Text4Heart II - improving medication adherence in people with heart disease: a study protocol for a randomized controlled trial

Mobile phone text messaging for medication adherence in secondary prevention of cardiovascular disease

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death globally, accounting for almost 18 million deaths annually. People with CVDs have a five times greater chance of suffering a recurrent cardiovascular event than people without known CVDs. Although drug interventions have been shown to be cost-effective in reducing the risk of recurrent cardiovascular events, adherence to medication remains suboptimal. As a scalable and cost-effective approach, mobile phone text messaging presents an opportunity to convey health information, deliver electronic reminders, and encourage behaviour change. However, it is uncertain whether text messaging can improve medication adherence and clinical outcomes. This is an update of a Cochrane review published in 2017.

OBJECTIVES

To evaluate the benefits and harms of mobile phone text messaging for improving medication adherence in people with CVDs compared to usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers. We also checked the reference lists of all primary included studies and relevant systematic reviews and meta-analyses. The date of the latest search was 30 August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with participants with established arterial occlusive events. We included trials investigating interventions using short message service (SMS) or multimedia messaging service (MMS) with the aim of improving adherence to medication for the secondary prevention of cardiovascular events. The comparator was usual care. We excluded cluster-RCTs and quasi-RCTs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were medication adherence, fatal cardiovascular events, non-fatal cardiovascular events, and combined CVD event. Secondary outcomes were low-density lipoprotein cholesterol for the effect of statins, blood pressure for antihypertensive drugs, heart rate for the effect of beta-blockers, urinary 11-dehydrothromboxane B2 for the antiplatelet effects of aspirin, adverse effects, and patient-reported experience. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 18 RCTs involving a total of 8136 participants with CVDs. We identified 11 new studies in the review update and seven studies in the previous version of the review. Participants had various CVDs including acute coronary syndrome, coronary heart disease, stroke, myocardial infarction, and angina. All studies were conducted in middle- and high-income countries, with no studies conducted in low-income countries. The mean age of participants was 53 to 64 years. Participants were recruited from hospitals or cardiac rehabilitation facilities. Follow-up ranged from one to 12 months. There was variation in the characteristics of text messages amongst studies (e.g. delivery method, frequency, theoretical grounding, content used, personalisation, and directionality). The content of text messages varied across studies, but generally included medication reminders and healthy lifestyle information such as diet, physical activity, and weight loss. Text messages offered advice, motivation, social support, and health education to promote behaviour changes and regular medication-taking. We assessed risk of bias for all studies as high, as all studies had at least one domain at unclear or high risk of bias. Medication adherence Due to different evaluation score systems and inconsistent definitions applied for the measurement of medication adherence, we did not conduct meta-analysis for medication adherence. Ten out of 18 studies showed a beneficial effect of mobile phone text messaging for medication adherence compared to usual care, whereas the other eight studies showed either a reduction or no difference in medication adherence with text messaging compared to usual care. Overall, the evidence is very uncertain about the effects of mobile phone text messaging for medication adherence when compared to usual care. Fatal cardiovascular events Text messaging may have little to no effect on fatal cardiovascular events compared to usual care (odds ratio 0.83, 95% confidence interval (CI) 0.47 to 1.45; 4 studies, 1654 participants; low-certainty evidence). Non-fatal cardiovascular events We found very low-certainty evidence that text messaging may have little to no effect on non-fatal cardiovascular events. Two studies reported non-fatal cardiovascular events, neither of which found evidence of a difference between groups. Combined CVD events We found very low-certainty evidence that text messaging may have little to no effect on combined CVD events. Only one study reported combined CVD events, and did not find evidence of a difference between groups. Low-density lipoprotein cholesterol Text messaging may have little to no effect on low-density lipoprotein cholesterol compared to usual care (mean difference (MD) -1.79 mg/dL, 95% CI -4.71 to 1.12; 8 studies, 4983 participants; very low-certainty evidence). Blood pressure Text messaging may have little to no effect on systolic blood pressure (MD -0.93 mmHg, 95% CI -3.55 to 1.69; 8 studies, 5173 participants; very low-certainty evidence) and diastolic blood pressure (MD -1.00 mmHg, 95% CI -2.49 to 0.50; 5 studies, 3137 participants; very low-certainty evidence) when compared to usual care. Heart rate Text messaging may have little to no effect on heart rate compared to usual care (MD -0.46 beats per minute, 95% CI -1.74 to 0.82; 4 studies, 2946 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Due to limited evidence, we are uncertain if text messaging reduces medication adherence, fatal and non-fatal cardiovascular events, and combined cardiovascular events in people with cardiovascular diseases when compared to usual care. Furthermore, text messaging may result in little or no effect on low-density lipoprotein cholesterol, blood pressure, and heart rate compared to usual care. The included studies were of low methodological quality, and no studies assessed the effects of text messaging in low-income countries or beyond the 12-month follow-up. Long-term and high-quality randomised trials are needed, particularly in low-income countries.

Personalization of Intervention Timing for Physical Activity: Scoping Review

Background

The use of sensors in smartphones, smartwatches, and wearable devices has facilitated the personalization of interventions to increase users’ physical activity (PA). Recent research has focused on evaluating the effects of personalized interventions in improving PA among users. However, it is critical to deliver the intervention at an appropriate time to each user to increase the likelihood of adoption of the intervention. Earlier review studies have not focused on the personalization of intervention timing for increasing PA.

Objective

This review aims to examine studies of information technology–based PA interventions with personalized intervention timing (PIT); identify inputs (eg, user location) used by the system for generating the PIT, the techniques and methods used for generating the PIT, the content of the PA intervention, and delivery mode of the intervention; and identify gaps in existing literature and suggest future research directions.

Methods

A scoping review was undertaken using PsycINFO, PubMed, Scopus, and Web of Science databases based on a structured search query. The main inclusion criteria were as follows: the study aimed to promote PA, included some form of PIT, and used some form of information technology for delivery of the intervention to the user. If deemed relevant, articles were included in this review after removing duplicates and examining the title, abstract, and full text of the shortlisted articles.

Results

The literature search resulted in 18 eligible studies. In this review, 72% (13/18) of the studies focused on increasing PA as the primary objective, whereas it was the secondary focus in the remaining studies. The inputs used to generate the PIT were categorized as user preference, activity level, schedule, location, and predicted patterns. On the basis of the intervention technique, studies were classified as manual, semiautomated, or automated. Of these, the automated interventions were either knowledge based (based on rules or guidelines) or data driven. Of the 18 studies, only 6 (33%) evaluated the effectiveness of the intervention and reported positive outcomes.

Conclusions

This work reviewed studies on PIT for PA interventions and identified several aspects of the interventions, that is, inputs, techniques, contents, and delivery mode. The reviewed studies evaluated PIT in conjunction with other personalization approaches such as activity recommendation, with no study evaluating the effectiveness of PIT alone. On the basis of the findings, several important directions for future research are also highlighted in this review.

An Intervention to Improve Medication Adherence in People With Heart Disease (Text4HeartII): Randomized Controlled Trial

Background

Mobile health technologies have the potential to improve the reach and delivery of interventions for promoting long-term secondary prevention of coronary heart disease.

Objective

This study aims to determine the effectiveness of an SMS text messaging intervention (Text4HeartII) for improving adherence to medication and lifestyle changes over and above usual care in people with coronary heart disease at 24 and 52 weeks.

Methods

A two-arm, parallel, randomized controlled trial was conducted in New Zealand. Participants with a recent acute coronary syndrome were randomized to receive usual cardiac services alone (control, n=153) or a 24-week SMS text message program for supporting self-management plus usual cardiac services (n=153). The primary outcome was adherence to medication at 24 weeks, defined as a medication possession ratio of 80% or more for aspirin, statin, and antihypertensive therapy. Secondary outcomes included medication possession ratio at 52 weeks, self-reported medication adherence, adherence to healthy lifestyle behaviors, and health-related quality of life at 24 and 52 weeks.

Results

Participants were predominantly male (113/306, 80.3%) and European New Zealanders (210/306, 68.6%), with a mean age of 61 years (SD 11 years). Groups were comparable at baseline. National hospitalization and pharmacy dispensing records were available for all participants; 92% (282/306, 92.1%) of participants completed a 24-week questionnaire and 95.1% (291/306) of participants completed a 52-week questionnaire. Adherence with 3 medication classes were lower in the intervention group than in the control group (87/153, 56.8% vs 105/153, 68.6%, odds ratio 0.60, 95% CI 0.38-0.96; P=.03) and 52 weeks (104/153, 67.9% vs 83/153, 54.2%; odds ratio 0.56, 95% CI 0.35-0.89; P=.01). Self-reported medication adherence scores showed the same trend at 52 weeks (mean difference 0.3; 95% CI 0.01-0.59; P=.04). Moreover, self-reported adherence to health-related behaviors was similar between groups.

Conclusions

Text4HeartII did not improve dispensed medication or adherence to a favorable lifestyle over and above usual care. This finding contrasts with previous studies and highlights that the benefits of text interventions may depend on the context in which they are used.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12616000422426; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370398.

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-018-2468-z

Effects of mobile text messaging on breast cancer and breast self-examination (BSE) knowledge, BSE self-efficacy, and BSE frequency: a randomised controlled trial

AIMS

Educating women regarding breast cancer and increasing breast self-examination uptake continues to remain a major challenge despite the intensive campaigns. An innovative, cost-effective and easily customised intervention is needed especially in under-resourced and hard to reach communities. This paper is a report examining the effects of mobile text messaging on women's knowledge of breast cancer and BSE, BSE self-efficacy and frequency of BSE.

METHODS

A randomised controlled trial design was used. The study sample consisted of 128 women of reproductive age (WRA) (64 in the experimental group and 64 in the control group) from two communities in the Philippines during the months of August to October 2018. Three to five short messages were sent to the participants in the experimental group daily for one month while the control group did not receive the messages.

RESULTS

Women who received mobile text messages had higher knowledge of breast cancer (F = 21.756, p = 0.001) and breast self-examination (F = 6.776, p = 0.010) than the control group. However, no significant improvements were seen in the BSE self-efficacy (F = 1.446, p = 0.232) and frequency of BSE (F = 3.374, p = 0.69).

CONCLUSION

Mobile text messaging significantly improved the knowledge on breast cancer and breast self-examination among women; however, it did not affect their breast self-examination self-efficacy and frequency. Mobile text messaging can be a viable tool that can be used by healthcare workers in order to educate women regarding breast cancer and breast self-examination.

Cardiac Rehabilitation to Optimize Medication Regimens in Heart Failure

Cardiac rehabilitation (CR) is an inherently patient-centered program that provides holistic care to adults with cardiovascular conditions to promote lifelong health and fitness, facilitate self-care and self-efficacy, and improve clinical outcomes. CR offers an excellent platform for patient-centered optimization of medication regimens for older adults with heart failure through its potential to address several aspects of care that have historically served as major challenges to clinicians-diuretic management, the use of guideline-directed medical therapy, review and reconciliation of noncardiovascular medications, and optimization of medication adherence. In this review, these challenges are described and strategies offered for leveraging CR toward addressing them.

Improving oncology nurses' knowledge, self-confidence, and self-efficacy in nutritional assessment and counseling for patients with cancer: A quasi-experimental design

OBJECTIVE

Our objective was to assess the effectiveness of a structured educational program on improving oncology nurses' knowledge, self-confidence, and self-efficacy in nutritional assessment and counseling for patients with cancer.

METHODS

A pretest-posttest quasi-experimental design was used. A sample of 60 nurses from oncology units participated as an experimental group (n = 30) and a control group (n = 30). The participants completed a knowledge test before completing the educational program. Self-confidence and self-efficacy also were assessed pre- and postintervention.

RESULTS

There was a significant difference between the experimental (mean [M] = 26.00, SD = 8.00) and control (M = 10.00, SD = 3.75) groups regarding knowledge after the interventional sessions (t = -16.00, P = 0.001). Furthermore, the results indicated a significant difference (t = -24.00, P = 0.001) between the experimental group (M = 60.50, SD = 13.10) and the control group (M = 36.50, SD = 7.60) regarding self- confidence in managing cancer patients. Finally, there was a significant difference between the experimental group (M = 33.50, SD = 3.10) and control group (M = 23.25, SD = 2.75) regarding self-efficacy (t = -10.25, P = 0.001).

CONCLUSIONS

The educational program improved the oncology nurses' knowledge, self-confidence, and self-efficacy in relation to nutritional assessment and counseling. Improving nurses' competencies will improve the quality of care provided to the patients and patient health outcomes.