Behavioral Insights into Digital Health: The Impact of Message Framing on Engagement with a CBT-I App

Abstract

Cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based, first-line treatment for insomnia. Despite its effectiveness, access to CBT-I remains limited due to barriers associated with provider shortages, financial cost, and geographical constraints. Digital CBT-I apps offer a scalable and accessible way to deliver care, yet initiating treatment use remains a key challenge in digital health treatment adoption. One approach to address this is through health communication strategies such as message framing. However, it remains unclear how message framing influences early decisions to initiate treatment use, particularly when individual differences in insomnia symptom severity are considered. This study examines whether gain- or loss-framed testimonials influence interest in downloading a digital CBT-I app and explores the association between baseline insomnia severity and this decision. Drawing on prospect theory, this study assesses whether emphasizing the benefits of improved sleep versus the consequences of untreated insomnia affects behavioral intention, and whether greater insomnia severity is associated with higher interest in downloading a CBT-I app. Participants experiencing sleep difficulties completed an online survey that involved viewing a brief informational video about a CBT-I app, CBT-I Coach, followed by exposure to a gain-framed or loss-framed testimonial about the app. Interest in downloading the app was then assessed as a binary outcome. Baseline insomnia severity was measured using the 3-item version of the Insomnia Severity Index (ISI-3). Fisher’s exact test was used to examine framing effects on download interest, and an independent samples t test was used to assess differences in insomnia severity between participants who did and did not express interest in downloading the app. Results indicated that app download interest did not differ significantly by framing condition. Meanwhile, interest in downloading the app was associated with significantly higher baseline insomnia severity than those who did not express interest in download the app. The findings suggest that early download intentions with digital CBT-I tools may be driven more by perceived need based on personal relevance rather than message framing at the point of first exposure. Thus, implications for the design and targeting strategies of digital sleep interventions suggest that baseline insomnia severity symptoms may be a more important factor in influencing download interest than message framing alone in digital health contexts.