Text2PreventCVD: protocol for a systematic review and individual participant data meta-analysis of text message-based interventions for the prevention of cardiovascular diseases

Are there inequalities in the attendance and effectiveness of behavioural weight management interventions for adults in the UK? Protocol for an individual participant data (IPD) meta-analysis

INTRODUCTION

It is important to identify whether behavioural weight management interventions work well across different groups in the population so health inequalities in obesity are not widened. Previous systematic reviews of inequalities in the attendance and effectiveness of behavioural weight management interventions have been limited because few trials report relevant analyses and heterogeneity in the categorisation of inequality characteristics prevents meta-analysis. An individual participant data meta-analysis (IPD-MA) allows us to reanalyse all trials with available data in a uniform way. We aim to conduct an IPD meta-analysis of UK randomised controlled trials to examine whether there are inequalities in the attendance and effectiveness of behavioural weight interventions.

METHODS AND ANALYSIS

In a recently published systematic review, we identified 17 UK-based randomised controlled trials of primary care-relevant behavioural interventions, conducted in adults living with overweight or obesity and reporting weight outcomes at baseline and 1-year follow-up. The corresponding author of each trial will be invited to contribute data to the IPD-MA. The outcomes of interest are weight at 12-months and intervention attendance (number of sessions offered vs number of sessions attended). We will primarily consider whether there is an interaction between intervention group and characteristics where inequalities occur, such as by gender/sex, socioeconomic status or age. The IPD-MA will be conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses of IPD guidelines.

ETHICS AND DISSEMINATION

No further ethical approval was required as ethical approval for each individual study was obtained by the original trial investigators from appropriate ethics committees. The completed IPD-MA will be disseminated at conferences, in a peer-reviewed journal and contribute to the lead author's PhD thesis. Investigators of each individual study included in the final IPD-MA will be invited to collaborate on any publications that arise from the project.

Reasons for poor blood pressure control in Eastern Sub-Saharan Africa: looking into 4P's (primary care, professional, patient, and public health policy) for improving blood pressure control: a scoping review

AIM

Hypertension control in Sub-Saharan Africa (SSA) is the worst (less than one out of ten) when compared to the rest of the world. Therefore, this scoping review was conducted to identify and describe the possible reasons for poor blood pressure (BP) control based on 4Ps' (patient, professional, primary healthcare system, and public health policy) factors.

METHODS

PRISMA extension for scoping review protocol was used. We systematically searched articles written in the English language from January 2000 to May 2020 from the following databases: PubMed/Medline, Embase, Scopus, Web of Science, and Google scholar.

RESULTS

Sixty-eight articles were included in this scoping review. The mean prevalence of hypertension, BP control, and patient adherence to prescribed medicines were 20.95%, 11.5%, and 60%, respectively. Only Kenya, Malawi, and Zambia out of ten countries started annual screening of the high-risk population for hypertension. Reasons for nonadherence to prescribed medicines were lack of awareness, lack of access to medicines and health services, professional inertia to intensify drugs, lack of knowledge on evidence-based guidelines, insufficient government commitment, and specific health behaviors related laws. Lack of screening for high-risk patients, non-treatment adherence, weak political commitment, poverty, maternal and child malnutrition were reasons for the worst BP control.

CONCLUSION

In conclusion, the rate of BP treatment, control, and medication adherence was low in Eastern SSA. Screening for high-risk populations was inadequate. Therefore, it is crucial to improve government commitment, patient awareness, and access to medicines, design country-specific annual screening programs, and empower clinicians to follow individualized treatment and conduct medication adherence research using more robust tools.

The Association between Parental Involvement Behavior and Self-Esteem among Adolescents Living in Poverty: Results from the K-CHILD Study

It is not yet known why some adolescents living in poverty show high self-esteem, while others do not. Parental involvement may be an important determinant to promote self-esteem among adolescents living in poverty. The aim of this study is to explore better parenting involvement behavior to promote self-esteem among adolescents living in poverty. Participants included fifth-, eighth-, and 11th-grade students living in Koichi prefecture, Japan. The participants were part of the Kochi Child Health Impact of Living Difficulty (K-CHILD) study, in 2016 (n = 10,784). Participants completed a questionnaire with questions about socioeconomic status and 14 parental involvement behaviors, including 9 specific kinds of parental interactions with their child (e.g., talking about school life), and 5 elements related to parental care for their child's physical health (e.g., access to health care). The numbers of parental involvement behaviors, parental interactions with their child, and parental care for their child's physical health were treated as continuous and quartile, to see the association. Overall, the study showed that the larger the number of parental involvement behaviors, the higher the self-esteem score of their off-spring (p < 0.01) among both adolescents living in poverty and not living in poverty, in which interaction between poverty and parental involvement behaviors was not significant. Both parental interaction with their child and parental care for their child's physical health were associated with higher self-esteem, in which parental interaction with their child had a larger effect than parental care for their child's physical health. To empower adolescents in poverty, caregivers need to provide both parental interaction with the child and parental care for the child's physical health.

A systematic review with meta-analyses of text message-delivered behaviour change interventions for weight loss and weight loss maintenance

Short Message Service (SMS)-delivered behaviour change interventions are frequently used to support weight management. This systematic review examines the effectiveness of SMS-delivered behaviour change interventions for weight management. Electronic databases were searched for randomised controlled trials (RCTs) comparing SMS-delivered adult weight management interventions to control groups, published between 1990 and 2018. Weight change was examined using random effects meta-analyses at intervention cessation and postintervention follow-up. Subgroup analyses examined intervention duration, SMS frequency, theory use, SMS interactivity, and SMS tailoring. Fifteen studies met inclusion criteria (2705 participants). For weight loss interventions (n = 12, 1977 participants), the mean difference in weight change was -2.28 kg (95% confidence interval [CI] -3.17 to -1.36 kg). No studies reported postintervention follow-up. For weight loss maintenance interventions (n = 3, 728 participants), the mean difference in weight change was -0.68 kg (95% CI, -1.31 to -0.05 kg), and postintervention follow-up (n = 2, 498 participants) effects were -0.57 kg (95% CI, -1.67 to 0.53 kg). No subgroup differences were found. SMS-delivered behaviour change interventions for weight loss led to significant small to moderate weight loss and weight loss maintenance compared with control groups. Evidence on long-term effects is limited. SMS-delivered behaviour change interventions are a potentially effective and scalable intervention option for obesity treatment.

Mobile phone text-messaging interventions aimed to prevent cardiovascular diseases (Text2PreventCVD): systematic review and individual patient data meta-analysis

Background

A variety of small mobile phone text-messaging interventions have indicated improvement in risk factors for cardiovascular disease (CVD). Yet the extent of this improvement and whether it impacts multiple risk factors together is uncertain. We aimed to conduct a systematic review and individual patient data (IPD) meta-analysis to investigate the effects of text-messaging interventions for CVD prevention.

Methods

Electronic databases were searched to identify trials investigating a text-messaging intervention focusing on CVD prevention with the potential to modify at least two CVD risk factors in adults. The main outcome was blood pressure (BP). We conducted standard and IPD meta-analysis on pooled data. We accounted for clustering of patients within studies and the primary analysis used random-effects models. Sensitivity and subgroup analyses were performed.

Results

Nine trials were included in the systematic review involving 3779 participants and 5 (n=2612) contributed data to the IPD meta-analysis. Standard meta-analysis showed that the weighted mean differences are as follows: systolic blood pressure (SBP), -4.13 mm Hg (95% CI -11.07 to 2.81, p<0.0001); diastolic blood pressure (DBP), -1.11 mm Hg (-1.91 to -0.31, p=0.002); and body mass index (BMI), -0.32 (-0.49 to -0.16, p=0.000). In the IPD meta-analysis, the mean difference are as follows: SBP, -1.3 mm Hg (-5.4 to 2.7, p=0.5236); DBP, -0.8 mm Hg (-2.5 to 1.0, p=0.3912); and BMI, -0.2 (-0.8 to 0.4, p=0.5200) in the random-effects model. The impact on other risk factors is described, but there were insufficient data to conduct meta-analyses.

Conclusion

Mobile phone text-messaging interventions have modest impacts on BP and BMI. Simultaneous but small impacts on multiple risk factors are likely to be clinically relevant and improve outcome, but there are currently insufficient data in pooled analyses to examine the extent to which simultaneous reduction in multiple risk factors occurs.

PROSPERO registration number

CRD42016033236.

Examining Development Processes for Text Messaging Interventions to Prevent Cardiovascular Disease: Systematic Literature Review

Background

Interventions delivered by mobile phones have the potential to prevent cardiovascular disease (CVD) by supporting behavior change toward healthier lifestyles and treatment adherence. To allow replication and adaptation of these interventions across settings, it is important to fully understand how they have been developed. However, the development processes of these interventions have not previously been systematically examined.

Objective

This study aimed to systematically describe and compare the development process of text messaging interventions identified in the Text2PreventCVD systematic review.

Methods

We extracted data about the development process of the 9 interventions identified in the Text2PreventCVD systematic review. Data extraction, which was guided by frameworks for the development of complex interventions, considered the following development stages: intervention planning, design, development, and pretesting. Following data extraction, we invited the developers of the interventions to contribute to our study by reviewing the accuracy of the extracted data and providing additional data not reported in the available publications.

Results

A comprehensive description of the development process was available for 5 interventions. Multiple methodologies were used for the development of each intervention. Intervention planning involved gathering information from stakeholder consultations, literature reviews, examination of relevant theory, and preliminary qualitative research. Intervention design involved the use of behavior change theories and behavior change techniques. Intervention development involved (1) generating message content based on clinical guidelines and expert opinions; (2) conducting literature reviews and primary qualitative research to inform decisions about message frequency, timing, and level of tailoring; and (3) gathering end-user feedback concerning message readability, intervention acceptability, and perceived utility. Intervention pretesting involved pilot studies with samples of 10 to 30 participants receiving messages for a period ranging from 1 to 4 weeks.

Conclusions

The development process of the text messaging interventions examined was complex and comprehensive, involving multiple studies to guide decisions about the scope, content, and structure of the interventions. Additional research is needed to establish whether effective messaging systems can be adapted from work already done or whether this level of development is needed for application in other conditions and settings.

DTEXT - text messaging intervention to improve outcomes of people with type 2 diabetes: protocol for randomised controlled trial and cost-effectiveness analysis

BACKGROUND

Diabetes prevalence is rapidly increasing, with type 2 diabetes predicted to be the leading contributor of non-communicable disease in Australia by 2020. It is anticipated that rates of type 2 diabetes will continue to increase if factors such as overweight and obesity, low physical activity and poor nutrition are not addressed. The majority of Australians with type 2 diabetes do not meet the guidelines for optimal diabetes management, and access to diabetes education is limited. This highlights the need for new interventions that can reduce existing barriers to diabetes education, attain greater population reach and support self-management strategies for people with type 2 diabetes. Mobile phone text messages have shown promising results as an intervention for people with chronic disease. They have the ability to achieve high levels of engagement and broad population reach, whilst requiring minimal resources. There is however, no evidence on the effect of text messaging to improve the health of people with type 2 diabetes in Australia.

METHODS/DESIGN

This randomised controlled trial aims to investigate if a 6 month text message intervention (DTEXT) can lead to improvements in glycated haemoglobin (HbA1c) and diabetes self-management among Australian residents in New South Wales (NSW) with type 2 diabetes. Community dwelling adults (n = 340) will be recruited with the primary outcome being change in HbA1c at 6 months. Secondary outcomes include behaviour change for diabetes self-management, self-efficacy, quality of life and intervention acceptability. An economic evaluation will be conducted using a funder plus patient perspective.

DISCUSSION

This study will provide evidence on the effectiveness and cost effectiveness of a text message intervention to reduce HbA1c and enhance self-management of type 2 diabetes in the Australian population. If successful, this intervention could be used as a model to complement and extend existing diabetes care in the Australian health care system.

TRIAL REGISTRATION

The study has been registered with the Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617000416392 . Registered: 23 March 2017.

Preferences for Health Information Technologies Among US Adults: Analysis of the Health Information National Trends Survey

BACKGROUND

Emerging health technologies are increasingly being used in health care for communication, data collection, patient monitoring, education, and facilitating adherence to chronic disease management. However, there is a lack of studies on differences in the preference for using information exchange technologies between patients with chronic and nonchronic diseases and factors affecting these differences.

OBJECTIVE

The purpose of this paper is to understand the preferences and use of information technology for information exchange among a nationally representative sample of adults with and without 3 chronic disease conditions (ie, cardiovascular disease [CVD], diabetes, and hypertension) and to assess whether these preferences differ according to varying demographic variables.

METHODS

We utilized data from the 2012 and 2014 iteration of the Health Information National Trends Survey (N=7307). We used multiple logistic regressions, adjusting for relevant demographic covariates, to identify the independent factors associated with lower odds of using health information technology (HIT), thus, identifying targets for awareness. Analyses were weighted for the US population and adjusted for the sociodemographic variables of age, gender, race, and US census region.

RESULTS

Of 7307 participants, 3529 reported CVD, diabetes, or hypertension. In the unadjusted models, individuals with diabetes, CVD, or hypertension were more likely to report using email to exchange medical information with their provider and less likely to not use any of the technology in health information exchange, as well as more likely to say it was not important for them to access personal medical information electronically. In the unadjusted model, additional significant odds ratio (OR) values were observed. However, after adjustment, most relationships regarding the use and interest in exchanging information with the provider were no longer significant. In the adjusted model, individuals with CVD, diabetes, or hypertension were more likely to access Web-based personal health information through a website or app. Furthermore, we assessed adjusted ORs for demographic variables. Those aged >65 years and Hispanic people were more likely to report no use of email to exchange medical information with their provider. Minorities (Hispanic, non-Hispanic black, and Asian people) were less likely to indicate they had no interest in exchanging general health tips with a provider electronically.

CONCLUSIONS

The analysis did not show any significant association among those with comorbidities and their proclivity toward health information, possibly implying that HIT-related interventions, particularly design of information technologies, should focus more on demographic factors, including race, age, and region, than on comorbidities or chronic disease status to increase the likelihood of use. Future research is needed to understand and explore more patient-friendly use and design of information technologies, which can be utilized by diverse age, race, and education or health literacy groups efficiently to further bridge the patient-provider communication gap.

Socioeconomic Status and Hypertension Control in Sub-Saharan Africa: The Multination EIGHT Study (Evaluation of Hypertension in Sub-Saharan Africa)

Systemic hypertension is a rapidly growing epidemic in Africa. The role of socioeconomic status on blood pressure control has not been well studied in this part of the world. We, therefore, aimed to quantify the association of socioeconomic status both at the individual and at the country level with blood pressure control in Sub-Saharan Africa. We conducted a cross-sectional survey in urban clinics of 12 countries, both low income and middle income, in Sub-Saharan Africa. Standardized blood pressure measures were made among the hypertensive patients attending the clinics. Blood pressure control was defined as blood pressure <140/90 mm Hg, and hypertension grades were defined according to the European Society of Cardiology guidelines. A total of 2198 hypertensive patients (58.4±11.8 years; 39.9% men) were included. Uncontrolled hypertension was present in 1692 patients (77.4%), including 1044 (47.7%) with ≥grade 2 hypertension. The proportion of uncontrolled hypertension progressively increased with decreasing level of patient individual wealth, respectively, 72.8%, 79.3%, and 81.8% (P for trend, <0.01). Stratified analysis shows that these differences of uncontrolled hypertension according to individual wealth index were observed in low-income countries (P for trend, 0.03) and not in middle-income countries (P for trend, 0.26). In low-income countries, the odds of uncontrolled hypertension increased 1.37-fold (odds ratio, 1.37 [0.99-1.90]) and 1.88-fold (odds ratio, 1.88 [1.10-3.21]) in patients with middle and low individual wealth as compared with high individual wealth. Similarly, the grade of hypertension increased progressively with decreasing level of individual patient wealth (P for trend, <0.01). Strategies for hypertension control in Sub-Saharan Africa should especially focus on people in the lowest individual wealth groups who also reside in low-income countries.

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

BACKGROUND

Worldwide at least 100 million people are thought to have prevalent cardiovascular disease (CVD). This population has a five times greater chance of suffering a recurrent cardiovascular event than people without known CVD. Secondary CVD prevention is defined as action aimed to reduce the probability of recurrence of such events. Drug interventions have been shown to be cost-effective in reducing this risk and are recommended in international guidelines. However, adherence to recommended treatments remains sub-optimal. In order to influence non-adherence, there is a need to develop scalable and cost-effective behaviour-change interventions.

OBJECTIVES

To assess the effects of mobile phone text messaging in patients with established arterial occlusive events on adherence to treatment, fatal and non-fatal cardiovascular events, and adverse effects.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science on Web of Science on 7 November 2016, and two clinical trial registers on 12 November 2016. We contacted authors of included studies for missing information and searched reference lists of relevant papers. We applied no language or date restrictions.

SELECTION CRITERIA

We included randomised trials with at least 50% of the participants with established arterial occlusive events. We included trials investigating interventions using short message service (SMS) or multimedia messaging service (MMS) with the aim to improve adherence to medication for the secondary prevention of cardiovascular events. Eligible comparators were no intervention or other modes of communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. In addition, we attempted to contact all authors on how the SMS were developed.

MAIN RESULTS

We included seven trials (reported in 13 reports) with 1310 participants randomised. Follow-up ranged from one month to 12 months. Due to heterogeneity in the methods, population and outcome measures, we were unable to conduct meta-analysis on these studies. All seven studies reported on adherence, but using different methods and scales. Six out of seven trials showed a beneficial effect of mobile phone text messaging for medication adherence. Dale 2015a, reported significantly greater medication adherence score in the intervention group (Mean Difference (MD) 0.58, 95% confidence interval (CI) 0.19 to 0.97; 123 participants randomised) at six months. Khonsari 2015 reported less adherence in the control group (Relative Risk (RR) 4.09, 95% CI 1.82 to 9.18; 62 participants randomised) at eight weeks. Pandey 2014 (34 participants randomised) assessed medication adherence through self-reported logs with 90% adherence in the intervention group compared to 70% in the control group at 12 months. Park 2014a (90 participants randomised) reported a greater increase of the medication adherence score in the control group, but also measured adherence with an event monitoring system for a number of medications with adherence levels ranging from 84.1% adherence to 86.2% in the intervention group and 79.7% to 85.7% in the control group at 30 days. Quilici 2013, reported reduced odds of non-adherence in the intervention group (Odds Ratio (OR) 0.43, 95% CI 0.22 to 0.86, 521 participants randomised) at 30 days. Fang 2016, reported that participants given SMS alone had reduced odds of being non-adherent compared to telephone reminders (OR 0.40 95% CI 0.18 to 0.63; 280 patients randomised). Kamal 2015 reported higher levels of adherence in the intervention arm (adjusted MD 0.54, 95% CI 0.22 to 0.85; 200 participants randomised). Khonsari 2015 was the only study to report fatal cardiovascular events and only reported two events, both in the control arm. No study reported on the other primary outcomes. No study reported repetitive thumb injury or road traffic crashes or other adverse events that were related to the intervention.Four authors replied to our questionnaire on SMS development. No study reported examining causes of non-adherence or provided SMS tailored to individual patient characteristics.The included studies were small, heterogeneous and included participants recruited directly after acute events. All studies were assessed as having high risk of bias across at least one domain. Most of the studies came from high-income countries, with two studies conducted in an upper middle-income country (China, Malaysia), and one study from a lower middle-income country (Pakistan). The quality of the evidence was found to be very low. There was no obvious conflicts of interest from authors, although only two declared their funding.

AUTHORS' CONCLUSIONS

While the results of this systematic review are promising, there is insufficient evidence to draw conclusions on the effectiveness of text message-based interventions for adherence to medications for secondary prevention of CVD. Sufficiently powered, high-quality randomised trials are needed, particularly in low- and middle-income countries.