Automated telephone communication systems for preventive healthcare and management of long-term conditions

The State of Digital Interventions for Demand Generation in Low- and Middle-Income Countries: Considerations, Emerging Approaches, and Research Gaps

The recent introduction of digital health into generating demand for health commodities and services has provided practitioners with an expanded universe of potential tools to strengthen demand and ensure service delivery receipt. However, considerable gaps remain in our understanding of which interventions are effective, which characteristics mediate their benefit for different target populations and health domains, and what is necessary to ensure effective deployment. This paper first provides an overview of the types of digital health interventions for demand generation, including untargeted client communication, client-to-client communication, on-demand information services, personal health tracking, client financial transactions, and targeted client communication. It then provides a general overview of 118 studies published between January 1, 2010, and October 3, 2017, that used digital interventions to generate demand for health interventions. The majority (61%) of these studies used targeted client communication to provide health education or reminders to improve treatment adherence, and the most frequently (27%) studied health condition was HIV/AIDS. Intervention characteristics that have been found to have some effect on gains in demand generation include modality, directionality, tailoring, phrasing, and schedule. The paper also explores new emergent digital approaches that expand the potential effect of traditional demand generation in terms of personalization of content and services, continuity of care, and accountability tracking. Applying existing frameworks for monitoring and evaluation and reporting, research on emerging approaches will need to consider not only their feasibility but also their effectiveness in achieving demand generation outcomes. We propose a research agenda to help guide the field of digital demand generation studies and programs within a broader health systems strengthening agenda, including establishing and documenting the influence of intervention characteristics within different populations and health domains and examining the long-term effects and cost-effectiveness of digital demand generation interventions, as well as equity in access to such interventions.

Health information technology uses for primary prevention in preventive medicine: a scoping review protocol

INTRODUCTION

The use of health information technologies (HITs) has been associated with positive benefits such as improved health outcomes and improved health services. Results from empirical studies reported potential benefits of HITs in preventive medicine measures such as primary prevention. This review will examine the broad range of HITs and their uses and effectiveness in primary prevention.

METHODS AND ANALYSIS

We will conduct searches in relevant databases (MEDLINE, EMBASE, the Cochrane Methodology Register, Cochrane Database of Systematic Reviews, CINAHL, SCOPUS and Web of Science) using Arksey and O'Malley's scoping review methodology. The scoping review will include all study designs to identify the literature on HIT uses. Two reviewers will independently screen the literature following our screening criteria and using a data abstraction form. Findings will be summarised quantitatively (using numerical counts of HITs) and qualitatively (using narrative synthesis).

ETHICS AND DISSEMINATION

The study will synthesise data from published literature and will not require an ethical approval. The results of the review will be disseminated through a peer-reviewed journal.

Technologies for Innovative Monitoring to Reduce Blood Pressure and Change Lifestyle Using Mobile Phones in Adult and Elderly Populations (TIM Study): Protocol for a Randomized Controlled Trial

BACKGROUND

Hypertension is a growing problem worldwide, markedly in low- and middle-income countries, where the rate of control slightly decreased. The overall prevalence of hypertension in Brazil is 28.7% among adult individuals and 68.9% in the population aged 60 years and older, and less than a third of patients have controlled blood pressure (BP). The use of technologies-mobile phones and the internet-to implement interventions to reduce blood pressure can minimize costs and diminish cardiovascular risk. Interventions through text messaging and electronic BP monitoring present divergent results.

OBJECTIVE

This trial evaluates the effectiveness of interventions-personalized messages and telemonitoring of BP-to reduce systolic BP and improve lifestyle compared to the usual care of patients with hypertension (control group).

METHODS

This factorial randomized controlled trial enrolls individuals aged 30 to 75 years who have a mobile phone and internet access with the diagnosis of hypertension under drug treatment with up to 2 medications and uncontrolled BP. Eligible participants should have both increased office BP and 24-hour BP with ambulatory BP monitoring. Participants with severe hypertension (systolic BP ≥180 or diastolic BP ≥110 mm Hg), life threatening conditions, low life expectancy, recent major cardiovascular event (last 6 months), other indications for the use of antihypertensive medication, diagnosis of secondary hypertension, pregnant or lactating women, or those unable to understand the interventions are excluded. Participants are randomly allocate to 1 of 4 experimental arms: (1) Telemonitoring of blood pressure (TELEM) group: receives an automatic oscillometric device to measure BP, (2) telemonitoring by text message (TELEMEV) group: receives personalized, standardized text messages to stimulate lifestyle changes and adhere with BP-lowering medication, (3) TELEM-TELEMEV group: receives both interventions, and (4) control group: receives usual clinical treatment (UCT). Data collection is performed in a clinical research center located in a referent hospital. The primary outcomes are reduction of systolic BP assessed by 24-hour ambulatory BP monitoring (primary outcome) and change of lifestyle (based on dietary approaches to stop hypertension (DASH)-type diet, sodium restriction, weight loss or control, increase of physical activity).

RESULTS

This study was funded by two Brazilian agencies: the National Council for Scientific and Technological Development and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul. Enrollment was completed at the end of 2017 (N=231), the follow-up is ongoing, and data analysis is expected to begin in early 2019. A reduction of 24-hour systolic BP of approximately 8.8 [SD 13.1] mm Hg for participants in the BP monitoring group versus 3.4 [SD 11.6] mm Hg in the UCT group is expected. A similar reduction in the text messaging group is expected.

CONCLUSIONS

The use of mobile technologies connected to the internet through mobile phones promotes time optimization, cost reduction, and better use of public health resources. However, it has not been established whether simple interventions such as text messaging are superior to electronic BP monitoring and whether both outperform conventional counseling.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03005470; https://clinicaltrials.gov/ct2/show/NCT03005470 (Archived by WebCite at http://www.webcitation.org/70AoANESu). Plataforma Brasil CAAE 31423214.0.0000.5327.

REGISTERED REPORT IDENTIFIER

RR1-10.2196/9619.

Physical Activity and Related Psychosocial Outcomes From a Pilot Randomized Trial of an Interactive Voice Response System-Supported Intervention in the Deep South

BACKGROUND

Physical activity exerts cancer-protective effects, yet most Americans are inactive, especially in the South, where cancer incidence rates are generally higher. Telephone-based approaches can help overcome physical activity intervention barriers in this region (literacy, costs, lack of transportation/technology, distance from facilities) and can be automated via interactive voice response (IVR) systems for improved reach and cost-effectiveness.

AIMS

To evaluate the Deep South IVR-supported Active Lifestyle (DIAL) intervention.

METHOD

A pilot randomized controlled trial was conducted among 63 underactive adults in Birmingham, Alabama, from 2015 to 2017.

RESULTS

Retention was 88.9% at 12 weeks, and ≥75% adherence (IVR contact on at least 63 out of 84 days) was noted among 62.5% of intervention participants. Intervention participants reported larger increases in self-reported minutes of moderate-to-vigorous intensity physical activity from baseline to 12 weeks than the wait-list control arm (median change = 47.5 vs. 5.0 minutes, respectively, p = .09). Moreover, the intervention produced significantly greater increases in physical activity self-regulation ( p < .001) and social support from family ( p = .001) and friends ( p = .009) from baseline to 12 weeks, compared with the wait-list control. Significant decreases in self-reported sleep disturbance also were found in the intervention arm but not among the controls, p < .05. Overall, intervention participants reported being satisfied with the DIAL program (71.4%) and would recommend it to friends (92.9%).

DISCUSSION

Findings support the feasibility, acceptability, and preliminary efficacy of the DIAL intervention.

CONCLUSION

Next steps include intervention refinement in preparation for a fully powered efficacy trial and eventual dissemination to rural counties.

Diabetes Care in the Digital Era: a Synoptic Overview

PURPOSE OF REVIEW

Diabetes care is undergoing a remarkable transformation by the advancements in information and communications technology (ICT). The aim of this review is to provide a general overview of various ICT-based interventions for diabetes care, challenges of their adoption, and consider future directions.

RECENT FINDINGS

A number of systematic reviews have examined studies on various aspects of telemedicine and eHealth for diabetes care, but they are generally focused on one specific type of technology application for diabetes care. A wide range of solutions from manual or automated telephone calls, short message services, websites, mobile health apps, remote monitoring devices, and sophisticated artificial intelligence systems has been studied in different settings and scopes with mixed results. However, despite the promising results of research studies, such innovative solutions are not widely adopted by health systems worldwide. Lack of supportive policy and legislation, unsustainable reimbursement, inefficient business models, and concerns regarding the security and privacy of health data are among the most problematic barriers.

Research priorities in health communication and participation: international survey of consumers and other stakeholders

OBJECTIVE

To identify research priorities of consumers and other stakeholders to inform Cochrane Reviews in 'health communication and participation' (including such concepts as patient experience, shared decision-making and health literacy).

SETTING

International.

PARTICIPANTS

We included anyone with an interest in health communication and participation. Up to 151 participants (18-80 years; 117 female) across 12 countries took part, including 48 consumers (patients, carers, consumer representatives) and 75 professionals (health professionals, policymakers, researchers) (plus 25 people who identified as both).

DESIGN

Survey.

METHODS

We invited people to submit their research ideas via an online survey open for 4 weeks. Using inductive thematic analysis, we generated priority research topics, then classified these into broader themes.

RESULTS

Participants submitted 200 research ideas, which we grouped into 21 priority topics. Key research priorities included: insufficient consumer involvement in research (19 responses), 'official' health information is contradictory and hard to understand (18 responses), communication/coordination breakdowns in health services (15 responses), health information provision a low priority for health professionals (15 responses), insufficient eliciting of patient preferences (14 responses), health services poorly understand/implement patient-centred care (14 responses), lack of holistic care impacting healthcare quality and safety (13 responses) and inadequate consumer involvement in service design (11 responses). These priorities encompassed acute and community health settings, with implications for policy and research. Priority populations of interest included people from diverse cultural and linguistic backgrounds, carers, and people with low educational attainment, or mental illness. Most frequently suggested interventions focused on training and cultural change activities for health services and health professionals.

CONCLUSIONS

Consumers and other stakeholders want research addressing structural and cultural challenges in health services (eg, lack of holistic, patient-centred, culturally safe care) and building health professionals' communication skills. Solutions should be devised in partnership with consumers, and focus on the needs of vulnerable groups.

Addiction-Like Mobile Phone Behavior - Validation and Association With Problem Gambling

Mobile phone use and its potential addiction has become a point of interest within the research community. The aim of the study was to translate and validate the Test of Mobile Dependence (TMD), and to investigate if there are any associations between mobile phone use and problem gambling. This was a cross-sectional study on a Swedish general population. A questionnaire consisting of a translated version of the TMD, three problem gambling questions (NODS-CLiP) together with two questions concerning previous addiction treatment was published online. Exploratory factor analysis based on polychoric correlations was performed on the TMD. Independent samples T-tests, Mann-Whitney test, logistic regression analyses and ANOVA were performed to examine mean differences between subjects based on TMD test score, gambling and previous addiction treatment. A total of 1,515 people (38.3% men) answered the questionnaire. The TMD showed acceptable internal consistency (Cronbach's alpha: 0.905), and significant correlation with subjective dependence on one's mobile phone. Women scored higher on the TMD and 15-18 year olds had the highest mean test score. The TMD test score was significantly associated with problem gambling, but only when controlling for age and sex. Various separated items related to mobile phone use were associated with problem gambling. The TMD had acceptable internal consistency and correlates with subjective dependence, while future confirmatory factor analysis is recommended. An association between mobile phone use and problem gambling may be possible, but requires further research.

Rationale, design, and baseline findings from a pilot randomized trial of an IVR-Supported physical activity intervention for cancer prevention in the Deep South: the DIAL study

Telephone-delivered interventions do not require frequent clinic visits, literacy, or costly technology and thus may represent promising approaches to promoting physical activity in the Deep South, a largely rural U.S. region, with generally lower physical activity, income, and education levels. Building on past Interactive Voice Response (IVR) system-based HIV studies and extensive formative research (11 focus groups on physical activity intervention needs/preferences in the Deep South), the resulting IVR-supported physical activity intervention is now being tested in a randomized controlled trial with a waitlist control. The sample (n=63) includes mostly obese (Mean BMI=30.1) adults (Mean age=43 years) in Birmingham, AL. Both genders (55.6% male) and African Americans (58.7%) are well-represented. Most participants reported at least some college (92%), full time employment (63.5%), and household income <$50,000 per year (61.9%). Baseline physical activity (Mean=39.6 minutes/week, SD=56.4), self-efficacy, self-regulation, and social support were low. However, high physical activity enjoyment and outcome expectations bode well. Self-report physical activity was associated with physical activity enjoyment (r=.36) and social support (friends r=.25, p's<.05) at baseline. Consequently, these may be important variables to emphasize in our program. Depression and anxiety were negatively correlated with some early indicators of behavior change (e.g., physical activity self-regulation; r's =-.43 and -.46, respectively, p's<.01) and thus may require additional attention. Such technology-supported strategies have great potential to reach underserved populations and address physical activity-related health disparities in this region.

Building partnerships: a pilot study of stakeholders' attitudes on technology disruption in behavioral health delivery and research

Collaborations between scientists, care providers, and technology industry professionals are becoming more relevant for developing, testing, and implementing behavioral health technologies. As the need for such partnerships increases, it is important to understand stakeholders' attitudes about their role in partnering for developing such technologies and how much do they expect technology to impact behavioral research and care. The aim of this study was to investigate how much technology disruption do stakeholders expect in healthcare, as well as their perceived contribution in partnering for developing behavioral health technologies. Stakeholders (N = 74) responded to an online convenience sampling survey. Over 89% of participants reported expecting that technology will bring at least a moderate amount of disruption in the current models of behavioral healthcare, with respondents with the most experience in digital health expecting the most disruption. As for their perception of each other's role in partnering for developing behavioral health technologies, one group's weakness was considered to be complemented by another group's strength. Academics were perceived as having more theoretical and research expertise but being less technology-savvy, while industry professionals were considered to excel at technological and marketing activities. Providers were considered to have the most clinical and real-world healthcare industry expertise. Our results indicate that technology is expected to disrupt current healthcare models, while also highlighting the need for collaboration, as no single group was considered to have sufficient expertise and resources to develop successful, effective behavioral health technologies on its own. These results may contribute to a better understanding of how technology disruption is affecting behavioral healthcare from the standpoint of its key players, which may lead to better collaborative models of research and care delivery.

Interactive voice response interventions targeting behaviour change: a systematic literature review with meta-analysis and meta-regression

OBJECTIVE

A number of promising automated behaviour change interventions have been developed using advanced phone technology. This paper reviewed the effectiveness of interactive voice response (IVR)-based interventions designed to promote changes in specific health behaviours.

METHODS

A systematic literature review of papers published between January 1990 and September 2017 in MEDLINE, CINAHL, Embase, PsycINFO, SCOPUS and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. From the total of 2546 papers identified, 15 randomised control trials (RCTs) met the eligibility criteria and were included in a random effects meta-analysis. Meta-regression analysis was used to explore whether behaviour change techniques (BCTs) that were used in the interventions were associated with intervention effectiveness.

RESULTS

Meta-analysis of 15 RCTs showed that IVR-based interventions had small but significant effects on promoting medication adherence (OR=1.527, 95% CI 1.207 to 1.932, k=9, p=0.000) and physical activity (Hedges' g=0.254, 95% CI 0.068 to 0.439, k=3, p=0.007). No effects were found for alcohol (Hedges' g=-0.077, 95% CI -0.162 to 0.007, k=4, p=0.073) or diet (Hedges' g=0.130, 95% CI -0.088 to 0.347, k=2, p=0.242). In the medication adherence studies, multivariable meta-regression including six BCTs explained 100% of the observed variance in effect size, but only the BCT 'information about health consequences' was significantly associated with effect size (β=0.690, SE=0.199, 95% CI 0.29 to 1.08, p=0.000).

CONCLUSION

IVR-based interventions appear promising in changing specific health behaviours, such as medication adherence and physical activity. However, more studies are needed to elucidate further the combination of active components of IVR interventions that make them effective and test their feasibility and effectiveness using robust designs and objective outcome measures.

Feasibility and preliminary efficacy of an exercise telephone counseling intervention for hematologic cancer survivors: a phase II randomized controlled trial

BACKGROUND

Supervised exercise interventions produce the largest improvements in patient-reported outcomes in cancer survivors but their scalability has been questioned. Telephone counseling has been proposed as a more feasible alternative but its impact on exercise behavior and health outcomes have been modest. Basing telephone counseling exercise (TCE) interventions on the theoretical advances described in the multi-process action control framework (M-PAC) may improve these outcomes.

PURPOSE

To assess the feasibility and preliminary efficacy of a M-PAC-based TCE intervention for increasing aerobic exercise behavior in hematologic cancer survivors (HCS).

METHODS

We recruited 51 HCS who were randomized to either a weekly TCE group (n = 26) or a self-directed exercise (SDE) group (n = 25). Participants completed online measures of self-reported aerobic exercise behavior, quality of life (QoL), fatigue, and program satisfaction at baseline and post-intervention (12 weeks).

RESULTS

Adherence to the TCE intervention was 93% and retention was 100%. Participants receiving TCE increased their weekly aerobic exercise by 218 min compared to 93 min in the SDE group [mean-adjusted between-group difference (MBGD_adj) = 139, 95%CI = 65 to 213, p < .001, effect size (d) = 2.19]. Clinically meaningful QoL improvements favored the TCE group for mental health (MBGD_adj = 3.7, 95%CI = - 0.4 to 7.9, p = .08, d = 0.42) and mental health component (MBGD_adj = 3.6, 95%CI = - 0.8 to 8.1, p = .10, d = 0.35) subscales.

CONCLUSIONS

The 12-week TCE intervention substantially increased exercise behavior and may have meaningfully improved QoL in HCS.

IMPLICATIONS FOR CANCER SURVIVORS

Though more definitive trials are needed, remote TCE interventions based on the M-PAC may improve exercise behavior and QoL in HCS and perhaps other cancer survivor groups.

TRIAL REGISTRATION NUMBER

Clinical Trials ID: NCT03052777.

Evaluation Criteria of Noninvasive Telemonitoring for Patients With Heart Failure: Systematic Review

BACKGROUND

Telemonitoring can improve heart failure (HF) management, but there is no standardized evaluation framework to comprehensively evaluate its impact.

OBJECTIVE

Our objectives were to list the criteria used in published evaluations of noninvasive HF telemonitoring projects, describe how they are used in the evaluation studies, and organize them into a consistent scheme.

METHODS

Articles published from January 1990 to August 2015 were obtained through MEDLINE, Web of Science, and EMBASE. Articles were eligible if they were original reports of a noninvasive HF telemonitoring evaluation study in the English language. Studies of implantable telemonitoring devices were excluded. Each selected article was screened to extract the description of the telemonitoring project and the evaluation process and criteria. A qualitative synthesis was performed.

RESULTS

We identified and reviewed 128 articles leading to 52 evaluation criteria classified into 6 dimensions: clinical, economic, user perspective, educational, organizational, and technical. The clinical and economic impacts were evaluated in more than 70% of studies, whereas the educational, organizational, and technical impacts were studied in fewer than 15%. User perspective was the most frequently covered dimension in the development phase of telemonitoring projects, whereas clinical and economic impacts were the focus of later phases.

CONCLUSIONS

Telemonitoring evaluation frameworks should cover all 6 dimensions appropriately distributed along the telemonitoring project lifecycle. Our next goal is to build such a comprehensive evaluation framework for telemonitoring and test it on an ongoing noninvasive HF telemonitoring project.

Improving postpartum retention in care for women living with HIV in the United States

: Research findings have consistently demonstrated that women living with HIV in the United States and globally experience declines in medication adherence and retention in care after giving birth. A number of studies have identified factors associated with postpartum retention in care, but the evidence base for interventions to address the problem and close this gap in the HIV care continuum is limited. Furthermore, the majority of studies have been conducted in low-resource or moderate-resource countries and may be less applicable or require adaptation for use in high resource countries. In the United States, up to two-thirds of women drop out of care after delivery and are unable to maintain or achieve viral suppression postpartum, at a time when maternal and pediatric health are closely linked. We conducted a critical review of the literature to identify existing gaps regarding maternal retention in the United States and conceptualize the problem through the lens of the integrated and ecological models of health behavior. This review describes existing barriers and facilitators to retention in HIV care postpartum from published studies and suggests steps that can be taken, using a multilevel approach, to improve maternal retention. We propose five core action steps related to increasing awareness of the problem of poor postpartum retention, addressing needs for improved care coordination and case management, and using novel approaches to adapt and implement peer support and technology-based interventions to improve postpartum retention and clinical outcomes of women living with HIV.

Thailand's national universal developmental screening programme for young children: action research for improved follow-up

Introduction

In low-income and middle-income countries, it is estimated that one in every three preschool-age children are failing to meet cognitive or socioemotional developmental milestones. Thailand has implemented a universal national developmental screening programme (DSPM) for young children to enable detection of developmental disorders and early intervention that can improve child health outcomes. DSPM implementation is being hampered by low attendance at follow-up appointments when children fail the initial screening.

Methods

Action research, using qualitative methods was conducted with 19 caregivers, 5 health workers and 1 chief at two Health Promotion Hospitals to explore the factors affecting attendance at follow-up appointments. Transcripts and notes were analysed using descriptive content analysis. Findings were then discussed with 48 health workers, managers, researchers and policymakers.

Results

The high workload of health workers during busy vaccination clinics, and inadequate materials prevented clear communication with caregivers about the screening, how to stimulate child development and the screening result. Caregivers, particularly grandparents, had a lack of understanding about how to stimulate child development, and did not fully understand failed screening results. Caregivers felt blamed for not stimulating their child’s development, and were either worried that their child was severely disabled, or they did not believe the screening result and therefore questioned its usefulness. This led to a lack of attendance at follow-up appointments.

Conclusion

Task-sharing, mobile health (mhealth), community outreach and targeted interventions for grandparent caregivers might increase awareness about child development and screening, and allow health workers more time to communicate effectively. Sharing best practices, communication training and mentoring of DSPM workers coupled with mhealth job aids could also improve caregiver attendance at follow-up. Engagement of caregivers in understanding the barriers to attendance at follow-up and engagement of stakeholders in the design and implementation of interventions is important to ensure their effectiveness.

Acceptability of a multilevel intervention to improve blood pressure control among patients with chronic kidney disease in a public health care delivery system

Background

The Kidney Awareness Registry and Education (KARE) trial examined the impact of a multilevel intervention on blood pressure control among patients with chronic kidney disease (CKD) in a public health care delivery system. KARE consisted of a clinic-based intervention (a primary care CKD registry with point-of-care provider notifications and quarterly feedback related to CKD management) and a patient-directed intervention [a CKD self-management support (CKD-SMS) program that included low literacy educational materials, automated telephone-administered self-management modules and telephone health coaching]. We explored the acceptability of these interventions among end users.

Methods

At trial conclusion, we surveyed 39 primary care providers (PCPs) to identify preferences about components of the clinic intervention, conducted two focus groups among non-PCP staff to elicit in-depth attitudes and experiences with operationalizing the team-based CKD registry, and conducted eight focus groups with English- and Spanish-speaking patients to hear about their experiences with the CKD-SMS program. Focus group transcripts were analyzed using thematic analysis. Self-reported participation and data from the automated telephone program were used to evaluate patient engagement.

Results

Most PCPs (94%) believed that the point-of-care notifications benefited clinic workflow and agreed that quarterly feedback enhanced their ability to identify (89.5%) and manage (73.7%) CKD. Staff confirmed usefulness of point-of-care notifications. Patients suggested the automated telephone system was impersonal, though easy to use; that frequent automated calls were helpful to reinforce self-management behaviors; and that telephone health coaching was convenient. Nearly 40% of patients completed >80% of automated phone calls, 95% participated in calls with their health coach and 77% created at least one action plan.

Conclusions

A CKD registry is acceptable to primary care health care teams and has potential to enhance identification and management of CKD in primary care. Low-income patients appreciated and engaged with a telephone-based CKD-SMS program, demonstrating its potential for increasing awareness and health engagement among populations with CKD within a public health care delivery system.

Stepwise strategy to improve Cervical Cancer Screening Adherence (SCAN-CC): automated text messages, phone calls and face-to-face interviews: protocol of a population-based randomised controlled trial

INTRODUCTION

Screening is highly effective for cervical cancer prevention and control. Population-based screening programmes are widely implemented in high-income countries, although adherence is often low. In Portugal, just over half of the women adhere to cervical cancer screening, contributing for greater mortality rates than in other European countries. The most effective adherence raising strategies are based on patient reminders, small/mass media and face-to-face educational programmes, but sequential interventions targeting the general population have seldom been evaluated. The aim of this study is to assess the effectiveness of a stepwise approach, with increasing complexity and cost, to improve adherence to organised cervical cancer screening: step 1a-customised text message invitation; step 1b-customised automated phone call invitation; step 2-secretary phone call; step 3-family health professional phone call and face-to-face appointment.

METHODS

A population-based randomised controlled trial will be implemented in Portuguese urban and rural areas. Women eligible for cervical cancer screening will be randomised (1:1) to intervention and control. In the intervention group, women will be invited for screening through text messages, automated phone calls, manual phone calls and health professional appointments, to be applied sequentially to participants remaining non-adherent after each step. Control will be the standard of care (written letter). The primary outcome is the proportion of women adherent to screening after step 1 or sequences of steps from 1 to 3. The secondary outcomes are: proportion of women screened after each step (1a, 2 and 3); proportion of text messages/phone calls delivered; proportion of women previously screened in a private health institution who change to organised screening. The intervention and control groups will be compared based on intention-to-treat and per-protocol analyses.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Northern Health Region Administration and National Data Protection Committee. Results will be disseminated through communications in scientific meetings and peer-reviewed journals.

TRIAL NUMBER

NCT03122275.

Improving diabetes care at primary care level with a multistrategic approach: results of the DIAPREM programme

AIM

To present results, 1 year postimplementation at primary care level, of an integrated diabetes care programme including systemic changes, education, registry (clinical, metabolic, and therapeutic indicators), and disease management (DIAPREM).

METHODS

We randomly selected and trained 15 physicians and 15 nurses from primary care units of La Matanza County (intervention-IG) and another 15 physicians/nurses to participate as controls (control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for 1 year; both groups used structured medical records. Patients in IG had quarterly clinical appointments, whereas those in CG received traditional care. Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions.

RESULTS

After 12 months, the dropout rate was significantly lower in IG than in CG. Whereas in IG HbA1c, blood pressure and lipid profile levels significantly decreased, no changes were recorded in CG. Drug prescriptions showed no significant changes in IG except a decrease in oral monotherapy.

CONCLUSIONS

DIAPREM is an expedient and simple multistrategic model to implement at the primary care level in order to decrease patient dropout and improve control and treatment adherence, and quality of care of people with diabetes.

eHealth in the future of medications management: personalisation, monitoring and adherence

BACKGROUND

Globally, healthcare systems face major challenges with medicines management and medication adherence. Medication adherence determines medication effectiveness and can be the single most effective intervention for improving health outcomes. In anticipation of growth in eHealth interventions worldwide, we explore the role of eHealth in the patients' medicines management journey in primary care, focusing on personalisation and intelligent monitoring for greater adherence.

DISCUSSION

eHealth offers opportunities to transform every step of the patient's medicines management journey. From booking appointments, consultation with a healthcare professional, decision-making, medication dispensing, carer support, information acquisition and monitoring, to learning about medicines and their management in daily life. It has the potential to support personalisation and monitoring and thus lead to better adherence. For some of these dimensions, such as supporting decision-making and providing reminders and prompts, evidence is stronger, but for many others more rigorous research is urgently needed.

CONCLUSIONS

Given the potential benefits and barriers to eHealth in medicines management, a fine balance needs to be established between evidence-based integration of technologies and constructive experimentation that could lead to a game-changing breakthrough. A concerted, transdisciplinary approach adapted to different contexts, including low- and middle-income contries is required to realise the benefits of eHealth at scale.