User preferences for and engagement with text messages to support antihypertensive medication adherence: Findings from a pilot study evaluating an emergency department-based behavioral intervention

The association of social determinants of health and medication adherence: A cross-sectional analysis across three urban emergency departments

INTRODUCTION

Social determinants of health (SDoH), including factors like income, education, and housing, can influence health outcomes and medication adherence, especially among emergency department (ED) patients. This study explores the relationship between SDoH and medication adherence among patients in urban EDs.

METHODS

We conducted a cross-sectional survey across three geographically diverse urban EDs from May 2022 to February 2024 among ED patients aged ≥18 who were taking ≥4 prescription medications or ≥ 1 "high-risk" medication, including immunosuppressants, antiepileptics, sedatives, anti-Parkinson agents, antithrombotics, antihyperglycemics, or cardiovascular medications. The AAFP Social Needs Screening Tool and a validated medication adherence questionnaire were used. Data were analyzed using univariate and multivariable logistic regression to identify associations between SDoH and medication adherence.

RESULTS

345 participants completed the survey. Among survey respondents, 28 % delayed medical visits due to transportation issues, while 31.9 % faced financial difficulties. Housing instability was reported by 16.3 % of participants. Regarding medication adherence, 42.4 % of patients forgot to take their medications, 23.7 % skipped doses, and 34.8 % missed appointments. Multivariate analysis revealed that younger patients (<65 years) were more likely to experience running out of medications. Financial instability and transportation difficulties were also associated with poor adherence to prescribed medications and increased difficulty with healthcare utilization tasks.

CONCLUSION

This study highlights the associations of SDoH with medication adherence in urban ED settings. Transportation, financial, and housing challenges were associated with greater odds of exhibiting poor medication adherence. Younger patients also demonstrated higher rates of non-adherence. Addressing these SDoH through targeted interventions could improve medication adherence and overall health outcomes.

Intention to use short messaging services for promoting drug adherence among individuals with diabetes in Addis Ababa, Ethiopia

Background

Suboptimal medication adherence among individuals with diabetes presents a significant challenge in low-income nations. Growing evidence demonstrates the effectiveness of text messaging interventions to enhance medication adherence. This study assesses the intention to use Short Messaging Service (SMS) based reminder services in promoting drug adherence among diabetic patients and associated factors in Addis Ababa, Ethiopia.

Methods

An institution-based cross-sectional study was conducted from February 06, 2023, to March 27, 2023, in Addis Ababa, Ethiopia. A sample of 351 patients was selected using systematic random sampling. Structured questionnaires were used for data collection. Binary and multivariable logistic regression models were used to analyze the association between intention to use SMS reminders to promote drug adherence among individuals with diabetes and related factors.

Results

A total of 333 respondents, with a 94.87% response rate, were interviewed for this study. The majority of respondents, 66.4 % (95% CI [61.9-71.2]), expressed an intention to use SMS-based reminder services to promote their drug adherence. Age < 45 years (AOR = 5.73, 95% CI [2.07-15.73]), higher educational level (AOR = 3.03, 95% CI [1.16-7.90]), type of diabetes (AOR = 3.71, 95% CI [1.16-7.90]), oral medication users (AOR = 2.99, 95% CI [1.42-6.32]), SMS as a preferred medium for communication (AOR = 2.86, 95% CI [1.17-7.00]) were deemed to be important variables linked to intention to use SMS reminders to promote drug adherence among individuals with diabetes.

Conclusion

The findings suggest the majority of individuals with diabetes have intention to use SMS reminders to enhance adherence. This result indicates the potential for utilization of SMS reminders to enhance adherence to diabetic medications. Furthermore, the findings highlight the importance of tailored interventions that take into account patient characteristics and preferences as factors that influence intention when designing such an intervention.

Development of an Emergency Department Family Navigator and Text Message Intervention for Caregivers to Reduce Youth Risk of Suicide and Self-injurious Behavior

BACKGROUND

Suicide and self-injurious behavior (SSIB) in youth 10 to 14 years old has rapidly increased, with suicide rates for youth 10 to 18 years being the second leading cause of death. Youth with SSIB seen in the Emergency Department (ED) are often discharged to the community, yet less than 40% receive subsequent mental health (MH) care within 30 days. This open pilot study examined the feasibility, acceptability, and sample characteristics of a two-component Family Navigator with text messaging intervention, ED REaCH, for caregivers of youth with SSIB discharged from the ED.

METHODS

Sixteen dyads of youth (M=12.67; SD=1.09) seeking emergency care for SSIB and their caregivers were enrolled from the ED of a pediatric hospital in the northeast US from November 2023 to March 2024. Dyads were enrolled in the ED REaCH intervention consisting of navigation procedures to promote linkage to care, engagement in community-based MH care for youth with SSIB, and a digital platform to extend purported mechanisms underlying the intervention's efficacy (MH literacy, MH communication, and MH engagement). Data was collected on measures of social identities, demographics, functioning, MH services, and intervention satisfaction.

RESULTS

All (100%) caregivers accepted the text messages. Most (75%) utilized the Family Navigator and completed the intervention feedback interviews. Overall, caregivers endorsed positive experiences and satisfaction with the two-component intervention. All caregivers who utilized the Family Navigator reported that 100% of youth attended MH care.

CONCLUSION

Preliminary findings suggest that the content and delivery methods of this intervention are perceived by caregivers as feasible and acceptable. As such, next steps include the evaluation of the ED REaCH intervention in a randomized clinical trial design. Future directions need to focus on intervention scalability, adaptability, personalization, and sustainability.

The evolution of motivational interviewing

This review traces the development of motivational interviewing (MI) from its happenstance beginnings and the first description published in this journal in 1983, to its continuing evolution as a method that is now in widespread practice in many professions, nations and languages. The efficacy of MI has been documented in hundreds of controlled clinical trials, and extensive process research sheds light on why and how it works. Developing proficiency in MI is facilitated by feedback and coaching based on observed practice after initial training. The author reflects on parallels between MI core processes and the characteristics found in 70 years of psychotherapy research to distinguish more effective therapists. This suggests that MI offers an evidence-based therapeutic style for delivering other treatments more effectively. The most common use of MI now is indeed in combination with other treatment methods such as cognitive behaviour therapies.

Impact of telenutrition protocols in a web-based nutrition counseling program on adult dietary practices: Randomized controlled pilto study

OBJECTIVE

To analyze the effectiveness of two different telenutrition protocols on the dietary practices of adults.

METHODS

This was a 12-week, randomized controlled trial, involving the application of different telenutrition protocols with online nutritional counseling. Two protocols were used, the multicomponent (MT), composed of multiple strategies combined, synchronously and asynchronously, and the traditional (TD), with only one synchronous strategy, in addition to the control group (CT). The primary outcome was assessed by the eating practices score.

RESULTS

Eighty-six individuals participated, 35 in the MT group, 30 in the TD group, and 21 in the CT group. After 12 weeks, the MT and TD groups showed a significant increase in their eating practices score (p = 0.049), and both were different from the control (MT × CT: p < 0.001; η2: 0.21); (TD × CT: p = 0.002; η2: 0.21). The MT group showed significant changes in four items assessing eating practices, while the TD group showed significant results in two, both compared to the CT group.

CONCLUSION AND PRACTICAL IMPLICATIONS

The multicomponent and traditional methodologies were effective in improving eating practices, with the combined methods standing out. The protocols tested may be useful to guide nutritionists regarding the methodologies in telenutrition.

Feasibility and Short-Term Effects of a Multi-Component Emergency Department Blood Pressure Intervention: A Pilot Randomized Trial

Background

Emergency department (ED) visits can be opportunities to address uncontrolled hypertension. We sought to compare short‐term blood pressure measures between the Vanderbilt Emergency Room Bundle (VERB) intervention and usual care plus education.

Methods and Results

We conducted a randomized trial of 206 adult patients with hypertension and elevated systolic blood pressure (SBP) presenting to 2 urban emergency departments in Tennessee, USA. The VERB intervention included educational materials, a brief motivational interview, pillbox, primary care engagement letter, pharmacy resources, and 45 days of informational and reminder text messages. The education arm received a hypertension pamphlet. After 78 participants were enrolled, text messages requested confirmation of receipt. The primary clinical outcome was 30‐day SBP. The median 30‐day SBP was 122 and 126 mm Hg in the VERB and education arms, respectively. We estimated the mean 30‐day SBP to be 3.98 mm Hg lower in the VERB arm (95% CI, −2.44 to 10.4; P=0.22). Among participants enrolled after text messages were adapted, the respective median SBPs were 121 and 130 mm Hg, and we estimated the mean 30‐day SBP to be 8.57 mm Hg lower in the VERB arm (95% CI, 0.98‒16.2; P=0.027). In this subgroup, the median response rate to VERB text messages was 56% (interquartile range, [26%‒80%]).

Conclusions

This pilot study demonstrated feasibility and found an improvement in SBP for the subgroup for whom interactive messages were featured. Future studies should evaluate the role of interactive text messaging as part of a comprehensive emergency department intervention to improve blood pressure control.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02672787.

Estimating the impact of engagement with digital health interventions on patient outcomes in randomized trials

OBJECTIVE

Guidance is needed on studying engagement and treatment effects in digital health interventions, including levels required for benefit. We evaluated multiple analytic approaches for understanding the association between engagement and clinical outcomes.

MATERIALS AND METHODS

We defined engagement as intervention participants' response rate to interactive text messages, and considered moderation, standard regression, mediation, and a modified instrumental variable (IV) analysis to investigate the relationship between engagement and clinical outcomes. We applied each approach to two randomized controlled trials featuring text message content in the intervention: REACH (Rapid Encouragement/Education and Communications for Health), which targeted diabetes, and VERB (Vanderbilt Emergency Room Bundle), which targeted hypertension.

RESULTS

In REACH, the treatment effect on hemoglobin A1c was estimated to be -0.73% (95% CI: [-1.29, -0.21]; P = 0.008), and in VERB, the treatment effect on systolic blood pressure was estimated to be -10.1 mmHg (95% CI: [-17.7, -2.8]; P = 0.007). Only the IV analyses suggested an effect of engagement on outcomes; the difference in treatment effects between engagers and non-engagers was -0.29% to -0.51% in the REACH study and -1.08 to -3.25 mmHg in the VERB study.

DISCUSSION

Standard regression and mediation have less power than a modified IV analysis, but the IV approach requires specification of assumptions. This is the first review of the strengths and limitations of various approaches to evaluating the impact of engagement on outcomes.

CONCLUSIONS

Understanding the role of engagement in digital health interventions can help reveal when and how these interventions achieve desired outcomes.