Using the behavior change wheel to develop text messages to promote diet and physical activity adherence following a diabetes prevention program

Improving diet and physical activity (PA) can reduce the risk of developing type 2 diabetes (T2D); however, long-term diet and PA adherence is poor. To impact population-level T2D risk, scalable interventions facilitating behavior change adherence are needed. Text messaging interventions supplementing behavior change interventions can positively influence health behaviors including diet and PA. The Behavior Change Wheel (BCW) provides structure to intervention design and has been used extensively in health behavior change interventions. Describe the development process of a bank of text messages targeting dietary and PA adherence following a diabetes prevention program using the BCW. The BCW was used to select the target behavior, barriers and facilitators to engaging in the behavior, and associated behavior change techniques (BCTs). Messages were written to map onto BCTs and were subsequently coded for BCT fidelity. The target behaviors were adherence to diet and PA recommendations. A total of 16 barriers/facilitators and 28 BCTs were selected for inclusion in the messages. One hundred and twenty-four messages were written based on selected BCTs. Following the fidelity check a total of 43 unique BCTs were present in the final bank of messages. This study demonstrates the application of the BCW to guide the development of a bank of text messages for individuals with prediabetes. Results underscore the potential utility of having independent coders for an unbiased expert evaluation of what active components are in use. Future research is needed to demonstrate the feasibility and effectiveness of resulting bank of messages.

Notifying donors when their deferral is ending: An effective donor retention strategy

BACKGROUND

The application of a temporary deferral often leads to donor lapse. Contributing factors may be donors not knowing when their deferral ends or not being contacted and asked to return. The aim of this study was to determine the effectiveness of a reminder message notifying donors that their deferral is coming to an end in increasing donors' postdeferral return rates. We evaluated the optimal time, content, and mode of delivery of the reminder message.

STUDY DESIGN AND METHODS

Two studies were conducted with deferred donors. Study 1: donors (n = 1676) were randomized to be sent a reminder message at one of three time points (4 weeks before, 1 week before, and 1 week after their deferral ended) or to a no contact control condition. Study 2: donors (n = 1973) were randomized to three message type conditions (emotive email, nonemotive email, nonemotive SMS). Attempted return behavior was extracted (appointments, attendances) at 1 month.

RESULTS

In Study 1, being sent the reminder message increased odds of donors attempting to return within 3 months compared with the control group (OR:2.01). Sending the reminder 1 week before the deferral ended was the most effective time point. In Study 2, the nonemotive message increased the odds of attempting to return compared with the emotive message (OR:1.38). No differences were found between email and SMS messages.

DISCUSSION

Sending a reminder message to donors when their deferral is coming to an end is a simple, effective, and cost-effective method to retain donors.

Evaluation of a mindfulness-based mobile application with college students: A pilot study

Objective: This pilot study assessed the feasibility and acceptability of The Mindfulness App with college students and the utility of daily text-message reminders for increasing adherence.Participants: Students from a mid-sized Midwestern University (N = 59) during the spring and fall of 2016.Methods: Using a pretest-posttest design, a group of students used The Mindfulness App for 5 weeks. All students were sent text-message reminders to submit daily practice time and completed a series of online measures.Results: Participants consistently used the application as intended, and reported positive attitudes toward the text-message reminders and the quality of the application.Conclusions:The Mindfulness App is a feasible, well-accepted tool for delivering mindfulness interventions to college students.

Patient-initiated appointment systems for adults with chronic conditions in secondary care

BACKGROUND

Missed hospital outpatient appointments is a commonly reported problem in healthcare services around the world; for example, they cost the National Health Service (NHS) in the UK millions of pounds every year and can cause operation and scheduling difficulties worldwide. In 2002, the World Health Organization (WHO) published a report highlighting the need for a model of care that more readily meets the needs of people with chronic conditions. Patient-initiated appointment systems may be able to meet this need at the same time as improving the efficiency of hospital appointments.

OBJECTIVES

To assess the effects of patient-initiated appointment systems compared with consultant-led appointment systems for people with chronic or recurrent conditions managed in secondary care.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and six other databases. We contacted authors of identified studies and conducted backwards and forwards citation searching. We searched for current/ongoing research in two trial registers. Searches were run on 13 March 2019.

SELECTION CRITERIA

We included randomised trials, published and unpublished in any language that compared the use of patient-initiated appointment systems to consultant-led appointment systems for adults with chronic or recurrent conditions managed in secondary care if they reported one or more of the following outcomes: physical measures of health status or disease activity (including harms), quality of life, service utilisation or cost, adverse effects, patient or clinician satisfaction, or failures of the 'system'.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all references at title/abstract stage and full-text stage using prespecified inclusion criteria. We resolved disagreements though discussion. Two review authors independently completed data extraction for all included studies. We discussed and resolved discrepancies with a third review author. Where needed, we contacted authors of included papers to provide more information. Two review authors independently assessed the risk of bias using the Cochrane Effective Practice and Organisation of Care 'Risk of bias' tool, resolving any discrepancies with a third review author. Two review authors independently assessed the certainty of the evidence using GRADE.

MAIN RESULTS

The 17 included randomised trials (3854 participants; mean age 41 to 76 years; follow-up 12 to 72 months) covered six broad health conditions: cancer, rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, psoriasis and inflammatory bowel disease. The certainty of the evidence using GRADE ratings was mainly low to very low. The results suggest that patient-initiated clinics may make little or no difference to anxiety (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.68 to 1.12; 5 studies, 1019 participants; low-certainty evidence) or depression (OR 0.79 95% CI 0.51 to 1.23; 6 studies, 1835 participants; low-certainty evidence) compared to the consultant-led appointment system. The results also suggest that patient-initiated clinics may make little or no difference to quality of life (standardised mean difference (SMD) 0.12, 95% CI 0.00 to 0.25; 7 studies, 1486 participants; low-certainty evidence) compared to the consultant-led appointment system. Results for service utilisation (contacts) suggest there may be little or no difference in service utilisation in terms of contacts between the patient-initiated and consultant-led appointment groups; however, the effect is not certain as the rate ratio ranged from 0.68 to 3.83 across the studies (median rate ratio 1.11, interquartile (IQR) 0.93 to 1.37; 15 studies, 3348 participants; low-certainty evidence). It is uncertain if service utilisation (costs) are reduced in the patient-initiated compared to the consultant-led appointment groups (8 studies, 2235 participants; very low-certainty evidence). The results suggest that adverse events such as relapses in some conditions (inflammatory bowel disease and cancer) may have little or no reduction in the patient-initiated appointment group in comparison with the consultant-led appointment group (MD -0.20, 95% CI -0.54 to 0.14; 3 studies, 888 participants; low-certainty evidence). The results are unclear about any differences the intervention may make to patient satisfaction (SMD 0.05, 95% CI -0.41 to 0.52; 2 studies, 375 participants) because the certainty of the evidence is low, as each study used different questions to collect their data at different time points and across different health conditions. Some areas of risk of bias across all the included studies was consistently high (i.e. for blinding of participants and personnel and blinding of outcome assessment, other areas were largely of low risk of bias or were affected by poor reporting making the assessment unclear).

AUTHORS' CONCLUSIONS

Patient-initiated appointment systems may have little or no effect on patient anxiety, depression and quality of life compared to consultant-led appointment systems. Other aspects of disease status and experience also appear to show little or no difference between patient-initiated and consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on service utilisation in terms of service contact and there is uncertainty about costs compared to consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on adverse events such as relapse or patient satisfaction compared to consultant-led appointment systems.

Effect of enhanced reminders on postnatal clinic attendance in Addis Ababa, Ethiopia: a cluster randomized controlled trial

Background: Failure to attend maternal health services is an intractable challenge for the health-care system in low- and middle-income countries. The use of technology for reminding patients about their appointments has been demonstrated to be an effective (future) tool toward increased health care services utilization in developing countries, such as Ethiopia. Objective: We aimed to investigate the effect of enhanced reminders on postnatal care attendance versus usual care (notification of an appointment at discharge). Methods: The study was a cluster randomized controlled trial: out of eligible 86 health centers, 16 health centers in Addis Ababa (AA) were randomized to either the intervention (8) or the control (8) groups; with a total of 350 mothers equally randomized into each arm. Mothers in the intervention group received the SMS (short message service) or a voice call reminder at 48 and 24 hours before the due postnatal appointment, whereas the control group received only the usual notification of appointments provided by health professionals at discharge from the ward following delivery. We recruited participants on wards after delivery at discharge and followed them up to 6 weeks. This study's primary outcome was postnatal visit compliance. Our assessment consisted of a two-level bivariate and a multivariate ordinal logistic regression analysis. Results: The majority (97.7%) of the participants completed the study; 173(98.9%) of women in the intervention group and 169 (96.5%) of women in the control group. There was a statistically significant difference in postnatal care (PNC) compliance among women who were in the intervention versus the control group (p-value = 0.005). Higher odds of postnatal compliance was observed among the intervention group (AOR:2.98, 95% CI 1.51-5.8). Conclusions: Mobile phone reminders were effective in terms of enhancing adherence to PNC appointments. This indicates integration of mobile phone reminders in postnatal care could improve postnatal appointment compliance.

A dynamic approach for outpatient scheduling

AIMS

Patient no-show is a recurrent problem in medical centers and, in conjunction with cancellation of appointments, often results in loss of productivity and excessive patient time to appointment. The purpose of this study was to develop a dynamic procedure for scheduling patients within an outpatient clinic where patients are expected to have multiple appointments, such as physical therapy, occupational therapy, primary care, and dentistry.

METHODS

This retrospective study involved the year 2014 de-identified patient records from an outpatient clinic affiliated with a large university hospital. A number of patient characteristics, appointment data, and historical attendance records were examined to determine whether they significantly impacted patients who missed scheduled appointments (no-shows). Patient attendance behaviors over multiple appointments were examined to determine whether their no-show and cancellation patterns differed from one appointment to the next. Decision tree analysis was applied to those predictors that significantly correlated with patient attendance behavior to assess the likelihood of a patient no-show. A sample dynamic appointment scheduling procedure that utilized different overbooking strategies for different appointment numbers was then developed. Computer simulation was used to assess the effectiveness of the dynamic procedure versus two other methods consisting of randomly assigned and uniformly assigned appointments.

RESULTS

The dynamic scheduling procedure resulted in increased scheduling efficiency through overbooking but with less than 5% risk of appointment conflicts (i.e. two patients showing at the same time), equating to approximately 0.16 conflicts per clinician per day. It also increased clinic utilization by about 6.7%. It consistently outperformed the other two methods with respect to the percentage of appointment conflicts.

LIMITATIONS

The study is limited with respect to potential clinician cost increase resulting from possible appointment conflicts. A second limitation is that patients experiencing appointment conflicts might not wait for treatment, resulting in potential loss of revenue. A third limitation is that the model does not take into account patient satisfaction, nor the ethics of overbooking patients.

CONCLUSIONS

A dynamic appointment scheduling procedure was developed using actual patient characteristics. The procedure resulted in creation of more efficient appointment schedules thereby increasing the clinic utilization.

Mobile phone messaging reminders for attendance at healthcare appointments

BACKGROUND

This review is an update of the original Cochrane review published in July 2012. Missed appointments are a major cause of inefficiency in healthcare delivery with substantial monetary costs for the health system, leading to delays in diagnosis and appropriate treatment. Patients' forgetfulness is one of the main reasons for missed appointments. Patient reminders may help reduce missed appointments. Modes of communicating reminders for appointments to patients include face-to-face communication, postal messages, calls to landlines or mobile phones, and mobile phone messaging. Mobile phone messaging applications, such as Short Message Service (SMS) and Multimedia Message Service (MMS), could provide an important, inexpensive delivery medium for reminders for healthcare appointments.

OBJECTIVES

To update our review assessing the effects of mobile phone messaging reminders for attendance at healthcare appointments. Secondary objectives include assessment of costs; health outcomes; patients' and healthcare providers' evaluation of the intervention and perceptions of safety; and possible harms and adverse effects associated with the intervention.

SEARCH METHODS

Original searches were run in June 2009. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library 2012, Issue 8), MEDLINE (OvidSP) (January 1993 to August 2012), EMBASE (OvidSP) (January 1993 to August 2012), PsycINFO (OvidSP) (January 1993 to August 2012) and CINAHL (EbscoHOST) (January 1993 to August 2012). We also reviewed grey literature (including trial registers) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing mobile phone messaging as reminders for healthcare appointments. We only included studies in which it was possible to assess effects of mobile phone messaging independent of other technologies or interventions.  

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies against the inclusion criteria, with any disagreements resolved by a third review author. Study design features, characteristics of target populations, interventions and controls, and results data were extracted by two review authors and confirmed by a third author. Two authors assessed the risk of bias of the included studies. As the intervention characteristics and outcome measures were similar across included studies, we conducted a meta-analysis to estimate an overall effect size.

MAIN RESULTS

We included eight randomised controlled trials involving 6615 participants. Four of these studies were newly identified during this update.We found moderate quality evidence from seven studies (5841 participants) that mobile text message reminders improved the rate of attendance at healthcare appointments compared to no reminders (risk ratio (RR) 1.14 (95% confidence interval (CI) 1.03 to 1.26)). There was also moderate quality evidence from three studies (2509 participants) that mobile text message reminders had a similar impact to phone call reminders (RR 0.99 (95% CI 0.95 to 1.02). Low quality evidence from one study (291 participants) suggests that mobile text message reminders combined with postal reminders improved the rate of attendance at healthcare appointments compared to postal reminders alone (RR 1.10 (95% CI 1.02 to 1.19)). Overall, the attendance to appointment rates were 67.8% for the no reminders group, 78.6% for the mobile phone messaging reminders group and 80.3% for the phone call reminders group. One study reported generally that there were no adverse effects during the study period; none of the studies reported in detail on specific adverse events such as loss of privacy, data misinterpretation, or message delivery failure. Two studies reported that the costs per text message per attendance were respectively 55% and 65% lower than costs per phone call reminder. The studies included in the review did not report on health outcomes or people's perceptions of safety related to receiving reminders by text message.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence included in this review shows that mobile phone text messaging reminders increase attendance at healthcare appointments compared to no reminders, or postal reminders.Text messaging reminders were similar to telephone reminders in terms of their effect on attendance rates, and cost less than telephone reminders. However, the included studies were heterogeneous and the quality of the evidence therein is low to moderate. Further, there is a lack of information about health effects, adverse effects and harms, user evaluation of the intervention and user perceptions of its safety. The current evidence therefore still remains insufficient to conclusively inform policy decisions.There is a need for more high-quality randomised trials of mobile phone messaging reminders, that measure not only patients' attendance rates, but also focus on the cost-effectiveness of these interventions. Health outcomes, patients' and healthcare providers' evaluation and perceptions of the safety of the interventions, potential harms, and adverse effects of mobile phone messaging reminders should be assessed. Studies should report message content and timing in relation to the appointment.

The effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis

BACKGROUND

Mobile health interventions could have beneficial effects on health care delivery processes. We aimed to conduct a systematic review of controlled trials of mobile technology interventions to improve health care delivery processes.

METHODS AND FINDINGS

We searched for all controlled trials of mobile technology based health interventions using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990-Sept 2010). Two authors independently extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and we used random effects meta-analysis to give pooled estimates. We identified 42 trials. None of the trials had low risk of bias. Seven trials of health care provider support reported 25 outcomes regarding appropriate disease management, of which 11 showed statistically significant benefits. One trial reported a statistically significant improvement in nurse/surgeon communication using mobile phones. Two trials reported statistically significant reductions in correct diagnoses using mobile technology photos compared to gold standard. The pooled effect on appointment attendance using text message (short message service or SMS) reminders versus no reminder was increased, with a relative risk (RR) of 1.06 (95% CI 1.05-1.07, I(2) = 6%). The pooled effects on the number of cancelled appointments was not significantly increased RR 1.08 (95% CI 0.89-1.30). There was no difference in attendance using SMS reminders versus other reminders (RR 0.98, 95% CI 0.94-1.02, respectively). To address the limitation of the older search, we also reviewed more recent literature.

CONCLUSIONS

The results for health care provider support interventions on diagnosis and management outcomes are generally consistent with modest benefits. Trials using mobile technology-based photos reported reductions in correct diagnoses when compared to the gold standard. SMS appointment reminders have modest benefits and may be appropriate for implementation. High quality trials measuring clinical outcomes are needed. Please see later in the article for the Editors' Summary.

Mobile phone messaging for communicating results of medical investigations

BACKGROUND

Mobile phone messaging, such as Short Message Service (SMS) and Multimedia Message Service (MMS), has rapidly grown into a mode of communication with a wide range of applications, including communicating the results from medical investigations to patients. Alternative modes of communication of results include face-to-face communication, postal messages, calls to landlines or mobile phones, through web-based health records and email. Possible advantages of mobile phone messaging include convenience to both patients and healthcare providers, reduced waiting times for health services and healthcare costs.

OBJECTIVES

To assess the effects of mobile phone messaging for communicating results of medical investigations, on people's healthcare-seeking behaviour and health outcomes. Secondary objectives include assessment of participants' evaluation of the intervention, direct and indirect healthcare costs and possible risks and harms associated with the intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2009, Issue 2), MEDLINE (OvidSP) (January 1993 to June 2009), EMBASE (OvidSP) (January 1993 to June 2009), PsycINFO (OvidSP) (January 1993 to June 2009), CINAHL (EbscoHOST) (January 1993 to June 2009), LILACS (January 1993 to June 2009) and African Health Anthology (January 1993 to June 2009). We also reviewed grey literature (including trial registers) and reference lists of articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised controlled trials (QRCTs), controlled before-after (CBA) studies, or interrupted time series (ITS) studies with at least three time points before and after the intervention. We included studies assessing mobile phone messaging for communicating results of medical tests, between a healthcare provider or 'treatment buddy' and patient. We only included studies in which it was possible to assess the effects of mobile phone messaging independent of other technologies or interventions.  

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all studies against the inclusion criteria, with any disagreements resolved by a third review author. Study design features, characteristics of target populations, interventions and controls, and results data were extracted by two review authors and confirmed by a third. Primary outcomes of interest were health outcomes and healthcare utilisation as a result of the intervention. We also considered patients' and providers' evaluation of the intervention, perceptions of safety, costs and potential harms or adverse effects of the intervention.

MAIN RESULTS

We included one randomised controlled trial involving 2782 participants. The study investigated the effects of mobile phone messaging in alleviating anxiety in women waiting for prenatal biochemical screening results for Down syndrome, by providing fast reporting of results before a follow-up appointment. The study measured health outcomes using the Spielberger State-Trait Anxiety Inventory (STAI), which includes a scale (20 to 80 points, higher score indicates higher anxiety) to describe how the respondent feels at a particular moment in time (state anxiety). The study, which was at high risk of bias, found that women who had received their test result early by text message had a mean anxiety score 2.48 points lower than women who had not yet received their result (95% CI - 8.79 to 3.84). Women with a serum-negative test result receiving their result early had a mean anxiety score 5.3 points lower (95% CI - 5.99 to -4.61) than women in the control group. Women with a serum-positive test result receiving their result early by text message had a mean anxiety score 1.2 points higher (95% CI - 3.48 to 5.88) than women in the control group.The evidence was of low quality due to high risk of bias in the included study, and the fact that the evidence comes from one study only. The study did not report on other outcomes of interest, such as patient satisfaction, adverse events or cost.

AUTHORS' CONCLUSIONS

We found very limited evidence of low quality that communicating results of medical investigations by mobile phone messaging may make little or no difference to women's anxiety overall or in women with positive test results, but may reduce anxiety in women with negative test results. However, with only one study included in this review, this evidence is insufficient to inform recommendations at this time. More research is needed on the effectiveness and user evaluation of these interventions. In particular, more research should be conducted into the potential risks and limitations of these interventions.

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.