Short Message Service Text Messaging Research Articles

The Use of SMS Text Messaging to Improve Glycemic Control, Diabetes Self-Management, and Patient Satisfaction

The prevalence of diabetes in the United States continues to grow at an alarming rate. Nonadherence to diabetes self-management leads to morbidity and mortality. Short message service (SMS) text messaging is an effective method for delivering support to increase patient engagement with diabetes self-care management. This quality improvement project evaluated the effectiveness of a unidirectional SMS text messaging intervention to improve glycemia targets in adult patients with diabetes in the primary care setting. Results showed significant improvements in glycemic control (ie, decrease in A1C of 1.04%; P = 0.05). The SMS text messaging intervention effectively supports this modality in providing ongoing motivation and support patients with diabetes.

Text messaging intervention for fatigue self-management in people with stroke, spinal cord injury, and multiple sclerosis: A pilot study

BackgroundFatigue negatively impacts the function and quality of life of people with disabilities (PwD). Mobile health (mHealth) platforms are recognized as effective and accessible approaches to delivering health interventions and may show higher satisfaction by tailoring the information toward personalized needs for PwD. ObjectiveTo evaluate the acceptability, feasibility, and participant engagement with a Short Message Service (SMS) text messaging intervention for fatigue self-management and to explore the pre- and post-score health changes in PwD. MethodsA total of 27 PwD (multiple sclerosis = 9, spinal cord injury = 9, or stroke = 9) experiencing fatigue in their daily lives participated in a 12-week self-management text messaging intervention. Participants completed a demographic survey and health outcome measures, including patient activation, self-efficacy for managing symptoms, fatigue, sleep, and satisfaction with participation in social roles before and after the intervention. Participants also completed a client satisfaction questionnaire after the intervention. We also tracked the program retention and SMS response rates over the 12-week intervention period. ResultsTwenty-five participants completed the entire intervention (93% retention rate), and the overall SMS response rate was 84.67%, indicating high acceptability and adherence to the intervention. The mean satisfaction score was 3.18, indicating high satisfaction with the intervention. Despite finding a negligible effect on patient activation, we found a small intervention effect on self-efficacy for managing symptoms (η2 = 0.04) and moderate effects on fatigue (η2 = 0.06-0.12), sleep (η2 = 0.11), and satisfaction with participation in social roles (η2 = 0.08). ConclusionsThis study provides initial feasibility and health outcome change evidence to support an SMS text messaging intervention to manage fatigue in PwD.

Rumour spread and control during the West African Ebola epidemic in Liberia.

The severity of the 2014-15 West African Ebola epidemic in Liberia was coupled with widespread misunderstanding of the virus among citizens and the proliferation of rumours. Rumour control during outbreaks is imperative to reduce the public's fears about a disease. In Liberia, a tracker system was developed to detect rumours as quickly as possible through SMS (short message service) text messaging. This study focused on assessing rumour circulation in newspapers and on radio and rumour control over time. It relied on a content analysis of SMS messages from the 'DeySay' tracker, print and audio communications of newspapers, and radio programmes, in the time frame between January 2014 and March 2015. The findings show that more rumours appeared in newspapers but were more likely to be overtly characterised as such on the radio. DeySay accurately predicted rumours before they appeared on the radio and in newspapers, supporting its usefulness in future health epidemics.

Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial

BackgroundFailure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes.MethodsStAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals.ResultsThe trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (− 0.08% (− 0.31 to 0.16) (IFCC − 0.82 mmol/mol (− 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was − 0.71% (− 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful.ConclusionsWhilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes.Trial registrationTrial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.

Embedding mentoring to support trial processes and implementation fidelity in a randomised controlled trial of vocational rehabilitation for stroke survivors

BackgroundLittle guidance exists regarding how best to upskill and support those delivering complex healthcare interventions to ensure robust trial outcomes and implementation fidelity. Mentoring was provided to occupational therapists (OTs) delivering a complex vocational rehabilitation (VR) intervention to stroke survivors. This study aimed to explore mentors’ roles in supporting OTs with intervention delivery and fidelity, and to describe factors affecting the mentoring process and intervention delivery.MethodsQuantitative data (duration, mode and total time of mentoring support) was extracted from mentoring records and emails between mentors and OTs, alongside qualitative data on barriers and facilitators to intervention delivery. Semi-structured interviews with mentors (n = 6) and OTs (n = 19) explored experiences and perceptions of intervention training, delivery and the mentoring process. Mean total and monthly time spent mentoring were calculated per trial site. Qualitative data were analysed thematically.ResultsForty-one OTs across 16 sites were mentored between March 2018 and April 2020. Most mentoring was provided by phone or Microsoft Teams (range: 88.6–100%), with the remainder via email and SMS (Short Message Service) text messages. Mentors suggested strategies to enhance trial recruitment, improved OTs’ understanding of- and adherence to trial processes, intervention delivery and fidelity, and facilitated independent problem-solving. Barriers to mentoring included OT non-attendance at mentoring sessions and mentors struggling to balance mentoring with clinical roles. Facilitators included support from the trial team and mentors having protected time for mentoring.ConclusionsMentoring supported mentee OTs in various ways, but it remains unclear to what extent the OTS would have been able to deliver the intervention without mentoring support, or how this might have impacted fidelity. Successful implementation of mentoring alongside new complex interventions may increase the likelihood of intervention effectiveness being observed and sustained in real-life contexts. Further research is needed to investigate how mentors could be selected, upskilled, funded and mentoring provided to maximise impact. The clinical- and cost-effectiveness of mentoring as an implementation strategy and its impact on fidelity also requires testing in a future trial.Trial registrationISRCTN, ISRCTN12464275. Registered on 13th March 2018.

Wellness Program Within Primary Health Care: How to Avoid “No Show” to Planned Appointments? – A Patient-Centred Care Perspective

<strong>Background:</strong> Wellness program is a service provided by Primary Health Care Corporation (PHCC) to deliver an exercise program dedicated to patients with unhealthy lifestyle. Failing to cancel health care appointments in advance “no show” results in a vacant appointment slot that cannot be offered to other patients, which in turn will have an adverse impact on management plan and expected health outcome measures. <strong>Objectives:</strong> The purpose of this study is to implement a patient-centred care (PCC) program as an interventional approach to engage patients in changing behaviour and to encourage self-awareness to improve health status. Another aim of this study is to evaluate the effectiveness of an appointment reminder system (either short message service (SMS) or telephone call) on completion rate of the 12-week Wellness program. <strong>Methods:</strong> Amongst 112 patients, 50 participants (age: 49.9 ± 12.56 years; height: 1.61 ± 0.08 m; body mass: 75.06 ± 15 kg; body mass index (BMI): 28.66 ± 3.51 kg/m²) completed two surveys as part of the PCC program. The first survey was regarding the appointment reminder’s method preference. Accordingly, the demanded reminder system has been implemented as per patients’ preferences and then the rate of completion of the 12-weeks-wellness-program has been compared to the months preceding the intervention to demonstrate the effectiveness of this new reminder system. Towards the end of the study, a second survey on patients’ satisfaction level with regard the new reminder system has been completed. <strong>Results:</strong> The PCC program showed that majority of the patients were in favour of an appointment reminder system through SMS text message and telephone calls. Implementing this tool based on patient preference resulted in a high improvement of the completion rate of the Wellness program. <strong>Conclusions:</strong> This study provides insight on the efficacy of implementing a PCC program in Wellness Centre as well as the effectiveness of an appointment reminder system in improving the completion rate of Wellness program in a primary health care facility. Completing the Wellness program may lead to improved lifestyle behaviour and health outcomes by complying with international physical activity recommendations from the American College of Exercise Medicine (ACEM) and the World Health Organization (WHO).

ED to EPI: protocol for a pragmatic randomised controlled trial of an SMS (text) messaging intervention to improve the transition from the emergency department to early psychosis intervention for young people with psychosis

IntroductionWhile nearly half of all new psychotic disorders are diagnosed in the emergency department (ED), most young people who present to the ED with psychosis do not receive timely follow-up...

Developing an SMS text message intervention on sexual and reproductive health with adolescents and youth in Peru

BackgroundImproved access to sexual and reproductive health (SRH) services and information is essential for supporting adolescents and youth in making informed decisions and optimizing each young person’s outcomes related to their SRH, health and well-being and countries’ current and future social and economic development. Mobile phones offer opportunities for young people to privately access SRH content and to be linked to SRH services. The objective of this study was to develop the content for an SMS (short message service or “text message”) platform jointly with adolescents and youth in three regions in Peru (Lima, Ayacucho and Loreto) as part of the ARMADILLO (Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes) Study.MethodsContent development was done in three stages. During Stage 1, we held community consultations with 13–17 year old adolescents, 18–24 year old youth and professionals who work with young people through the education and health sectors (“adult advisers”) to identify and rate SRH topics of interest through group free- and guided-brainstorming activities and an individual written sharing activity. During Stage 2, the team developed the preliminary domains, sub-domains and content for the SMS platform. During Stage 3, we held focus groups with adolescents to validate the SMS content, including both individual scoring of and group feedback for each SMS. Group feedback asked about their general impressions and understanding and their thoughts about the language and usefulness of the SMS.ResultsA total of 172 adolescents and youth ages 13–24 and 20 adult advisers participated. Adolescents and youth brainstormed and rated SRH topics and sub-topics that led to the initial structure for the SMS platform, with 9 domains, 25 sub-domains and 146 draft SMS. Adolescents provided high scores for the SMS, with all sub-domains receiving average scores of 3.0 or higher (out of 4.0) for the SMS included. Adolescents also provided suggestions to optimize content, including improvements to unclear messages, resulting in SMS with adolescent-friendly content in simple, straightforward language. This process also revealed that adolescents lacked knowledge and had misconceptions related to contraceptive methods.ConclusionThis study details the systematic process used to develop relevant and accessible SRH information through a participatory approach. We document critical information about what young people know and how they think, enabling us to understand their perspective and literally speak their language. Results also provide future directions for programmatic, research and policy efforts with young people, in particular around gender norms, interpersonal violence, and access to SRH information and services, in similar settings.

A Short Message Service Intervention to Support Adherence to Home-Based Strengthening Exercise for People With Knee Osteoarthritis: Intervention Design Applying the Behavior Change Wheel.

BackgroundKnee osteoarthritis is a chronic condition with no known cure. Treatment focuses on symptom management, with exercise recommended as a core component by all clinical practice guidelines. However, long-term adherence to exercise is poor among many people with knee osteoarthritis, which limits its capacity to provide sustained symptom relief. To improve exercise outcomes, scalable interventions that facilitate exercise adherence are needed. SMS (short message service) interventions show promise in health behavior change. The Behavior Change Wheel (BCW) is a widely used framework that provides a structured approach to designing behavior change interventions and has been used extensively in health behavior change intervention design.ObjectiveThe study aimed to describe the development of, and rationale for, an SMS program to support exercise adherence in people with knee osteoarthritis using the BCW framework.MethodsThe intervention was developed in two phases. Phase 1 involved using the BCW to select the target behavior and associated barriers, facilitators, and behavior change techniques (BCTs). Phase 2 involved design of the program functionality and message library. Messages arranged into a 24-week schedule were provided to an external company to be developed into an automated SMS program.ResultsThe target behavior was identified as participation in self-directed home-based strengthening exercise 3 times a week for 24 weeks. A total of 13 barriers and 9 facilitators of the behavior and 20 BCTs were selected to use in the intervention. In addition, 198 SMS text messages were developed and organized into a 24-week automated program that functions by prompting users to self-report the number of home exercise sessions completed each week. Users who reported ≥3 exercise sessions/week (adherent) received positive reinforcement messages. Users who reported <3 exercise sessions/week (nonadherent) were asked to select a barrier (from a list of standardized response options) that best explains why they found performing the exercises challenging in the previous week. This automatically triggers an SMS containing a BCT suggestion relevant to overcoming the selected barrier. Users also received BCT messages to facilitate exercise adherence, irrespective of self-reported adherence.ConclusionsThis study demonstrates application of the BCW to guide development of an automated SMS intervention to support exercise adherence in knee osteoarthritis. Future research is needed to assess whether the intervention improves adherence to the prescribed home-based strengthening exercise.

CN14 - Turkish cancer patients’ preference for information and communication technologies

BackgroundThe use of ICTs has become widespread in recent years. There is little information available in Turkey about the level of usage of ICTs for and by cancer patients. MethodsThis descriptive study was conducted to determine the level of ICTs use and patterns of preferences among cancer patients in Ankara, Turkey. The survey was started on March 2019 and the data collection process is continuing. The sample size was determined as 334 and 173 patients were reached. In data collection, a questionnaire including 38 questions about patient demographics, use of cell phones, the interest of patients in using ICTs to receive information about cancer, and the interest of patients in using ICTs to communicate with health care providers about cancer. The study was approved by university research and ethics committees and informed consent were obtained from patients. ResultsThe mean age of the participants was 60.19±12.60 (range 27-89 years), 68.2% were female, 45.7% were primary school graduate. Mean duration of diagnosis was 24.12± 28.56 (range 1-120) months, 26% were breast cancer, 21.4 % had metastasis. Of the total, 78.6% of participants reported that they had access to the internet. The ICTs used at least once a week was found to be respectively WhatsApp (63.5%), Facebook (60.7%), instagram (34.1%), youtube (32.3%) and short message service (SMS) text messaging (31.7%). With regard to the preferences on how patients would like to use ICTs to receive information about diseases, Internet (63.0%), SMS (21.3%) and WhatsApp (19.6%) were widely reported as interesting communication channels. Participants 61.8% rely on information obtained through ICTs. Internet (36.4%), SMS (17.3%) followed by WhatsApp (15.0%, 26/173) were reported as the preferred ICTs through which patients would like to ask health providers about diseases. Adjusted regression analysis showed that patients aged between 45-64 years were more likely to be interested in receiving information through SMS than the oldest group. ConclusionsIn this study, we have determined that SMS text messaging presented the highest rate of interest for receiving information and communicating with health providers, followed by WhatsApp. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

210EMF Four-Week Text Messaging Follow-Up of Subjects With Low-Risk Chest Pain Associated With Anxiety

Approximately 40% of patients presenting to the emergency department (ED) with low-risk chest pain have anxiety as a significant contributor to their symptoms. Often unaddressed in this population, anxiety is associated with multiple psychological comorbidities, impaired quality of life, and significantly higher ED recidivism. Although evidence points to persistent anxiety symptom elevation at six-weeks, traditional methods of follow-up assessment in this population are prone to recall bias given the unpredictable nature of anxiety symptomatology. One method of overcoming this propensity for recall bias is through frequent repeated measures known as ecological momentary assessment (EMA). Short message service (SMS) messaging or text-messaging is a readily accessible and cheap EMA method. Our objective is to determine the feasibility of using an automated weekly SMS text message protocol to assess the prevalence and rate of persistent anxiety symptoms, chest pain recurrence, and ED utilization among a cohort of ED subjects with low-risk chest pain. This is a single academic center, two hospital, prospective observational cohort study of ED subjects with low risk chest pain. Eligible subjects between 18 and 70 years old with no history of acute coronary syndrome (ACS) and a physician-reported HEART score < 4, are eligible for enrollment. The Generalized Anxiety Disorder 7 item scale (GAD-7) is used to stratify participants by anxiety symptom severity: (none ≤4, mild 5-9, moderate 10-14, and severe ≥15). Subjects are followed for a total of 12 weeks receiving automated SMS conversations from our Research Electronic Data Capture (REDCap) software facilitated by third-party partner Twilio. These 9-item SMS conversations assess anxiety symptoms, chest pain recurrence and ED utilization in weeks 1-5 and 7-11. This is an interim analysis using descriptive statistics of this cohort through 4 weeks of follow-up. To date, 117 of the 200 planned subjects have been enrolled and their baseline characteristics are shown in Table 1.The prevalence of abnormal levels of anxiety (moderate or severe) at enrollment was 44% (n=51). GAD-7 scores ≥15 (severe) were found in 30 subjects (26%). The overall study response rate to SMS prompts is 76%. Two and four-week follow-up SMS response rates are 74% and 72% respectively. At 2 weeks, of the 41 responding subjects with abnormal anxiety at enrollment, 26 (64%) had persistently abnormal scores. Additionally, of the subjects with severe anxiety at enrollment, 77% remained abnormal compared with 40% of those with moderate scores at 2 weeks. For subjects with severe anxiety at enrollment, the rate of persistently abnormal anxiety was 72% at 4 weeks. In this interim analysis investigating the feasibility of using automated SMS conversations for follow-up of low risk chest patients, our rate of SMS response is >75%, which is currently higher than our a priori feasibility threshold of 70%. Additionally, >70% of those with severe anxiety symptoms at enrollment had persistently abnormal anxiety scores at 2- and 4-week SMS follow-up.Tabled 1Baseline cohort demographicsGAD-7 ≤9 (n=66)GAD-7 ≥10 (n=51)Age43.743.8Female Sex39 (59%)33 (65%)Race/EthnicityBlack28 (42%)37 (73%)White34 (52%)12 (24%)Hispanic3 (5%)4 (8%) Open table in a new tab

Role of mobile health on patient enrollment for cleft lip-palate surgery: A comparative study using SMS blast text messaging in zimbabwe.

BackgroundPatients' lack of awareness of available services is a significant barrier to delivering surgical care in resource‐limited settings. Short message service (SMS) text messaging is a potential means to disseminate this information in resource‐limited settings, where rates of mobile phone usage are high.MethodsA blast SMS text informing local populations of upcoming cleft lip‐palate (CLP) surgical services was distributed to 25% of the subscriber base 1 week prior to arrival of a (CLP) surgical team in Zimbabwe. A retrospective cohort analysis comparing characteristics of patients presenting to the CLP clinic in the year prior to (2016) and 2 years following (2017–2018) the implementation of the blast SMS text messaging system is performed to assess its impact.ResultsPatients presenting to a single Zimbabwean CLP surgical program in the years with SMS messaging notifications were significantly more likely (52 [64%] vs. 5 [17%], P < .001) to have been informed of surgical services through their mobile phones. The average distance traveled per patient was not significantly different prior to implementation of mass text messaging (180.4 km [SD114.8] vs. 167.4 km [SD105.9], P = .580). The average patient age was significantly higher following the implementation of mass text messaging (7.4 [SD8.7] vs. 3.0 [SD2.8] years, P = .010).ConclusionsSMS messaging is an effective method of informing patients of CLP surgical services in resource‐limited settings. After implementation of SMS text notifications, surgical patients were of increased age, but showed no difference in distance traveled.Level of EvidenceIV

The Feasibility of a Using a Smart Button Mobile Health System to Self-Track Medication Adherence and Deliver Tailored Short Message Service Text Message Feedback.

BackgroundAs many as 50% of people experience medication nonadherence, yet studies for detecting nonadherence and delivering real-time interventions to improve adherence are lacking. Mobile health (mHealth) technologies show promise to track and support medication adherence.ObjectiveThe study aimed to evaluate the feasibility and acceptability of using an mHealth system for medication adherence tracking and intervention delivery. The mHealth system comprises a smart button device to self-track medication taking, a companion smartphone app, a computer algorithm used to determine adherence and then deliver a standard or tailored SMS (short message service) text message on the basis of timing of medication taking. Standard SMS text messages indicated that the smartphone app registered the button press, whereas tailored SMS text messages encouraged habit formation and systems thinking on the basis of the timing the medications were taken.MethodsA convenience sample of 5 adults with chronic kidney disease (CKD), who were prescribed antihypertensive medication, participated in a 52-day longitudinal study. The study was conducted in 3 phases, with a standard SMS text message sent in phases 1 (study days 1-14) and 3 (study days 46-52) and tailored SMS text messages sent during phase 2 (study days 15-45) in response to participant medication self-tracking. Medication adherence was measured using: (1) the smart button and (2) electronic medication monitoring caps. Concordance between these 2 methods was evaluated using percentage of measurements made on the same day and occurring within ±5 min of one another. Acceptability was evaluated using qualitative feedback from participants.ResultsA total of 5 patients with CKD, stages 1-4, were enrolled in the study, with the majority being men (60%), white (80%), and Hispanic/Latino (40%) of middle age (52.6 years, SD 22.49; range 20-70). The mHealth system was successfully initiated in the clinic setting for all enrolled participants. Of the expected 260 data points, 36.5% (n=95) were recorded with the smart button and 76.2% (n=198) with electronic monitoring. Concordant events (n=94), in which events were recorded with both the smart button and electronic monitoring, occurred 47% of the time and 58% of these events occurred within ±5 min of one another. Participant comments suggested SMS text messages were encouraging.ConclusionsIt was feasible to recruit participants in the clinic setting for an mHealth study, and our system was successfully initiated for all enrolled participants. The smart button is an innovative way to self-report adherence data, including date and timing of medication taking, which were not previously available from measures that rely on recall of adherence. Although the selected smart button had poor concordance with electronic monitoring caps, participants were willing to use it to self-track medication adherence, and they found the mHealth system acceptable to use in most cases.

SmokefreeTXT for Homeless Smokers: Pilot Randomized Controlled Trial.

BackgroundHomeless smokers want to quit smoking but face numerous barriers to doing so, including pervasive smoking among peers and a lack of social support for quitting. An SMS (short message service) text messaging intervention could address these challenges by providing virtual daily support for homeless smokers who are trying to quit but coping with multiple triggers to smoke.ObjectiveThis study aimed to assess whether a free SMS text messaging program, added to evidence-based pharmacotherapy and counseling, improved smoking abstinence among homeless adult smokers.MethodsFrom October 2015 to June 2016, we conducted an 8-week pilot randomized controlled trial (RCT) of nicotine patch therapy and weekly in-person counseling with (n=25) or without (n=25) SmokefreeTXT, a free SMS text messaging service administered by the National Cancer Institute (NCI) at Boston Health Care for the Homeless Program. All participants were provided with a mobile phone and a 2-month prepaid voice and text plan at no cost. SmokefreeTXT enrollees were sent 1 to 5 automated SMS text messages daily for up to 8 weeks and could receive on-demand tips for managing cravings, mood symptoms, and smoking lapses. The primary outcome was smoking abstinence, defined as an exhaled carbon monoxide count of <8 parts per million, assessed 14 times over 8 weeks of follow-up, and analyzed using repeated-measures logistic regression with generalized estimating equations. Other outcomes were use of SmokefreeTXT, assessed by data obtained from NCI; perceptions of SmokefreeTXT, assessed by surveys and qualitative interviews; and mobile phone retention, assessed by self-report.ResultsOf the SmokefreeTXT arm participants (n=25), 88% (22) enrolled in the program, but only 56% (14) had confirmed enrollment for ≥2 weeks. Among 2-week enrollees, the median response rate to interactive messages from SmokefreeTXT was 2.1% (interquartile range 0-10.5%). Across all time points, smoking abstinence did not differ significantly between SmokefreeTXT and control arm participants (odds ratio 0.92, 95% CI 0.30-2.84). Of SmokefreeTXT enrollees who completed exit surveys (n=15), two-thirds were very or extremely satisfied with the program. However, qualitative interviews (n=14) revealed that many participants preferred in-person intervention formats over phone-based, found the SMS text messages impersonal and robotic, and felt that the messages were too frequent and repetitive. Only 40% (10/25) of SmokefreeTXT arm participants retained their study-supplied mobile phone for the 8-week duration of the trial, with phone theft being common. Storing and charging phones were cited as challenges.ConclusionsSmokefreeTXT, added to nicotine patch therapy and in-person counseling, did not significantly improve smoking abstinence in this 8-week pilot RCT for homeless smokers. SMS text messaging interventions for this population should be better tuned to the unique circumstances of homelessness and coupled with efforts to promote mobile phone retention over time.Trial RegistrationClinicalTrials.gov NCT02565381; https://clinicaltrials.gov/ct2/show/NCT02565381 (Archived by WebCite at http://www.webcitation.org/78PLpDptZ)

Building Electronic Disease Surveillance Capacity in the Peruvian Navy with SAGES

ObjectiveTo introduce SMS-based data collection into the Peruvian Navy’s public health surveillance system for increased reporting rates and timeliness, particularly from remote areas, as well as improve capabilities for analysis of surveillance data by decision makers.IntroductionIn the past 15 years, public health surveillance has undergone a revolution driven by advances in information technology (IT) with vast improvements in the collection, analysis, visualization, and reporting of health data. Mobile technologies and open source software have played a key role in advancing surveillance techniques, particularly in resource-limited settings. Johns Hopkins University Applied Physics Laboratory (JHU/APL) is an internationally recognized leader in the area of electronic disease surveillance. In addition to the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) used by several state and local jurisdictions and the CDC in the U.S., JHU/APL has also developed the Suite for Automated Global Electronic bioSurveillance (SAGES). SAGES is a collection of modular, open-source software tools designed to meet the challenges of electronic disease surveillance in resource-limited settings.JHU/APL is working with the Peruvian Navy health system to improve their electronic disease surveillance capabilities. The Peruvian Navy currently uses a SAGES-based system called Alerta DISAMAR that was implemented several years ago in an effort supported by the Armed Forces Health Surveillance Branch, and in collaboration with the Naval Medical Research Unit No. 6 (NAMRU-6). The system uses both web-based and IVR-based (interactive voice response) data collection from several Navy health facilities in Peru. For the present effort, JHU/APL is implementing a new SMS-based data collection capability for the Peruvian Navy.MethodsJHU/APL is engaged with the Peruvian Navy Health System to upgrade the existing SAGES-based Alerta DISAMAR surveillance system which relies on remote data collection using IVR (interactive voice recording) technology, with a SAGES-based system that uses SMS (short message service) text messages for remote data collection. Based on Peruvian Navy requirements, JHU/APL created mobile data entry forms for Android smartphones using the SAGES mCollect application. SAGES mCollect is built using Open Data Kit open source tools along with added features such as 128-bit encryption and quality checks.The JHU/APL team engages closely with end users and other stakeholders to determine system requirements and to deploy the system, as well as to train end users and the system administrators who will need to maintain the system once it is deployed. The JHU/APL team, consisting of both information technology and public health expertise, conduct a country-level capabilities and needs assessment to address design considerations and operational end user requirements. This assessment takes into account the requirements and objectives of the Peruvian Navy, while keeping in mind infrastructure, cost, and personnel constraints. A pilot test of SMS-based data collection is currently underway with 10 health clinics within the Navy.ResultsMany challenges exist when implementing electronic disease surveillance tools in resource-limited settings, but using a tailored approach to implementation in which specific needs, constraints, and expectations are identified with stakeholders helps increase the overall adoption and sustainment of the system. JHU/APL believes SMS-based data collection will be more sustainable than IVR-based data collection for the Peruvian Navy.ConclusionsJHU/APL is deploying a SAGES-based electronic disease surveillance system for the Peruvian Navy that has great potential to increase reporting rates from its health facilities as well as improve data quality and timeliness, thus resulting in greater awareness and enhanced public health decision making.

Mobile Messaging Support Versus Usual Care for People With Type 2 Diabetes on Glycemic Control: Protocol for a Multicenter Randomized Controlled Trial.

BackgroundHealth outcomes for people treated for type 2 diabetes could be substantially improved in sub-Saharan Africa. Failure to take medicine regularly to treat diabetes has been identified as a major problem. Resources to identify and support patients who are not making the best use of medicine in low- and middle-income settings are scarce. Mobile phones are widely available in these settings, including among people with diabetes; linked technologies, such as short message service (SMS) text messaging, have shown promise in delivering low-cost interventions efficiently. However, evidence showing that these interventions will work when carried out at a larger scale and measuring the extent to which they will improve health outcomes when added to usual care is limited.ObjectiveThe objective of this trial is to test the effectiveness of sending brief, automated SMS text messages for improving health outcomes and medication adherence in patients with type 2 diabetes compared to an active control.MethodsWe will carry out a randomized trial recruiting from clinics in two contrasting settings in sub-Saharan Africa: Cape Town, South Africa, and Lilongwe, Malawi. Intervention messages will advise people about the benefits of their diabetes treatment and offer motivation and encouragement around lifestyle and use of medication. We allocated patients, using randomization with a minimization algorithm, to receive either three to four intervention messages per week or non-health-related messages every 6 weeks. We will follow up with participants for 12 months, measuring important risk factors for poor health outcomes and complications in diabetes. This will enable us to estimate potential health benefits, including the primary outcome of hemoglobin A1c (HbA1c) levels as a marker for long-term blood glucose control and a secondary outcome of blood pressure control. We will record the costs of performing these activities and estimate cost-effectiveness. We will also use process evaluation to capture the collection of medication and assess the reception of the intervention by participants and health care workers.ResultsRecruitment to the trial began in September 2016 and follow-up of participants was completed in October 2018. Data collection from electronic health records and other routinely collected sources is continuing. The database lock is anticipated in June 2019, followed by analysis and disclosing of group allocation.ConclusionsThe knowledge gained from this study will have wide applications and advance the evidence base for effectiveness of mobile phone-based, brief text messaging on clinical outcomes and in large-scale, operational settings. It will provide evidence for cost-effectiveness and acceptability that will further inform policy development and decision making. We will work with a wide network that includes patients, clinicians, academics, industry, and policy makers to help us identify opportunities for informing people about the work and raise awareness of what is being developed and studied.Trial RegistrationISRCTN Registry ISRCTN70768808; http://www.isrctn.com/ISRCTN70768808 (Archived by WebCite at http://www.webcitation.org/786316Zqk)International Registered Report Identifier (IRRID)DERR1-10.2196/12377

Personalized Text Messages and Automated Calls for Improving Vaccine Coverage Among Children in Pakistan: Protocol for a Community-Based Cluster Randomized Clinical Trial.

BackgroundA major reason for poor childhood vaccine coverage in developing countries is the lack of awareness among parents and caregivers regarding the need for immunization and the importance of completing the entire series of vaccines. Short message service (SMS)–based interventions have been quite effective in different programs such as smoking cessation, treatment adherence, health care scheduled appointment attendance, antenatal care attendance, and compliance to immunization. However, there are limited data from low- and middle-income countries on the role of SMS and automated call–based messages and interventions to improve routine immunization (RI) coverage.ObjectiveThe primary objective of this study is to evaluate whether automated mobile phone–based personalized messages (SMS or automated call) can improve RI uptake at 6, 10, and 14 weeks of age per the expanded program immunization schedule, compared with a usual care control group. Secondary objectives include assessing the effects of different types of automated SMS text or calls on RI coverage at 20 weeks of age.MethodsThis is a mixed methods study using a clustered randomized controlled trial with 4 intervention arms and 1 control arm, augmented by qualitative interviews for personalizing the message. The study is being conducted in Pakistan (an urban site in Karachi and a rural site Matiari). In Karachi, 250 administrative structures are taken as 1 cluster, whereas in Matiari, a catchment area of 4 Lady Health Workers is considered as 1 cluster. The intervention targets families to receive weekly 1-way or 2-way (interactive) personalized automated SMS or automated phone call messages regarding vaccination. Possible barriers to vaccination are assessed in each family at the time of inclusion to determine the type of personalized messages that should be sent to the family to increase the chance of a positive response. Finally, in-depth interviews using purposive sampling are conducted before and after the trial to determine the family’s vaccination experience and related factors.ResultsAll study participants for the cluster randomized trial were enrolled by January 14, 2019. Study exit interviews at 20-weeks follow-up visits will be completed by June 2019.ConclusionsThe results of this study will be useful to understand the respective effects of SMS text messages versus automated phone–based communication to improve RI coverage and timelines. Moreover, information regarding families’ perceptions of vaccination and the daily life challenges for timely visits to the vaccine clinic will be used for developing more complex interventions that use mobile phone messages and possibly other approaches to overcome barriers in the uptake of correct and timely immunization practices.Trial RegistrationClinicalTrials.gov NCT03341195; https://clinicaltrials.gov/ct2/show/NCT03341195 (Archived by WebCite at http://www.webcitation.org/78EWA56Uo)International Registered Report Identifier (IRRID)DERR1-10.2196/12851

A Qualitative Evaluation of the Acceptability of a Tailored Smartphone Alcohol Intervention for a Military Population: Information About Drinking for Ex-Serving Personnel (InDEx) App.

BackgroundAlcohol consumption in the UK Armed Forces is higher than in the general population, and this pattern continues after leaving the service. Smartphone apps may be useful to increase ex-serving personnel’s awareness of their alcohol consumption, support self-monitoring, and prompt a change in behavior.ObjectiveThe study aimed to explore the acceptability of Information about Drinking in Ex-serving personnel (InDEx), a tailored smartphone app, combined with personalized short message service (SMS) text messaging designed to target ex-serving personnel who meet the criteria for hazardous alcohol use.MethodsThe InDEx intervention included 4 key modules: (1) assessment and normative feedback, (2) self-monitoring and feedback, (3) goal setting and review, and (4) personalized SMS text messaging. A semistructured telephone interview study was conducted with ex-serving personnel after using the app for a 28-day period. Interviews were used to explore the acceptability of app modules and its functionality and the perceived changes in participant’s drinking. Interview transcripts were analyzed using inductive thematic analysis.ResultsOverall, 94% (29/31) participants who used InDEx agreed to take part in a telephone interview. Overall, 4 themes were identified: Credibility, Meeting their needs, Simplicity, and Helpful for ex-serving personnel. The importance of credibility, functionality, and meeting the individual needs of ex-serving personnel was emphasized. Acceptability and engagement with specific modules of the app and text messages were influenced by the following: (1) if they felt it provided credible information, (2) whether the content was appropriately personalized to them, (3) the ease of use, and (4) beliefs about their own drinking behaviors. Participants recommended that the app would be most suitable for personnel about to leave the Armed Forces.ConclusionsInDEx was an acceptable smartphone app for ex-serving personnel for monitoring alcohol consumption and in providing meaningful feedback to the individual. Pages that met the participant’s interests and provided real time personalized, credible feedback on their drinking and text messages tailored to participant’s interactions with the app were particularly favored.

A Two-Way Interactive Text Messaging Application for Low-Income Patients with Chronic Medical Conditions: Design-Thinking Development Approach.

BackgroundTwo-way interactive text messaging between patient and community health workers (CHWs) through mobile phone SMS (short message service) text messaging is a form of digital health that can potentially enhance patient engagement in young adults and families that have a child with chronic medical conditions such as diabetes mellitus, sickle cell disease, and asthma. These patients have complex needs, and a user-centered way can be useful for designing a tool to address their needs.ObjectiveThe aim of this study was to utilize the user-centered approach of design thinking to develop a two-way interactive communication SMS text messaging tool for communication between patients or caregivers and CHWs.MethodsWe applied a design thinking methodology for development of the SMS text messaging tool. We collected qualitative data from 127 patients/caregivers and 13 CHWs, health care professionals, and experts. In total, 4 iterative phases were used to design the final prototype.ResultsThe design thinking process led to the final SMS text messaging tool that was transformed from a one-dimensional, template-driven prototype (phases 1 and 2) into a dynamic, interactive, and individually tailored tool (phases 3 and 4). The individualized components consider social factors that influence patients’ ability to engage such as transportation issues and appointment reminders. SMS text messaging components also include operational factors to support staff such as patient contact lists, SMS text messaging templates, and technology chat support.ConclusionsDesign thinking can develop a tool to meet the engagement needs of patients with complex health care needs and be user-friendly for health care staff.

SMS SOS: a randomized controlled trial to reduce self-harm and suicide attempts using SMS text messaging

BackgroundHospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia.Methods/designOur study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge.DiscussionThis study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense.Trial registration and ethics approvalThis trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370. Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170).