Evaluation of SMS reminder messages for altering treatment adherence and health seeking perceptions among malaria care-seekers in Nigeria

Investigating How the Use of Technology Can Reduce Missed Appointments: Quantitative Case Study at a General Practitioner Surgery

BACKGROUND

SMS texting systems have been considered a potential solution to reduce missed appointments in primary care. Existing research in this area focuses on qualitative studies investigating the attitudes of SMS text users and receivers.

OBJECTIVE

This study aimed to examine appointment data from an independent general practitioner (GP) surgery in Wrexham, United Kingdom, with approximately 15,000 patients, to determine the impact of text messaging systems on reducing missed appointments. The objective of this study was to investigate whether the use of text messages can effectively reduce missed appointments.

METHODS

To collect data for the study, SQL reports were run on EMIS Web, the United Kingdom's most widely used clinical system. The data spanned 10 years, from September 1, 2010, to March 31, 2020. Data accuracy was verified by cross-referencing with appointment diary records. Mann-Whitney and Kruskal-Wallis tests, chosen for their suitability in comparing groups in nonparametric settings, were conducted in Microsoft Excel due to its accessibility.

RESULTS

Statistical analyses were conducted to compare data before and after implementation of the text messaging system. The results revealed a significant 42.8% reduction in missed appointments (before: 5848; after: 3343; P<.001). Further analysis of demographic characteristics revealed interesting trends, with no significant difference in missed appointments between genders, and variations observed across different age groups. The median number of missed appointments was not significantly different between genders (women: 1.55, IQR 1.11-2.16; men: 1.61, IQR 1.08-2.12; P=.73). Despite the prevalence of mobile phone use among young adults aged 20-25 years, the highest rates of missed appointments (848/7256, 11.7%) were noted in this group, whereas the lowest rates were noted in the 75-80 years age group (377/7256; 5.2%; P<.001). Analysis by age and gender indicated inconsistencies: women aged 20-25 years (571/4216) and men aged 35-40 years (306/3040) had the highest rates of missed appointments, whereas women aged 70-75 years (177/4216) and men aged 75-80 years (129/3040) had the lowest rates (P<.001 for both).

CONCLUSIONS

This study demonstrates that SMS text messaging in primary care can significantly reduce missed appointments. Implementing technology such as SMS text messaging systems enables patients to cancel appointments on time, leading to improved efficiency in primary care settings.

Strengthening therapeutic adherence and pharmacovigilance to antimalarial treatment in Manaus, Brazil: a multicomponent strategy using mHealth

BACKGROUND

Public health initiatives for improving adherence to primaquine based regimens and enhancing effective pharmacovigilance are needed to support the efforts for malaria elimination in real world conditions.

METHODS

A multicomponent patient-oriented strategy using a Smart Safety Surveillance (3S) approach including: (1) educational materials for treatment counselling and identification of warning symptoms of haemolytic anaemia; (2) an mHealth component using Short Message Service (SMS) treatment reminders and (3) development and implementation of follow-up phone surveys three days after treatment completion, using a web-based platform linked to the local information system of malaria. Adherence was measured using the Morisky Medication Adherence Scale. Self-reported events were registered using a structured questionnaire and communicated to the Brazilian Health Regulatory Agency.

RESULTS

Educational materials were disseminated to 5594 patients, of whom 1512 voluntarily entered the mHealth component through the local information system; 7323 SMS were sent, and 1062 participants completed a follow-up survey after treatment. The mean age of patients was 37.36 years (SD 13.65), 61.24% were male, 98.54% were infected with. Plasmodium vivax and 95.90% received a short regimen of chloroquine plus primaquine (CQ + PQ 7 days), as per malaria case management guidelines in Brazil. From the 1062 surveyed participants 93.31% were considered adherent to the treatment. Most of the patients (95.20%) reported at least one adverse event. Headache, lack of appetite and nausea/vomiting were the most frequently reported adverse events by 77.31%, 70.90% and 56.78% of the patients respectively. A quarter of the patients reported anxiety or depression symptoms; 57 (5.37%) patients reported 5 to 6 warning symptoms of haemolytic anaemia including jaundice and dark urine in 44 (4.14%). Overall, three patients presenting symptoms of haemolytic anaemia attended a hospital and were diagnosed with G6PD deficiency, and one had haemolysis. All of them recovered.

CONCLUSIONS

Under real world conditions, a multicomponent patient-oriented strategy using information and communication technologies allowed health care providers to reinforce treatment adherence and enhance safety surveillance of adverse events associated with regimens using primaquine. Active monitoring through phone surveys also reduced under-reporting of ADRs. This approach is low-cost, scalable and able to support prioritized activities of the national malaria programme.

One-way SMS and healthcare outcomes in Africa: Systematic review of randomised trials with meta-analysis

Background

The impact of one-way SMS on health outcomes in Africa is unclear. We aimed to conduct a systematic review of one-way SMS randomised trials in Africa and a meta-analysis of their effect on healthcare appointments attendance and medicine adherence.

Methods

PubMed, Embase, CENTRAL, The Global Health Library, ClinicalTrials.gov, ICTRP, and PACTR were searched for published and unpublished trials in Africa without language restriction (up to April 2018). Trials reporting effect estimates on healthcare appointment attendance and medicine adherence were assessed for risk of bias and included in meta-analyses using random-effects models. Other outcomes were reported descriptively. The protocol is registered in PROSPERO, ID:CRD42018081062.

Results

We included 38 one-way SMS trials conducted in Africa within a broad range of clinical conditions. Eighteen trials were included in the meta-analyses, and four were assessed as overall low risk of bias. One-way SMS improved appointment attendance, OR:2·03; 95% CI:1·40–2·95 (12 trials, 6448 participants), but not medicine adherence, RR:1·10; 95% CI:0·98–1·23 (nine trials, 4213 participants). Subgroup analyses showed that one-way SMS had the highest impact on childhood immunization attendance, OR:3·69; 95% CI:1·67–8·13 (three trials, 1943 participants). There was no clear evidence of one-way SMS improving facility delivery, knowledge level (reproductive/antenatal health, hypertension), diabetes- and hypertension management.

Conclusion

In an African setting, the clinical effect of one-way SMS is uncertain except for appointment attendance where the effect seems to vary depending on which clinical condition it is used in.

Post-discharge malaria chemoprevention (PMC) in Malawi: caregivers` acceptance and preferences with regard to delivery methods

Background

In malaria endemic countries of sub-Saharan Africa, many children develop severe anaemia due to previous and current malaria infections. After blood transfusions and antimalarial treatment at the hospital they are usually discharged without any follow-up. In the post-discharge period, these children may contract new malaria infections and develop rebound severe anaemia. A randomised placebo-controlled trial in Malawi showed 31% reduction in malaria- and anaemia-related deaths or hospital readmissions among children under 5 years of age given antimalarial drugs for 3 months post-discharge. Thus, post-discharge malaria chemoprevention (PMC) may provide substantial protection against malaria and anaemia in young children living in areas of high malaria transmission. A delivery implementation trial is currently being conducted in Malawi to determine the optimal strategy for PMC delivery. In the trial, PMC is delivered through community- or facility-based methods with or without the use of reminders via phone text message or visit from a Health Surveillance Assistant. This paper describes the acceptance of PMC among caregivers.

Methods

From October to December 2016, 30 in-depth interviews and 5 focus group discussions were conducted with caregivers of children who recently completed the last treatment course in the trial. Views on the feasibility of various delivery methods and reminder strategies were collected. The interviews were transcribed verbatim, translated to English, and coded using the software programme NVivo.

Results

Community-based delivery was perceived as more favourable than facility-based delivery due to easy home access to drugs and fewer financial concerns. Many caregivers reported lack of visits from Health Surveillance Assistants and preferred text message reminders sent directly to their phones rather than waiting on these visits. Positive attitudes towards active use of health cards for remembering treatment dates were especially evident. Additionally, caregivers shared positive experiences from participation in the programme and described dihydroartemisinin-piperaquine as a safe and effective antimalarial drug that improved the health and well-being of their children.

Conclusions

Post-discharge malaria chemoprevention given to children under the age of 5 previously treated for severe anaemia is highly accepted among caregivers. Caregivers prefer community-based delivery with use of health cards as their primary tool of reference.

Trial registration

NCT02721420 (February 13, 2016).

Adherence to treatment with artemether-lumefantrine or amodiaquine-artesunate for uncomplicated malaria in children in Sierra Leone: a randomized trial

BACKGROUND

Prompt, effective treatment of confirmed malaria cases with artemisinin-based combination therapy (ACT) is a cornerstone of malaria control. Maximizing adherence to ACT medicines is key to ensuring treatment effectiveness.

METHODS

This open-label, randomized trial evaluated caregiver adherence to co-formulated artemether-lumefantrine (AL) and fixed-dose amodiaquine-artesunate (AQAS) in Sierra Leone. Children aged 6-59 months diagnosed with malaria were recruited from two public clinics, randomized to receive AL or AQAS, and visited at home the day after completing treatment. Analyses were stratified by site, due to differences in participant characteristics and outcomes.

RESULTS

Of the 784 randomized children, 680 (85.6%) were included in the final per-protocol analysis (340 AL, 340 AQAS). Definite adherence (self-reported adherence plus empty package) was higher for AL than AQAS at both sites (Site 1: 79.4% AL vs 63.4% AQAS, odds ratio [OR] 2.16, compared to probable adherence plus probable or definite non-adherence, 95% confidence interval [CI] 1.34-3.49; p = 0.001; Site 2: 52.1% AL vs 37.5% AQAS, OR 1.53, 95% CI 1.00-2.33, p = 0.049). However, self-reported adherence (ignoring drug package inspection) was higher for both regimens at both sites and there was no strong evidence of variation by treatment (Site 1: 96.6% AL vs 95.9% AQAS, OR 1.19, 95% CI 0.39-3.63, p = 0.753; Site 2: 91.5% AL vs 96.4% AQAS, OR 0.40, 95% CI 0.15-1.07, p = 0.067). In Site 2, correct treatment (correct dose + timing + duration) was lower for AL than AQAS (75.8% vs 88.1%, OR 0.42, 95% CI 0.23-0.76, p = 0.004). In both sites, more caregivers in the AQAS arm reported adverse events (Site 1: 3.4% AL vs 15.7% AQAS, p < 0.001; Site 2: 15.2% AL vs 24.4% AQAS, p = 0.039).

CONCLUSIONS

Self-reported adherence was high for both AL and AQAS, but varied by site. These results suggest that each regimen has potential disadvantages that might affect adherence; AL was less likely to be taken correctly at one site, but was better tolerated than AQAS at both sites. Measuring adherence to anti-malarials remains challenging, but important. Future research should focus on comparative studies of new drug regimens, and improving the methodology of measuring adherence.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01967472. Retrospectively registered 18 October 2013, https://clinicaltrials.gov/ct2/show/NCT01967472.

Comparison of Health Service Utilization for Febrile Children Before and After Introduction of Malaria Rapid Diagnostic Tests and Artemisinin-Based Combination Therapy in Rural Papua New Guinea

Background

In Papua New Guinea (PNG), a malaria treatment policy using rapid diagnostic tests (RDTs) plus artemisinin-based combination therapy (ACT) was widely introduced to rural communities in 2012. The objectives of the study were to evaluate the effect of this RDT/ACT introduction to a rural PNG population on health service utilization and to compare factors associated with health service utilization before and after the RDT/ACT introduction.

Methods

Household surveys with structured questionnaires were conducted before and after the introduction of RDT/ACT in a catchment area of a health center in East Sepik Province, PNG. We interviewed caregivers with children less than 15 years of age and collected data on fever episodes in the preceding 2 weeks. Using propensity score matching, febrile children before the introduction of RDT/ACT were matched to febrile children after the introduction. Then, the adjusted difference in the proportion of health service utilization [i.e., the average treatment effect (ATE) of the introduction of RDT/ACT on health service utilization] was estimated. We also employed a multilevel Poisson regression model to investigate factors influencing the use of health services.

Results

Of 4,690 children, 911 (19%) were reported to have a fever episode. The unadjusted proportion of health service utilization was 51.7 and 57.2% before and after the RDT/ACT introduction, respectively. After matching, no significant difference in the health service utilization was observed before and after the introduction of RDT/ACT (ATE: 0.063, 95% confidence interval −0.024 to 0.150). Multilevel regression analysis showed that the consistent factors associated with a higher utilization of health services were severe illness and being female.

Conclusion

The utilization of health services was not significantly different before and after the introduction of RDT/ACT. Villagers may have neither sufficient informations on the new protocol nor high acceptance of RDT/ACT. The observed gender bias in health service utilization could be due to female caregivers’ preferences toward girls.

Correlates of social behavior change communication on care-seeking behaviors for children with fever: an analysis of malaria household survey data from Liberia

Background

In 2010, malaria was responsible for an estimated 41% of deaths among children under the age of five years in Liberia. The same year, the Rebuilding Basic Health Services Project launched “Healthy Baby, Happy Mother,” a social and behavior change communication campaign. The campaign encouraged caregivers to take children under the age of five years to a health facility as soon as children developed fever. This study investigated correlates of two case management outcomes: care-seeking for children under five with fever during the past two weeks and administration of an artemisinin-based combination therapy (ACT) the same or next day as fever onset.

Methods

Data from a 2014 cross-sectional household survey from four counties was used to investigate correlates of two case management outcomes. Using multilevel analysis, the association between these outcomes and a caregiver’s recall of the campaign, her sociodemographic characteristics, and unmeasured characteristics of the community she lived in was investigated.

Results

Caregivers living in Grand Kru County were less likely (OR = 0.21, 95% CI 0.073, 0.632) to take a child to a health facility than those in Bong County. Caregiver recall of the campaign was positively associated with the odds that a child received an ACT promptly (OR 3.62, 95% CI 1.398–9.372), but not with the odds of a caregiver taking a child in their care to a health facility. While unmeasured community-level factors accounted for 19.0% of the variation in the odds that a caregiver’s child was brought to a health facility, they did not play a role in the odds of prompt ACT treatment.

Conclusions

Recalling the “Healthy Mother, Happy Baby” campaign was positively associated with the odds that children received ACT promptly, even in the absence of other malaria prevention and treatment messaging. While caregiver exposure was not associated with care-seeking during the two weeks before interview, prompt care-seeking likely preceded prompt receipt of ACT since most ACT came from health facilities. Unmeasured community-level factors, such as distance from the health facility, may play a role in determining the odds that a caregiver takes a child to a health facility.

Challenges for achieving safe and effective radical cure of Plasmodium vivax: a round table discussion of the APMEN Vivax Working Group

The delivery of safe and effective radical cure for Plasmodium vivax is one of the greatest challenges for achieving malaria elimination from the Asia-Pacific by 2030. During the annual meeting of the Asia Pacific Malaria Elimination Network Vivax Working Group in October 2016, a round table discussion was held to discuss the programmatic issues hindering the widespread use of primaquine (PQ) radical cure. Participants included 73 representatives from 16 partner countries and 33 institutional partners and other research institutes. In this meeting report, the key discussion points are presented and grouped into five themes: (i) current barriers for glucose-6-phosphate deficiency (G6PD) testing prior to PQ radical cure, (ii) necessary properties of G6PD tests for wide scale deployment, (iii) the promotion of G6PD testing, (iv) improving adherence to PQ regimens and (v) the challenges for future tafenoquine (TQ) roll out. Robust point of care (PoC) G6PD tests are needed, which are suitable and cost-effective for clinical settings with limited infrastructure. An affordable and competitive test price is needed, accompanied by sustainable funding for the product with appropriate training of healthcare staff, and robust quality control and assurance processes. In the absence of quantitative PoC G6PD tests, G6PD status can be gauged with qualitative diagnostics, however none of the available tests is currently sensitive enough to guide TQ treatment. TQ introduction will require overcoming additional challenges including the management of severely and intermediately G6PD deficient individuals. Robust strategies are needed to ensure that effective treatment practices can be deployed widely, and these should ensure that the caveats are outweighed by  the benefits of radical cure for both the patients and the community. Widespread access to quality controlled G6PD testing will be critical.