Text messaging in healthcare: the elephant knocking at the door

Effectiveness and implementation of a text messaging intervention to reduce depression and anxiety symptoms among Latinx and Non-Latinx white users during the COVID-19 pandemic

Text messaging interventions are increasingly used to help people manage depression and anxiety. However, little is known about the effectiveness and implementation of these interventions among U.S. Latinxs, who often face barriers to using mental health tools. The StayWell at Home (StayWell) intervention, a 60-day text messaging program based on cognitive behavioral therapy (CBT), was developed to help adults cope with depressive and anxiety symptoms during the COVID-19 pandemic. StayWell users (n = 398) received daily mood inquiries and automated skills-based text messages delivering CBT-informed coping strategies from an investigator-generated message bank. We conduct a Hybrid Type 1 mixed-methods study to compare the effectiveness and implementation of StayWell for Latinx and Non-Latinx White (NLW) adults using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Effectiveness was measured using the PHQ-8 depression and GAD-7 anxiety scales, assessed before starting and after completing StayWell. Guided by RE-AIM, we conducted a thematic text analysis of responses to an open-ended question about user experiences to help contextualize quantitative findings. Approximately 65.8% (n = 262) of StayWell users completed pre-and-post surveys. On average, depressive (-1.48, p = 0.001) and anxiety (-1.38, p = 0.001) symptoms decreased from pre-to-post StayWell. Compared to NLW users (n = 192), Latinx users (n = 70) reported an additional -1.45 point (p < 0.05) decline in depressive symptoms, adjusting for demographics. Although Latinxs reported StayWell as relatively less useable (76.8 vs. 83.9, p = 0.001) than NLWs, they were more interested in continuing the program (7.5 vs. 6.2 out of 10, p = 0.001) and recommending it to a family member/friend (7.8 vs. 7.0 out of 10, p = 0.01). Based on the thematic analysis, both Latinx and NLW users enjoyed responding to mood inquiries and sought bi-directional, personalized text messages and texts with links to more information to resources. Only NLW users stated that StayWell provided no new information than they already knew from therapy or other sources. In contrast, Latinx users suggested that engagement with a behavioral provider through text or support groups would be beneficial, highlighting this group's unmet need for behavioral health care. mHealth interventions like StayWell are well-positioned to address population-level disparities by serving those with the greatest unmet needs if they are culturally adapted and actively disseminated to marginalized groups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04473599.

Text Messages in the Field of Mental Health: Rapid Review of the Reviews

BACKGROUND

While mental health problems constitute a worldwide concern contributing to the global rates of morbidity and mortality, conventional mental healthcare services do not meet the current needs. Text messages (TM) represent a live model that incorporates technology into health services, spanning a large number of health conditions and playing different roles that may support the current healthcare system.

OBJECTIVE

To examine the TM services in the field of mental health, regarding their effectiveness, feasibility, acceptability, and economic evaluation in different contexts of mental health diagnoses and during critical times, when provided to individuals with mental health symptoms/disorders.

METHODS

This rapid review was conducted through an online search in PubMed, Embase, PsycINFO, and Medline databases. The review targeted the review studies which examined online or mobile addiction and mental health services, utilizing TM services. The search was run from the inception up to September 30, 2021.

RESULTS

Sixty review articles met the inclusion criteria and were included in this review. All reviews were published over the last decade. The results showed that people of a young age were fairly represented, and most reviews were run over substance use disorders (SUD), including Alcohol. Most reviews examined the effectiveness outcomes of the texting service, while to a lesser extent the acceptability and feasibility, among others. Texting services were reported as effective in psychotic disorders and SUD. However, the results related to depression and anxiety were mixed. Most reviews reported a considerably high risk of bias among their included studies. High satisfaction and acceptability of the texting services were reported for patients with various mental health conditions, including those with severe mental illness.

CONCLUSIONS

This rapid review highlighted the applications, usability, benefits, and satisfaction with the TM in the field of mental health. For a higher quality of evidence, future studies should consider TM interventions in the contexts with mixed results or a dearth of literature, and during critical times, such as the COVID-19 pandemic. Policy- and decision-makers, therefore, need to further support text-based services with guided investments in interventions that were evidenced to be accepted, economic and feasible.

Outcome of reminder text messages intervention on completion of routine immunization in rural areas, Nigeria

Completion of routine immunization for infants has been a challenge in Nigeria, and existing strategies implemented to promote immunization coverage yielded limited success. The use of reminder short services message (SMS) in mobilizing mothers of infants, especially in rural areas with lower immunization coverage has been suggested. This study investigated the effect of reminder SMS sent to mothers in rural communities on full and timely completion of routine childhood immunization. A quasi-experimental design was adopted, 3500 mothers of infants were categorized into the Intervention and Control groups recruited at various Primary Healthcare Centres in 6 states and the FCT, Nigeria. Reminder SMS were sent to mothers in the intervention group for 10 months. We adopted mixed methods of data collection, significance level set at p = 0.05. Majority of respondents were married (Control 94.3%; Intervention 95.5%), have experienced multiple births (Control 79.0%; Intervention 74.9%). Adherence to routine immunization appointment dates and completion of all immunizations was higher in the Intervention group (76.0%) compared with the Control (73.3%). A significant association between adherence to appointment dates and completeness of routine immunization vaccine was found. The Intervention group had a significantly higher completion rate for measles and yellow fever vaccines (55.3%; 75.9%) compared with the Control group (26.8%; 23.9%). Qualitative findings revealed positive comments from mothers in the intervention group that the messages increase awareness of immunization dates, assisted in readjusting their time which influenced timely completion. Interventions using reminder SMS enhanced infant immunization delivery; we recommend scale-up and integration into the health system to increase national immunization coverage.

Impact of mhealth messages and environmental cues on hand hygiene practice among healthcare workers in the greater Kampala metropolitan area, Uganda: study protocol for a cluster randomized trial

Background

Hand hygiene (HH) among healthcare workers (HCWs) is critical for infection prevention and control (IPC) in healthcare facilities (HCFs). Nonetheless, it remains a challenge in HCFs, largely due to lack of high-impact and efficacious interventions. Environmental cues and mobile phone health messaging (mhealth) have the potential to improve HH compliance among HCWs, however, these remain under-studied. Our study will determine the impact of mhealth hygiene messages and environmental cues on HH practice among HCWs in the Greater Kampala Metropolitan Area (GKMA).

Methods

The study is a cluster-randomized trial, which will be guided by the behaviour centred design model and theory for behaviour change. During the formative phase, we shall conduct 30 key informants’ interviews and 30 semi-structured interviews to explore the barriers and facilitators to HCWs’ HH practice. Besides, observations of HH facilities in 100 HCFs will be conducted. Findings from the formative phase will guide the intervention design during a stakeholders’ insight workshop.

The intervention will be implemented for a period of 4 months in 30 HCFs, with a sample of 450 HCWs who work in maternity and children’s wards. HCFs in the control arm will receive innovatively designed HH facilities and supplies. HCWs in the intervention arm, in addition to the HH facilities and supplies, will receive environmental cues and mhealth messages. The main outcome will be the proportion of utilized HH opportunities out of the 9000 HH opportunities to be observed. The secondary outcome will be E. coli concentration levels in 100mls of hand rinsates from HCWs, an indicator of recent fecal contamination and HH failure. We shall run multivariable logistic regression under the generalized estimating equations (GEE) framework to account for the dependence of HH on the intervention.

Discussion

The study will provide critical findings on barriers and facilitators to HH practice among HCWs, and the impact of environmental cues and mhealth messages on HCWs’ HH practice.

Trial registration

ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06082-3.

Text4Support Mobile-Based Programming for Individuals Accessing Addictions and Mental Health Services-Retroactive Program Analysis at Baseline, 12 Weeks, and 6 Months

Objective: Where traditional approaches fall short, widely accessible and accepted, yet under leveraged, digital technologies such as text messaging present novel opportunities to solve a range of health care solutions. The following provides a preliminary analysis of the Text4Support program, a text-messaging intervention using the principles of cognitive behavioral therapy, which seeks to support the health and well-being of individuals seeking support for addiction or mental health concerns. The goal of this study was to assess whether the Text4Support program improved the perceived overall mental well-being of participants. Methods: The evaluation analyzes survey responses of individuals who were enrolled in the Text4Support program beginning in July 2019, who had completed the 6-months program by May 2020. Participants were asked to provide responses to three surveys during their time in the program-at baseline, 12-weeks and 6-months, which included questions documenting demographic information, general satisfaction with the program, and a participants' level of "global distress" through use of the Clinical Outcomes Routine Evaluation System (CORE-10)-a validated brief 10-item assessment and outcome measurement tool used to assess conditions including anxiety, depression, physical problems, and risk to self. Results and Conclusions: This data set did not include a large enough sample of participants to reach statistical significance. Nevertheless, the study provides some preliminary analysis, and identifies opportunities for the future analysis and research.

Changes in Stress, Anxiety, and Depression Levels of Subscribers to a Daily Supportive Text Message Program (Text4Hope) During the COVID-19 Pandemic: Cross-Sectional Survey Study

BACKGROUND

In addition to the obvious physical medical impact of COVID-19, the disease poses evident threats to people's mental health, psychological safety, and well-being. Provision of support for these challenges is complicated by the high number of people requiring support and the need to maintain physical distancing. Text4Hope, a daily supportive SMS text messaging program, was launched in Canada to mitigate the negative mental health impacts of the pandemic among Canadians.

OBJECTIVE

This paper describes the changes in the stress, anxiety, and depression levels of subscribers to the Text4Hope program after 6 weeks of exposure to daily supportive SMS text messages.

METHODS

We used self-administered, empirically supported web-based questionnaires to assess the demographic and clinical characteristics of Text4Hope subscribers. Perceived stress, anxiety, and depression were measured with the 10-Item Perceived Stress Scale (PSS-10), the Generalized Anxiety Disorder-7 (GAD-7) scale, and the Patient Health Questionnaire-9 (PHQ-9) scale at baseline and sixth week time points. Moderate or high perceived stress, likely generalized anxiety disorder, and likely major depressive disorder were assessed using cutoff scores of ≥14 for the PSS-10, ≥10 for the GAD-7, and ≥10 for the PHQ-9, respectively. At 6 weeks into the program, 766 participants had completed the questionnaires at both time points.

RESULTS

At the 6-week time point, there were statistically significant reductions in mean scores on the PSS-10 and GAD-7 scales but not on the PHQ-9 scale. Effect sizes were small overall. There were statistically significant reductions in the prevalence rates of moderate or high stress and likely generalized anxiety disorder but not likely major depressive disorder for the group that completed both the baseline and 6-week assessments. The largest reductions in mean scores and prevalence rates were for anxiety (18.7% and 13.5%, respectively).

CONCLUSIONS

Text4Hope is a convenient, cost-effective, and accessible means of implementing a population-level psychological intervention. This service demonstrated significant reductions in anxiety and stress levels during the COVID-19 pandemic and could be used as a population-level mental health intervention during natural disasters and other emergencies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19292.

"The flu… is a little more complicated than a cold": Knowledge, beliefs, and practices related to influenza and influenza vaccination among at-risk populations and health professionals in Peru

BACKGROUND

Influenza is a major source of morbidity and mortality with an annual global attack rate estimated at 5-10% in adults and 20-30% in children. Influenza vaccination is the main strategy for reducing influenza-related morbidity and mortality. Like several other countries, Peru has low vaccination coverage, estimated at 25-50% among young children and older adults. Therefore, the study objective was to explore the knowledge, beliefs, attitudes, and practices related to influenza vaccination among populations at higher risk for infection and/or complications and health professionals in Peru, and their perspectives on health communication channels.

METHODS

This qualitative study was carried out in three cities. We held nine focus groups with pregnant and postpartum women, parents of young children, and older adults. We carried out 25 in-depth interviews with health professionals (HPs) working in, leading or advising immunization-related programs.

RESULTS

HPs correctly identified the causes of influenza and HPs and at risk community members identified major symptoms. Community members had poor awareness of the potential severity of influenza and were generally unaware of influenza-related mortality. Both HPs and community members greatly underestimated the prevalence of influenza in Peru. HPs in our study overestimated major side effects of the influenza vaccine and community members perceived that the vaccine caused illness. HPs missed important opportunities to promote vaccination in patients with minor illness (runny nose, allergies, colds) and community members did not understand that the vaccine should be received annually.

CONCLUSIONS

There is no single strategy that will increase influenza vaccination rates to World Health Organization recommended levels. Instead, it requires multi-faceted commitment from HPs, other healthcare authorities and the government. Addressing important knowledge barriers, specifically negative views regarding the influenza vaccine and the severe morbidity and mortality associated with influenza illness, both in the community and especially among HPs, could have significant impacts.

Increasing Perioperative Communication With Automated Mobile Phone Messaging in Total Joint Arthroplasty

BACKGROUND

Automated mobile phone messaging has not been reported in total joint arthroplasty (TJA). Our purpose was to compare Press Ganey (PG) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores between TJA patients who did and did not receive perioperative automated mobile phone messages.

METHODS

Patients were prospectively enrolled and received messages for 1 week prior until 2 weeks after TJA. Message content included reminders, activity, and pain control. Patients answered select PG/HCAHPS and questions regarding their experience with the automated communication platform. Average PG/HCAHPS scores were compared to historical TJA patients in the 3-year window prior (control group) with significance P < .05.

RESULTS

Thirty-seven consecutive patients were approached and 92% (n = 34) were enrolled. The experimental group was 47% male, with 80% patients between 51 and 75 years. The experimental (n = 30) and control groups (n = 26) were similar. Patients receiving messages were more likely to have a good understanding of health responsibilities (P = .024) and feel that the care team demonstrated shared decision-making (P = .024). Of patients enrolled, 87% felt messages helped them be more prepared for surgery, 100% felt messages kept them better informed, and 97% would participate again.

CONCLUSION

TJA patients who received perioperative communication via automated mobile phone messaging had improved patient satisfaction scores postoperatively. Patients perceived this form of communication was useful and kept them better informed. Automated mobile phone messaging can be an easily integrated, helpful adjunct to surgeons, healthcare systems, and case managers to more effectively communicate with patients undergoing TJA in this era of value-based care.

Impact of Trust and Technology on Interprofessional Collaboration in Healthcare Settings

The increases in complexity of patient care, healthcare costs, and technological advancements shifted the healthcare delivery to interprofessional collaborative care. The study aims for identifying the factors influencing the quality of team collaboration. The study examines the impact of trust and technology orientation on collaboration with the mediating effects of communication, coordination and cooperation. A questionnaire survey was conducted to gather data from healthcare professionals (N=216). Statistical analysis conducted for this study include correlations, factor analysis with reliability and validity tests and Partial Least Squares (PLS) method. The results of the study validate that (i) collaboration has positive and significant relationship with coordination, and cooperation; (ii) trust has positive and significant relationship with communication, coordination, and cooperation; and (iii) technology orientation has positive and significant relationship with cooperation but not with communication and coordination. The research and managerial implications of these factors are given in discussion. As with most empirical studies, the subjectivity of the opinion of respondents present some limitations to generalization. Other limitations include the lack of availability and use of standard measures for various constructs in the research model. The results can be used by healthcare professionals and managers to advance their understanding on the impact of trust and technology on collaboration mediating communication, coordination and cooperation practices. The significant value of this study is the identification of the factors influencing the quality of team collaboration in healthcare industry.

Developing a mHealth intervention to promote uptake of HIV testing among African communities in the UK: a qualitative study

BACKGROUND

HIV-related mHealth interventions have demonstrable efficacy in supporting treatment adherence, although the evidence base for promoting HIV testing is inconclusive. Progress is constrained by a limited understanding of processes used to develop interventions and weak theoretical underpinnings. This paper describes a research project that informed the development of a theory-based mHealth intervention to promote HIV testing amongst city-dwelling African communities in the conditions.

METHODS

A community-based participatory social marketing design was adopted. Six focus groups (48 participants in total) were undertaken and analysed using a thematic framework approach, guided by constructs from the Health Belief Model. Key themes were incorporated into a set of text messages, which were pre-tested and refined.

RESULTS

The focus groups identified a relatively low perception of HIV risk, especially amongst men, and a range of social and structural barriers to HIV testing. In terms of self-efficacy around HIV testing, respondents highlighted a need for communities and professionals to work together to build a context of trust through co-location in, and co-involvement of, local communities which would in turn enhance confidence in, and support for, HIV testing activities of health professionals. Findings suggested that messages should: avoid an exclusive focus on HIV, be tailored and personalised, come from a trusted source, allay fears and focus on support and health benefits.

CONCLUSIONS

HIV remains a stigmatized and de-prioritized issue within African migrant communities in the UK, posing barriers to HIV testing initiatives. A community-based participatory social marketing design can be successfully used to develop a culturally appropriate text messaging HIV intervention. Key challenges involved turning community research recommendations into brief text messages of only 160 characters. The intervention needs to be evaluated in a randomized control trial. Future research should explore the application of the processes and methodologies described in this paper within other communities.

Short Text Messages (SMS) as an Additional Tool for Notifying Medical Staff in Case of a Hospital Mass Casualty Incident

Objective

The aim of the study was to verify the effectiveness of short text messages (short message service, or SMS) as an additional notification tool in case of fire or a mass casualty incident in a hospital.

Methods

A total of 2242 SMS text messages were sent to 59 hospital workers divided into 3 groups (n=21, n=19, n=19). Messages were sent from a Samsung GT-S8500 Wave cell phone and Orange Poland was chosen as the telecommunication provider. During a 3-month trial period, messages were sent between 3:35 PM and midnight with no regular pattern. Employees were asked to respond by telling how much time it would take them to reach the hospital in case of a mass casualty incident.

Results

The mean reaction time (SMS reply) was 36.41 minutes. The mean declared time of arrival to the hospital was 100.5 minutes. After excluding 10% of extreme values for declared arrival time, the mean arrival time was estimated as 38.35 minutes.

Conclusions

Short text messages (SMS) can be considered an additional tool for notifying medical staff in case of a mass casualty incident. (Disaster Med Public Health Preparedness. 2016;10:38–41)

User preferences for text message-delivered skin cancer prevention and early detection

Evidence is needed for the acceptability and user preferences of receiving skin cancer-related text messages. We prepared 27 questions to evaluate attitudes, satisfaction with program characteristics such as timing and spacing, and overall satisfaction with the Healthy Text program in young adults. Within this randomised controlled trial (age 18-42 years), 546 participants were assigned to one of three Healthy Text message groups; sun protection, skin self-examination, or attention-control. Over a 12-month period, 21 behaviour-specific text messages were sent to each group. Participants' preferences were compared between the two interventions and control group at the 12-month follow-up telephone interview. In all three groups, participants reported the messages were easy to understand (98%), provided good suggestions or ideas (88%), and were encouraging (86%) and informative (85%) with little difference between the groups. The timing of the texts was received positively (92%); however, some suggestions for frequency or time of day the messages were received from 8% of participants. Participants in the two intervention groups found their messages more informative, and triggering behaviour change compared to control. Text messages about skin cancer prevention and early detection are novel and acceptable to induce behaviour change in young adults.

Beyond mobile populations: a critical review of the literature on malaria and population mobility and suggestions for future directions

BACKGROUND

Although population mobility is frequently cited as a barrier to malaria elimination, a comparatively small body of literature has attempted to systematically examine this issue. This article reviews the literature on malaria and mobile populations in order to critically examine the ways that malaria elimination experts perceive the risks surrounding population mobility. The article brings in perspectives from HIV/AIDS and other infectious disease control programmes working in areas of high population mobility. The article aims to move beyond the current tendency to identify mobile populations as a risk group and suggests ways to reconceptualize and respond to population mobility within malaria elimination.

METHODS

The review was commissioned by the Asia Pacific Malaria Elimination Network (APMEN). Searches were made using PubMed, ProQuest, Google and Google Scholar. The review includes English language published peer-reviewed literature and grey literature published up to November 2013.

RESULTS

The review identified three key themes in the literature: mobility, economic development and shifting land use; concerns about accessing mobile populations; and imported and border malaria. The review found that the literature treats mobile populations as a homogenous entity and is yet to develop a more accurate understanding of the true risks surrounding population mobility. Concerns about accessing mobile populations are overstated, and methods are suggested for working collaboratively with mobile populations. Finally, the review found that many concerns about mobile populations and imported malaria would be more productively framed as border health issues.

CONCLUSION

The focus on mobile populations is both excessive and insufficiently examined within the current literature. By its very nature, population mobility requires malaria elimination programmes to look beyond isolated localities and demographic groups to respond to the interconnections that mobility creates between localities and population groups. Malaria programmes will gain greater clarity by refocusing the discussion away from mobile populations as a risk group and toward mobility as a system involving interconnected localities and multiple demographic groups. Rather than focusing on mobile populations as a risk group and a barrier to elimination, malaria elimination programmes ought to develop collaborative community engagement efforts in border areas and regions of high population mobility and where imported malaria is of concern.

Mobile health in China: a review of research and programs in medical care, health education, and public health

There are nearly 1 billion mobile phone subscribers in China. Health care providers, telecommunications companies, technology firms, and Chinese governmental organizations use existing mobile technology and social networks to improve patient-provider communication, promote health education and awareness, add efficiency to administrative practices, and enhance public health campaigns. This review of mobile health in China summarizes existing clinical research and public health text messaging campaigns while highlighting potential future areas of research and program implementation. Databases and search engines served as the primary means of gathering relevant resources. Included material largely consists of scientific articles and official reports that met predefined inclusion criteria. This review includes 10 reports of controlled studies that assessed the use of mobile technology in health care settings and 17 official reports of public health awareness campaigns that used text messaging. All source material was published between 2006 and 2011. The controlled studies suggested that mobile technology interventions significantly improved an array of health care outcomes. However, additional efforts are needed to refine mobile health research and better understand the applicability of mobile technology in China's health care settings. A vast potential exists for the expansion of mobile health in China, especially as costs decrease and increasingly sophisticated technology becomes more widespread.

Using mobile health to support the chronic care model: developing an institutional initiative

Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a "human face" to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.

Mobile phone text messaging: tool for malaria control in Africa

Dejan Zurovac and colleagues discuss six areas where text messaging could improve the delivery of health services and health outcomes in malaria in Africa.

A re-conceptualization of access for 21st century healthcare

Many e-health technologies are available to promote virtual patient-provider communication outside the context of face-to-face clinical encounters. Current digital communication modalities include cell phones, smartphones, interactive voice response, text messages, e-mails, clinic-based interactive video, home-based web-cams, mobile smartphone two-way cameras, personal monitoring devices, kiosks, dashboards, personal health records, web-based portals, social networking sites, secure chat rooms, and on-line forums. Improvements in digital access could drastically diminish the geographical, temporal, and cultural access problems faced by many patients. Conversely, a growing digital divide could create greater access disparities for some populations. As the paradigm of healthcare delivery evolves towards greater reliance on non-encounter-based digital communications between patients and their care teams, it is critical that our theoretical conceptualization of access undergoes a concurrent paradigm shift to make it more relevant for the digital age. The traditional conceptualizations and indicators of access are not well adapted to measure access to health services that are delivered digitally outside the context of face-to-face encounters with providers. This paper provides an overview of digital "encounterless" utilization, discusses the weaknesses of traditional conceptual frameworks of access, presents a new access framework, provides recommendations for how to measure access in the new framework, and discusses future directions for research on access.

Feasibility and usability of a text message-based program for diabetes self-management in an urban African-American population

PURPOSE

We pilot-tested a text message-based diabetes care program in an urban African-American population in which automated text messages were sent to participants with personalized medication, foot care, and appointment reminders and text messages were received from participants on adherence.

METHODS

Eighteen patients participated in a 4-week pilot study. Baseline surveys collected data about demographics, historical cell phone usage, and adherence to core diabetes care measures. Exit interview surveys (using close-coded and open-ended questions) were administered to patients at the end of the program. A 1-month follow-up interview was conducted surveying patients on perceived self-efficacy. Wilcoxon signed-rank tests were used to compare baseline survey responses about self-management activities to those at the pilot's end and at 1-month follow-up.

RESULTS

Eighteen urban African-American participants completed the pilot study. The average age was 55 and the average number of years with diabetes was 8. Half the participants were initially uncomfortable with text messaging. Example messages include "Did you take your diabetes medications today" and "How many times did you check your feet for wounds this week?" Participants averaged 220 text messages with the system, responded to messages 80% of the time, and on average responded within 6 minutes. Participants strongly agreed that text messaging was easy to perform and helped with diabetes self-care. Missed medication doses decreased from 1.6 per week to 0.6 (p = .003). Patient confidence in diabetes self-management was significantly increased during and 1 month after the pilot (p = .002, p = .008).

CONCLUSIONS

Text messaging may be a feasible and useful approach to improve diabetes self-management in urban African Americans.

The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial

BACKGROUND

Health workers' malaria case-management practices often differ from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya.

METHODS

From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. With a computer-generated sequence, health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for 6 months, or the control group, in which health workers did not receive any text messages. Health workers were not masked to the intervention, although patients were unaware of whether they were in an intervention or control facility. The primary outcome was correct management with artemether-lumefantrine, defined as a dichotomous composite indicator of treatment, dispensing, and counselling tasks concordant with Kenyan national guidelines. The primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, ISRCTN72328636.

FINDINGS

119 health workers received the intervention. Case-management practices were assessed for 2269 children who needed treatment (1157 in the intervention group and 1112 in the control group). Intention-to-treat analysis showed that correct artemether-lumefantrine management improved by 23·7 percentage-points (95% CI 7·6-40·0; p=0·004) immediately after intervention and by 24·5 percentage-points (8·1-41·0; p=0·003) 6 months later.

INTERPRETATION

In resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices.

FUNDING

The Wellcome Trust.

Text messaging as a tool for behavior change in disease prevention and management

Mobile phone text messaging is a potentially powerful tool for behavior change because it is widely available, inexpensive, and instant. This systematic review provides an overview of behavior change interventions for disease management and prevention delivered through text messaging. Evidence on behavior change and clinical outcomes was compiled from randomized or quasi-experimental controlled trials of text message interventions published in peer-reviewed journals by June 2009. Only those interventions using text message as the primary mode of communication were included. Study quality was assessed by using a standardized measure. Seventeen articles representing 12 studies (5 disease prevention and 7 disease management) were included. Intervention length ranged from 3 months to 12 months, none had long-term follow-up, and message frequency varied. Of 9 sufficiently powered studies, 8 found evidence to support text messaging as a tool for behavior change. Effects exist across age, minority status, and nationality. Nine countries are represented in this review, but it is problematic that only one is a developing country, given potential benefits of such a widely accessible, relatively inexpensive tool for health behavior change. Methodological issues and gaps in the literature are highlighted, and recommendations for future studies are provided.