislation. More specifically, healthcare providers must adhere to HIPAA Rules when disseminating health-related information via text. 

Even though the trial was performed in the UK and therefore may not have been under the jurisdiction of HIPAA standards, the findings are bound to affect programs globally. In the U.S. environment, sending weight-related data or progress reports through unencrypted SMS would expose protected health information to third-party users.

So, any organization that wants to conform to or adapt the intervention described in the abovementioned study must use a HIPAA compliant communication system. 

HIPAA compliant text messaging systems, like Paubox, automatically encrypt outgoing messages, safeguarding patients’ protected health information (PHI) during transmission and at rest. Paubox allows health plans and healthcare organizations to send secure messages without sacrificing usability. Unlike traditional patient portals, which gather dust due to a lack of use because of poor user experience, HIPAA compliant messaging solutions allow for communications to take place directly to the patient’s inbox or phone.

This is particularly relevant for individuals who may prefer fewer in-person interactions and more autonomy over their healthcare. If a text and incentive-based weight loss intervention is going to transition from the research to the practice stage, infrastructure needs to adapt to address behavioral as well as regulatory imperatives. 

Behavioral science informs us that individuals require frequent, preferably decision-point nudges. However, these nudges should also safeguard the individuals' privacy. Therefore, a message telling an individual they are halfway there, or that they just lost a bonus for putting on weight, contains sensitive information. Transmitting the message on an insecure channel, like standard text messaging, exposes users to privacy breaches and trust loss.

Secure communication also facilitates the sustainability of programs. Participants in a program are likely to maintain a program when they realize their data is secure, particularly if they are discussing issues traditionally taboo. Trust is a form of behavioral currency. If it is not there, even the most well-crafted intervention will not succeed.

How HIPAA compliant texts can enhance incentive programs

Employer wellness programs

Employers can tie financial incentives to employee wellness activities to build a culture of health. For example, a company could offer a $300 annual wellness stipend that is reduced if employees fail to meet monthly activity targets. Each week, employees receive secure text reminders encouraging them to track steps, eat balanced meals, or attend health coaching sessions.

These HIPAA compliant text messages could say, “You’re only 1,500 steps away from your weekly goal!” or “You’ve completed three of four wellness sessions this month, so stay on track to earn your full stipend.” Regular prompts would keep employees aware of their progress, while the financial incentive creates accountability. 

Ultimately, these texts could help boost engagement, reducing absenteeism and long-term healthcare costs for the employer.

Insurer-led chronic disease management

Health insurers often manage populations at risk for chronic conditions like diabetes or hypertension. Using HIPAA compliant text messaging, insurers can send reminders for medication adherence, preventive screenings, and lifestyle changes.

Participants who meet adherence goals might earn premium credits or financial rewards. A secure message could say, “Congratulations! You’ve maintained 90% medication adherence this month and earned a $25 credit toward your premium.” This model could help reduce member hospitalizations and emergency visits while giving them a sense of accomplishment.

These secure texts help insurers also protect sensitive health data, building trust among members who might otherwise be wary of sharing their information.

Public health campaigns

City or state health departments can use this strategy to address obesity or other community health concerns. Participants sign up for HIPAA compliant text messages with daily tips, healthy recipes, and reminders about local exercise classes. Those who attend monthly weigh-ins or meet step-count goals receive grocery vouchers or discounts on public transportation.

The approach could be more effective for lower-income populations, where incentives like vouchers could help alleviate food insecurity while motivating participants to stay engaged in healthier behaviors. Messages like “You’re just 500 steps away from meeting your weekly goal, keep going for your $20 grocery voucher!” provide immediate encouragement and link actions to tangible rewards.

Hospital discharge and follow-up care

Hospitals can reduce readmission rates by pairing secure text messaging with financial incentives. After discharge, patients receive HIPAA compliant texts reminding them to attend follow-up appointments, take medications, and report symptoms.

For example, a message could say, “Your appointment with Dr. Smith is tomorrow at 10 a.m. Attending all follow-ups earns you a $50 transportation stipend.”

Therefore, patients who adhere to their discharge plans improve recovery outcomes and benefit financially, while hospitals avoid costly readmissions.

Smoking cessation initiatives

Community-based smoking cessation programs can use a similar model. Participants receive encrypted text messages with motivational tips and resources. If they remain smoke-free for specific milestones (e.g., 1 month, 3 months, 6 months), they receive escalating financial rewards.

For example, a secure text could say, “You’ve been smoke-free for 30 days. Great work! You’ve just earned your first $50 reward.” These milestones help participants celebrate progress while staying motivated for the long term.

Go deeper: How HIPAA compliant emails and texts can help smoking cessation

FAQs

What makes a text HIPAA compliant?

An email is HIPAA compliant if it includes encryption, secure access controls, and audit trails. So, providers must use a HIPAA compliant texting platform, like Paubox, to protect patients’ PHI.

Can text messages be personalized and HIPAA compliant? 

Yes, healthcare providers can send personalized text messages containing protected health information (PHI) for patient communication, if done according to HIPAA regulations.  Obtain patient authorization to share PHI via text, and use HIPAA compliant text messaging software like Paubox to encrypt messages for privacy and compliance. 

Are minors protected by HIPAA regulations, and how does this affect communication?

Yes, minors under the age of 18 are protected under HIPAA regulations. While parents or legal guardians usually have the authority to manage their minor child's health information, there are exceptions. 

In certain cases, minors as young as 12 years old may have the legal capacity to consent to their own treatment or control access to their health information, particularly for sensitive services like reproductive health or mental health treatment.