Qualitative Analysis of Programmatic Initiatives to Text Patients with Mobile Devices in Resource-Limited Health Systems

Background

Text messaging is an affordable, ubiquitous, and expanding mobile communication technology. However, safety net health systems in the United States that provide more care to uninsured and low-income patients may face additional financial and infrastructural challenges in utilizing this technology. Formative evaluations of texting implementation experiences are limited. We interviewed safety net health systems piloting texting initiatives to study facilitators and barriers to real-world implementation.

Methods

We conducted telephone interviews with various stakeholders who volunteered from each of the eight California-based safety net systems that received external funding to pilot a texting-based program of their choosing to serve a primary care need. We developed a semi-structured interview guide based partly on the Consolidated Framework for Implementation Research (CFIR), which encompasses several domains: the intervention, individuals involved, contextual factors, and implementation process. We inductively and deductively (using CFIR) coded transcripts, and categorized themes into facilitators and barriers.

Results

We performed eight interviews (one interview per pilot site). Five sites had no prior texting experience. Sites applied texting for programs related to medication adherence and monitoring, appointment reminders, care coordination, and health education and promotion. No site texted patient-identifying health information, and most sites manually obtained informed consent from each participating patient. Facilitators of implementation included perceived enthusiasm from patients, staff and management belief that texting is patient-centered, and the early identification of potential barriers through peer collaboration among grantees. Navigating government regulations that protect patient privacy and guide the handling of protected health information emerged as a crucial barrier. A related technical challenge in five sites was the labor-intensive tracking and documenting of texting communications due to an inability to integrate texting platforms with electronic health records.

Conclusions

Despite enthusiasm for the texting programs from the involved individuals and organizations, inadequate data management capabilities and unclear privacy and security regulations for mobile health technology slowed the initial implementation and limited the clinical use of texting in the safety net and scope of pilots. Future implementation work and research should investigate how different texting platform and intervention designs affect efficacy, as well as explore issues that may affect sustainability and the scalability.

Full article at:   http://goo.gl/SAsnqs

By:  Sachin K. Garg, Courtney R. Lyles, Sara Ackerman, Margaret A. Handley, Dean Schillinger, Gato Gourley, Veenu Aulakh, and Urmimala Sarkar

Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA

Department of Social and Behavior Sciences, UCSF, San Francisco, USA

Center for Care Innovations, Oakland, USA

Department of Epidemiology and Biostatistics, UCSF, San Francisco, USA

Sachin K. Garg, Phone: (415) 353-7900, Email: ude.fscu@grag.nihcas.

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As Good As It Gets? Retention in Care of People Newly Diagnosed with HIV at the Sydney Sexual Health Centre

A retrospective review of all new HIV positive patients attending the Sydney Sexual Health Centre in 2012 and 2013 was performed to ascertain the retention in care rates, proportion that achieved viral suppression, number of SMS reminders sent and counselling uptake. 

• Ninety-six patients had a retention rate of 66%. 
• Thirty-three patients (34%) were not retained in care, 
• 16 (17%) were knowingly attending another healthcare service with 17 (18%) categorised as lost to follow up. 
• Counselling referrals had a 74% (71/96) uptake, with SMS reminders sent in 97% (93/96) of cases. 

Overall, the clinic performed well compared with international standards but the lost to follow-up rate remains a concern

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By:  Dominic Rowley A E, Amel Ahmed A, Anna McNulty A B, Lynne Wray A C and Vickie Knight A D 

A Sydney Sexual Health Centre, Nightingale Wing, Sydney Hospital, 8 Macquarie Street, Sydney, NSW 2000, Australia. B School of Public Health and Community Medicine, University of NSW Australia, Sydney, NSW 2052, Australia. C School of Women’s and Children’s Health, University of NSW Australia, NSW 2052, Australia. D The Kirby Institute, Wallace Wurth Building, University of NSW Australia, Sydney, NSW 2052, Australia. E Corresponding author. Email: dominicrowley@hotmail.com 

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The Acceptability and Perceived Usefulness of a Weekly Clinical SMS Program to Promote HIV Antiretroviral Medication Adherence in KwaZulu-Natal, South Africa

Short message service (SMS) text messages have been used to remind and encourage patients to take ART in research studies. However, few studies have assessed the feasibility and acceptability of SMS in routine clinical practice. 

We report patient perspectives on a weekly SMS adherence support program after implementation into clinical care at an HIV clinic in KwaZulu-Natal, South Africa. We conducted structured interviews with a cross-sectional convenience sample of 100 adult patients who were invited to join the program, 88 of whom had received a program SMS. 

Of these respondents, 81 (92 %) would recommend the program to a friend. Sixty-eight (77 %) felt the program helped them remember clinic appointments, a response associated with male gender [odds ratio (OR) 5.88, 95 % confidence interval (CI) 1.52-23.26, P = 0.011] and HIV disclosure outside the home [OR 3.40, 95 %CI 1.00-11.60, P = 0.050]. 

This clinical SMS adherence program was found to have high patient-perceived usefulness.

Purchase full article at:   http://goo.gl/U452ka

By:  Georgette N1, Siedner MJ1,2,3, Zanoni B1,2,3, Sibaya T4, Petty CR5, Carpenter S6, Haberer JE7,8,9.

• 1Harvard Medical School, Boston, MA, USA.
• 2Center for Global Health, Massachusetts General Hospital, 100 Cambridge St, 15th Floor, Boston, MA, USA.
• 3Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
• 4University of KwaZulu-Natal, Durban, South Africa.
• 5Boston Children's Hospital, Boston, MA, USA.
• 6Don McKenzie Hospital, Botha's Hill, South Africa.
• 7Harvard Medical School, Boston, MA, USA. jhaberer@partners.org.
• 8Center for Global Health, Massachusetts General Hospital, 100 Cambridge St, 15th Floor, Boston, MA, USA. jhaberer@partners.org.
• 9Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. jhaberer@partners.org. 
• AIDS Behav. 2016 Jan 18.

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'It's All In The Message': The Utility of Personalised Short Message Service (SMS) Texts to Remind Patients at Higher Risk of STIs & HIV to Reattend for Testing

BACKGROUND:

Patients at increased risk of sexually transmitted infections (STIs)/HIV acquisition are advised to reattend for retesting. A previous study showed that 'generic' text reminders did not improve reattendance.

AIM:

To assess if a personalised text message with increased contact information would increase reattendance rates of at-risk patients.

METHODS:

Patients who are at risk of future STIs, defined by having a current acute STI, attending for emergency contraception, commercial sex workers (CSWs) or men who have sex with men (MSM), were sent a text reminder to reattend for retesting 6 weeks after initial visit. Reattendance rates were measured for September to December 2012 (control group who received a generic text message) and February to May 2014 (intervention 'personalised message' group who received a text message containing their first name and ways to contact the clinic). Reattendance was counted within 4 months of the end of the initial episode of care.

RESULTS:

The reattendance rate was significantly higher for the intervention group: 149/266 (56%) than the control group: 90/273 (33%) (p=0.0001) and was also significantly higher in the intervention group than the control group in patients with the following risks: recent chlamydia (64/123 (52%) vs 43/121 (36%)) (p=0.03), recent gonorrhoea (41/64 (64%) vs 4/21 (19%)) (p=0.0003) and MSM (26/45 (58%) vs 3/18 (16%)) (p=0.006). New STI rates in the reattending intervention group and controls were 26/ 149 (17%) and 13/90 (14%) (n.s), respectively.

CONCLUSIONS:

Sending a personalised text message with increased contact information as a reminder for retesting increased reattendance rates by 23% in patients who are at higher risk of STIs.

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By:   Nyatsanza F1, McSorley J1, Murphy S1, Brook G1.

1Patrick Clements Clinic, Department of Sexual Health and HIV, London North West Healthcare NHS Trust, Central Middlesex Hospital, London, UK

 

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Pilot RCT of Bidirectional Text Messaging for ART Adherence among Nonurban Substance Users with HIV

OBJECTIVE:

This pilot study tested the preliminary efficacy of a theory-based bidirectional text messaging intervention (TEXT) on antiretroviral (ART) adherence, missed care visits, and substance use among people with HIV.

METHOD:

Participants with recent substance use and ART nonadherence from 2 nonurban HIV clinics were randomized to TEXT or to usual care (UC). The TEXT intervention included daily queries of ART adherence, mood, and substance use. The system sent contingent intervention messages created by participants for reports of adherence/nonadherence, good mood/poor mood, and no substance use/use. Assessments were at preintervention, postintervention, and 3-month postintervention follow-up. Objective primary outcomes were adherence, measured by past 3-month pharmacy refill rate, and proportion of missed visits (PMV), measured by medical records. The rate of substance-using days from the timeline follow-back was a secondary outcome.

RESULTS:

Sixty-three patients participated, with 33 randomized to TEXT and 30 to UC. At preintervention, adherence was 64.0%, PMV was 26.9%, and proportion of days using substances was 53.0%. At post intervention, adherence in the TEXT condition improved from 66% to 85%, compared with 62% to 71% in UC participants (p = .04). PMV improved from 23% to 9% for TEXT participants and 31% to 28% in UC participants (p = .12). There were no significant differences between conditions in substance-using days at postintervention. At 3-month follow-up, differences were not significant.

CONCLUSIONS:

Personalized bidirectional text messaging improved adherence and shows promise to improve visit attendance, but did not reduce substance using days. This intervention merits further testing and may be cost-efficient given its automation.

Below:  Raw rate of adherence, missed visits, and substance-using days by condition over time

Full article at:  http://goo.gl/B1X2uI

By:   Ingersoll KS1, Dillingham RA2, Hettema JE1, Conaway M3, Freeman J1, Reynolds G4, Hosseinbor S1.

• 1Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine.
• 2Department of Medicine, University of Virginia School of Medicine.
• 3Department of Public Health Sciences, University of Virginia School of Medicine.
• 4Health Decision Technologies. 

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Electronic Case Management with Homeless Youth

Case management, a widely practiced form of service brokerage, is associated with a variety of positive outcomes for homeless youth, but it may be difficult to implement, as youth face logistical barriers to attending in-person meetings. As part of a larger clinical trial, the current study investigates the feasibility of providing electronic case management (ECM) to homeless youth, using cell-phones, texts, email, and Facebook. 

Youth were given prepaid cell-phones and a case manager who provided four ECM sessions every 2-3 weeks over a 3-month period. Contact logs were used to record how many youth engaged in ECM, how many attempts were necessary to elicit engagement, and youths' preferred technology methods for engaging. Although engagement in the number of ECM sessions varied, the majority of youth (87.5%) engaged in at least one ECM session. Youth (41%) most commonly needed one contact before they engaged in an ECM session, and the majority responded by the third attempt. While youth most commonly answered calls directly, their chosen method of returning calls was texting. The majority of youth (80%) described ECM positively, reporting themes of convenience, connection, and accountability. 

The use of ECM, particularly of texting, offers promising implications for providing services to homeless youth.

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By:   Bender K1, Schau N2, Begun S3, Haffejee B4, Barman-Adhikari A5, Hathaway J6.

• 12148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: Kimberly.bender@du.edu.
• 22148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: ndschau@gmail.com.
• 32148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: Stephanie.begun@du.edu.
• 42148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: badiah.haffejee@du.edu.
• 52148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: Anamika.BarmanAdhikari@du.edu.
• 62148 S. High Street, Graduate School of Social Work, University of Denver, Denver, CO 80208, United States. Electronic address: jessica.kaylyn.hathaway@gmail.com. 

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Mobile Phone Text Message Reminders: Measuring Preferences of People with Antipsychotic Medication

Mobile technology use, including Short Messaging Service (SMS) text messaging, has increased in health care services. Preferences regarding the type or timing of text messages sent by healthcare providers to people with antipsychotic medication have not yet been fully investigated. This study examines the relationship between patients' demographic characteristics and the tailored messages they select. 

The study ("Mobile.Net", ISRCTN: 27704027) includes a structured analysis of a random sub-sample of participants who received messages for 12months. The data were collected in 24 sites and 45 psychiatric hospitals in Finland and analyzed with descriptive statistics and Poisson regression models. The study sample involved 562 people on antipsychotic medication, and a total of 2112 text messages (2 to 25 monthly) were analysed. 

Regarding message content, there was no significant variation in the proportions relating to 'medication', 'treatment appointments' or 'free time'. Monday was the most popular day to receive messages and morning was preferred to later in the day. Age was most closely associated with 'number of messages' and 'time of messages'. 

Older women and younger men preferred higher numbers of messages (p=0.0031). Participants preferred positive, encouraging and slightly humorous messages. 

The findings suggest that messages may be acceptable for difficult to access groups in follow-up. This type of intervention may be useful for various types of patients especially for younger males. To further support the evidence about factors related to message utilization and use, it is important to evaluate the effectiveness of text messages in psychiatric care.

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Perceptions, Attitudes, and Experience Regarding mHealth among Homeless Persons in New York City Shelters

Mobile health may be an effective means of providing access and education to the millions of homeless Americans. We conducted semi-structured interviews with 50 homeless people from different shelters in New York City to evaluate their perceptions, attitudes, and experiences regarding mobile health. Participants' average age was 51.66 (SD = 11.34) years; duration of homelessness was 2.0 (SD = 3.10) years. 

The majority had a mobile phone with the ability to receive and send text messages. Most participants attempted to maintain the same phone number over time. The homeless were welcoming and supportive of text messaging regarding health care issues, including appointment reminders, health education, or management of diseases considering their barriers and mobility, and believed it would help them access necessary health care. 

Overwhelmingly they preferred text reminders that were short, positively framed, and directive in nature compared to lengthy or motivational texts. The majority believed that free cell phone plans would improve their engagement with, help them navigate, and ultimately improve their access to care. 

These positive attitudes and experience could be effectively used to improve health care for the homeless. Policies to improve access to mobile health and adapted text messaging strategies regarding the health care needs of this mobile population should be considered.

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