The Cameroon mobile phone SMS (CAMPS) trial: a protocol for a randomized controlled trial of mobile phone text messaging versus usual care for improving adherence to highly active anti-retroviral therapy

Strategies for Successful Clinical Trial Recruitment of People Living with HIV in Low- and Middle-Income Countries: Lessons Learned and Implementation Implications from the Nigeria Renal Risk Reduction (R3) Trial

PURPOSE OF REVIEW

Clinical trials represent a bedrock for measuring efficacy of interventions in biomedical research, but recruitment into clinical trials remains a challenge. Few data have focused on recruitment strategies from the perspective of clinical trial teams, especially in low- and middle-income countries (LMIC), where HIV is most prevalent.

RECENT FINDINGS

We summarized data from the literature and our experience with recruitment for the Renal Risk Reduction trial, aimed at reducing risk of kidney complications among people living with HIV in Nigeria. Using an implementation science framework, we identified strategies that contributed to successful clinical trial recruitment. For strategies that could not be categorized by this framework, we summarized key features according to selected action, actor, target, context, and time. We identified how these identified strategies could map to subsequent implementation outcomes at the patient and provider/health system level, as well as capacity-building efforts to meet needs identified by LMIC partners, which is a priority for success. Our experience highlights the importance of considering implementation outcomes, and the strategies necessary to achieve those outcomes early, in the planning and execution of clinical trials. Clinical trial recruitment can be optimized via methodologies grounded in implementation science.

An Interactive Voice Response Software to Improve the Quality of Life of People Living With HIV in Uganda: Randomized Controlled Trial

Background

Following the successful scale-up of antiretroviral therapy (ART), the focus is now on ensuring good quality of life (QoL) and sustained viral suppression in people living with HIV. The access to mobile technology in the most burdened countries is increasing rapidly, and therefore, mobile health (mHealth) technologies could be leveraged to improve QoL in people living with HIV. However, data on the impact of mHealth tools on the QoL in people living with HIV are limited to the evaluation of SMS text messaging; these are infeasible in high-illiteracy settings.

Objective

The primary and secondary outcomes were to determine the impact of interactive voice response (IVR) technology on Medical Outcomes Study HIV QoL scores and viral suppression at 12 months, respectively.

Methods

Within the Call for Life study, ART-experienced and ART-naïve people living with HIV commencing ART were randomized (1:1 ratio) to the control (no IVR support) or intervention arm (daily adherence and pre-appointment reminders, health information tips, and option to report symptoms). The software evaluated was Call for Life Uganda, an IVR technology that is based on the Mobile Technology for Community Health open-source software. Eligibility criteria for participation included access to a phone, fluency in local languages, and provision of consent. The differences in differences (DIDs) were computed, adjusting for baseline HIV RNA and CD4.

Results

Overall, 600 participants (413 female, 68.8%) were enrolled and followed-up for 12 months. In the intervention arm of 300 participants, 298 (99.3%) opted for IVR and 2 (0.7%) chose SMS text messaging as the mode of receiving reminders and health tips. At 12 months, there was no overall difference in the QoL between the intervention and control arms (DID=0.0; P=.99) or HIV RNA (DID=0.01; P=.94). At 12 months, 124 of the 256 (48.4%) active participants had picked up at least 50% of the calls. In the active intervention participants, high users (received >75% of reminders) had overall higher QoL compared to low users (received <25% of reminders) (92.2 versus 87.8, P=.02). Similarly, high users also had higher QoL scores in the mental health domain (93.1 versus 86.8, P=.008) and better appointment keeping. Similarly, participants with moderate use (51%-75%) had better viral suppression at 12 months (80/94, 85% versus 11/19, 58%, P=.006).

Conclusions

Overall, there was high uptake and acceptability of the IVR tool. While we found no overall difference in the QoL and viral suppression between study arms, people living with HIV with higher usage of the tool showed greater improvements in QoL, viral suppression, and appointment keeping. With the declining resources available to HIV programs and the increasing number of people living with HIV accessing ART, IVR technology could be used to support patient care. The tool may be helpful in situations where physical consultations are infeasible, including the current COVID epidemic.

Trial Registration

ClinicalTrials.gov NCT02953080; https://clinicaltrials.gov/ct2/show/NCT02953080

Level of adherence and associated factors among HIV-positive adolescents on antiretroviral therapy in Cameroon

Aim: Globally, there were over 250 000 new HIV infections among adolescents in 2017, with a higher proportion of these in sub-Saharan Africa. In Cameroon, UNICEF estimated over 4 200 new HIV infections in adolescents in 2015; by 2016, there were over 40 000 adolescents who had HIV. Given that the number of adolescents living with HIV in Cameroon is on the increase, there is a need to better understand the factors influencing adherence to treatment. The objective of this study was to assess the factors associated with adherence among adolescents in Cameroon. Methods: A cross-sectional study was conducted. A total of 460 HIV+ adolescents who were receiving antiretroviral therapy were sampled randomly from nine health facilities. Questionnaires and data extraction forms were used to collect data. Descriptive (frequencies and proportions) and inferential (chi-square and multivariate logistic regression) statistical analyses methods were used to analyse the data. Statistical significance was set at p = 0.05 and 95% confidence level. Results: The level of adherence to antiretroviral therapy among the adolescents was 83%. Twelve out of 30 independent variables examined showed significant statistical association with adherence at the bivariate level. In the multivariable logistic regression analyses, however, only two variables significantly predicted adherence - experiencing side effects (AOR = 2.63; 95% CI = 1.14, 6.09; p = 0.02), and internalized stigma (AOR = 2.51; 95% CI = 1.04, 6.04; p = 0.04). Conclusion: Adherence to treatment among adolescents in Cameroon was found to be suboptimal. There is a need for more individualized, targeted medication counselling for adolescents and their guardians as well as strategies to reduce internalized stigma and improve adherence to antiretroviral treatment.

mHealth Interventions to Promote Anti-Retroviral Adherence in HIV: Narrative Review

Background

Antiretrovirals (ARVs) are key in the management of HIV. Although no cure exists, ARVs help patients live healthy lives and prevent transmission to others. Adherence to complex regimens is paramount to outcomes and in avoiding the emergence of drug-resistant viruses. The goal of therapy is to reach an undetectable viral load. However, adherence is a common problem, stemming from issues such as mental health, chaotic home situations, and busy work schedules. Mobile health (mHealth) represents a new approach in improving medication adherence, and multiple studies have been performed in this area.

Objective

This study aims to review the current implementation of mHealth in the management of HIV among different groups of patients.

Methods

We used PubMed, Academic Search Elite, and 1 journal database with various search terms to review the current implementation of mHealth in HIV care.

Results

Titles and abstracts were screened, and 61 papers were identified and fully reviewed. The literature was divided into lower- and higher-income nations, as defined by the United Nations. A total of 20 studies with quantitative results were identified, with 10 being text- and SMS-based interventions (the majority of these being in lower-income countries) and 8 being smartphone-based apps (primarily in higher-income countries). The majority of these studies determined whether there was an effect on adherence or biochemical parameters (viral load and CD4 count). Various qualitative studies have also been conducted, and many have focused on determining the specific design of interventions that were successful (frequency of messaging, types of messages, etc) as well as priorities for patients with regard to mHealth interventions.

Conclusions

There seems to be a role of mHealth in the management of HIV in lower-income nations; however, the optimal design of an intervention needs to be delineated. In higher-income countries, where the 2 significant risk factors were injection drugs and men who have sex with men, the benefit was less clear, and more research is needed.

Improving Retention in Care and Promoting Adherence to HIV Treatment: Protocol for a Multisite Randomized Controlled Trial of Mobile Phone Text Messaging

BACKGROUND

The World Health Organization has prioritized the use of new technologies to assist in health care delivery in resource-limited settings. Findings suggest that the use of SMS on mobile phones is an advantageous application in health care delivery, especially in communities with an increasing use of this device.

OBJECTIVE

The main aim of this trial is to assess whether sending weekly motivational text messages (SMS) through mobile phones versus no text messaging will improve retention in care and promote adherence to treatment and health outcomes among patients receiving HIV treatment in Fako Division of Cameroon.

METHODS

This is a multisite randomized controlled single-blinded trial. Computer-generated random block sizes shall be used to produce a randomization list. Participants shall be randomly allocated into the intervention and control groups determined by serially numbered sealed opaque envelopes. The 156 participants will either receive the mobile phone text message or usual standard of care. We hypothesize that sending weekly motivational SMS reminders will produce a change in behavior to enhance retention; treatment adherence; and, hence, health outcomes. Participants shall be evaluated and data collected at baseline and then at 2, 4, and 6 months after the launch of the intervention. Text messages shall be sent out, and the delivery will be recorded. Primary outcome measures are retention in care and adherence to treatment. Secondary outcomes are clinical (weight, body mass index), biological (virologic suppression, tuberculosis coinfection), quality of life, treatment discontinuation, and mortality. The analysis shall be by intention-to-treat. Analysis of covariates shall be performed to determine factors influencing outcomes.

RESULTS

Recruitment and random allocation are complete; 160 participants were allocated into 3 groups (52 in the single SMS, 55 in the double SMS, and 53 in the control). Data collection and analysis are ongoing, and statistical results will be available by the end of August 2019.

CONCLUSIONS

The interventions will contribute to an improved understanding of which intervention types can be feasible in improving retention in care and promoting adherence to antiretroviral therapy.

TRIAL REGISTRATION

Pan African Clinical Trial Registry in South Africa PACTR201802003035922; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=3035.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15680.

Content guidance for mobile phones short message service (SMS)-based antiretroviral therapy adherence and appointment reminders: a review of the literature

Mobile phones are increasingly being used to support health activities, including the care and management of people living with HIV/AIDS. Short message service (SMS) has been explored as a means to optimize and support behaviour change. However, there is minimal guidance on messaging content development. The purpose of this review was to inform the content of SMS messages for mobile health (mHealth) initiatives designed to support anti-retroviral therapy adherence and clinic appointment keeping in resource-limited settings. PubMed, OvidMedline, Google Scholar, K4Health's mHealth Evidence database, the mHealth Working Group project resource, and Health COMpass were searched. A request to online communities for recommendations on message content was also made. 1010 unique sources were identified, of which 51 were included. The information was organized into three categories: pre-message development, message development, and security and privacy. Fifteen of the publications explicitly provided their message content. Important lessons when developing the content of SMS were: (1) conducting formative research; (2) grounding content in behaviour change theory; and (3) reviewing proposed content with experts. Best practices exist for developing message content for behaviour change. Efforts should be continued to apply lessons learned from the existing literature to inform mHealth initiatives supporting HIV/AIDS care and treatment.

Impact of smartphone-assisted prenatal home visits on women's use of facility delivery: Results from a cluster-randomized trial in rural Tanzania

BACKGROUND

About half of births in rural Tanzania are assisted by skilled providers. Point-of-care mobile phone applications hold promise in boosting job support for community health workers aiming to ensure safe motherhood through increased facility delivery awareness, access and uptake. We conducted a controlled comparison to evaluate a smartphone-based application designed to assist community health workers with data collection, education delivery, gestational danger sign identification, and referrals.

METHODS

Community health workers in 32 randomly selected villages were cluster-randomized to training on either smartphone (intervention) or paper-based (control) protocols for use during household visits with pregnant women. The primary outcome measure was postnatal report of delivery location by 572 women randomly selected to participate in a survey conducted by home visit. A mixed-effects model was used to account for clustering of subjects and other measured factors influencing facility delivery.

FINDINGS

The smartphone intervention was associated with significantly higher facility delivery: 74% of mothers in intervention areas delivered at or in transit to a health facility, versus 63% in control areas. The odds of facility delivery among women counseled by smartphone-assisted health workers were double the odds among women living in control villages (OR, 1.96; CI, 1.21-3.19; adjusted analyses). Women in intervention areas were more likely to receive two or more visits from a community health worker during pregnancy than women in the control group (72% vs. 60%; chi-square = 6.9; p < 0.01). Previous facility delivery, uptake of antenatal care, and distance to the nearest facility were also strong independent predictors of facility delivery.

INTERPRETATION

Community health worker use of smartphones increased facility delivery, likely through increased frequency of prenatal home visits. Smartphone-based job aids may enhance community health worker support and effectiveness as one component of intervention packages targeting safe motherhood.

TRIAL REGISTRATION

NCT03161184.

Enhancing research publications and advancing scientific writing in health research collaborations: sharing lessons learnt from the trenches

BACKGROUND

Disseminating research protocols, processes, methods or findings via peer-reviewed publications has substantive merits and benefits to various stakeholders.

PURPOSE

In this article, we share strategies to enhance research publication contents (ie, what to write about) and to facilitate scientific writing (ie, how to write) in health research collaborations.

METHODS

Empirical experience sharing.

RESULTS

To enhance research publication contents, we encourage identifying appropriate opportunities for publications, publishing protocols ahead of results papers, seeking publications related to methodological issues, considering justified secondary analyses, and sharing academic process or experience. To advance writing, we suggest setting up scientific writing as a goal, seeking an appropriate mentorship, making full use of scientific meetings and presentations, taking some necessary formal training in areas such as effective communication and time and stress management, and embracing the iterative process of writing.

CONCLUSION

All the strategies we share are dependent upon each other; and they advocate gradual academic accomplishments through study and training in a "success-breeds-success" way. It is expected that the foregoing shared strategies in this paper, together with other previous guidance articles, can assist one with enhancing research publications, and eventually one's academic success in health research collaborations.

Using Mobile Health Intervention to Improve Secondary Prevention of Coronary Heart Diseases in China: Mixed-Methods Feasibility Study

Background

Coronary heart disease (CHD) is the leading cause of cardiovascular mortality worldwide, yet implementation of evidence-based strategies for secondary prevention remains suboptimal.

Objective

This study aimed to evaluate the feasibility, specifically the usability and acceptability, and estimate the preliminary effectiveness of a mobile health (mHealth) intervention targeting both physicians and patients to improve adherence to evidence-based medications and lifestyle modifications.

Methods

We conducted a 12-week pre-post interventional pilot study at two sites in Shanghai and Hainan, China. Physicians used the app designed in this study to prescribe evidence-based medicines and record patient information. Eligible and consenting patients received automatic text messages or voice calls 4 to 5 times per week for 12 weeks on medication adherence and healthy behaviors. Interviews were conducted among 10 physicians and 24 patients at the two sites for their thoughts on medication adherence and feedback on the usability and acceptability. Questions on usability and acceptability were also asked in a patient follow-up survey. With regard to estimating effectiveness, the primary outcome was medication adherence (as estimated by the Morisky Green Levine Scale) at 12 weeks. Secondary outcomes included physical activity, smoking status, fruits and vegetables consumption, and facility visit frequency.

Results

Interview findings and patient survey showed the good usability and acceptability of the intervention. Among 190 patients who completed the intervention, there was a significant increase in medication adherence (odds ratio [OR] 1.80, 95% CI 1.14-2.85). The study also showed decrease of smokers’ percentage (−5%, P=.05), increase of daily vegetables consumption frequency (+0.3/day, P=.01), and community health care center visit frequency (+3 in 3 months, P=.04). The following site-specific differences were noted: medication adherence appeared to increase in Hainan (OR 14.68, 95% CI 5.20-41.45) but not in Shanghai (OR 0.61, 95% CI 0.33-1.12).

Conclusions

Our study demonstrated that the intervention was feasible in both a tertiary care center and an urban community health center in China. Preliminary results from pre-post comparison suggest the possibility that provider and patient-linked mHealth interventions may improve medication adherence and lifestyle modifications among CHD patients, especially in resource-scarce settings. Randomized controlled trials are needed to verify the findings.

The effectiveness of daily SMS reminders in pharmaceutical care of older adults on improving patients' adherence to antihypertensive medication (SPPA): study protocol for a randomized controlled trial

BACKGROUND

Despite a variety of efficient and cost-effective antihypertensive medication, hypertension remains a serious health and economic burden. High consumption of cardiovascular drugs in the Slovak Republic does result neither in better hypertension control nor in significant decrease in cardiovascular mortality. At the same time, Slovakia has alarmingly low patients' adherence to medication intake. Studies have shown the efficiency of short messaging service (SMS) reminders to improve patients' adherence and health outcomes at low costs. Since SMS is popular among Slovaks, this approach may be feasible also in Slovakia. The primary objective is to assess if daily SMS reminders of antihypertensive medication intake provided by pharmacists in addition to the standard pharmaceutical care increase the proportion of adherent older hypertensive ambulatory patients.

METHODS

The SPPA trial is a pragmatic randomized parallel group (1:1) trial in 300 older hypertensive patients carried out in community pharmacies in Slovakia. Trial pharmacies will be selected from all main regions of Slovakia. Trial intervention comprises daily personalized SMS reminders of medication intake embedded into usual pharmaceutical practice. The primary outcome is a combined adherence endpoint consisting of subjective self-reported medication adherence via the eight-item Morisky Medication Adherence Scale (MMAS-8) and objective pill count rate. Secondary outcomes include: change in the MMAS-8; comparison of adherence rates using pill count; change in systolic blood pressure; and patient satisfaction. Also, direct treatment costs will be evaluated and a cost-effectiveness analysis will be carried out.

DISCUSSION

The SPPA trial engages community pharmacists and mobile health (mHealth) technologies via evidence-based pharmaceutical care to efficiently and cost-effectively addresses current main healthcare challenges: high prevalence of hypertension; overconsumption of cardiovascular medicines; low adherence to medication treatment; and resulting uncontrolled blood pressure. The results may identify new possibilities and capacities in healthcare with low additional costs and high value to patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03105687 . Registered on 07 March 2017.

A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa

BACKGROUND

The prevalence of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa. At the same time, the use of mobile phones is rising, expanding the opportunities for the implementation of mobile phone-based health (mHealth) interventions. This review aims to understand how, why, for whom, and in what circumstances mHealth interventions against NCDs improve treatment and care in sub-Saharan Africa.

METHODS

Four main databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) and references of included articles were searched for studies reporting effects of mHealth interventions on patients with NCDs in sub-Saharan Africa. All studies published up until May 2015 were included in the review. Following a realist review approach, middle-range theories were identified and integrated into a Framework for Understanding the Contribution of mHealth Interventions to Improved Access to Care for patients with NCDs in sub-Saharan Africa. The main indicators of the framework consist of predisposing characteristics, needs, enabling resources, perceived usefulness, and perceived ease of use. Studies were analyzed in depth to populate the framework.

RESULTS

The search identified 6137 titles for screening, of which 20 were retained for the realist synthesis. The contribution of mHealth interventions to improved treatment and care is that they facilitate (remote) access to previously unavailable (specialized) services. Three contextual factors (predisposing characteristics, needs, and enabling resources) influence if patients and providers believe that mHealth interventions are useful and easy to use. Only if they believe mHealth to be useful and easy to use, will mHealth ultimately contribute to improved access to care. The analysis of included studies showed that the most important predisposing characteristics are a positive attitude and a common language of communication. The most relevant needs are a high burden of disease and a lack of capacity of first-contact providers. Essential enabling resources are the availability of a stable communications network, accessible maintenance services, and regulatory policies.

CONCLUSIONS

Policy makers and program managers should consider predisposing characteristics and needs of patients and providers as well as the necessary enabling resources prior to the introduction of an mHealth intervention. Researchers would benefit from placing greater attention on the context in which mHealth interventions are being implemented instead of focusing (too strongly) on the technical aspects of these interventions.

Mobile phone use for a social strategy to improve antiretroviral refill experience at a low-resource HIV clinic: patient responses from Nigeria

In sub-Saharan African areas where antiretroviral (ARV) drugs are not available through community pharmacies, clinic-based pharmacies are often the primary source of ARV drug refills. Social pressure is mounting on treatment providers to adjust ARV refill services towards user-friendly approaches which prioritize patients' convenience and engage their resourcefulness. By this demand, patients may be signalling dissatisfaction with the current provider-led model of monthly visits to facility-based pharmacies for ARV refill. Mobile phones are increasingly popular in sub-Saharan Africa, and have been used to support ARV treatment goals in this setting. A patient-centred response to on-going social pressure requires treatment providers to view ARV refill activities through the eyes of patients who are negotiating the challenges of day-to-day life while contemplating their next refill appointment. Using focus groups of five categories of adult patients receiving combination ARV therapy, we conducted this cross-sectional qualitative study to provide insight into modifiable gaps between patients' expectations and experiences of the use of mobile phones in facility-based ARV refill service at a public HIV clinic in Nigeria. A notable finding was patients' preference for harnessing informal social support (through intermediaries with mobile phones) to maintain adherence to ARV refill appointments when they could not present in person. This evolving social support strategy also has the potential to enhance defaulter tracking. Our study findings may inform the development of ARV refill strategies and the design of future qualitative studies on client-provider communication by mobile phones in under-resourced HIV treatment programmes.

Cell phone utilization among foreign-born Latinos: a promising tool for dissemination of health and HIV information

Latinos in the US are disproportionately affected by HIV and are at risk for late presentation to care. Between June 2011 and January 2012, we conducted a cross-sectional survey of 209 Baltimore Latinos at community-based venues to evaluate the feasibility of using information communication technology-based interventions to improve access to HIV testing and education within the Spanish-speaking community in Baltimore. Participants had a median age of 33 years interquartile range (IQR) (IQR 28-42), 51.7 % were male, and 95.7 % were foreign-born. Approximately two-thirds (63.2 %) had been in the US less than 10 years and 70.1 % had been previously tested for HIV. Cell phone (92.3 %) and text messaging (74.2 %) was used more than Internet (52.2 %) or e-mail (42.8 %) (p < 0.01). In multivariate analysis, older age and lower education were associated with less utilization of Internet, e-mail and text messaging, but not cell phones. Interest was high for receiving health education (73.1 %), HIV education (70.2 %), and test results (68.8 %) via text messaging. Innovative cell phone-based communication interventions have the potential to link Latino migrants to HIV prevention, testing and treatment services.

Feasibility of Real Time Medication Monitoring Among HIV Infected and TB Patients in a Resource-Limited Setting

HIV infected and tuberculosis (TB) patients need high levels of treatment adherence to achieve optimal treatment outcomes. We conducted a pilot-study on real time medication monitoring (RTMM) in a resource-limited setting. We enrolled five HIV infected and five TB patients from Kilimanjaro, Tanzania. They took their medication using RTMM. When the device was not opened on time, patients received a reminder SMS. After 3 months, we interviewed patients. Six patients (60 %) reached adherence of >95 %. Nine-hundred-twenty-two of 1104 intakes (84 %) were on time. Five-hundred reminders (45 %) were sent, of which 202 (40 %) were incorrect, because of an unstable mobile network. Nine patients found the device helpful and nine mentioned it keeps medication safe. Six patients reported that the size was too big. Five patients mentioned they received incorrect reminders. The device is considered useful in Kilimanjaro. Optimization of the device should consider network connectivity and the size of the device.

Using a tailored health information technology- driven intervention to improve health literacy and medication adherence in a Pakistani population with vascular disease (Talking Rx) - study protocol for a randomized controlled trial

BACKGROUND

Vascular disease, manifesting as myocardial infarction and stroke, is a major cause of morbidity and mortality, especially in low- and middle-income countries. Current estimates are that only one in six patients have good adherence to medications and very few have sufficient health literacy. Our aim is to explore the effectiveness and acceptability of Prescription Interactive Voice Response (IVR) Talking Prescriptions (Talking Rx) and SMS reminders in increasing medication adherence and health literacy in Pakistani patients with vascular disease.

METHODS

This is a randomized, controlled, single center trial. Adult participants, with access to a cell phone and a history of vascular disease, taking multiple risk-modifying medications (inclusive of anti-platelets and statins) will be selected from cerebrovascular and cardiovascular clinics. They will be randomized in a 1:1 ratio via a block design to the intervention or the control arm with both groups having access to a helpline number to address their queries in addition to standard of care as per institutional guidelines. Participants in the intervention group will also have access to Interactive Voice Response (IVR) technology tailored to their respective prescriptions in the native language (Urdu) and will have the ability to hear information about their medication dosage, correct use, side effects, mechanism of action and how and why they should use their medication, as many times as they like. Participants in the intervention arm will also receive scheduled SMS messages reminding them to take their medications. The primary outcome measure will be the comparison of the difference in adherence to anti-platelet and statin medication between baseline and at 3-month follow-up in each group measured by the Morisky Medication Adherence Scale. To ascertain the impact of our intervention on health literacy, we will also compare a local content-validated and modified version of Test of Health Literacy in Adults (TOFHLA) between the intervention and the control arm. We estimate that a sample size of 86 participants in each arm will be able to detect a difference of 1 point on the MMAS with a power of 90 % and significance level of 5 %. Accounting for an attrition rate of 15 %, we plan to enroll 100 participants in each arm (total study population = 200). We hypothesize that a linguistically tailored health IT intervention based on IVR and SMS will be associated with an improvement in adherence (to anti-platelet and lipid-lowering medications) and an improvement in health literacy in Pakistani patients with vascular disease.

DISCUSSION

This innovative study will provide early data for the feasibility of the use of IT based prescriptions in an lower middle incorme country setting with limited numeracy and literacy skills.

TRIAL REGISTRATION

Clinical Trials.gov: NCT02354040 - 2 February 2015.

mHealth: An updated systematic review with a focus on HIV/AIDS and tuberculosis long term management using mobile phones

OBJECTIVE

To evaluate the utilization of mobile phone technology for treatment adherence, prevention, education, data collection, monitoring long-term management of HIV/AIDS and TB patients.

METHODS

Articles published in English language from January 2005 until now from PubMed/MEDLINE, EMBASE, Web of Science, WHO databases, and clinical trials were included. Data extraction is based on medication adherence, quality of care, prevention, education, motivation for HIV test, data collection from HIV lab test results and patient monitoring. Articles selected for the analysis cover RCTs and non RCTs related to the use of mobile phones for long-term care and treatment of HIV/AIDS and TB patients.

RESULTS

Out of 90 articles selected for the analysis, a large number of studies, 44 (49%) were conducted in developing countries, 24 (26%) studies from developed countries, 12 (13%) are systematic reviews and 10 (11%) did not mention study location. Forty seven (52.2%) articles focused on treatment, 11 (12.2%) on quality of care, 8 (9%) on prevention, 13 (14.4%) on education, 6 (6.6%) on data collection, and 5 (5.5%) on patient monitoring. Overall, 66 (73%) articles reported positive effects, 21 (23%) were neutral and 3 (4%) reported negative results.

CONCLUSIONS

Mobile phone technology is widely reported to be an effective tool for HIV/AIDS and TB long-term care. It can substantially reduce disease burden on health care systems by rendering more efficient prevention, treatment, education, data collection and management support.

Current Clinical Status of Telehealth in Korea: Categories, Scientific Basis, and Obstacles

Objectives

Through telehealth, medical services have expanded beyond spatial boundaries and are now available in living spaces outside of hospitals. It can also contribute to patient medical knowledge improvement because patients can access their hospital records and data from home. However, concepts of telehealth are rather vague in Korea.

Methods

We refer to several clinical reports to determine the current clinical status of and obstacles to telehealth in Korea.

Results

Patients' health conditions are now reported regularly to doctors remotely, and patients can receive varied assistance. Self-improvement based on minute details that are beyond medical staff's reach is another possible benefit that may be realized with the help of a variety of medical equipment (sensors). The feasibility, clinical effect, and cost-benefit of telehealth have been verified by scientific evidence.

Conclusions

Patients will be able to improve their treatment adherence by receiving help from various professionals, such as doctors, nurses, nutritionists, and sports therapists. This means that the actual treatment time per patient will increase as well. Ultimately, this will increase the quality of patients' self-administration of care to impede disease progression and prevent complications.

Just text me! Texting sexually transmitted disease clients their test results in Florida, February 2012-January 2013

BACKGROUND

In response to increasing sexually transmitted diseases (STDs), diminishing resources, and delays in prompt treatment, the Florida STD Program began providing test results through text message in 2011. The aims of the evaluation of the first year of the project were to assess (1) client uptake and completion of texting and (2) whether texting was associated with a shorter treatment time frame.

METHODS

Clients screened for STDs at clinics in 3 Florida counties were offered the option to receive test results through coded texts. A positive code prompted clients to call back for treatment information. Texting was conducted through the state's surveillance application, Patient Reporting Investigation Surveillance Manager (PRISM). Evaluation data on clients who opted in (texters) and clients who did not opt in (nontexters) were retrieved from Patient Reporting Investigation Surveillance Manager and descriptively analyzed.

RESULTS

From February 2012 to January 2013, 10,272 clients were offered texting in Clay, Duval, and Seminole counties. Of those offered, 52% opted in. Among texters who were positive and had not been treated (n = 345), 57% called back. Texters received treatment in 5.1 days and nontexters received treatment in 6.7 days (P = 0.036). Texters who called back received treatment 3 days sooner than texters who did not call back (P < 0.001).

CONCLUSIONS

Texting offers STD programs an alternative to traditional notification procedures and may be a viable option for STD programs to reduce the use of staff resources and increase timely treatment for clients. In addition, it can be integrated within an existing surveillance database to minimize the burden of the new process.

Improving medication adherence in stroke patients through Short Text Messages (SMS4Stroke)-study protocol for a randomized, controlled trial

Background

Stroke is a major cause of morbidity and mortality, especially in low and middle income countries. Medical management is the mainstay of therapy to prevent recurrence of stroke. Current estimates are that only 1 in 6 patients have perfect adherence to medication schedules. Using SMS (Short Messaging Service) as reminders to take medicines have been used previously for diseases such as diabetes and HIV with moderate success. We aim to explore the effectiveness and acceptability of SMS in increasing adherence to medications in patients with stroke.

Methods

This will be a randomized, controlled, assessor blinded single center superiority trial. Adult participants with access to a cell phone and a history of stroke longer than 1 month on multiple risk modifying medications will be selected from Neurology and Stroke Clinic. They will be randomized into two parallel groups in a 1:1 ratio via block technique with one group receiving the standard of care as per institutional guidelines while the parallel group receiving SMS reminders for each dose of medicine in addition to the standard of care. In addition intervention group will receive messages for lifestyle changes, medication information, risk factors and motivation for medication adherence. These will bemodeled on Social Cognitive Theory and Health Belief Model and will be categorized by Michies Taxonomy of Behavioral Change Communication. Patient compliance to medicines will be measured at baseline and then after 2 months in each group by using the Morisky Medication Adherence Scale. The change in compliance to medication regimen after the intervention and the difference between the two groups will be used to determine the effectiveness of SMS reminders as a tool to increase medication compliance. The acceptability of the SMS will be determined by a tool designed for this study whose attributes are based Rogers Diffusion of innovation theory.

A sample size of 86 participants in each arm will be sufficient to detect a difference of 1 point on the MMAS with a power of 90 % and significance level of 5 % between the two groups; using an attrition rate of 15 %, 200 participants in all will be randomized.

Discussion

The SMS for Stroke Study will provide evidence for feasibility and effectiveness of SMS in improving post stroke medication adherence in an LMIC setting.

Trial registration

https://clinicaltrials.gov/ct2/show/NCT01986023 11 /11/2013

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0413-2) contains supplementary material, which is available to authorized users.

Does mHealth increase adherence to medication? Results of a systematic review

AIMS

Adherence to medication is a major problem that affects 50-60% of chronically ill patients. As mobile phone use spreads rapidly, a new model of remote health delivery via mobile phone – mHealth – is increasingly used. The objective of this study is to provide a comprehensive overview of how mHealth can be used to improve adherence to medication.

METHODS

A systematic literature review was conducted using four databases (CINAHL, PubMed, Scopus and PsycARTICLES). Eligible articles available on March 2014 had to be written in English or Spanish and have a comparative design. Articles were reviewed by two authors independently. A Cochrane Collaboration tool was used to assess the studies based on their internal validity.

RESULTS

Of the 1504 articles found, 20 fulfilled the inclusion criteria [13 randomised clinical trials (RCT), one quasi-RCT, one non-randomised parallel group study and five studies with a pre-post design]. Nearly all the trials were conducted in high-income countries (80.0%). Articles were categorised depending on the target population into three different groups: (i) HIV-infected patients, n = 5; (ii) patients with other chronic diseases (asthma, coronary heart disease, diabetes mellitus, hypertension, infectious diseases, transplant recipients and psoriasis), n = 11; and (iii) healthy individuals, n = 4. Adherence improved in four of the studies on HIV-infected patients, in eight of the studies on patients with other chronic diseases, and in 1 study performed in healthy individuals. All studies reported sending SMS as medication reminders, healthy lifestyle reminders, or both. Only one trial (HIV-infected patients) had a low risk of bias.

CONCLUSIONS

Our results showed mixed evidence regarding the benefits of interventions because of the variety of the study designs and the results found. Nevertheless, the interventions do seem to have been beneficial, as 65% of the studies had positive outcomes. Therefore, more high-quality studies should be conducted.

A role for health communication in the continuum of HIV care, treatment, and prevention

: Health communication has played a pivotal role in HIV prevention efforts since the beginning of the epidemic. The recent paradigm of combination prevention, which integrates behavioral, biomedical, and structural interventions, offers new opportunities for employing health communication approaches across the entire continuum of care. We describe key areas where health communication can significantly enhance HIV treatment, care, and prevention, presenting evidence from interventions that include health communication components. These interventions rely primarily on interpersonal communication, especially individual and group counseling, both within and beyond clinical settings to enhance the uptake of and continued engagement in care. Many successful interventions mobilize a network of trained community supporters or accompagnateurs, who provide education, counseling, psychosocial support, treatment supervision, and other pragmatic assistance across the care continuum. Community treatment supporters reduce the burden on overworked medical providers, engage a wider segment of the community, and offer a more sustainable model for supporting people living with HIV. Additionally, mobile technologies are increasingly seen as promising avenues for ongoing cost-effective communication throughout the treatment cascade. A broader range of communication approaches, traditionally employed in HIV prevention efforts, that address community and sociopolitical levels through mass media, school- or workplace-based education, and entertainment modalities may be useful to interventions seeking to address the full care continuum. Future interventions would benefit from development of a framework that maps appropriate communication theories and approaches onto each step of the care continuum to evaluate the efficacy of communication components on treatment outcomes.

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.

Future prospects of health management systems using cellular phones

BACKGROUND

Cellular phones enable communication between healthcare providers and patients for prevention, diagnosis, and treatment of diseases. However, few studies have examined the user-friendliness or effectiveness of cellular phone-based medical informatics (CPBMI) for healthcare.

MATERIALS AND METHODS

This study investigated the use of CPBMI to identify its current status within the medical field, advantages and disadvantages, practicability, clinical effectiveness, costs, and cost-saving potential.

RESULTS

CPBMI was validated in terms of practicality and provision of medical benefits. It is critical to use CPBMI in accordance with the different features of each disease and condition. Use of CPBMI is expected to be especially useful for patients with chronic disease.

CONCLUSIONS

We discussed the current status of the clinical use, benefits, and risks of CPBMI. CPBMI and information technology-based health management tools are anticipated to become useful and effective components of healthcare management in the future.

Mobile technologies and geographic information systems to improve health care systems: a literature review

Background

A growing body of research has employed mobile technologies and geographic information systems (GIS) for enhancing health care and health information systems, but there is yet a lack of studies of how these two types of systems are integrated together into the information infrastructure of an organization so as to provide a basis for data analysis and decision support. Integration of data and technical systems across the organization is necessary for efficient large-scale implementation.

Objective

The aim of this paper is to identify how mobile technologies and GIS applications have been used, independently as well as in combination, for improving health care.

Methods

The electronic databases PubMed, BioMed Central, Wiley Online Library, Scopus, Science Direct, and Web of Science were searched to retrieve English language articles published in international academic journals after 2005. Only articles addressing the use of mobile or GIS technologies and that met a prespecified keyword strategy were selected for review.

Results

A total of 271 articles were selected, among which 220 concerned mobile technologies and 51 GIS. Most articles concern developed countries (198/271, 73.1%), and in particular the United States (81/271, 29.9%), United Kingdom (31/271, 11.4%), and Canada (14/271, 5.2%). Applications of mobile technologies can be categorized by six themes: treatment and disease management, data collection and disease surveillance, health support systems, health promotion and disease prevention, communication between patients and health care providers or among providers, and medical education. GIS applications can be categorized by four themes: disease surveillance, health support systems, health promotion and disease prevention, and communication to or between health care providers. Mobile applications typically focus on using text messaging (short message service, SMS) for communication between patients and health care providers, most prominently reminders and advice to patients. These applications generally have modest benefits and may be appropriate for implementation. Integration of health data using GIS technology also exhibit modest benefits such as improved understanding of the interplay of psychological, social, environmental, area-level, and sociodemographic influences on physical activity. The studies evaluated showed promising results in helping patients treating different illnesses and managing their condition effectively. However, most studies use small sample sizes and short intervention periods, which means limited clinical or statistical significance.

Conclusions

A vast majority of the papers report positive results, including retention rate, benefits for patients, and economic gains for the health care provider. However, implementation issues are little discussed, which means the reasons for the scarcity of large-scale implementations, which might be expected given the overwhelmingly positive results, are yet unclear. There is also little combination between GIS and mobile technologies. In order for health care processes to be effective they must integrate different kinds of existing technologies and data. Further research and development is necessary to provide integration and better understand implementation issues.

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.

SMS reminders to improve the tuberculosis cure rate in developing countries (TB-SMS Cameroon): a protocol of a randomised control study

Background

Tuberculosis is a public health problem in Cameroon, just like in many other countries in the world. The National Tuberculosis Control Programme (PNLT) put in place by the state, aims to fight tuberculosis through the implementation of international directives (Directly Observed Treatment Short, DOTS). Despite the deployment of this strategy across the world, its implementation is difficult in the context of low-resource countries. Some expected results are not achieved. In Cameroon, the cure rate for patients with sputum positive pulmonary tuberculosis (TPM+) after 6 months is only about 65%, 20% below the target. This is mainly due to poor patient adherence to treatment. By relying on the potential of mobile Health, the objective of this study is to evaluate the effect of SMS reminders on the cure rate of TPM + patients, measured using 6-month bacilloscopy.

Methods/design

This is a blinded, randomised controlled multicentre study carried out in Cameroon. The research hypothesis is that sending daily SMS messages to remind patients to take their prescribed tuberculosis medication, together with the standard DOTS strategy, will increase the cure rate from 65% (control group: DOTS, no SMS intervention) to 85% (intervention group: DOTS, with SMS intervention) in a group of new TPM + patients. In accordance with each treatment centre, the participants will be randomly allocated into the two groups using a computer program: the intervention group and the control group. A member of the research team will send daily SMS messages. Study data will be collected by health professionals involved in the care of patients. Data analysis will be done by the intention-to-treat method.

Discussion

The achieving of expected outcomes by the PNLT through implementation of DOTS requires several challenges. Although it has been demonstrated that the DOTS strategy is effective in the fight against tuberculosis, its application remains difficult in developing countries. This study explores the potential of mHealth to support DOTS strategy. It will gather new evidence on the effectiveness of mHealth-based interventions and SMS reminders in the improvement of treatment adherence and the cure rate of tuberculosis patients, especially in a low-resource country such as Cameroon.

Trial registration

The trial is registered on the Pan-African Clinical Trials Registry (http://www.pactr.org) under unique identification number: PACTR201307000583416.

MHEALTH INTERVENTION DEVELOPMENT TO SUPPORT PATIENTS WITH ACTIVE TUBERCULOSIS

BACKGROUND

Mobile Health (mHealth) based interventions have been increasingly used to improve a broad range of health outcomes. However, few researchers have reported on the process or the application of theory to guide the development of mHealth based interventions, or specifically for tuberculosis (TB) treatment management.

AIMS

To describe the steps, process, and considerations in developing a text messaging-based intervention to promote treatment adherence and provide support to patients with active TB.

METHODS

Traditional qualitative techniques, including semi-structured interviews, field notes, content analysis, iterative coding, and thematic analysis, were used to design and document the intervention development with a multidisciplinary team of researchers, clinicians, administrators, and patients who were in active TB treatment. The Information-Motivation-Behavioral Skills (IMB) model was used to guide the coding scheme for content analysis of patient-directed TB educational material and intervention development.

RESULTS

The development steps included: a) establishing intervention components, including justifications, considerations, timing and frequency of components; b) developing educational messages, including cultural adaption, text or short message service (SMS) formatting, and prioritizing message delivery order; and c) determining implementation protocol. A set of 16 IMB-based messages were developed for the educational component. Final intervention development was achieved in 3 months.

CONCLUSION

A collaborative approach and application of a theory to guide the intervention design and development is supported. Although a collaborative approach was more time consuming, it resulted in a more responsive, culturally appropriate, and comprehensive intervention. Considerations for developing a text messaging based intervention are provided and may serve as a guide for similar interventions. Further empirical evidence is needed for applying the IMB model for adherence-promotion in TB efforts.

Ownership and use of mobile phones among health workers, caregivers of sick children and adult patients in Kenya: cross-sectional national survey

Background

The rapid growth in mobile phone penetration and use of Short Message Service (SMS) has been seen as a potential solution to improve medical and public health practice in Africa. Several studies have shown effectiveness of SMS interventions to improve health workers’ practices, patients’ adherence to medications and availability of health facility commodities. To inform policy makers about the feasibility of facility-based SMS interventions, the coverage data on mobile phone ownership and SMS use among health workers and patients are needed.

Methods

In 2012, a national, cross-sectional, cluster sample survey was undertaken at 172 public health facilities in Kenya. Outpatient health workers and caregivers of sick children and adult patients were interviewed. The main outcomes were personal ownership of mobile phones and use of SMS among phone owners. The predictors analysis examined factors influencing phone ownership and SMS use.

Results

The analysis included 219 health workers and 1,177 patients’ respondents (767 caregivers and 410 adult patients). All health workers possessed personal mobile phones and 98.6% used SMS. Among patients’ respondents, 61.2% owned phones and 71.4% of phone owners used SMS. The phone ownership and SMS use was similar between caregivers of sick children and adult patients. The respondents who were male, more educated, literate and living in urban area were significantly more likely to own the phone and use SMS. The youngest respondents were less likely to own phones, however when the phones were owned, younger age groups were more likely to use SMS. Respondents living in wealthier areas were more likely to own phones; however when phones are owned no significant association between the poverty and SMS use was observed.

Conclusions

Mobile phone ownership and SMS use is ubiquitous among Kenyan health workers in the public sector. Among patients they serve the coverage in phone ownership and SMS use is lower and disparities exist with respect to gender, age, education, literacy, urbanization and poverty. Some of the disparities on SMS use can be addressed through the modalities of mHealth interventions and enhanced implementation processes while further growth in mobile phone penetration is needed to reduce the ownership gap.

Short Text Messages to Motivate HIV Testing Among Men Who have Sex with Men: A Qualitative Study in Lima, Peru

Objective:

The objective of this study is to identify features and content that short message service (SMS) should have in order to motivate HIV testing among men who have sex with men (MSM) in Lima, Peru.

Methods:

From October, 2010 to February, 2011, we conducted focus groups at two stages; six focus groups were conducted to explore and identify SMS content and features and two additional focus groups were conducted to tailor SMS content. The text messages were elaborated within the theoretical framework of the Information-Motivation-Behavioral Skills model and the Social Support Theory.

Results:

A total of 62 individuals participated in the focus groups. The mean age of participants was 28 years (range 18-39). We identified important features and content items needed for the successful delivery of text messages, including: a) the use of neutral and coded language; b) appropriate frequency and time of delivery; c) avoiding mass and repetitive messages; and d) use of short, concise and creative messages. Although in Peru receiving text messages is usually a free service, it is important to remind participants that receiving messages will be free of charge.

Conclusion:

Text messages can be used to promote HIV testing among Peruvian MSM. It is important to consider adequate frequency, message content and cost when delivering messages to promote HIV testing in this population.

Opening communication channels with people living with HIV using mobile phone text messaging: insights from the CAMPS trial

Background

Using two-way mobile phone text messages to improve adherence to antiretroviral medication enhances communication between patients and health workers. We describe the implications of participants’ responses to text messages in the Cameroon Mobile Phone SMS (CAMPS) trial.

Findings

This is a cross-sectional analysis of data from the intervention arm of the CAMPS trial. CAMPS was a randomized controlled trial of motivational text messaging versus usual care to improve adherence to antiretroviral medication among people living with HIV in Yaounde, Cameroon (n = 200) over a 6 month period. Participants in the intervention arm (n = 101) were given a contact phone number, but were not required to respond to their reminder messages. If they did, their responses were noted and reported as counts and percentages. We received 99 phone calls and 55 text messages (154 responses) from 48 participants during the study period. The median number of responses was 1 (first quartile [Q1]: 1; third quartile [Q3]: 3). Half (n = 79, 51.1%) of them were expressions of gratitude. The rest included requests for logistical (n = 21, 13.6%), medical (n = 20, 12.9%) and financial (n = 11, 7.1%) support.

Conclusion

Initiating two-way mobile communication opens more channels for people living with HIV to express unmet needs. Researchers, policy makers and clinicians should be ready to respond to the needs expressed by patients who respond to text messages.

Trial registration

Pan-African Clinical Trials Registry: PACTR201011000261458;

Clinicaltrials.gov: NCT01247181

Effects of a Phone Call Intervention to Promote Adherence to Antiretroviral Therapy and Quality of Life of HIV/AIDS Patients in Baoshan, China: A Randomized Controlled Trial

Background. Suboptimal adherence to antiretroviral therapy (ART) is still pervasive. The effect of using a mobile phone call intervention to improve patient adherence is currently not known. Objective. This study aims to investigate the effects of a phone call intervention on adherence to ART and quality of life (QOL) of treatment-naive and treatment-experienced patients. Methods. A randomized controlled trial was conducted in the three largest public hospitals. Adherence was measured by self-completed questionnaires. QOL was assessed by the WHOQOL-HIV BREF. Outcomes were assessed at day 15, at 1, 2, and 3 months after start of treatment for treatment-naive patients and at 3 months after study enrollment for treatment-experienced patients. Results. A total of 103 treatment-naive and 93 treatment-experienced HIV/AIDS patients were consecutively recruited. Results show that a phone call intervention could maintain high self-reported adherence among both treatment-naive and treatment-experienced patients. After three months, significant QOL improvements were observed in domains of physical health (P = 0.003), level of independence (P = 0.018), environment (P = 0.002), and spirituality/religion/personal beliefs (P = 0.021) among treatment-naive patients. Conclusion. A mobile phone call intervention to patients could maintain high adherence rates although no statistically significant differences were found. A phone call could improve some domains of QOL among treatment-naive patients.

Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings

The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world's HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.

Trends and determining factors associated with adherence to antiretroviral therapy (ART) in Cameroon: a systematic review and analysis of the CAMPS trial

BACKGROUND

The benefits of antiretroviral therapy (ART) cannot be experienced if they are not taken as prescribed. Yet, not all causes of non-adherence are dependent on the patient. Having to pay for medication reduces adherence rates. Non- adherence has severe public health implications which must be addressed locally and globally. This paper seeks to describe the trends in adherence rates reported in Cameroon and to investigate the determinants of adherence to ART in the Cameroon Mobile Phone SMS (CAMPS) trial.

METHODS

We conducted a systematic review of electronic databases (PubMed, Google Scholar, Web of Science, CINAHL, EMBASE and PSYCINFO) for publications on adherence to ART in Cameroon (from January 1999 to May 2012) and described the trend in reported adherence rates and the factors associated with adherence. Data were extracted in duplicate. We used multivariable analyses on the baseline data for 200 participants in the CAMPS trial to determine the factors associated with adherence in four models using different measures of adherence (more than 90% or 95% on the visual analogue scale, no missed doses and a composite measure: 100% on the visual analogue scale, no missed doses and all pills taken on time).

RESULTS

We identified nine studies meeting our inclusion criteria. Adherence to ART in Cameroon has risen steadily between 2000 and 2010, corresponding to reductions in the cost of medication. The factors associated with adherence to ART in Cameroon are grouped into patient, medication and disease related factors. We also identified factors related to the health system and the patient-provider relationship. In the CAMPS trial, education, side effects experienced and number of reminder methods were found to improve adherence, but only using multiple reminder methods was associated with better adherence in all the regression models (Adjusted Odds Ratio [AOR] 4.11, 95% Confidence Interval [CI] 1.89, 8.93; p<0.001; model IV).

CONCLUSIONS

Reducing the cost of ART is an important aspect of ensuring adequate adherence rates. Using multiple reminder methods may have a cumulative effect on adherence to ART, but should be investigated further.

The Cameroon Mobile Phone SMS (CAMPS) trial: a randomized trial of text messaging versus usual care for adherence to antiretroviral therapy

Background

Mobile phone technology is a novel way of delivering health care and improving health outcomes. This trial investigates the use of motivational mobile phone text messages (SMS) to improve adherence to antiretroviral therapy (ART) over six months.

Methodology/Principal Findings

CAMPS was a single-site randomized two-arm parallel design trial in Yaoundé, Cameroon. We enrolled and randomized HIV-positive adults on ART, aged 21 years and above to receive a weekly standardized motivational text message versus usual care alone. The primary outcome was adherence measured using a visual analogue scale (VAS), number of doses missed (in the week preceding the interview) and pharmacy refill data. Outcomes were measured at 3 and 6 months. Service providers and outcome assessors were blinded to allocation. Analysis was by intention-to-treat. Between November and December 2010, 200 participants were randomized, with 101 in the intervention group and 99 in the control group. At 6 months, overall retention was 81.5%. We found no significant effect on adherence by VAS>95% (risk ratio [RR] 1.06, 95% confidence interval [CI] 0.89, 1.29; p = 0.542; reported missed doses (RR 1.01, 95% CI 0.87, 1.16; p>0.999) or number of pharmacy refills (mean difference [MD] 0.1, 95% CI: 0.23, 0.43; p = 0.617. One participant in the intervention arm reported a possible disclosure of status.

Conclusions/Significance

Standardized motivational mobile phone text messages did not significantly improve adherence to ART in this study. Other types of messaging or longer term studies are recommended.

Registration

1. Pan-African Clinical Trials Registry; PACTR201011000261458

2. Clinicaltrials.gov; NCT01247181

Identifying gender-preferred communication styles within online cancer communities: a retrospective, longitudinal analysis

BACKGROUND

The goal of this research is to determine if different gender-preferred social styles can be observed within the user interactions at an online cancer community. To achieve this goal, we identify and measure variables that pertain to each gender-specific social style.

METHODS AND FINDINGS

We perform social network and statistical analysis on the communication flow of 8,388 members at six different cancer forums over eight years. Kruskal-Wallis tests were conducted to measure the difference between the number of intimate (and highly intimate) dyads, relationship length, and number of communications. We determine that two patients are more likely to form an intimate bond on a gender-specific cancer forum (ovarian P = <0.0001, breast P = 0.0089, prostate P = 0.0021). Two female patients are more likely to form a highly intimate bond on a female-specific cancer forum (Ovarian P<0.0001, Breast P<0.01). Typically a male patient communicates with more members than a female patient (Ovarian forum P = 0.0406, Breast forum P = 0.0013). A relationship between two patients is longer on the gender-specific cancer forums than a connection between two members not identified as patients (ovarian forum P = 0.00406, breast forum P = 0.00013, prostate forum P = .0.0003).

CONCLUSION

The high level of interconnectedness among the prostate patients supports the hypothesis that men prefer to socialize in large, interconnected, less-intimate groups. A female patient is more likely to form a highly intimate connection with another female patient; this finding is consistent with the hypothesis that woman prefer fewer, more intimate connections. The relationships of same-gender cancer patients last longer than other relationships; this finding demonstrates homophily within these online communities. Our findings regarding online communication preferences are in agreement with research findings from person-to-person communication preference studies. These findings should be considered when designing online communities as well as designing and evaluating psychosocial and educational interventions for cancer patients.

Supporting adherence to antiretroviral therapy with mobile phone reminders: results from a cohort in South India

Background

Adherence is central to the success of antiretroviral therapy. Supporting adherence has gained importance in HIV care in many national treatment programs. The ubiquity of mobile phones, even in resource-constrained settings, has provided an opportunity to utilize an inexpensive, contextually feasible technology for adherence support in HIV in these settings. We aimed to assess the influence of mobile phone reminders on adherence to antiretroviral therapy in South India. Participant experiences with the intervention were also studied. This is the first report of such an intervention for antiretroviral adherence from India, a country with over 800 million mobile connections.

Methods

Study design: Quasi-experimental cohort study involving 150 HIV-infected individuals from Bangalore, India, who were on antiretroviral therapy between April and July 2010. The intervention: All participants received two types of adherence reminders on their mobile phones, (i) an automated interactive voice response (IVR) call and (ii) A non-interactive neutral picture short messaging service (SMS), once a week for 6 months. Adherence measured by pill count, was assessed at study recruitment and at months one, three, six, nine and twelve. Participant experiences were assessed at the end of the intervention period.

Results

The mean age of the participants was 38 years, 27% were female and 90% urban. Overall, 3,895 IVRs and 3,073 SMSs were sent to the participants over 6 months. Complete case analysis revealed that the proportion of participants with optimal adherence increased from 85% to 91% patients during the intervention period, an effect that was maintained 6 months after the intervention was discontinued (p = 0.016). Both, IVR calls and SMS reminders were considered non-intrusive and not a threat to privacy. A significantly higher proportion agreed that the IVR was helpful compared to the SMS (p<0.001).

Conclusion

Mobile phone reminders may improve medication adherence in HIV infected individuals in this setting, the effect of which was found to persist for at least 6 months after cessation of the intervention.

Scope and effectiveness of mobile phone messaging for HIV/AIDS care: a systematic review

The objective of this mixed method systematic review was to assess the scope, effectiveness, acceptability and feasibility of the use of mobile phone messaging for HIV infection prevention, treatment and care. We comprehensively searched the peer-reviewed and grey literature. Two authors independently screened citations, extracted data and assessed study quality of included studies (any research design) focusing on mobile phone messaging interventions for HIV care. We present a narrative overview of the results. Twenty-one studies met the inclusion criteria: three randomized controlled trials, 11 interventional studies using other study designs and seven qualitative or cross-sectional studies. We also found six on-going trials and 21 projects. Five of the on-going trials and all the above mentioned projects took place in low or middle-income countries. Mobile phone messaging was researched for HIV prevention, appointment reminders, HIV testing reminders, medication adherence and for communication between health workers. Of the three randomized controlled trials assessing the use of short message service (SMS) to improve medication adherence, two showed positive results. Other interventional studies did not provide significant results. In conclusion, despite an extensive search we found limited evidence on the effectiveness of mobile phone messaging for HIV care. There is a need to adequately document outcomes and constraints of programs using mobile phone messaging to support HIV care to assess the impact and to focus on best practice.

Considerations in using text messages to improve adherence to highly active antiretroviral therapy: a qualitative study among clients in Yaoundé, Cameroon

Poor adherence to highly active antiretroviral therapy (HAART) is a major hindrance to the reduction of mortality and morbidity due to HIV. This qualitative study used focus groups to explore the views and experiences of HIV patients on HAART with adherence reminders, especially the text message (SMS [short message service]). The ethnographic data obtained were used to design a clinical trial to assess the effect of motivational text messages versus usual care to enhance adherence to HAART among HIV patients in Yaoundé, Cameroon. Participants appreciated the idea of a timely SMS reminder, and cited the physician as a role model. They expressed concerns about privacy. Long-term life goals were a motivating factor to adhere. Overall, text messaging was viewed positively as a tool with a dual function of reminder and motivator. Messages coming from the attending physician may have a stronger impact. Trials investigating the use of text messages to improve adherence to HAART need to consider the content and timing of SMS, taking into account technical challenges and privacy.

Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection

BACKGROUND

More than 34 million people are presently living with HIV infection. Antiretroviral therapy (ART) can help these people to live longer, healthier lives, but adherence to ART can be difficult. Mobile phone text-messaging has the potential to help promote adherence in these patients.

OBJECTIVES

To determine whether mobile phone text-messaging is efficacious in enhancing adherence to ART in patients with HIV infection.

SEARCH METHODS

Using the Cochrane Collaboration's validated search strategies for identifying randomised controlled trials and reports of HIV interventions, along with appropriate keywords and MeSH terms, we searched a range of electronic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), MEDLINE (via PubMed), PsycINFO, Web of Science, and the World Health Organization (WHO) Global Index Medicus. The date range was from  01 January 1980 to 01 November 2011. There were no limits to language or publication status.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which patients or their caregivers (in the case of infants and children) of any age, in any setting, and receiving ART were provided with mobile phone text messages as a means of promoting adherence to ART.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the abstracts of all identified trials. We initially identified 243 references. Seventeen full-text articles were closely reviewed. Both authors abstracted data independently, using a pre-designed, standardised data collection form. When appropriate, data were combined in meta-analysis.

MAIN RESULTS

Two RCTs from Kenya were included in the review. One trial compared short weekly text messages against standard care. The other trial compared short daily, long daily, short weekly and long weekly messages against standard care. Both trials were with adult patients.In the trial comparing only short weekly messages to standard care, text messaging was associated with a lower risk of non-adherence at 12 months (RR 0.77, 95% CI 0.63 to 0.93) and with the non-occurrence of virologic failure at 12 months (RR 0.83, 95% CI 0.69 to 0.99).In the trial that compared different intervals and lengths for text-messaging to standard care, long weekly text-messaging was not significantly associated with a lower risk of non-adherence compared to standard care (RR 0.79, 95% CI 0.60 to 1.04). Patients receiving weekly text-messages of any length were at lower risk of non-adherence at 48 weeks than were patients receiving daily messages of any length (RR 0.79, 95% CI 0.64 to 0.99). There were no significant differences between weekly text-messaging of any length (RR 1.01, 95% CI 0.75 to 1.37) and between short or long messaging at either interval (RR 0.99, 95% CI 0.78 to 1.27). Compared to standard care, any daily text-messaging, whether short or long, did not reduce the risk for non-adherence (RR 0.99, 95% CI 0.82 to 1.20).In meta-analysis of both trials, any weekly text-messaging (i.e. whether short or long messages) was associated with a lower risk of non-adherence at 48-52 weeks (RR 0.78, 95% CI 0.68 to 0.89). The effect of short weekly text-messaging was also significant (RR 0.77, 95% CI 0.67 to 0.89).

AUTHORS' CONCLUSIONS

There is high-quality evidence from the two RCTs that mobile phone text-messaging at weekly intervals is efficacious in enhancing adherence to ART, compared to standard care. There is high quality evidence from one trial that weekly mobile phone text-messaging is efficacious in improving HIV viral load suppression. Policy-makers should consider funding programs proposing to provide weekly mobile phone text-messaging as a means for promoting adherence to antiretroviral therapy. Clinics and hospitals should consider implementing such programs. There is a need for large RCTs of this intervention in adolescent populations, as well as in high-income countries.

A workshop report on HIV mHealth synergy and strategy meeting to review emerging evidence-based mHealth interventions and develop a framework for scale-up of these interventions

mHealth is a term used to refer to mobile technologies such as personal digital assistants and mobile phones for healthcare. mHealth initiatives to support care and treatment of patients are emerging globally and this workshop brought together researchers, policy makers, information, communication and technology programmers, academics and civil society representatives for one and a half days synergy meeting in Kenya to review regional evidence based mHealth research for HIV care and treatment, review mHealth technologies for adherence and retention interventions in anti-retroviral therapy (ART) programs and develop a framework for scale up of evidence based mHealth interventions. The workshop was held in May 2011 in Nairobi, Kenya and was funded by the Canadian Global Health Research Initiatives (GHRI) and the US Centre for Disease Control and Prevention (CDC). At the end of the workshop participants came up with a framework to guide mHealth initiatives in the region and a plan to work together in scaling up evidence based mHealth interventions. The participants acknowledged the importance of the meeting in setting the pace for strengthening and coordinating mHealth initiatives and unanimously agreed to hold a follow up meeting after three months.

Beyond reminders: a conceptual framework for using short message service to promote prevention and improve healthcare quality and clinical outcomes for people living with HIV

The availability of effective antiretroviral therapy has altered HIV from being an acute disease to being a chronic, manageable condition for many people living with HIV (PLWH). Because of their ubiquity and flexibility, mobile phones with short message service (SMS) offer a unique opportunity to enhance treatment and prevention for people managing HIV. To date, very few US studies using SMS for HIV self-management have been published. In this article, we review the published SMS-based intervention research that aimed to improve healthcare quality and outcomes for PLWH and other chronic health conditions, and propose a conceptual model that integrates the communication functionality of SMS with important psychosocial factors that could mediate the impact of SMS on health outcomes. We posit that an SMS-based intervention that incorporates the elements of interactivity, frequency, timing, and tailoring of messages could be implemented to encourage greater medication adherence as well as impact other mutually reinforcing behaviors and factors (e.g., increasing patient involvement and social support, reducing risk behaviors, and promoting general health and well-being) to support better healthcare quality and clinical outcomes for PLWH. We recommend that future studies explore the potential linkages between variations in SMS characteristics and these mediating factors to determine if and how they influence the larger outcomes.

The challenges and opportunities of conducting a clinical trial in a low resource setting: the case of the Cameroon mobile phone SMS (CAMPS) trial, an investigator initiated trial

Conducting clinical trials in developing countries often presents significant ethical, organisational, cultural and infrastructural challenges to researchers, pharmaceutical companies, sponsors and regulatory bodies. Globally, these regions are under-represented in research, yet this population stands to gain more from research in these settings as the burdens on health are greater than those in developed resourceful countries. However, developing countries also offer an attractive setting for clinical trials because they often have larger treatment naive populations with higher incidence rates of disease and more advanced stages. These factors can present a reduction in costs and time required to recruit patients. So, balance needs to be found where research can be encouraged and supported in order to bring maximum public health benefits to these communities. The difficulties with such trials arise from problems with obtaining valid informed consent, ethical compensation mechanisms for extremely poor populations, poor health infrastructure and considerable socio-economic and cultural divides. Ethical concerns with trials in developing countries have received attention, even though many other non-ethical issues may arise. Local investigator initiated trials also face a variety of difficulties that have not been adequately reported in literature. This paper uses the example of the Cameroon Mobile Phone SMS trial to describe in detail, the specific difficulties encountered in an investigator-initiated trial in a developing country. It highlights administrative, ethical, financial and staff related issues, proposes solutions and gives a list of additional documentation to ease the organisational process.