Pilot Randomized Controlled Trial of Game Plan for PrEP: A Brief, Web and Text Message Intervention to Help Sexual Minority Men Adhere to PrEP and Reduce Their Alcohol Use.

Suboptimal adherence to oral PrEP medications, particularly among younger sexual minority men (SMM), continues to be a key barrier to achieving more substantial declines in new HIV infections. Although variety of interventions, including web and text-message-based applications, have successfully addressed PrEP adherence, very few have addressed the potential influence of alcohol. This pilot study explored whether the Game Plan for PrEP, a brief, web-based and text messaging intervention, helped promote PrEP persistence and adherence and reduced condomless sex and alcohol use. Seventy-three heavy-drinking SMM on PrEP were recruited online from states with Ending the HIV Epidemic jurisdictions and randomly assigned 1:1 to receive either the Game Plan for PrEP intervention or an attention-matched control. We collected online surveys assessing primary outcomes at one, three, and six months post-enrollment. As secondary outcomes, we also collected dried blood spot samples at baseline, three, and six months to analyze for biomarkers of PrEP and alcohol use. Our results showed that the odds of stopping PrEP or experiencing a clinically meaningful lapse in PrEP adherence (≥ 4 consecutive missed doses) were not different across the two conditions. We also did not find evidence of any differences in condomless sex or drinking outcomes across conditions, although participants in both conditions reported drinking less often over time. These findings were consistent across both self-reported outcomes and biomarkers. Overall, we did not find evidence that our brief, web and text messaging intervention encouraged more optimal PrEP coverage or moderate their alcohol use.

Implementation of free-draft text messaging to enhance care retention and satisfaction for persons living with HIV infection.

Eligible persons with HIV infection can receive client-centered case management to coordinate medical and social services. Novel mobile health interventions could improve effective case management and retention in care, an important goal to help end the HIV epidemic. Using a hybrid type I effectiveness-implementation design, we assessed whether access to bidirectional, free-draft secure text messaging with a case manager and clinic pharmacist could improve client satisfaction and care retention in a Southern academic HIV clinic. Sixty-four clients enrolled between November 2019 and March 2020, had a median age of 39 years, and were mostly male, single, and African-American. Heavy app users texted over 100 times (n = 6) over the course of the 12-month intervention while others never texted (n = 12). App usage peaked during months of clinic closure due to COVID-19. Most participants reported high satisfaction with the app and planned continued usage after study completion. Changes in clinic retention and virologic suppression rates were not observed, a result confounded by practice changes due to COVID-19. High usage and satisfaction of free-draft text messaging in case-managed HIV clients supports inclusion of this communication option in routine HIV clinical care.

Randomized comparison of the effects of tailored text messaging versus pillbox organizers on medication adherence of heart failure patients.

BACKGROUND: Heart failure (HF) is a major public health issue worldwide, affecting approximately 64.3 million people in 2017. Non-adherence to medication is a common and serious issue in the management of HF. However, new reminder systems utilizing mobile technology, such as text messaging, have shown promise in improving medication adherence. The purpose of this study was to compare the impact of tailored text messaging (TTM) and pillbox organizers on medication adherence in individuals with HF. METHODS: A randomized controlled trial was conducted, involving 189 eligible patients with HF who were randomly assigned to either the TTM, pillbox organizer, or control group. Medication adherence was evaluated using pill counting and the Medication Adherence Rating Scale (MARS) over a period of three months and compared across the groups. The data were analyzed using Kruskal-Wallis, Analysis of Variance (ANOVA), and Repeated Measures ANOVA tests. RESULTS: The results indicate that both the TTM and pillbox organizers groups had significantly higher medication adherence compared to the control group, as measured by pill counting (MD = 0.05, 95%CI = 0.03-0.06; p < 0.001 for TTM group, MD = 0.04, 95%CI = 0.03-0.06; p < 0.001 for pillbox organizers group) and the MARS (MD = 1.32, 95%CI = 0.93 to 1.72; p < 0.001 for TTM group, MD = 1.33, 95%CI = 0.95 to 1.72; p < 0.001 for pillbox organizers group). However, there was no statistically significant difference in medication adherence between the two intervention groups using either measurement method. The TTM group exhibited a lower hospitalization rate than the other groups in the first follow up (p = 0.016). CONCLUSIONS: Both the TTM and pillbox organizers were shown to be effective in enhancing medication adherence among patients with HF. Therefore, healthcare providers should take into account the patient's condition and preferences when selecting one of these methods to promote medication adherence. Future research should aim to address the limitations of this study, such as controlling for confounding variables, considering long-term effects, and comparing the effectiveness of different interventions.

Feasibility of text message follow-up for pediatric asthma care after an emergency department visit.

Background: Many children seen in the Emergency Department (ED) for asthma do not follow-up with their primary care provider. Text messaging via short message service (SMS) is a ubiquitous, but untested means of providing post-ED asthma follow-up care.Objective: To evaluate responses to an asthma assessment survey via SMS following an ED visit and estimate the likelihood of response by sociodemographic and clinical characteristics. Methods: We recruited 173 parents of children 2-17 years-old presenting for ED asthma care to receive a follow-up text (participation rate: 85%). One month later, parents received via SMS a 22-item survey that assessed asthma morbidity. We assessed response rates overall and by various sociodemographic and clinical characteristics, including age, parental education, and indicators of asthma severity.Results: Overall, 55% of parents (n = 95) responded to the SMS survey. In multivariable logistic regression (MLR), parents who graduated high school had a four-fold higher response rate compared to parents with less than a high school degree (OR: 4.05 (1.62, 10.13)). More parents of children with oral steroid use in the prior 12 months responded to survey items (OR: 2.53 (1.2, 5.31)). Reported asthma characteristics included: 48% uncontrolled, 22% unimproved/worse, 21% with sleep disruption, and 10% who were hospitalized for asthma.Conclusions: Text messaging may be a viable strategy to improve post-ED asthma assessment and to identify children with persistent symptoms in need of enhanced care or modification of care plans.

Individualized treatment effects of a digital alcohol intervention and their associations with participant characteristics and engagement.

AIMS: Conditional average treatment effects are often reported in intervention studies, in which assumptions are made regarding how effects are similar across a heterogeneous sample. Nonetheless, differing factors, such as genetics, age, and sex, can impact an intervention's effect on outcomes. The study aimed to estimate the individualized effects of a digital alcohol intervention among individuals looking online to reduce their drinking. METHODS: We used data from a randomized controlled trial (RCT), including 2129 adults from the Swedish general population. The RCT concerned a text message-based alcohol intervention that sought to engender change through increasing knowledge on how to change and instilling confidence in changing behaviour. Outcomes were total weekly alcohol consumption and monthly heavy episodic drinking. Individualized treatment effects were modelled using baseline characteristics (age, gender, alcohol consumption, and psychosocial variables) and engagement with the intervention content. RESULTS: We found evidence that the effects of the digital alcohol intervention were heterogeneous concerning participants' age, baseline alcohol consumption, confidence, and importance. For heavy episodic drinking, there was evidence that effects were heterogeneous concerning age, sex, and baseline alcohol consumption. Overall, women, older individuals, and heavier drinkers benefitted more from the intervention in terms of effect size. In addition, participants who engaged more with the goal-setting and screening content reported better outcomes. CONCLUSIONS: The results highlight how different individuals respond differently to a digital alcohol intervention. This allows insight into who benefits the most and least from the intervention and highlights the potential merit of designing interventions adapted to different individuals' needs.

The use, adherence, and evaluation of interactive text-messaging among women admitted to prevention of mother-to-child transmission of HIV care in Kenya (WelTel PMTCT).

BACKGROUND: To improve future mobile health (mHealth) interventions in resource-limited settings, knowledge of participants' adherence to interactive interventions is needed, but previous studies are limited. We aimed to investigate how women in prevention of mother-to-child transmission of HIV (PMTCT) care in Kenya used, adhered to, and evaluated an interactive text-messaging intervention. METHODS: We conducted a cohort study nested within the WelTel PMTCT trial among 299 pregnant women living with HIV aged ≥ 18 years. They received weekly text messages from their first antenatal care visit until 24 months postpartum asking "How are you?". They were instructed to text within 48 h stating that they were "okay" or had a "problem". Healthcare workers phoned non-responders and problem-responders to manage any issue. We used multivariable-adjusted logistic and negative binomial regression to estimate adjusted odds ratios (aORs), rate ratios (aRRs) and 95% confidence intervals (CIs) to assess associations between baseline characteristics and text responses. Perceptions of the intervention were evaluated through interviewer-administered follow-up questionnaires at 24 months postpartum. RESULTS: The 299 participants sent 15,183 (48%) okay-responses and 438 (1%) problem-responses. There were 16,017 (51%) instances of non-response. The proportion of non-responses increased with time and exceeded 50% around 14 months from enrolment. Most reported problems were health related (84%). Having secondary education was associated with reporting a problem (aOR:1.88; 95%CI: 1.08-3.27) compared to having primary education or less. Younger age (18-24 years) was associated with responding to < 50% of messages (aOR:2.20; 95%CI: 1.03-4.72), compared to being 35-44 years. Women with higher than secondary education were less likely (aOR:0.28; 95%CI: 0.13-0.64), to respond to < 50% of messages compared to women with primary education or less. Women who had disclosed their HIV status had a lower rate of non-response (aRR:0.77; 95%CI: 0.60-0.97). In interviews with 176 women, 167 (95%) agreed or strongly agreed that the intervention had been helpful, mainly by improving access to and communication with their healthcare providers (43%). CONCLUSION: In this observational study, women of younger age, lower education, and who had not disclosed their HIV status were less likely to adhere to interactive text-messaging. The majority of those still enrolled at the end of the intervention reported that text-messaging had been helpful, mainly by improving access to healthcare providers. Future mHealth interventions aiming to improve PMTCT care need to be targeted to attract the attention of women with lower education and younger age.

The impact of text message reminders on cryotherapy uptake among women testing positive for HPV in western Kenya: a prospective cohort study.

BACKGROUND: Mobile health (mHealth) has become an increasingly popular strategy to improve healthcare delivery and health outcomes. Communicating results and health education via text may facilitate program planning and promote better engagement in care for women undergoing human papillomavirus (HPV) screening. We sought to develop and evaluate an mHealth strategy with enhanced text messaging to improve follow-up throughout the cervical cancer screening cascade. METHODS: Women aged 25-65 participated in HPV testing in six community health campaigns (CHCs) in western Kenya as part of a single arm of a cluster-randomized trial. Women received their HPV results via text message, phone call, or home visit. Those who opted for text in the first four communities received "standard" texts. After completing the fourth CHC, we conducted two semi-structured focus group discussions with women to develop an "enhanced" text strategy, including modifying the content, number, and timing of texts, for the subsequent two communities. We compared the overall receipt of results and follow-up for treatment evaluation among women in standard and enhanced text groups. RESULTS: Among 2368 women who were screened in the first four communities, 566 (23.9%) received results via text, 1170 (49.4%) via phone call, and 632 (26.7%) via home visit. In the communities where enhanced text notification was offered, 264 of the 935 screened women (28.2%) opted for text, 474 (51.2%) opted for phone call, and 192 (20.5%) for home visit. Among 555 women (16.8%) who tested HPV-positive, 257 (46.3%) accessed treatment, with no difference in treatment uptake between the standard text group (48/90, 53.3%) and the enhanced text group (22/41, 53.7%). More women in the enhanced text group had prior cervical cancer screening (25.8% vs. 18.4%; p < 0.05) and reported living with HIV (32.6% vs. 20.2%; p < 0.001) than those in the standard text group. CONCLUSIONS: Modifying the content and number of texts as an enhanced text messaging strategy was not sufficient to increase follow-up in an HPV-based cervical cancer screening program in western Kenya. A one-size approach to mHealth delivery does not meet the needs of all women in this region. More comprehensive programs are needed to improve linkage to care to further reduce structural and logistical barriers to cervical cancer treatment.

A randomized controlled trial testing theory-driven enhancements to increase the efficacy of and engagement in a brief cognitive-behavioural therapy text-message intervention for co-occurring posttraumatic stress disorder symptoms and alcohol misuse.

OBJECTIVE: Engaging individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol misuse (AM) in effective treatments is difficult. Brief, self-directed approaches that deliver empirically supported intervention techniques, such as cognitive-behavioural therapy (CBT) strategies, via technology may be effective and easier-to-access alternatives to traditional in-person therapy approaches for PTSD + AM. This paper describes the protocol for an intervention development study (NCT05372042) that evaluates a text-message intervention combining CBT texts with techniques from cognitive psychology (message framing) and social psychology (growth mindsets) for treatment of PTSD + AM. METHOD: The study uses a 3 (message framing: gain vs. loss vs. no framing) × 2 (mindset: growth mindsets vs. not) factorial design to test enhancements to CBT texts. Individuals age 18+, who report symptoms of PTSD and AM, will be recruited to participate. Participants will complete screening, verification, and baseline measures. They will be randomized to condition and receive 3 text messages per week for 4 weeks. Participants will be assessed at post-, 1-, and 3-month follow-up. RESULTS: Analyses will evaluate whether framing and growth mindsets enhance the efficacy of CBT texts. A priori decision rules will be applied to select the intervention condition that is both the most effective and the simplest, which will be tested in a follow-up randomized controlled trial. CONCLUSIONS: This study will identify the simplest, most efficacious CBT intervention for PTSD + AM. Its use of cognitive and social psychology-based enhancement and of a factorial decision can serve as examples of how to enhance and increase engagement in brief, self-directed CBT interventions.

Effect of Adding Personalized Instant Messaging Apps to a Brief Smoking Cessation Model in Community Smokers in Hong Kong: Pragmatic Randomized Clinical Trial.

BACKGROUND: While text messaging has proven effective for smoking cessation (SC), engagement in the intervention remains suboptimal. OBJECTIVE: This study aims to evaluate whether using more interactive and adaptive instant messaging (IM) apps on smartphones, which enable personalization and chatting with SC advisors, can enhance SC outcomes beyond the provision of brief SC advice and active referral (AR) to SC services. METHODS: From December 2018 to November 2019, we proactively recruited 700 adult Chinese daily cigarette users in Hong Kong. Participants were randomized in a 1:1 ratio. At baseline, all participants received face-to-face brief advice on SC. Additionally, they were introduced to local SC services and assisted in selecting one. The intervention group received an additional 26 personalized regular messages and access to interactive chatting through IM apps for 3 months. The regular messages aimed to enhance self-efficacy, social support, and behavioral capacity for quitting, as well as to clarify outcome expectations related to cessation. We developed 3 sets of messages tailored to the planned quit date (within 30 days, 60 days, and undecided). Participants in the intervention group could initiate chatting with SC advisors on IM themselves or through prompts from regular messages or proactive inquiries from SC advisors. The control group received 26 SMS text messages focusing on general health. The primary outcomes were smoking abstinence validated by carbon monoxide levels of <4 parts per million at 6 and 12 months after the start of the intervention. RESULTS: Of the participants, 505/700 (72.1%) were male, and 450/648 (69.4%) were aged 40 or above. Planning to quit within 30 days was reported by 500/648 (77.2%) participants, with fewer intervention group members (124/332, 37.3%) reporting previous quit attempts compared with the control group (152/335, 45.4%; P=.04). At the 6- and 12-month follow-ups (with retention rates of 456/700, 65.1%, and 446/700, 63.7%, respectively), validated abstinence rates were comparable between the intervention (14/350, 4.0%, and 19/350, 5.4%) and control (11/350, 3.1% and 21/350, 6.0%) groups. Compared with the control group, the intervention group reported greater utilization of SC services at 12 months (RR 1.26, 95% CI 1.01-1.56). Within the intervention group, engaging in chat sessions with SC advisors predicted better validated abstinence at 6 months (RR 3.29, 95% CI 1.13-9.63) and any use of SC services (RR 1.66, 95% CI 1.14-2.43 at 6 months; RR 1.67, 95% CI 1.26-2.23 at 12 months). CONCLUSIONS: An IM-based intervention, providing support and assistance alongside brief SC advice and AR, did not yield further increases in quitting rates but did encourage the utilization of SC services. Future research could explore whether enhanced SC service utilization leads to improved long-term SC outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03800719; https://clinicaltrials.gov/ct2/show/NCT03800719.

What Adolescents Say in Text Messages to Motivate Peer Networks to Access Health Care and Sexually Transmitted Infection Testing: Qualitative Thematic Analysis.

BACKGROUND: While rates of HIV and sexually transmitted infections (STIs) are extremely high among adolescents and young adults in the United States, rates of HIV and STI testing remain low. Given the ubiquity of mobile phones and the saliency of peers for youths, text messaging strategies may successfully promote HIV or STI testing among youths. OBJECTIVE: This study aimed to understand the types of messages youths believe were motivating and persuasive when asked to text friends to encourage them to seek HIV or STI testing services at a neighborhood clinic. METHODS: We implemented an adolescent peer-based text messaging intervention to encourage clinic attendance and increase STI and HIV testing among youths (n=100) at an adolescent clinic in San Francisco, California. Participants were asked to send a text message to 5 friends they believed were sexually active to encourage their friends to visit the clinic and receive STI or HIV screening. Thematic analysis was used to analyze the content of the text messages sent and received during the clinic visit. Member checking and consensus coding were used to ensure interrater reliability and significance of themes. RESULTS: We identified four themes in the messages sent by participants: (1) calls to action to encourage peers to get tested, (2) personalized messages with sender-specific information, (3) clinic information such as location and hours, and (4) self-disclosure of personal clinic experience. We found that nearly all text messages included some combination of 2 or more of these broad themes. We also found that youths were inclined to send messages they created themselves, as opposed to sending the same message to each peer, which they tailored to each individual to whom they were sent. Many (40/100, 40%) received an immediate response to their message, and most participants reported receiving at least 1 positive response, while a few reported that they had received at least 1 negative response. There were some differences in responses depending on the type of message sent. CONCLUSIONS: Given the high rates of STI and HIV and low rates of testing among adolescents, peer-driven text messaging interventions to encourage accessing care may be successful at reaching this population. This study suggests that youths are willing to text message their friends, and there are clear types of messages they develop and use. Future research should use these methods with a large, more diverse sample of youths and young adults for long-term evaluation of care seeking and care retention outcomes to make progress in reducing HIV and STI among adolescents and young adults.

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

BACKGROUND: SMS texting systems have been considered a potential solution to reduce missed appointments in primary care. Existing research in this area focuses on qualitative studies investigating the attitudes of SMS text users and receivers. OBJECTIVE: This study aimed to examine appointment data from an independent general practitioner (GP) surgery in Wrexham, United Kingdom, with approximately 15,000 patients, to determine the impact of text messaging systems on reducing missed appointments. The objective of this study was to investigate whether the use of text messages can effectively reduce missed appointments. METHODS: To collect data for the study, SQL reports were run on EMIS Web, the United Kingdom's most widely used clinical system. The data spanned 10 years, from September 1, 2010, to March 31, 2020. Data accuracy was verified by cross-referencing with appointment diary records. Mann-Whitney and Kruskal-Wallis tests, chosen for their suitability in comparing groups in nonparametric settings, were conducted in Microsoft Excel due to its accessibility. RESULTS: Statistical analyses were conducted to compare data before and after implementation of the text messaging system. The results revealed a significant 42.8% reduction in missed appointments (before: 5848; after: 3343; P<.001). Further analysis of demographic characteristics revealed interesting trends, with no significant difference in missed appointments between genders, and variations observed across different age groups. The median number of missed appointments was not significantly different between genders (women: 1.55, IQR 1.11-2.16; men: 1.61, IQR 1.08-2.12; P=.73). Despite the prevalence of mobile phone use among young adults aged 20-25 years, the highest rates of missed appointments (848/7256, 11.7%) were noted in this group, whereas the lowest rates were noted in the 75-80 years age group (377/7256; 5.2%; P<.001). Analysis by age and gender indicated inconsistencies: women aged 20-25 years (571/4216) and men aged 35-40 years (306/3040) had the highest rates of missed appointments, whereas women aged 70-75 years (177/4216) and men aged 75-80 years (129/3040) had the lowest rates (P<.001 for both). CONCLUSIONS: This study demonstrates that SMS text messaging in primary care can significantly reduce missed appointments. Implementing technology such as SMS text messaging systems enables patients to cancel appointments on time, leading to improved efficiency in primary care settings.

The Use of Mobile Technologies to Promote Physical Activity and Reduce Sedentary Behaviors in the Middle East and North Africa Region: Systematic Review and Meta-Analysis.

BACKGROUND: The Middle East and North Africa (MENA) region faces unique challenges in promoting physical activity and reducing sedentary behaviors, as the prevalence of insufficient physical activity is higher than the global average. Mobile technologies present a promising approach to delivering behavioral interventions; however, little is known about the effectiveness and user perspectives on these technologies in the MENA region. OBJECTIVE: This study aims to evaluate the effectiveness of mobile interventions targeting physical activity and sedentary behaviors in the MENA region and explore users' perspectives on these interventions as well as any other outcomes that might influence users' adoption and use of mobile technologies (eg, appropriateness and cultural fit). METHODS: A systematic search of 5 databases (MEDLINE, Embase, CINAHL, Scopus, and Global Index Medicus) was performed. Any primary studies (participants of all ages regardless of medical condition) conducted in the MENA region that investigated the use of mobile technologies and reported any measures of physical activity, sedentary behaviors, or user perceptions were included. We conducted a narrative synthesis of all studies and a meta-analysis of randomized controlled trials (RCTs). The Cochrane risk-of-bias tool was used to assess the quality of the included RCTs; quality assessment of the rest of the included studies was completed using the relevant Joanna Briggs Institute critical appraisal tools. RESULTS: In total, 27 articles describing 22 interventions (n=10, 37% RCTs) and 4 (15%) nonexperimental studies were included (n=6141, 46% women). Half (11/22, 50%) of the interventions included mobile apps, whereas the other half examined SMS. The main app functions were goal setting and self-monitoring of activity, whereas SMS interventions were primarily used to deliver educational content. Users in experimental studies described several benefits of the interventions (eg, gaining knowledge and receiving reminders to be active). Engagement with the interventions was poorly reported; few studies (8/27, 30%) examined users' perspectives on the appropriateness or cultural fit of the interventions. Nonexperimental studies examined users' perspectives on mobile apps and fitness trackers, reporting several barriers to their use, such as perceived lack of usefulness, loss of interest, and technical issues. The meta-analysis of RCTs showed a positive effect of mobile interventions on physical activity outcomes (standardized mean difference=0.45, 95% CI 0.17-0.73); several sensitivity analyses showed similar results. The trim-and-fill method showed possible publication bias. Only 20% (2/10) of the RCTs measured sedentary behaviors; both reported positive changes. CONCLUSIONS: The use of mobile interventions for physical activity and sedentary behaviors in the MENA region is in its early stages, with preliminary evidence of effectiveness. Policy makers and researchers should invest in high-quality studies to evaluate long-term effectiveness, intervention engagement, and implementation outcomes, which can inform the design of culturally and socially appropriate interventions for countries in the MENA region. TRIAL REGISTRATION: PROSPERO CRD42023392699; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=392699.

Providing clinicians with 'how to' knowledge for technology-based innovation: Introducing the SMS4dads texts.

ISSUE ADDRESSED: Male partners are key supports for women in birth preparation and postnatally. Text-messaging can deliver timely information to expectant and new fathers to increase their support of the mother. However, technological innovations in healthcare often fail to be adopted. This study aims to assess the impact of disseminating a 'taster' set of SMS messages to increase clinicians' engagement with the intervention. METHODS: Example messages from SMS4dads were delivered to clinicians over a 3-week period and a link provided to an evaluation survey. Agreement to two closed questions was rated on a five-point Likert scale; the frequency of specific recalled messages was calculated for the first open-ended question. Responses to the remaining open-ended questions were analysed with a descriptive thematic approach. RESULTS: A total of 418 participants (female 61.5%) working in health organisations (80.4%), mostly in nursing (33.9%) or midwifery (19.6%) enrolled. Of the 77 (18.4%) participants who provided an evaluation, 96% agreed or strongly agreed that the Professional Taster gave them a better understanding of how to explain the program, and 88% agreed or strongly agreed that they are now more likely to tell parents about the program. Analysis of the remaining two open-ended questions revealed clinicians' concerns for fathers alongside their primary focus on maternal wellbeing. CONCLUSION: Providing 'how to' knowledge through receiving a sample of the intervention may increase clinicians' acceptance of technological innovation. SO WHAT?: Health-promoting digital interventions using text are increasing. Novel tested strategies for gaining buy-in from healthcare staff will be needed.

Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome: The TEXTMEDS Randomized Clinical Trial.

BACKGROUND: TEXTMEDS (Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome) examined the effects of text message-delivered cardiac education and support on medication adherence after an acute coronary syndrome. METHODS: TEXTMEDS was a single-blind, multicenter, randomized controlled trial of patients after acute coronary syndrome. The control group received usual care (secondary prevention as determined by the treating clinician); the intervention group also received multiple motivational and supportive weekly text messages on medications and healthy lifestyle with the opportunity for 2-way communication (text or telephone). The primary end point of self-reported medication adherence was the percentage of patients who were adherent, defined as >80% adherence to each of up to 5 indicated cardioprotective medications, at both 6 and 12 months. RESULTS: A total of 1424 patients (mean age, 58 years [SD, 11]; 79% male) were randomized from 18 Australian public teaching hospitals. There was no significant difference in the primary end point of self-reported medication adherence between the intervention and control groups (relative risk, 0.93 [95% CI, 0.84-1.03]; P=0.15). There was no difference between intervention and control groups at 12 months in adherence to individual medications (aspirin, 96% vs 96%; ß-blocker, 84% vs 84%; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 77% vs 80%; statin, 95% vs 95%; second antiplatelet, 84% vs 84% [all P>0.05]), systolic blood pressure (130 vs 129 mm Hg; P=0.26), low-density lipoprotein cholesterol (2.0 vs 1.9 mmol/L; P=0.34), smoking (P=0.59), or exercising regularly (71% vs 68%; P=0.52). There were small differences in lifestyle risk factors in favor of intervention on body mass index <25 kg/m2 (21% vs 18%; P=0.01), eating ≥5 servings per day of vegetables (9% vs 5%; P=0.03), and eating ≥2 servings per day of fruit (44% vs 39%; P=0.01). CONCLUSIONS: A text message-based program had no effect on medical adherence but small effects on lifestyle risk factors. REGISTRATION: URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448; Unique identifier: ANZCTR ACTRN12613000793718.

Barriers to Adoption of a Secure Text Messaging System: a Qualitative Study of Practicing Clinicians.

BACKGROUND: Secure text messaging systems (STMS) offer HIPAA-compliant text messaging and mobile phone call functionalities that are more efficient than traditional paging. Although some studies associate improved provider satisfaction and healthcare delivery with STMS use, healthcare organizations continue to struggle with achieving widespread and sustained STMS adoption. OBJECTIVE: To understand the barriers to adoption of an STMS among physicians and advanced practice providers (APPs). DESIGN: We qualitatively analyzed free-text comments that clinicians (physicians and APPs) across a large healthcare organization offered on a survey about STMS perceptions. PARTICIPANTS: A total of 1110 clinicians who provided a free-text comment in response to one of four open-ended survey questions. APPROACH: Data were analyzed using a grounded theory approach and constant comparative method to characterize responses and identify themes. KEY RESULTS: The overall survey response rate was 20.5% (n = 1254). Clinicians familiar with the STMS frequently believed the STMS was unnecessary (existing tools worked well enough) and would overburden them with more communications. They were frustrated that the STMS app had to be downloaded onto their personal mobile device and that it drained their battery. Ambiguity regarding who was reachable in the app led to missed messages and drove distrust of the STMS. Clinicians saw the exclusion of other care team members (e.g., nurses) from the STMS as problematic; however, some clinicians at hospitals with expanded STMS access complained of excessive messages. Secondhand reports of several of these barriers prevented new users from downloading the app and contributed to ongoing low use. CONCLUSIONS: Clinicians are reluctant to adopt an STMS that does not offer a clear and trustworthy communication benefit to offset its potential burden and intrusiveness. Our findings can be incorporated into STMS implementation strategies that maximize active users by targeting and mitigating barriers to adoption.

More than just Reminders: Using text Messaging to Improve HIV care Outcomes Among Youth and Young Adults Living with HIV.

This study evaluated engagement, satisfaction, and efficacy of an automated and live two-way text messaging intervention that linked youth and young adults at high risk for poor HIV outcomes to their medical case managers, with the aims of increasing viral load suppression rates and improving medical visit attendance. Participants (N = 100) were an average age of 22-23 years old. Most were Black (93%) and men who have sex with men (82%). A total of 89,681 automated text messages were sent to participants; and 62% of participants engaged in monthly text-message exchanges with medical case managers. McNemar's test results indicated that a significantly greater proportion of intervention participants were virally suppressed at 6 and 12 month follow-up than at enrollment. Adjusted odds ratio results showed a significant association between likelihood of achieving viral suppression at 6 and 12 months, and a greater number of participant responses to automated text messages. Future research should prospectively compare outcomes between usual care case management and usual care plus text-messaging to test for significant differences between groups.

RESUMEN: La presente investigación evaluó el compromiso, la satisfacción y la eficacia de una intervención de mensajes de texto bidireccional automatizada y en vivo que vinculó a jóvenes y adultos jóvenes con altos riesgos de resultados deficientes del VIH con sus administradores de casos médicos, con el objetivo de aumentar las tasas de supresión de la carga viral y mejorar la asistencia a las visitas médicas. Los participantes (n = 100) tenían una edad promedio de 22 a 23 años. La mayoría eran negros (93,0%) y hombres que tienen sexo con hombres (82,0%). Un total de 89.681 mensajes de texto automatizados fueron enviados a los participantes; y 62,0% de los participantes participaron en intercambios de mensajes de texto mensuales con los administradores de casos médicos. Los resultados de la prueba de McNemar indicaron que una proporción significativamente mayor de participantes de la intervención fueron suprimidos viralmente a los 6 y 12 meses de seguimiento que al momento de la inscripción. Los resultados del índice de probabilidad ajustado mostraron una asociación significativa entre la probabilidad de lograr la supresión viral a los 6 y 12 meses, así como un mayor número de respuestas de los participantes a los mensajes de texto automatizados. Las investigaciones futuras deben comparar prospectivamente los resultados entre la gestión de casos de atención habitual y la atención habitual más mensajes de texto para evaluar las diferencias significativas entre los grupos.

Preventing alcohol use post-bariatric surgery: patient perspectives on a technology-based approach.

BACKGROUND: Nearly two-thirds of patients engage in alcohol use after bariatric surgery, while a substantial number meet criteria for alcohol use disorder after their procedure. Given that pre-surgical education may not be sufficient, alternative methods of preventing post-surgical drinking are needed. We sought feedback on a proposed technology-based intervention to reduce alcohol use for individuals who have undergone bariatric surgery. METHODS: Twenty patients who consumed alcohol post-surgery completed qualitative interviews where they provided opinions on sample intervention content, delivery method, timing, and other aspects of a two-session web-based intervention followed by tailored text messaging for 6 months. Interviews were recorded, transcribed, and coded using thematic analysis principles. RESULTS: Participants strongly endorsed using technology to deliver an alcohol intervention, citing the interactivity and personal tailoring available in the proposed software. Education about the effects of post-surgical drinking and learning new coping strategies for social situations were the two most salient themes to emerge from questions about intervention content. Throughout the interviews, participants strongly highlighted the importance of measuring patient readiness to change alcohol use and matching intervention content to such motivation levels. Respondents felt that text messages could extend what they had learned, but also requested additional non-alcohol content (e.g., recipes, exercise tips). Most participants agreed that an online forum consisting of peers and professionals with whom they could ask questions and interact would be useful. CONCLUSION: Web- and text message-based interventions may be an acceptable approach to prevent alcohol use post-bariatric surgery.

Exploring the views and experiences of people recovering from a stroke about a new text message intervention to promote physical activity after rehabilitation-Keeping Active with Texting After Stroke: A qualitative study.

BACKGROUND: Participating in exercise following a stroke is essential for recovery. When community-based rehabilitation services end, some people struggle to remain active. We codesigned Keeping Active with Texting After Stroke (KATS), a text message intervention to support home-based, self-directed plans to continue exercising. KATS delivers a series of automated text messages over a 12-week period from the point of discharge from National Health Service-funded therapy. The aim of this study was to explore the views and experiences of the first cohort of participants to complete the KATS intervention about the meaning, engagement, workability and worth of the intervention. METHODS: We undertook a qualitative study, theoretically informed by Normalisation Process Theory. We conducted semi-structured telephone interviews with people with stroke from two Health Boards in Scotland. Data collection took place over two phases, with each participant being interviewed twice: first, halfway through intervention delivery (Week 6) and then again at the end of the intervention (Week 12). All interviews were audio-recorded, transcribed and analysed thematically. RESULTS: A total of 24 interviews were conducted with 12 participants. Our findings were organised around four overarching analytical themes: (1) making sense of KATS: timing and complementarity in the rehabilitation journey; (2) engaging with KATS: connection and identification with others; (3) making KATS work: flexibility and tailorable guidance; (4) appraising the worth of KATS: encouragement and friendliness. Participants differentiated KATS from current rehabilitation practice, finding it relevant, fitting and worthwhile. Variations were reported in engagement with behaviour change techniques, but participants were able to tailor KATS use, making it work for them in different ways. CONCLUSIONS: Perceived benefits went beyond promoting physical activity, including feeling supported and connected. Future research will test the effectiveness of KATS in promoting physical activity and explore any associations with relevant social and emotional secondary outcomes. PATIENT OR PUBLIC CONTRIBUTION: A research funding proposal was developed in collaboration with five people with stroke and three spouses. After securing funding, six people with stroke were invited to join the project's Collaborative Working Group, alongside health professionals and stroke rehabilitation experts, to codevelop the intervention and support the feasibility study.

Implementing text-messaging to support and enhance delivery of health behavior change interventions in low- to middle-income countries: case study of the Lifestyle Africa intervention.

The prevalence of non-communicable diseases, such as diabetes and cardiovascular disease, is rising in low- and middle-income countries (LMICs). Health behavior change (HBC) interventions such as the widely used Diabetes Prevention Program (DPP) are effective at reducing chronic disease risk, but have not been adapted for LMICs. Leveraging mobile health (mHealth) technology such as text messaging (SMS) to enhance reach and participant engagement with these interventions has great promise, yet we lack evidence-informed approaches to guide the integration of SMS specifically to support HBC interventions in LMIC contexts. To address this gap, we integrated guidance from the mHealth literature with expertise and first-hand experience to establish specific development steps for building and implementing SMS systems to support HBC programming in LMICs. Specifically, we provide real-world examples of each development step by describing our experience in designing and delivering an SMS system to support a culturally-adapted DPP designed for delivery in South Africa. We outline eight key SMS development steps, including: 1) determining if SMS is appropriate; 2) developing system architecture and programming; 3) developing theory-based messages; 4) developing SMS technology; 5) addressing international SMS delivery; 6) testing; 7) system training and technical support; and 8) cost considerations. We discuss lessons learned and extractable principles that may be of use to other mHealth and HBC researchers working in similar LMIC contexts.Trial registration Clinicaltrials.gov, NCT03342274 . Registered 10 November 2017.

'In the end, I'm the one who has to do the job': Participant experience of a lifestyle intervention for patients with hypertension.

OBJECTIVE: Cardiovascular disease can be prevented through lifestyle changes, but such changes are often hard to attain. Text message interventions with lifestyle advice have shown small but promising effects. Our objective was to explore participant experience of a text message lifestyle intervention for patients with hypertension, and implications for future lifestyle interventions. DESIGN AND SUBJECTS: Fourteen participants were purposefully selected for telephone interviews after completion of a text message lifestyle intervention. A semi-structured interview guide with open-ended questions was used. Interviews were recorded and transcribed verbatim. The material was analyzed through systematic text condensation as described by Malterud, a data-driven analysis style that includes deductive elements. SETTING: Primary care in three regions in southern Sweden. RESULTS: The analysis resulted in three themes. 'Blood pressure and lifestyle, how seriously to take it?' revealed a remaining need for knowledge regarding to what extent lifestyle affects risk for cardiovascular disease. 'The text messages - a useful reminder in need of tailoring' described that the design of the intervention was satisfactory, but suggested improvements through increased individualization. Finally, 'Water off a duck's back or a kick in the pants - when does behavior change?' showed how some participants responded to the push to change while others did not, supplying material for further analysis in a framework of behavioral change theory. CONCLUSION: A key to adoption was advice that was applicable in daily life. Timing in relation to a diagnosis of hypertension or other motivational factors, and tailoring to prior knowledge, habits, and limitations could increase effectiveness.

Text message interventions with lifestyle advice for hypertension and cardiovascular disease have shown small effects, but effectiveness may be improved.Our qualitative analysis of patient experience revealed a remaining need for increased knowledge regarding blood pressure, lifestyle, and cardiovascular disease.Text message advice that was applicable in daily life, or perceived as new, seemed most useful to facilitate lifestyle change.Timing in relation to motivational factors and tailoring to individual habits and limitations could increase effectiveness of similar interventions.