Feasibility of a randomized controlled trial to evaluate Text Reminders for Immunization Compliance in Kids (TRICKs)

SMS-based interventions for improving child and adolescent vaccine coverage and timeliness: a systematic review

BACKGROUND

The aim of this review was to investigate the impact of short message service (SMS)-based interventions on childhood and adolescent vaccine coverage and timeliness.

METHODS

A pre-defined search strategy was used to identify all relevant publications up until July 2022 from electronic databases. Reports of randomised trials written in English and involving children and adolescents less than 18 years old were included. The review was conducted in accordance with PRISMA guidelines.

RESULTS

Thirty randomised trials were identified. Most trials were conducted in high-income countries. There was marked heterogeneity between studies. SMS-based interventions were associated with small to moderate improvements in vaccine coverage and timeliness compared to no SMS reminder. Reminders with embedded education or which were combined with monetary incentives performed better than simple reminders in some settings.

CONCLUSION

Some SMS-based interventions appear effective for improving child vaccine coverage and timeliness in some settings. Future studies should focus on identifying which features of SMS-based strategies, including the message content and timing, are determinants of effectiveness.

Reminder design and childhood vaccination coverage

A major policy concern across public vaccination programs is non-compliance. Exploiting Danish population data and three national reforms in regression discontinuity designs, we document the effects of reminders for childhood vaccination coverage. Retrospective reminders are primarily effective for families with small children and when sent out close to the recommended vaccination age. Digital and postal reminders are equally effective. Prospective reminders increase timely vaccinations in later childhood and help reaching high coverage for new vaccines in increasingly complex vaccination programs. While reminders prompt additional preventive care for focal children, we find no spillovers to other health behaviors or relatives.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Maturity Level of Digital Reproductive, Maternal, Newborn, and Child Health Initiatives in Jordan and Palestine

Background While there is a rapid increase in digital health initiatives focusing on the processing of personal data for strengthening the delivery of reproductive, maternal, newborn, and child health (RMNCH) services in fragile settings, these are often unaccompanied at both the policy and operational levels with adequate legal and regulatory frameworks.

Objective The main aim was to understand the maturity level of digital personal data initiatives for RMNCH services within fragile contexts. This aim was performed by choosing digital health initiatives from each country (two in Jordan and three in Palestine) based on RMNCH.

Methods A qualitative study design was adopted. We developed a digital maturity assessment tool assessing two maturity levels: the information and communications technology digital infrastructure, and data governance and interoperability in place for the five selected RMNCH initiatives in Jordan and Palestine.

Results Overall, the digital infrastructure and technological readiness components are more advanced and show higher maturity levels compared with data governance and interoperability components in Jordan and Palestine. In Jordan, the overall Jordan stillbirths and neonatal deaths surveillance initiative maturity indicators are somehow less advanced than those of the Electronic Maternal and Child Health Handbook-Jordan (EMCH-J) application. In Palestine, the Electronic Maternal and Child Health-registry initiative maturity indicators are more advanced than both Avicenna and EMCH-Palestine initiatives.

Discussions The findings highlighted several challenges and opportunities around the application and implementation of selected digital health initiatives in the provision of RMNCH in Jordan and Palestine. Our findings shed lights on the maturity level of these initiatives within fragile contexts. The maturity level of the five RMNCH initiatives in both countries is inadequate and requires further advancement before they can be scaled up and scaled out. Taking the World Health Organization recommendations into account when developing, implementing, and scaling digital health initiatives in low- and middle-income countries can result in successful and sustainable initiatives, thus meeting health needs and improving the quality of health care received by individuals especially those living in fragile contexts.

Text Message Reminders to Improve Immunization Appointment Attendance in Alberta, Canada: The Childhood Immunization Reminder Project Pilot Study

BACKGROUND

Vaccine coverage for 18-month-old children in Canada is often below the recommended level, which may be partially because of parental forgetfulness. SMS text message reminders have been shown to potentially improve childhood immunization uptake but have not been widely used in Alberta, Canada. In addition, it has been noted that language barriers may impede immunization service delivery but continue to remain unaddressed in many existing reminder and recall systems.

OBJECTIVE

This study aimed to assess the effectiveness and acceptability of using SMS text messages containing a link to web-based immunization information in different languages to remind parents of their child's 18-month immunization appointment.

METHODS

The Childhood Immunization Reminder Project was a pilot intervention at 2 public health centers, one each in Lethbridge and Edmonton, Alberta, Canada. Two SMS text message reminders were sent to parents: a booking reminder 3 months before their child turned 18 months old and an appointment reminder 3 days before their scheduled appointment. Booking reminders included a link to the study website hosting immunization information in 9 languages. To evaluate intervention effectiveness, we compared the absolute attendance no-show rates before the intervention and after the intervention. The acceptability of the intervention was evaluated through web-based surveys completed by parents and public health center staff. Google Analytics was used to determine how often web-based immunization information was accessed, from where, and in which languages.

RESULTS

Following the intervention, the health center in Edmonton had a reduction of 6.4% (95% CI 3%-9.8%) in appointment no-shows, with no change at the Lethbridge Health Center (0.8%, 95% CI -1.4% to 3%). The acceptability surveys were completed by 222 parents (response rate: 23.9%) and 22 staff members. Almost all (>95%) respondents indicated that the reminders were helpful and provided useful suggestions for improvement. All surveyed parents (222/222, 100%) found it helpful to read web-based immunization information in their language of choice. Google Analytics data showed that immunization information was most often read in English (118/207, 57%), Punjabi (52/207, 25.1%), Arabic (13/207, 6.3%), Spanish (12/207, 5.8%), Italian (4/207, 1.9%), Chinese (4/207, 1.9%), French (2/207, 0.9%), Tagalog (1/207, 0.5%), and Vietnamese (1/207, 0.5%).

CONCLUSIONS

The study's findings support the use of SMS text message reminders as a convenient and acceptable method to minimize parental forgetfulness and potentially reduce appointment no-shows. The diverse languages accessed in web-based immunization information suggest the need to provide appropriate translated immunization information. Further research is needed to evaluate the impact of SMS text message reminders on childhood immunization coverage in different settings.

Text Message Reminders for the Second Dose of Influenza Vaccine for Children: An RCT

BACKGROUND AND OBJECTIVES

Among children requiring 2 influenza doses in a given season, second dose receipt nearly halves the odds of influenza. Nationally, many children do not receive both needed doses. This study sought to compare the effectiveness of text message reminders with embedded interactive educational information versus usual care on receipt and timeliness of the second dose of influenza vaccine.

METHODS

This trial took place over the 2017 to 2018 and 2018 to 2019 influenza seasons among 50 pediatric primary care offices across 24 states primarily from the American Academy of Pediatrics' Pediatric Research in Office Settings practice-based research network. Caregiver-child dyads of children 6 months to 8 years in need of a second influenza vaccination that season were individually randomized 1:1 into intervention versus usual care, stratified by age and language within each practice. Intervention caregivers received automated, personalized text messages, including educational information. Second dose receipt by April 30 (season end) and by day 42 (2 weeks after second dose due date) were assessed using Mantel Haenszel methods by practice and language. Analyses were intention to treat.

RESULTS

Among 2086 dyads enrolled, most children were 6 to 23 months and half publicly insured. Intervention children were more likely to receive a second dose by season end (83.8% versus 80.9%; adjusted risk difference (ARD) 3.8%; 95% confidence interval [0.1 to 7.5]) and day 42 (62.4% versus 55.7%; ARD 8.3% [3.6 to 13.0]).

CONCLUSIONS

In this large-scale trial of primary care pediatric practices across the United States, text message reminders were effective in promoting increased and timelier second dose influenza vaccine receipt.

Nudging toward vaccination: a systematic review

Background

Vaccine hesitancy (VH) and the global decline of vaccine coverage are a major global health threat, and novel approaches for increasing vaccine confidence and uptake are urgently needed. ‘Nudging’, defined as altering the environmental context in which a decision is made or a certain behaviour is enacted, has shown promising results in several health promotion strategies. We present a comprehensive synthesis of evidence regarding the value and impact of nudges to address VH.

Methods

We conducted a systematic review to determine if nudging can mitigate VH and improve vaccine uptake. Our search strategy used Medical Subject Headings (MeSH) and non-MeSH terms to identify articles related to nudging and vaccination in nine research databases. 15 177 titles were extracted and assessed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The final list of included articles was evaluated using the Mixed Methods Appraisal Tool and the Grading of Recommendations, Assessment, Development and Evaluations framework.

Findings

Identified interventions are presented according to a framework for behaviour change, MINDSPACE. Articles (n=48) from 10 primarily high-income countries were included in the review. Nudging-based interventions identified include using reminders and recall, changing the way information is framed and delivered to an intended audience, changing the messenger delivering information, invoking social norms and emotional affect (eg, through storytelling, dramatic narratives and graphical presentations), and offering incentives or changing defaults. The most promising evidence exists for nudges that offer incentives to parents and healthcare workers, that make information more salient or that use trusted messengers to deliver information. The effectiveness of nudging interventions and the direction of the effect varies substantially by context. Evidence for some approaches is mixed, highlighting a need for further research, including how successful interventions can be adapted across settings.

Conclusion

Nudging-based interventions show potential to increase vaccine confidence and uptake, but further evidence is needed for the development of clear recommendations. The ongoing COVID-19 pandemic increases the urgency of undertaking nudging-focused research.

PROSPERO registration number

CRD42020185817.

Short message service (SMS) reminders for childhood immunisation in low-income and middle-income countries: a systematic review and meta-analysis

Introduction

Childhood vaccine delivery services in the low- and middle-income countries (LMIC) are struggling to reach every child with lifesaving vaccines. Short message service (SMS) reminders have demonstrated positive impact on a number of attrition-prone healthcare delivery services. We aimed to evaluate the effectiveness of SMS reminders in improving immunisation coverage and timeliness in LMICs.

Methods

PubMed, Embase, Scopus, Cochrane CENTRAL, CINAHL, CNKI, PsycINFO and Web of Science including grey literatures and Google Scholar were systematically searched for randomised controlled trials (RCTs) and non-RCTs that evaluated the effect of SMS reminders on childhood immunisation and timeliness in LMICs. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 assessment tool for RCTs and Cochrane Risk of Bias in Non-randomised Studies of Interventions tool for non-RCTs. Meta-analysis was conducted using random-effects models to generate pooled estimates of risk ratio (RR).

Results

18 studies, 13 RCTs and 5 non-RCTs involving 32 712 infants (17 135 in intervention groups and 15 577 in control groups) from 11 LMICs met inclusion criteria. Pooled estimates showed that SMS reminders significantly improved childhood immunisation coverage (RR=1.16; 95% CI: 1.10 to 1.21; I²=90.4%). Meta-analysis of 12 included studies involving 25 257 infants showed that SMS reminders significantly improved timely receipt of childhood vaccines (RR=1.21; 95% CI: 1.12 to 1.30; I²=87.3%). Subgroup analysis showed that SMS reminders are significantly more effective in raising childhood immunisation coverage in lower middle-income and low-income countries than in upper middle-income countries (p<0.001) and sending more than two SMS reminders significantly improves timely receipt of childhood vaccines than one or two SMS reminders (p=0.040).

Conclusion

Current evidence from LMICs, although with significant heterogeneity, suggests that SMS reminders can contribute to achieving high and timely childhood immunisation coverage.

PROSPERO registration number

CRD42021225843.

Effect of Mobile Phone Text Message Reminders on the Completion and Timely Receipt of Routine Childhood Vaccinations: Superiority Randomized Controlled Trial in Northwest Ethiopia

BACKGROUND

Nonattendance at vaccination appointments is a big challenge for health workers as it is difficult to track routine vaccination schedules. In Ethiopia, 3 out of 10 children have incomplete vaccination and the timely receipt of the recommended vaccines is low. Thus, innovative strategies are required to reach the last mile where mobile technology can be effectively utilized to achieve better compliance. Despite this promising technology, little is known about the role of text message-based mobile health interventions in improving the complete and timely receipt of routine childhood vaccinations in Ethiopia.

OBJECTIVE

This trial aimed to determine the effect of mobile phone text message reminders on the completion and timely receipt of routine childhood vaccinations in northwest Ethiopia.

METHODS

A two-arm, parallel, superiority randomized controlled trial was conducted in 9 health facilities in northwest Ethiopia. A sample size of 434 mother-infant pairs was considered in this trial. Randomization was applied in selected health facilities during enrollment with a 1:1 allocation ratio by using sealed and opaque envelopes. Participants assigned to the intervention group received mobile phone text message reminders one day before the scheduled vaccination visits. Owing to the nature of the intervention, blinding of participants was not possible. Primary outcomes of full and timely completion of vaccinations were measured objectively at 12 months. A two-sample test of proportion and log-binomial regression analyses were used to compare the outcomes between the study groups. A modified intention-to-treat analysis approach was applied and a one-tailed test was reported, considering the superiority design of the trial.

RESULTS

A total of 426 participants were included for the analysis. We found that a higher proportion of infants in the intervention group received Penta-3 (204/213, 95.8% vs 185/213, 86.9%, respectively; P<.001), measles (195/213, 91.5% vs 169/213, 79.3%, respectively; P<.001), and full vaccination (176/213, 82.6% vs 151/213, 70.9%, respectively; P=.002; risk ratio 1.17, 95% lower CI 1.07) compared to infants in the usual care group. Similarly, a higher proportion of infants in the intervention group received Penta-3 (181/204, 88.7% vs 128/185, 69.2%, respectively; P<.001), measles (170/195, 87.1% vs 116/169, 68.6%, respectively; P<.001), and all scheduled vaccinations (135/213, 63.3% vs 85/213, 39.9%, respectively; P<.001; risk ratio 1.59, 95% lower CI 1.35) on time compared to infants in the usual care group. Of the automatically sent 852 mobile phone text messages, 764 (89.7%) were delivered successfully to the participants.

CONCLUSIONS

Mobile phone text message reminders significantly improved complete and timely receipt of all recommended vaccines. Besides, they had a significant effect in improving the timely receipt of specific vaccines. Thus, text message reminders can be used to supplement the routine immunization program in resource-limited settings. Considering different contexts, studies on the implementation challenges of mobile health interventions are recommended.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR201901533237287; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5839.

Acceptability, Barriers and Facilitators of Mobile Text Message Reminder System Implementation in Improving Child Vaccination: A Qualitative Study in Northwest Ethiopia

Background

Mobile phone text message-based mHealth interventions have shown promise in improving health service delivery. Despite the promising findings at a small scale and few contexts, implementing new technologies as part of changes to health care services is inherently challenging. Though there is a potential to introduce mHealth initiatives to health systems of developing countries, existing evidence on the barriers and facilitators of implementation in different contexts is not adequate. Therefore, this study aimed to explore the acceptability, barriers and facilitators of implementing mobile text message reminder system for child vaccination in Ethiopia.

Methods

This study applied a phenomenological study design. The study was conducted in north-west, Ethiopia between July 28 and August 19, 2020. A total of 23 participants were purposively selected for the in-depth and key informant interviews. We used an interview guide to collect data and audio-records of interviews were transcribed verbatim. Coding was done to identify patterns and thematic analysis was conducted using ATLAS ti7 software.

Results

The findings indicated that mothers were receptive to mobile text message reminders for their child’s vaccination. Low mobile phone ownership, access to mobile network, access to electricity and illiteracy among the target population were identified as barriers that would affect implementation. Confidentiality and security-related issues are not barriers to implementation of text message reminders for child vaccination service. Facilitators for implementation include stakeholder collaboration, providing orientation/training to users, and willingness to pay by clients.

Conclusion

In this study, using mobile phone text message reminders for child vaccination services are acceptable by clients. Barriers identified were related to inadequate ICT infrastructure and other technical issues. Addressing the potential barriers and leveraging the existing opportunities could optimize the implementation in resource-limited settings. Before actual implementation, program implementers should also consider providing orientation to users on the proposed mHealth program.

Mobile phone reminders for enhancing uptake, completeness and timeliness of routine childhood immunization in low and middle income countries: A systematic review and meta-analysis

Immunization remains one of the most effective public health interventions offering protection for children from vaccine preventable diseases. However, many children living in low- and- middle income countries do not get adequate immunization due to several factors. Mobile phone reminder interventions have shown great potential in enhancing a number of immunization outcomes. However, the evidence supporting its use in these countries is vague. This systematic review was conducted to provide evidence for mobile phone reminder in enhancing immunization uptake, completeness and timeliness. This review was conducted in accordance to the PRISMA recommendations. Three online databases; PubMed, Cochrane Library and African Journals Online, were systematically searched for potentially relevant studies. Screening of records (titles/abstracts from and full-texts) was done using Covidence. Meta-analyses were conducted using the Cochrane Collaboration Review Manager (v5.4). The GRADEpro was used to evaluate the certainty of evidence/summary of findings. Eleven RCTs assessing immunization uptake, completeness and/or timeliness by means of SMS, phone calls or a combination of voice message and SMS were included in both quantitative and qualitative synthesis. Overall, the included studies were of moderate quality. Majority of the included studies indicated that mobile phone reminders were beneficial. Meta-analyses indicated that using mobile phone reminder interventions for the review outcomes was of variable effect with high level of heterogeneity. A combination of voice message and SMS has a greater effect followed by phone calls then SMS reminders for immunization completeness. The use of SMS for immunization uptake and timeliness were largely insignificant (p > 0.05). Furthermore, evidence to support the efficacy of mobile phone reminder from the GRADE synthesis was between low and moderate. Mobile phone reminders, particularly a combination of voice message + SMS and perhaps phone calls appears to be more effective in enhancing immunization outcomes. However, more studies are required in view of methodological inadequacies in existing studies.

Information and communication technologies in neonatal health

Objectives. To identify scientific evidence on the use and results of information and communication technologies for the improvement of neonatal health in general or specific health problems or interventions, and to describe the type of intervention and its results.

Methods. A systematic review of the available evidence was performed. The search was carried out in peerreviewed journals between January 1, 2008 and April 30, 2018, in English and Spanish. The searched key terms were (health informatics OR telemedicine OR mHealth) AND (newborn OR newborn care OR neonatal care).

Results. From a total of 305 articles initially identified, 10 articles fulfilled the inclusion criteria. The main domains of eHealth identified as applied to neonatal health were telemedicine (3 studies), eLearning (1 study) and mHealth (7 studies). Target population were health care providers or parents. The studies aimed at diagnosis, provision of health care and training, promoting adherence to interventions in parents or improving quality of care.

Conclusions. The use of eHealth in general and specifically focused on neonatal health shows important possibilities for development and expansion, given the advances and present needs, and should be considered a key tool for the reduction of inequalities.

Cost-effectiveness of SMS appointment reminders in increasing vaccination uptake in Lagos, Nigeria: A multi-centered randomized controlled trial

OBJECTIVE

It is expected that mHealth largely contribute to increasing the coverages of key maternal and child health services. This study aims to estimate the cost-effectiveness of the SMS text reminders in clients' return visits to the health facilities for child vaccinations (incl. vitamin A supplementations), antenatal care (ANC) and family planning (FP), in urban communities of Lagos, Nigeria.

METHODS

A multi-centered randomized control trial was conducted at 33 primary health centers (PHCs) in Lagos, Nigeria. All the clients having visited any of the 33 PHCs for child vaccinations, ANC and FP were randomly assigned either to intervention group or to control group. The participants in the intervention group were sent an SMS text reminder two days before their appointments. Those not having showed up on the appointment dates received an additional SMS text reminder seven days after original appointment dates as defaulter tracing. The primary outcome was whether a client made return visit to PHCs for the upcoming appointments.

RESULTS

Of 12,779 appointments for 9,368 clients during the period of 1stApril to 30thJune 2019, 12,175 were included in the analysis. The return rate for child vaccinations in the intervention group was significantly higher (p < 0.001) by 4.8% - 6.0% than that in the control group, consistently across all the five different timings (on time as scheduled, and by 7 days, 14 days, 30 days, and 3 months after appointment dates). No significant difference between the two groups was detected in the increase in return rates for ANC and FP services. The incremental recurrent cost was estimated at 7.90 US Dollars per return case.

CONCLUSION

SMS text reminders led to a significant increase in the number of return visits for child vaccinations, Lagos, Nigeria, while no significant increase in return visits was confirmed for ANC and FP appointments.

Targeted client communication via mobile devices for improving maternal, neonatal, and child health

BACKGROUND

The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH.

OBJECTIVES

To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second.

MAIN RESULTS

We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences.

AUTHORS' CONCLUSIONS

The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

Clients' perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis

BACKGROUND

Governments and health systems are increasingly using mobile devices to communicate with patients and the public. Targeted digital client communication is when the health system transmits information to particular individuals or groups of people, based on their health or demographic status. Common types of targeted client communication are text messages that remind people to go to appointments or take their medicines. Other types include phone calls, interactive voice response, or multimedia messages that offer healthcare information, advice, monitoring, and support.

OBJECTIVES

To explore clients' perceptions and experiences of targeted digital communication via mobile devices on topics related to reproductive, maternal, newborn, child, or adolescent health (RMNCAH).

SEARCH METHODS

We searched MEDLINE (OvidSP), MEDLINE In-Process & Other Non-Indexed Citations (OvidSP), Embase (Ovid), World Health Organization Global Health Library, and POPLINE databases for eligible studies from inception to 3-6 July 2017 dependant on the database (See appendix 2).

SELECTION CRITERIA

We included studies that used qualitative methods for data collection and analysis; that explored clinets' perceptions and experiences of targeted digital communication via mobile device in the areas of RMNCAH; and were from any setting globally.

DATA COLLECTION AND ANALYSIS

We used maximum variation purposive sampling for data synthesis, employing a three-step sampling frame. We conducted a framework thematic analysis using the Supporting the Use of Research Evidence (SURE) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether potential implementation barriers identified in our synthesis had been addressed in the trials included in the related Cochrane Reviews of effectiveness.

MAIN RESULTS

We included 35 studies, from a wide range of countries on six continents. Nineteen studies were conducted in low- and middle-income settings and sixteen in high-income settings. Some of the studies explored the views of people who had experienced the interventions, whereas others were hypothetical in nature, asking what people felt they would like from a digital health intervention. The studies covered a range of digital targeted client communication, for example medication or appointment reminders, prenatal health information, support for smoking cessation while pregnant, or general sexual health information.Our synthesis showed that clients' experiences of these types of programmes were mixed. Some felt that these programmes provided them with feelings of support and connectedness, as they felt that someone was taking the time to send them messages (moderate confidence in the evidence). They also described sharing the messages with their friends and family (moderate confidence).However, clients also pointed to problems when using these programmes. Some clients had poor access to cell networks and to the internet (high confidence). Others had no phone, had lost or broken their phone, could not afford airtime, or had changed their phone number (moderate confidence). Some clients, particularly women and teenagers, had their access to phones controlled by others (moderate confidence). The cost of messages could also be a problem, and many thought that messages should be free of charge (high confidence). Language issues as well as skills in reading, writing, and using mobile phones could also be a problem (moderate confidence).Clients dealing with stigmatised or personal health conditions such as HIV, family planning, or abortion care were also concerned about privacy and confidentiality (high confidence). Some clients suggested strategies to deal with these issues, such as using neutral language and tailoring the content, timing, and frequency of messages (high confidence).Clients wanted messages at a time and frequency that was convenient for them (moderate confidence). They had preferences for different delivery channels (e.g. short message service (SMS) or interactive voice response) (moderate confidence). They also had preferences about message content, including new knowledge, reminders, solutions, and suggestions about health issues (moderate confidence). Clients' views about who sent the digital health communication could influence their views of the programme (moderate confidence).For an overview of the findings and our confidence in the evidence, please see the 'Summary of qualitative findings' tables.Our matrix shows that many of the trials assessing these types of programmes did not try to address the problems we identified, although this may have been a reporting issue.

AUTHORS' CONCLUSIONS

Our synthesis identified several factors that can influence the successful implementation of targeted client communication programmes using mobile devices. These include barriers to use that have equity implications. Programme planners should take these factors into account when designing and implementing programmes. Future trial authors also need to actively address these factors and to report their efforts in their trial publications.

Text message reminders to improve infant immunization in Guatemala: A randomized clinical trial

OBJECTIVE

Millions of infants worldwide remain under-immunized and at risk for unnecessary morbidity and mortality. Text messaging may offer a low-cost solution. We aimed to evaluate text message reminders to improve infant immunization in Guatemala.

METHODS

A randomized clinical trial was conducted at four public health clinics in rural and urban Guatemala. Infants ages six weeks to six months presenting for the first visit of the primary immunization series were randomly and equally allocated to an intervention or usual care group. Intervention participants were sent three text reminders before the second and third vaccine visits. The main outcome was timeliness of the second and third visits of the primary immunization series.

RESULTS

Of 1088 families approached for enrollment between March to November 2016, 871 were eligible and 720 (82.7%) participated; only 54 families did not own a cell phone. Due to country-wide vaccine shortages, visit completion was used as a proxy for overall immunization coverage. In intention to treat analysis, both intervention and usual care groups had high rates of visit completion, but intervention participants presented on the scheduled date more often (151 [42.2%] of 358 intervention vs. 111 [30.7%] of 362 usual care participants for visit 2, p = 0.001, and 112 [34.0%] of 329 intervention vs. 90 [27.0%] of 333 usual care participants for visit 3, p = 0.05). Intervention caregivers were significantly more likely to want to receive future text message reminders for vaccines and other appointments and were more willing to pay for these reminders.

CONCLUSION

Caregivers who were sent text message reminders in urban and rural Guatemala were less delayed for their child's immunization visits and reported high user satisfaction. Text message reminders may be an effective tool to increase infant vaccination coverage in low-income settings by reminding parents to vaccinate.

TRIAL REGISTRATION

NCT02567006 at clinicaltrials.gov.

Acceptability of a text message-based intervention for obesity prevention in infants from Hawai'i and Puerto Rico WIC

Background

Low-income and minority children are at increased risk for obesity. Text messaging offers advantages for delivering education, but few studies have assessed the acceptability of text messaging in interventions aimed at preventing excessive weight gain in infants. This study investigated the acceptability of a text message-based intervention for prevention of excessive weight gain in infants from Hawai‘i and Puerto Rico WIC clinics.

Methods

The four-month text message based intervention designed to improve infant feeding practices and reduce excessive weight gain was a randomized controlled trial that included mothers with infants ages 0–2 months at baseline. Participants in the intervention arm received 18 text messages (1/week) promoting breastfeeding and appropriate complementary feeding. Acceptability of the intervention was assessed from participant retention, satisfaction, and evidence of behavior change in a sequential multimethod approach, quantitatively from questions sent via text and qualitatively during the in-person exit interview. The final analysis included 80 mother-infant pairs from the intervention arm.

Results

When asked about messages liked and disliked the most, the majority of responses via text indicated that they liked all messages. From the qualitative analyses, most participants reported that all messages were useful and that the messages led them to make changes in the way they fed their infants. Participant retention was good at 78.4%.

Conclusions

The intervention was acceptable to participants based upon participant retention, measures of satisfaction, and reports of behavior change. Results may inform development of mobile health programs for minority childhood obesity prevention.

Trial registration

ClinicalTrials.gov Identifier; NCT02903186; September 16, 2016.

Effect of mobile text message reminders on routine childhood vaccination: a systematic review and meta-analysis

BACKGROUND

The World Health Organization estimates that 29% of under-five mortality could be prevented with existing vaccines. However, non-consistent attendance for immunization appointments remains a global challenge to healthcare providers. Thus, innovative strategies are required to reach the last mile where technology could be effectively utilized to achieve better compliance with children immunization schedules. Therefore, the aim of the review was to systematically collect and summarize the available evidence on the effectiveness of text message reminders on childhood vaccination.

METHODS

This review was conducted according to a priori published protocol on PROSPERO. A systematic literature search of databases (PubMed/MEDLINE, EMBASE, Cochrane/Wiley library, and Science direct) was conducted. Eligibility and risk of bias assessments were performed independently by two reviewers. PRISMA flow diagrams were used to summarize the study selection process. Taking into account the level of heterogeneity, a random effects model was used and risk ratios with their 95% CI were used to present the pooled estimates. To investigate the sources of heterogeneity, subgroup analysis and meta-regression analysis were also considered. In this review, publication bias was assessed statistically using Harbord test.

RESULTS

A total of 1771 articles were searched. Out of those 1771 articles, 558 duplicated articles were removed. About 1213 articles were further screened, and finally, ten articles met the inclusion criteria. The meta-analysis showed that there is a significant effect of text message reminders on childhood vaccination coverage (RR = 1.11; 95% CI 1.05-1.17) with a moderate level of heterogeneity (I² = 64.3%, P = 0.003). The results from the Harbord test suggested that there is no evidence for publication bias (P = 0.340).

CONCLUSION

This review highlights the potential benefits of incorporating mobile text message reminders into the standard management of childhood immunizations, especially in low- and middle-income countries. The frequency and timing of the text message reminders are also crucial in determining the effectiveness of text message reminders. Hence, mHealth interventions deserve more attention as a potential innovation to improve healthcare programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074230.

Effectiveness of digital technologies at improving vaccine uptake and series completion - A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Recent outbreaks and renewed concerns about immunization coverage call for new and effective interventions to improve vaccine uptake. Digital technologies have the potential to help address both suboptimal vaccine uptake and series completion. However, the effectiveness of pushing information and reminders to patients through digital technologies to address vaccination is not known.

OBJECTIVE(S)

The aim of this study is to determine if digital push interventions are effective in increasing vaccine uptake and series completion compared to non-digital interventions.

METHODS

We searched for RCTs where adults or parents of children were eligible for vaccination, the intervention was digital-push and the comparison group was non-digital. We included outcomes of vaccine uptake or series completion. We estimated summary effect sizes, heterogeneity using the χ² test and quantified using the I² statistic. Where heterogeneity remained significant, we conducted subgroup analyses. We assessed risk of bias, certainty of evidence and publication bias.

RESULTS

The search identified 159 peer-reviewed scientific publications. After review, a total of 12 manuscripts representing 13 empirical studies published between 2012 and 2016 were included. When comparing digital push interventions to non-digital ones, patients had 1.18[1.11,1.25] the odds of receiving vaccination or series completion compared to controls. In parents of children aged 18 and younger, those receiving digital push had a 1.22[1.15,1.30] increased odds compared to controls. Both analyses had high statistical heterogeneity, with I² values of 86% and 79% respectively. The risk of bias was low with 10 of 13 studies considered low risk in five or more domains. The certainty of evidence for series completion was very low and for vaccine uptake was assessed to be moderate.

CONCLUSION

This study provides evidence that digital push technologies have a modest, positive impact on vaccine uptake and series completion compared to non-digital interventions.

Cell Phone and Computer Use Among Parents Visiting an Urban Pediatric Emergency Department

OBJECTIVES

The objectives of this study were to estimate the prevalence of cell phone and computer use among urban families bringing their children to an emergency department and to determine which technologies parents prefer to use to receive health information.

METHODS

We visited 2 pediatric emergency departments in Baltimore, Md, and Little Rock, Ark. A convenience sample of parents of children 8 years old or younger completed a self-administered survey in the waiting area.

RESULTS

Two hundred thirty-eight surveys were completed. Respondents were primarily female (83%), less than 35 years old (74%), and had at least a high school diploma or General Educational Development (94%). Forty-three percent were employed full time. A majority (95%) of respondents reported owning a cell phone, with most (88%) owning a smartphone and 96% reported having some internet access. Of cell phone owners, 91% reported daily text messaging activity. Over half (63%) of respondents reported having computer internet access at home; 31% reported having internet access at work. Patterns of behavior and preferences emerged for both cell phone and computer use. Respondents were more likely to check their email (75% vs 50%, P < 0.0001) and access the internet (78% vs 67%, P = 0.002) with a smartphone rather than their computer.

CONCLUSIONS

Both cell phones and computers are prevalent and used among urban families seen in pediatric emergency departments, offering new ways to deliver health information to these often underserved populations. Providers aiming to deliver health information should consider smartphone applications, text message-based programs, and email to communicate with their patients.

The use of technology to promote vaccination: A social ecological model based framework

Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.

Effect of Mobile Phone Text Message Reminders on Routine Immunization Uptake in Pakistan: Randomized Controlled Trial

Background

Improved routine immunization (RI) coverage is recommended as the priority public health strategy to decrease vaccine-preventable diseases and eradicate polio in Pakistan and worldwide.

Objective

The objective of this study was to ascertain whether customized, automated, one-way text messaging (short message service, SMS) reminders delivered to caregivers via mobile phones when a child is due for an RI visit can improve vaccination uptake and timelines in Pakistan.

Methods

This was a randomized controlled trial, conducted in an urban squatter settlement area of Karachi, Pakistan. Infants less than 2 weeks of age with at least one family member who had a valid mobile phone connection and was comfortable receiving and reading SMS text messages were included. Participants were randomized to the intervention (standard care + one-way SMS reminder) or control (standard care) groups. The primary outcome was to compare the proportion of children immunized up to date at 18 weeks of age. Vaccine given at 6, 10, and 14 weeks schedule includes DPT-Hep-B-Hib vaccine (ie, diphtheria, pertussis, and tetanus; hepatitis B; and Haemophilus influenza type b) and oral poliovirus vaccine (OPV). Data were analyzed using chi-square tests of independence and tested for both per protocol (PP) and intention-to-treat (ITT) analyses.

Results

Out of those approached, 84.3% (300/356) of the participants were eligible for enrollment and 94.1% (318/338) of the participants had a working mobile phone. Only children in the PP analyses, who received an SMS reminder for vaccine uptake at 6 weeks visit, showed a statistically significant difference (96.0%, 86/90 vs 86.4%, 102/118; P=.03).The immunization coverage was consistently higher in the intervention group according to ITT analyses at the 6 weeks scheduled visit (76.0% vs 71.3%, P=.36). The 10 weeks scheduled visit (58.7% vs 52.7%, P=.30) and the 14 weeks scheduled visit (31.3% vs 26.0%, P=.31), however, were not statistically significant.

Conclusions

Automated simple one-way SMS reminders in local languages might be feasible for improving routine vaccination coverage. Whether one-way SMS reminders alone can have a strong impact on parental attitudes and behavior for improvement of RI coverage and timeliness needs to be further evaluated by better-powered studies and by comparing different types and content of text messages in low-and middle-income countries (LMICs).

Trial Registration

ClinicalTrials.gov NCT01859546; https://clinicaltrials.gov/ct2/show/NCT01859546 (Archived by WebCite at http://www.webcitation.org/6xFr57AOc)

Patient reminder and recall interventions to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.

OBJECTIVES

To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.

SELECTION CRITERIA

We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.

MAIN RESULTS

The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).

AUTHORS' CONCLUSIONS

Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Newborn follow-up after discharge from a tertiary care hospital in the Western Cape region of South Africa: a prospective observational cohort study

Background

Current practice in the Western Cape region of South Africa is to discharge newborns born in-hospital within 24 h following uncomplicated vaginal delivery and two days after caesarean section. Mothers are instructed to bring their newborn to a clinic after discharge for a health assessment. We sought to determine the rate of newborn follow-up visits and the potential barriers to timely follow-up.

Methods

Mother-newborn dyads at Tygerberg Hospital in Cape Town, South Africa were enrolled from November 2014 to April 2015. Demographic data were obtained via questionnaire and medical records. Mothers were contacted one week after discharge to determine if they had brought their newborns for a follow-up visit, and if not, the barriers to follow-up. Factors associated with follow-up were analyzed using logistic regression.

Results

Of 972 newborns, 794 (82%) were seen at a clinic for a follow-up visit within one week of discharge. Mothers with a higher education level or whose newborns were less than 37 weeks were more likely to follow up. The follow-up rate did not differ based on hospital length of stay. Main reported barriers to follow-up included maternal illness, lack of money for transportation, and mother felt follow-up was unnecessary because newborn was healthy.

Conclusions

Nearly 4 in 5 newborns were seen at a clinic within one week after hospital discharge, in keeping with local practice guidelines. Further research on the outcomes of this population and those who fail to follow up is needed to determine the impact of postnatal healthcare policy.

Effectiveness and Appropriateness of mHealth Interventions for Maternal and Child Health: Systematic Review

Background

The application of mobile health (mHealth) technology in reproductive, maternal, newborn, and child health (RMNCH) is increasing worldwide. However, best practice and the most effective mHealth interventions have not been reviewed systematically.

Objective

A systematic review and meta-analysis of studies of mHealth interventions for RMNCH around the world were conducted to investigate their characteristics as well as the features and effectiveness of mHealth interventions.

Methods

Studies of mHealth interventions for RMNCH between January 2011 and December 2016 were retrieved from 6 databases (PubMed, EMBASE, Global Health, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, and Wanfang Data Knowledge Service Medium). Comparable studies were included in a random-effects meta-analysis for both exclusive breastfeeding (EBF) and antenatal checks (ANC). Descriptive analyses were conducted for mHealth studies with a range of study designs.

Results

Analyses of 245 studies were included, including 51 randomized controlled trials (RCTs). Results showed that there are increasing numbers of studies on mHealth interventions for RMNCH. Although 2 meta-analysis, one with 2 RCTs on EBF (odds ratio [OR] 2.03, 95% CI 1.34-3.08, I²=25%) and the other with 3 RCTs on ANC (OR 1.43, 95% CI 1.13-1.79, I²=78%), showed that mHealth interventions are more effective than usual care, almost half (43%) of RCTs showed negative or unclear results on mHealth interventions. Functions described in mHealth interventions were diverse, and the health stages covered were broad. However, single function or single stage appeared to be dominant among mHealth interventions compared with multiple functions or stages.

Conclusions

More rigorous evaluations are needed to draw consistent conclusions and to analyze mHealth products with multiple functions, especially those popular in the app markets.

Characteristics of mobile phone access and usage in rural and urban Guatemala: assessing feasibility of text message reminders to increase childhood immunizations

BACKGROUND

Despite efforts to promote vaccination in low- and middle-income countries (LMICs), over 20 million infants remain under-immunized and at risk for unnecessary morbidity and mortality. Mobile health technologies, such as Short Message Service (SMS) texts, have tremendous and untapped potential for disease management. Patient reminder systems are an important mechanism for improving childhood vaccination coverage and can be easily adapted to SMS platforms. However, current research lacks an understanding of the barriers and facilitators to mHealth program design, implementation, and scale in LMICs.

METHODS

We analyzed survey data collected March-November 2016 at the enrollment visit from a randomized controlled trial conducted at public health clinics in urban and rural Guatemala. Participants included eligible infants 6 weeks to 6 months of age receiving the first dose of the primary immunization series. At least one parent needed to own a mobile phone and be capable of deciphering SMS. Chi-square or Fisher's exact and Student's t-test were used to assess significance levels in demographic differences to describe factors that contribute to the feasibility of using an SMS-based vaccination reminder system.

RESULTS

Of 1,088 families approached for enrollment, 871 were eligible and 720 (82.7%) participated with equal numbers of urban and rural children enrolled; 54 parents did not own a mobile phone with SMS capability and three parents could not use SMS. There was no significant difference between urban and rural maternal mobile phone ownership (94.4% vs. 93.3%, P=0.53), but more urban fathers owned mobile phones (72.8% vs. 47.1%, P<0.0001) and, overall, more mothers compared to fathers owned mobile phones (93.9% vs. 61.1%, P<0.0001). Most families (90.4%) chose to have reminders sent to the mother. Urban participants reported more mobile phones present in the home (P<0.0001), but rural participants reported more telephone landlines (34.7% vs. 15.6%, P<0.0001). Most participants reported a daily average of ≤5 telephone calls made (87.4%), ≤10 texts sent (91.0%), and ≤10 texts received (89.9%), with urban families reporting greater telephone usage (P=0.006, P<0.001, and P<0.001 respectively). Parents preferred to make calls over sending texts (74.7% vs. 25.3%, P<0.0001), with more urban families preferring text messaging (31.9% vs. 18.6%, P<0.0001).

CONCLUSIONS

Our study results provide important insight into mobile phone access, usage, and preferences for voice and text communication across rural and urban populations of an LMIC that can be used to inform future mHealth interventions. Our findings suggest that offering a combination of more traditional communication methods with newer, modern technologies may be more effective at reminding families about vaccination visits, particularly for our rural population, and that targeting mothers for mobile phone interventions may provide the greatest benefits. Overall, our study suggests that using SMS reminders in LMICs can be a feasible tool for public health interventions.

Facilitating Development Research: Suggestions for Recruiting and Re-Recruiting Children and Families

Recruiting children and families for research studies can be challenging, and re-recruiting former participants for longitudinal research can be even more difficult, especially when a study was not prospectively designed to encompass continuous data collection. In this article, we explain how researchers can set up initial studies to potentially facilitate later waves of data collection; locate former study participants using newer, often digital, tools; schedule families using recruitment phone/email/mail scripts that highlight the many benefits to continued study participation; and confirm appointments with other digital tools. We draw from prior methodological and longitudinal pieces to provide suggestions to others wishing to re-recruit families for longitudinal studies. In addition, we draw upon our own experience conducting a non-prospective longitudinal study 6 years after an educational intervention, in which we successfully re-located 122 (90%) and interviewed 101 of 136 (83% of the located sample and 74% of the full original sample) parents and their early adolescent children. Although the majority of participants were recruited via original contact information (especially phone numbers), using a range of strategies to recruit (e.g., search engines focused on contact information, social media) and motivate participation (e.g., multifaceted phone/email/mail scheduling scripts, flexibility in location and means of participation) yielded a more desirable sample size at relatively low costs.

Mobile Health Interventions for Improving Health Outcomes in Youth: A Meta-analysis

IMPORTANCE

Mobile health interventions are increasingly popular in pediatrics; however, it is unclear how effective these interventions are in changing health outcomes.

OBJECTIVE

To determine the effectiveness of mobile health interventions for improving health outcomes in youth 18 years or younger.

DATA SOURCES

Studies published through November 30, 2016, were collected through PubMed, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, and PsychINFO. Backward and forward literature searches were conducted on articles meeting study inclusion criteria. Search terms included telemedicine, eHealth, mobile health, mHealth, app, and mobile application.

STUDY SELECTION

Search results were limited to infants, children, adolescents, or young adults when possible. Studies were included if quantitative methods were used to evaluate an application of mobile intervention technology in a primary or secondary capacity to promote or modify health behavior in youth 18 years or younger. Studies were excluded if the article was an unpublished dissertation or thesis, the mean age of participants was older than 18 years, the study did not assess a health behavior and disease outcome, or the article did not include sufficient statistics. Inclusion and exclusion criteria were applied by 2 independent coders with 20% overlap. Of 9773 unique articles, 36 articles (containing 37 unique studies with a total of 29 822 participants) met the inclusion criteria.

DATA EXTRACTION AND SYNTHESIS

Of 9773 unique articles, 36 articles (containing 37 unique studies) with a total of 29 822 participants met the inclusion criteria. Effect sizes were calculated from statistical tests that could be converted to standardized mean differences. All aggregate effect sizes and moderator variables were tested using random-effects models.

MAIN OUTCOMES AND MEASURES

Change in health behavior or disease control.

RESULTS

A total of 29 822 participants were included in the studies. In studies that reported sex, the total number of females was 11 226 (53.2%). Of those reporting age, the average was 11.35 years. The random effects aggregate effect size of mobile health interventions was significant (n = 37; Cohen d = 0.22; 95% CI, 0.14-0.29). The random effects model indicated that providing mobile health intervention to a caregiver increased the strength of the intervention effect. Studies that involved caregivers in the intervention produced effect sizes (n = 16; Cohen d = 0.28; 95% CI, 0.18-0.39) larger than those that did not include caregivers (n = 21; Cohen d = 0.13; 95% CI, 0.02-0.25). Other coded variables did not moderate study effect size.

CONCLUSIONS AND RELEVANCE

Mobile health interventions appear to be a viable health behavior change intervention modality for youth. Given the ubiquity of mobile phones, mobile health interventions offer promise in improving public health.

A Research Protocol to Test the Effectiveness of Text Messaging and Reminder Calls to Increase Service Use Referrals in a Community Engagement Program

Background

Mobile phoned–based interventions have been increasingly used in clinical populations to improve health and health care delivery. The literature has shown that mobile phone–based text messages (short message service, SMS) are instantaneous, cost effective, and have less chance of being misplaced. Studies using mobile phone based–text messages have reported text messages as effective reminders that have resulted in increased appointment attendance, adherence to treatment, and better self-management. There have been no reports of adverse events when using text messaging in terms of misreading or misinterpreting data, transmitting inaccurate data, losing verbal or nonverbal communication cues, privacy issues, or failure or delay in message delivery. However, the literature has cited a need for personalized messages that are more responsive to individual needs. In addition, there has been a dearth of information on the use of reminders in nonclinical populations.

Objective

The goal of this study is to assess the effectiveness of adding reminders in the form of text messaging versus reminder calls versus text messages and reminder calls to increase use of service referrals provided through community outreach.

Methods

A total of 300 participants will be recruited for the study. Each participant will be randomized to one of three arms: a group that receives only reminder calls (CALLSONLY); a group that receives only text message reminders (TEXTONLY); and a group that receives both reminder calls and text messages (CALLS+TEXT). All groups will receive their reminder intervention on the 15th and 45th day after baseline when they receive medical and social service referrals from the community health workers (CHWs). A standard script will be used to administer the call and text reminders and a 15-item telephone-based satisfaction survey will be administered to assess the participant satisfaction with the process of receiving periodic reminders.

Results

The study is in the recruitment and follow-up phase. The authors anticipate completion of recruitment, interventions, and data entry by July 2016. Preliminary results are expected to be available by September 2016.

Conclusions

This study will provide an opportunity to test the effectiveness of mobile-based interventions on nonclinical, community-recruited populations. In particular, such a protocol would increase the effectiveness of a community-based engagement program by instating a formal reminder system for all program members who receive social and/or medical service referrals during outreach in the community. Findings from this study would guide the development and implementation of reminder protocols for community-based engagement programs nationwide.

SMS text message reminders to improve infant vaccination coverage in Guatemala: A pilot randomized controlled trial

•

A novel SMS vaccine reminder platform was created in a LMIC.

•

SMS vaccine reminders were proven feasible to implement in a LMIC.

•

SMS vaccine reminders were acceptable to use in a LMIC with high user satisfaction.

•

SMS vaccine reminders have the potential for widespread scalability at low cost.

Background

Patient reminder systems are an evidence-based way to improve childhood vaccination rates but are difficult to implement in low- and middle-income countries (LMICs). Short Message Service (SMS) texts may offer a potential low-cost solution, especially in LMICs where mobile phones are becoming more ubiquitous.

Objective

To determine if an SMS-based vaccination reminder system aimed at improving completion of the infant primary immunization series is feasible and acceptable in Guatemala.

Methods

A pilot randomized controlled trial was conducted at two public health clinics in Guatemala City. Infants aged 8–14 weeks presenting for the first dose of the primary immunization series were enrolled in March–April 2013. Participants randomized into the intervention received three SMS reminders one week before the second and third dose. A follow-up acceptability survey was administered to both groups.

Results

The participation rate was 86.8% (321/370); 8 did not own a cell phone and 12 could not use SMS. 96.9% of intervention parents were sent at least one SMS reminder prior to visit 2 and 96.3% prior to visit 3. Both intervention and usual care participants had high rates of vaccine and visit completion, with a non-statistically significant higher percentage of children in the intervention completing both visit 2 (95.0% vs. 90.1%, p = .12) and visit 3 (84.4% vs. 80.7%, p = .69). More intervention vs. usual care parents agreed that SMS reminders would be helpful for remembering appointments (p < .0001), agreed to being interested in receiving future SMS reminders (p < .0001), and said that they would be willing to pay for future SMS reminders (p = .01).

Conclusion

This proof of concept evaluation showed that a new application of SMS technology is feasible to implement in a LMIC with high user satisfaction. Larger studies with modifications in the SMS system are needed to determine effectiveness (Clinical Trial Registry NCT01663636).

Interventions to Improve Adolescent Vaccination: What May Work and What Still Needs to Be Tested

Since the development of the "adolescent platform" of vaccination in 1997, hundreds of studies have been conducted, identifying barriers to and facilitators of adolescent vaccination. More recent research has focused on developing and evaluating interventions to increase uptake of adolescent vaccines. This review describes a selection of recent intervention studies for increasing adolescent vaccination, divided into three categories: those with promising results that may warrant more widespread implementation, those with mixed results requiring more research, and those with proven effectiveness in other domains that have not yet been tested with regard to adolescent vaccination.

Effectiveness and Cost of Bidirectional Text Messaging for Adolescent Vaccines and Well Care

OBJECTIVE

To evaluate the effectiveness and cost of bidirectional short messaging service in increasing rates of vaccination and well child care (WCC) among adolescents.

METHODS

We included all adolescents needing a recommended adolescent vaccine (n = 4587) whose parents had a cell-phone number in 5 private and 2 safety-net pediatric practices. Adolescents were randomized to intervention (n = 2228) or control (n = 2359). Parents in the intervention group received up to 3 personalized short messaging services with response options 1 (clinic will call to schedule), 2 (parent will call clinic), or STOP (no further short messaging service). Primary outcomes included completion of all needed services, WCC only, all needed vaccinations, any vaccination, and missed opportunity for vaccination.

RESULTS

Intervention patients were more likely to complete all needed services (risk ratio [RR] 1.31, 95% confidence interval [CI] 1.12-1.53), all needed vaccinations (RR 1.29, 95% CI 1.12-1.50), and any vaccination (RR 1.36, 95% CI 1.20-1.54). Seventy-five percent of control patients had a missed opportunity versus 69% of intervention (P = .002). There was not a significant difference for WCC visits. Responding that the clinic should call to schedule ("1") was associated with the highest effect size for completion of all needed services (RR 1.89, 95% CI 1.41-2.54). Net cost ranged from $855 to $3394 per practice.

CONCLUSIONS

Bidirectional short messaging service to parents was effective at improving rates for all adolescent vaccinations and for all needed services, especially among parents who responded they desired a call from the practice.

Text message reminders for timely routine MMR vaccination: A randomized controlled trial

OBJECTIVE

Measles-mumps-rubella (MMR) vaccination is important for preventing disease outbreaks, yet pockets of under-vaccination persist. Text message reminders have been employed successfully for other pediatric vaccines, but studies examining their use for MMR vaccination are limited. This study assessed the impact of text message reminders on timely MMR vaccination.

STUDY DESIGN

Parents (n=2054) of 9.5-10.5-month-old children from four urban academically-affiliated pediatric clinics were randomized to scheduling plus appointment text message reminders, appointment text message reminder-only, or usual care. The former included up to three text reminders to schedule the one-year preventive care visit. Both text messaging arms included a text reminder sent 2 days before that visit. Outcomes included appointment scheduling, appointment attendance, and MMR vaccination by age 13 months, the standard of care at study sites.

RESULTS

Children of parents in the scheduling plus appointment text message reminders arm were more likely to have a scheduled one-year visit than those in the other arms (71.9% vs. 67.4%, relative risk ratio (RRR) 1.07 [95% CI 1.005-1.13]), particularly if no appointment was scheduled before randomization (i.e., no baseline appointment) (62.1% vs. 54.7%, RRR 1.14 [95% CI 1.04-1.24]). One-year visit attendance and timely MMR vaccination were similar between arms. However, among children without a baseline appointment, those with parents in the scheduling plus appointment text message reminders arm were more likely to undergo timely MMR vaccination (61.1% vs. 55.1%, RRR 1.11 [95% CI 1.01-1.21]).

CONCLUSION

Text message reminders improved timely MMR vaccination of high-risk children without a baseline one-year visit.

Vaccines4Kids: Assessing the impact of text message reminders on immunization rates in infants

The purpose of this study was to examine the effect text messages (TM) immunization reminders have on immunization rates in the first 7 months of life. This randomized-control trial enrolled 57 parent/infant dyads and had a 74% completion rate (43) at the end of the study period. The study was approved by Committee on Human Subjects at the University of Hawaii Institutional Board Review. All participants completed a demographics form and a Barriers to Immunization Survey (SHOTS survey) at the start and end of the study. Parents received TM at 4, 7, 12, 15, 20, & 23 weeks of child's age. The intervention group received immunization reminders and the control group received healthy baby messages. In the overall mixed model, between enrollment and 7 months of age, the barriers to immunizations decreased for all parents significantly. There were no significant differences in immunization rates between groups at 7 months of age. Positive responses from regarding TM interventions show this is a promising intervention, but further research is required regarding how to address behavior change and motivation for health prevention behaviors with TM.

Parental reminder, recall and educational interventions to improve early childhood immunisation uptake: A systematic review and meta-analysis

Vaccination is one of the most effective ways of reducing childhood mortality. Despite global uptake of childhood vaccinations increasing, rates remain sub-optimal, meaning that vaccine-preventable diseases still pose a public health risk. A range of interventions to promote vaccine uptake have been developed, although this range has not specifically been reviewed in early childhood. We conducted a systematic review and meta-analysis of parental interventions to improve early childhood (0-5 years) vaccine uptake. Twenty-eight controlled studies contributed to six separate meta-analyses evaluating aspects of parental reminders and education. All interventions were to some extent effective, although findings were generally heterogeneous and random effects models were estimated. Receiving both postal and telephone reminders was the most effective reminder-based intervention (RD=0.1132; 95% CI=0.033-0.193). Sub-group analyses suggested that educational interventions were more effective in low- and middle-income countries (RD=0.13; 95% CI=0.05-0.22) and when conducted through discussion (RD=0.12; 95% CI=0.02-0.21). Current evidence most supports the use of postal reminders as part of the standard management of childhood immunisations. Parents at high risk of non-compliance may benefit from recall strategies and/or discussion-based forums, however further research is needed to assess the appropriateness of these strategies.

Direct messaging to parents/guardians to improve adolescent immunizations

PURPOSE

To study the impact on adolescent immunization rates of direct messages to parents/guardians.

METHODS

Electronic health record rules identified adolescents needing an immunization. Parents/guardians of adolescents were messaged via a single vendor using automated text, prerecorded voice, and/or postcard.

RESULTS

Parents/guardians of 3,393 patients, ages 11-18 years, with one or more primary care visits in the prior 2 years, identified as needing (average of 2.04 years) a vaccination (meningococcal conjugate, human papillomavirus, or tetanus, diphtheria, and pertussis vaccines) were messaged (mean age, 14 years; 50% male; 38% African-American; 23% white; 19% Hispanic; and 79% public health insurance). A total of 7,094 messages were sent: 3,334 automated voice (47%), 2,631 texts (37%), and 1,129 postcards (16%). After the first message, 865 adolescents (25.5%) received at least one vaccine. Within 24 weeks of messaging 1,324 vaccines (745 human papillomavirus; 403 meningococcal conjugate; and 176 tetanus, diphtheria, and pertussis vaccines) occurred in 959 visits (83.8% physician visits and 16.2% nurse visits). Average visits generated $204 gross reimbursement for $1.77 in messaging expenses per vaccine given. No differences in immunization completion rates occurred by age, gender, race/ethnicity, or insurance type. At 24 weeks, one message was more effective than two or three messages (35.6%, 19.4%, and 24.1% effectiveness, respectively; p < .0001). Texts and postcards correlated with more vaccination visits (38.8% and 40.1%, respectively) than phone calls (31.5%; p = .04). More vaccines due led to increasing message effectiveness.

CONCLUSIONS

Automated texts, voice messages, and postcards had a significant positive effect on vaccination rates in adolescents needing vaccination and required minimal financial expenditure.

Comparison of reminder methods in selected adolescents with records in an immunization registry

PURPOSE

The aim of this study was to assess the effectiveness and cost efficiency of three reminder/recall methods for improving adolescent vaccination rates using the San Diego Immunization Registry.

METHODS

Parents of 5,050 adolescents whose records indicated they lacked one or more adolescent vaccines were identified from the San Diego Immunization Registry and contacted by telephone. Based on their preference, consenting participants were enrolled to receive either postal mail (n = 282), e-mail (n = 963), or text (n = 552) reminders for vaccination. The intervention groups were sent a series of up to three reminders. The vaccination completion rate was compared between the intervention groups and two control groups-the enrollment phone call-only group who declined to participate and a no contact group-using logistic regression.

RESULTS

The participants who received any reminder were more likely (24.6% vs. 12.4%; p < .001) to become up-to-date (UTD) than those in the enrollment phone call-only group. At the conclusion of the study observation, UTD status was reached by 32.1% of text message recipients, 23.0% of postcard recipients, and 20.8% of e-mail recipients compared to 12.4% for the enrollment phone call recipients. Only 9.7% of nonintervention adolescents became UTD.

CONCLUSIONS

All three reminder interventions were effective in improving adolescent vaccination rates. Although postal mail reminders were preferred by most participants, text messaging and e-mail were the more effective reminder methods. Text messaging and e-mail as reminder methods for receiving vaccinations should be considered for use to boost vaccination completion among adolescents.

Factors associated with non-adherence to scheduled medical follow-up appointments among Cameroonian children requiring HIV care: a case-control analysis of the usual-care group in the MORE CARE trial

BACKGROUND

A better understanding of why HIV-exposed/infected children fail to attend their scheduled follow-up medical appointments for HIV-related care would allow for interventions to enhance the delivery of care. The aim of this study was to determine characteristics of the caregiver-child dyad (CCD) associated with children's non-adherence to scheduled follow-up medical appointments in HIV programs in Cameroon.

METHODS

We conducted a case-control analysis of the usual-care group of CCDs from the MORE CARE trial, in which the effect of mobile phone reminders for HIV-exposed/infected children in attending follow-up appointments was assessed from January to March 2013. For this study, the absence of a child at their appointment was considered a case and the presence of a child at their appointment was defined as a control. We used three multivariate binary logistic regression analyses. The best-fit model was the one which had the smallest chi-square value with the Hosmer-Lemeshow test (HLχ²). Magnitudes of associations were expressed by odds ratio (OR), with a p-value <0.05 considered as statistically significant.

RESULTS

We included 30 cases and 31 controls. Our best-fit model which considered the sex of the adults and children separately (HL χ²=3.5) showed that missing scheduled medical appointments was associated with: lack of formal education of the caregiver (OR 29.1, 95% CI 1.1-777.0; p=0.044), prolonged time to the next appointment/follow-up (OR [1 week increase] 1.4, 95% CI 1.03-2.0; p=0.032), and being a female child (OR 5.2, 95% CI 1.2-23.1; p=0.032). One model (HLχ²=10.5) revealed that woman-boy pairs adhered less to medical appointments compared to woman-girl pairs (OR 4.9, 95% CI 1.05-22.9; p=0.044). Another model (HLχ²=11.1) revealed that man-boy pairs were more likely to attend appointments compared to woman-girl pairs (OR 0.23, 95% CI 0.06-0.93; p=0.039). There were no statistical associations for the ages of the children or the caregivers, the study sites, or the HIV status (confirmed vs. suspected) of the children.

CONCLUSION

The profile of children who would not attend follow-up medical appointments in an HIV program was: a female, with a caregiver who has had no formal education, and with a longer follow-up appointment interval. There is a possibility that female children are favored by female caregivers and that male children are favored by male caregivers when they come to medical care.

Effectiveness of interventions that apply new media to improve vaccine uptake and vaccine coverage

BACKGROUND

Vaccine-preventable diseases (VPD) are still a major cause of morbidity and mortality worldwide. In high and middle-income settings, immunization coverage is relatively high. However, in many countries coverage rates of routinely recommended vaccines are still below the targets established by international and national advisory committees. Progress in the field of communication technology might provide useful tools to enhance immunization strategies.

OBJECTIVE

To systematically collect and summarize the available evidence on the effectiveness of interventions that apply new media to promote vaccination uptake and increase vaccination coverage.

DESIGN

We conducted a systematic literature review. Studies published from January 1999 to September 2013 were identified by searching electronic resources (Pubmed, Embase), manual searches of references and expert consultation. Study setting We focused on interventions that targeted recommended vaccinations for children, adolescents and adults and: (1) aimed at increasing community demand for immunizations, or (2) were provider-based interventions. We limited the study setting to countries that are members of the Organisation for Economic Co-operation and Development (OECD).

MAIN OUTCOME MEASURES

The primary outcome was a measure of vaccination (vaccine uptake or vaccine coverage). Considered secondary outcomes included willingness to receive immunization, attitudes and perceptions toward vaccination, and perceived helpfulness of the intervention.

RESULTS

Nineteen studies were included in the systematic review. The majority of the studies were conducted in the US (74%, n = 14); 68% (n = 13) of the studies were experimental, the rest having an observational study design. Eleven (58%) reported results on the primary outcome. Retrieved studies explored the role of: text messaging (n.7, 37%), smartphone applications (n.1, 5%), Youtube videos (n.1, 5%), Facebook (n.1, 5%), targeted websites and portals (n.4, 21%), software for physicians and health professionals (n.4, 21%), and email communication (n.1, 5%). There is some evidence that text messaging, accessing immunization campaign websites, using patient-held web-based portals and computerized reminders increase immunization coverage rates. Insufficient evidence is available on the use of social networks, email communication and smartphone applications.

CONCLUSION

Although there is great potential for improving vaccine uptake and vaccine coverage by implementing programs and interventions that apply new media, scant data are available and further rigorous research - including cost-effectiveness assessments - is needed.

Use of mobile phone text message reminders in health care services: a narrative literature review

BACKGROUND

Mobile text messages are a widely recognized communication method in societies, as the global penetration of the technology approaches 100% worldwide. Systematic knowledge is still lacking on how the mobile telephone text messaging (short message service, SMS) has been used in health care services.

OBJECTIVE

This study aims to review the literature on the use of mobile phone text message reminders in health care.

METHODS

We conducted a systematic literature review of studies on mobile telephone text message reminders. The data sources used were PubMed (MEDLINE), CINAHL, Proquest Databases/ PsycINFO, EMBASE, Cochrane Library, Scopus, and hand searching since 2003. Studies reporting the use of SMS intended to remind patients in health services were included. Given the heterogeneity in the studies, descriptive characteristics, purpose of the study, response rates, description of the intervention, dose and timing, instruments, outcome measures, and outcome data from the studies were synthesized using a narrative approach.

RESULTS

From 911 initial citations, 60 studies were included in the review. The studies reported a variety of use for SMS. Mobile telephone text message reminders were used as the only intervention in 73% (44/60) of the studies, and in 27% (16/60) of the remaining studies, SMS was connected to another comprehensive health intervention system. SMS reminders were sent to different patient groups: patients with HIV/AIDS (15%, 9/60) and diabetes (13%, 8/60) being the most common groups. The response rates of the studies varied from 22-100%. Typically, the text message reminders were sent daily. The time before the specific intervention to be rendered varied from 10 minutes (eg, medication taken) to 2 weeks (eg, scheduled appointment). A wide range of different evaluation methods and outcomes were used to assess the impact of SMS varying from existing databases (eg, attendance rate based on medical records), questionnaires, and physiological measures. About three quarters of the studies (77%, 46/60) reported improved outcomes: adherence to medication or to treatment reportedly improved in 40% (24/60) of the studies, appointment attendance in 18% (11/60) of the studies, and non-attendance rates decreased in 18% (11/60) of the studies. Other positive impacts were decreased amount of missed medication doses, more positive attitudes towards medication, and reductions in treatment interruptions.

CONCLUSIONS

We can conclude that although SMS reminders are used with different patient groups in health care, SMS is less systematically studied with randomized controlled trial study design. Although the amount of evidence for SMS application recommendations is still limited, having 77% (46/60) of the studies showing improved outcomes may indicate its use in health care settings. However, more well-conducted SMS studies are still needed.

Outcomes after management of young women with cervical intraepithelial neoplasia 2 with a 6-month observation protocol

OBJECTIVE

Recommendations regarding treatment of cervical intraepithelial neoplasia (CIN) 2 in women have evolved over the years: young women with CIN 2 may be offered observation with Pap smears and colposcopy every 6 months instead of immediate excision or ablation of disease. The purpose of this study was to observe patient follow-up during the initiation of this management protocol for young women with CIN 2.

MATERIALS AND METHODS

This was a retrospective review of clinical outcomes of women younger than 30 years with CIN 2 on index biopsy and planned follow-up at UNC between July 2009 and August 2010. A chart review for clinical variables, follow-up visits, and progression of disease was conducted. Primary analysis determined the rate of follow-up and pathology at 6 months. Secondary analysis investigated risk factors for incomplete follow-up.

RESULTS

Seventy women met inclusion criteria; 46 were managed with observation. Twenty-eight (60.8%; 28/46) women completed a follow-up visit. Demographic and clinical variables did not reach statistical significance in predicting the likelihood of completion of a follow-up visit, although there was a trend toward greater follow-up in employed patients (odds ratio = 5.25, 95% confidence interval = 0.84-34.78). Approximately half (52.4%; 11/21) of women with a completed cervical biopsy demonstrated regression of disease during the study period.

CONCLUSIONS

On the basis of these data, follow-up in this population was unpredictable based on basic demographic or clinical factors that we often use to judge likelihood of compliance with medical recommendations. The percentage of patients with regression at follow-up was as expected from the natural history of CIN 2.

Mobile phones support adherence and retention of indigenous participants in a randomised controlled trial: strategies and lessons learnt

BACKGROUND

Ensuring adherence to treatment and retention is important in clinical trials, particularly in remote areas and minority groups. We describe a novel approach to improve adherence, retention and clinical review rates of Indigenous children.

METHODS

This descriptive study was nested within a placebo-controlled, randomised trial (RCT) on weekly azithromycin (or placebo) for 3-weeks. Indigenous children aged ≤24-months hospitalised with acute bronchiolitis were recruited from two tertiary hospitals in northern Australia (Darwin and Townsville). Using mobile phones embedded within a culturally-sensitive approach and framework, we report our strategies used and results obtained. Our main outcome measure was rates of adherence to medications, retention in the RCT and self-presentation (with child) to clinic for a clinical review on day-21.

RESULTS

Of 301 eligible children, 76 (21%) families declined participation and 39 (13%) did not have access to a mobile phone. 186 Indigenous children were randomised and received dose one under supervision in hospital. Subsequently, 182 (99%) children received dose two (day-7), 169 (93%) dose three (day-14) and 180 (97%) attended their clinical review (day-21). A median of 2 calls (IQR 1-3) were needed to verify adherence. Importantly, over 97% of children remained in the RCT until their clinical endpoint at day-21.

CONCLUSIONS

In our setting, the use of mobile phones within an Indigenous-appropriate framework has been an effective strategy to support a clinical trial involving Australian Indigenous children in urban and remote Australia. Further research is required to explore other applications of this approach, including the impact on clinical outcomes.

TRIAL REGISTRATION

ACTRN12608000150347 (RCT component).

Effect of mobile phone reminders on follow-up medical care of children exposed to or infected with HIV in Cameroon (MORE CARE): a multicentre, single-blind, factorial, randomised controlled trial

BACKGROUND

Missed scheduled HIV appointments lead to increased mortality, resistance to antiretroviral therapy, and suboptimum virological response. We aimed to assess whether reminders sent to carers by text message, mobile phone call, or concomitant text message and mobile phone call increase attendance at medical appointments for HIV care in a population of children infected with or exposed to HIV in Cameroon. We also aimed to ascertain the most cost-effective method of mobile-phone-based reminder.

METHODS

MORE CARE was a multicentre, single-blind, factorial, randomised controlled trial in urban, semi-urban, and rural settings in Cameroon. Carers of children who were infected with or had been exposed to HIV were randomly assigned electronically in blocks of four and allocated (1:1:1:1) sequentially to receive a text message and a call, a text message only, a call only, or no reminder (control). Investigators were masked to group assignment. Text messages were sent and calls made 2 or 3 days before a scheduled follow-up appointment. The primary outcomes were efficacy (the proportion of patients attending a previously scheduled appointment) and efficiency (attendance/[measures of staff working time × cost of the reminders]), as a measure of cost-effectiveness. The primary analysis was by intention to treat. This study is registered with the Pan African Clinical Trials Register, number PACTR201304000528276.

FINDINGS

The study took place between Jan 28 and May 24, 2013. We randomly assigned 242 adult-child (carer-patient) pairs into four groups: text message plus call (n=61), call (n=60), text message (n=60), and control (n=61). 54 participants (89%) in the text message plus call group, 51 (85%) in the call group, 45 (75%) in the text message group, and 31 (51%) in the control group attended their scheduled appointment. Compared with control, the odds ratios for improvement in the primary efficacy outcome were 7·5 (95% CI 2·9-19·0; p<0·0001) for text message plus call, 5·5 (2·3-13·1; p=0·0002) for call, and 2·9 (1·3-6·3; p=0·012) for text message. No significant differences were seen in comparisons of the three intervention groups with each other, and there was no synergism between text messages and calls. For the primary efficiency outcome, the mean difference for text message versus text message plus call was 1·5 (95% CI 0·7 to 2·4; p=0·002), for call versus text message plus call was 1·2 (0·7 to 1·6; p<0·0001), and for call versus text message was 0·4 (-1·3 to 0·6; p=0·47).

INTERPRETATION

Mobile-phone-based reminders of scheduled HIV appointments for carers of paediatric patients in low-resource settings can increase attendance. The most effective method of reminder was text message plus phone call, but text messaging alone was the most efficient (ie, cost-effective) method.

FUNDING

No external funding.

Is health literacy related to health behaviors and cell phone usage patterns among the text4baby target population?

BACKGROUND

Text4baby provides educational text messages to pregnant and postpartum women and targets underserved women. The primary purpose of this study is to examine the health behaviors and cell phone usage patterns of a text4baby target population and the associations with health literacy.

METHODS

Pregnant and postpartum women were recruited from two Women, Infant and Children clinics in Atlanta. Women were asked about their demographics, selected pregnancy or postpartum health behaviors, and cell phone usage patterns. Health literacy skills were measured with the English version of the Newest Vital Sign. Multivariable logistic regression was used to examine health behaviors and cell usage patterns by health literacy classification, controlling for commonly accepted confounders.

RESULTS

Four hundred sixty-eight women were recruited, and 445 completed the Newest Vital Sign. Of these, 22% had inadequate health literacy, 50% had intermediate health literacy, and 28% had adequate health literacy skills. Compared to adequate health literacy, limited literacy was independently associated with not taking a daily vitamin during pregnancy (OR 3.6, 95% CI: 1.6, 8.5) and never breastfeeding their infant (OR 1.4, 95% CI: 1.1, 1.8). The majority (69.4%) of respondents received nine or more text messages a day prior to enrollment, one in four participants (24.6%) had changed their number within the last six months, and 7.0% of study participants shared a cell phone. Controlling for potentially confounding factors, those with limited health literacy were more likely to share a cell phone than those with adequate health literacy (OR 2.57, 95% CI: 1.79, 3.69).

CONCLUSIONS

Text4baby messages should be appropriate for low health literacy levels, especially as this population may have higher prevalence of targeted unhealthy behaviors. Text4baby and other mhealth programs targetting low health literacy populations should also be aware of the different ways that these populations use their cell phones, including: sharing cell phones, which may mean participants will not receive messages or have special privacy concerns; frequently changing cell phone numbers which could lead to higher drop-off rates; and the penetrance of text messages in a population that receives many messages daily.

mHealth: Using Mobile Technology to Support Healthcare

Adherence to long-term therapy in outpatient setting is required to reduce the prevalence of chronic diseases such as HIV/AIDS, Diabetes, Tuberculosis and Malaria. This paper presents a mobile technology-based medical alert system for outpatient adherence in Nigeria. The system makes use of the SMS and voice features of mobile phones. The system has the potential of improving adherence to medication in outpatient setting by reminding patients of dosing schedules and attendance to scheduled appointments through SMS and voice calls. It will also inform patients of benefits and risks associated with adherence. Interventions aimed at improving adherence would provide significant positive return on investment through primary prevention (of risk factors) and secondary prevention of adverse health outcomes.