Healthcare workers' informal uses of mobile phones and other mobile devices to support their work: a qualitative evidence synthesis.

BACKGROUND: Healthcare workers sometimes develop their own informal solutions to deliver services. One such solution is to use their personal mobile phones or other mobile devices in ways that are unregulated by their workplace. This can help them carry out their work when their workplace lacks functional formal communication and information systems, but it can also lead to new challenges. OBJECTIVES: To explore the views, experiences, and practices of healthcare workers, managers and other professionals working in healthcare services regarding their informal, innovative uses of mobile devices to support their work. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL and Scopus on 11 August 2022 for studies published since 2008 in any language. We carried out citation searches and contacted study authors to clarify published information and seek unpublished data. SELECTION CRITERIA: We included qualitative studies and mixed-methods studies with a qualitative component. We included studies that explored healthcare workers' views, experiences, and practices regarding mobile phones and other mobile devices, and that included data about healthcare workers' informal use of these devices for work purposes. DATA COLLECTION AND ANALYSIS: We extracted data using an extraction form designed for this synthesis, assessed methodological limitations using predefined criteria, and used a thematic synthesis approach to synthesise the data. We used the 'street-level bureaucrat' concept to apply a conceptual lens to our findings and prepare a line of argument that links these findings. We used the GRADE-CERQual approach to assess our confidence in the review findings and the line-of-argument statements. We collaborated with relevant stakeholders when defining the review scope, interpreting the findings, and developing implications for practice. MAIN RESULTS: We included 30 studies in the review, published between 2013 and 2022. The studies were from high-, middle- and low-income countries and covered a range of healthcare settings and healthcare worker cadres. Most described mobile phone use as opposed to other mobile devices, such as tablets. We have moderate to high confidence in the statements in the following line of argument. The healthcare workers in this review, like other 'street-level bureaucrats', face a gap between what is expected of them and the resources available to them. To plug this gap, healthcare workers develop their own strategies, including using their own mobile phones, data and airtime. They also use other personal resources, including their personal time when taking and making calls outside working hours, and their personal networks when contacting others for help and advice. In some settings, healthcare workers' personal phone use, although unregulated, has become a normal part of many work processes. Some healthcare workers therefore experience pressure or expectations from colleagues and managers to use their personal phones. Some also feel driven to use their phones at work and at home because of feelings of obligation towards their patients and colleagues. At best, healthcare workers' use of their personal phones, time and networks helps humanise healthcare. It allows healthcare workers to be more flexible, efficient and responsive to the needs of the patient. It can give patients access to individual healthcare workers rather than generic systems and can help patients keep their sensitive information out of the formal system. It also allows healthcare workers to communicate with each other in more personalised, socially appropriate ways than formal systems allow. All of this can strengthen healthcare workers' relationships with community members and colleagues. However, these informal approaches can also replicate existing social hierarchies and deepen existing inequities among healthcare workers. Personal phone use costs healthcare workers money. This is a particular problem for lower-level healthcare workers and healthcare workers in low-income settings as they are likely to be paid less and may have less access to work phones or compensation. Out-of-hours use may also be more of a burden for lower-level healthcare workers, as they may find it harder to ignore calls when they are at home. Healthcare workers with poor access to electricity and the internet are less able to use informal mobile phone solutions, while healthcare workers who lack skills and training in how to appraise unendorsed online information are likely to struggle to identify trustworthy information. Informal digital channels can help healthcare workers expand their networks. But healthcare workers who rely on personal networks to seek help and advice are at a disadvantage if these networks are weak. Healthcare workers' use of their personal resources can also lead to problems for patients and can benefit some patients more than others. For instance, when healthcare workers store and share patient information on their personal phones, the confidentiality of this information may be broken. In addition, healthcare workers may decide to use their personal resources on some types of patients, but not others. Healthcare workers sometimes describe using their personal phones and their personal time and networks to help patients and clients whom they assess as being particularly in need. These decisions are likely to reflect their own values and ideas, for instance about social equity and patient 'worthiness'. But these may not necessarily reflect the goals, ideals and regulations of the formal healthcare system. Finally, informal mobile phone use plugs gaps in the system but can also weaken the system. The storing and sharing of information on personal phones and through informal channels can represent a 'shadow IT' (information technology) system where information about patient flow, logistics, etc., is not recorded in the formal system. Healthcare workers may also be more distracted at work, for instance, by calls from colleagues and family members or by social media use. Such challenges may be particularly difficult for weak healthcare systems. AUTHORS' CONCLUSIONS: By finding their own informal solutions to workplace challenges, healthcare workers can be more efficient and more responsive to the needs of patients, colleagues and themselves. But these solutions also have several drawbacks. Efforts to strengthen formal health systems should consider how to retain the benefits of informal solutions and reduce their negative effects.

Development and Use of Mobile Messaging for Individuals With Musculoskeletal Pain Conditions: Scoping Review.

BACKGROUND: Population studies show that musculoskeletal conditions are a leading contributor to the total burden of healthy life lost, second only to cancer and with a similar burden to cardiovascular disease. Prioritizing the delivery of effective treatments is necessary, and with the ubiquity of consumer smart devices, the use of digital health interventions is increasing. Messaging is popular and easy to use and has been studied for a range of health-related uses, including health promotion, encouragement of behavior change, and monitoring of disease progression. It may have a useful role to play in the management and self-management of musculoskeletal conditions. OBJECTIVE: Previous reviews on the use of messaging for people with musculoskeletal conditions have focused on synthesizing evidence of effectiveness from randomized controlled trials. In this review, our objective was to map the musculoskeletal messaging literature more broadly to identify information that may inform the design of future messaging interventions and summarize the current evidence of efficacy, effectiveness, and economics. METHODS: Following a prepublished protocol developed using the Joanna Briggs Institute Manual for Evidence Synthesis, we conducted a comprehensive scoping review of the literature (2010-2022; sources: PubMed, CINAHL, Embase, and PsycINFO) related to SMS text messaging and app-based messaging for people with musculoskeletal conditions. We described our findings using tables, plots, and a narrative summary. RESULTS: We identified a total of 8328 papers for screening, of which 50 (0.6%) were included in this review (3/50, 6% previous reviews and 47/50, 94% papers describing 40 primary studies). Rheumatic diseases accounted for the largest proportion of the included primary studies (19/40, 48%), followed by studies on multiple musculoskeletal conditions or pain sites (10/40, 25%), back pain (9/40, 23%), neck pain (1/40, 3%), and "other" (1/40, 3%). Most studies (33/40, 83%) described interventions intended to promote positive behavior change, typically by encouraging increased physical activity and exercise. The studies evaluated a range of outcomes, including pain, function, quality of life, and medication adherence. Overall, the results either favored messaging interventions or had equivocal outcomes. While the theoretical underpinnings of the interventions were generally well described, only 4% (2/47) of the papers provided comprehensive descriptions of the messaging intervention design and development process. We found no relevant economic evaluations. CONCLUSIONS: Messaging has been used for the care and self-management of a range of musculoskeletal conditions with generally favorable outcomes reported. However, with few exceptions, design considerations are poorly described in the literature. Further work is needed to understand and disseminate information about messaging content and message delivery characteristics, such as timing and frequency specifically for people with musculoskeletal conditions. Similarly, further work is needed to understand the economic effects of messaging and practical considerations related to implementation and sustainability. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2021-048964.

Assessing Artificial Intelligence-Generated Responses to Urology Patient In-Basket Messages.

INTRODUCTION: Electronic patient messaging utilization has increased in recent years and has been associated with physician burnout. ChatGPT is a language model that has shown the ability to generate near-human level text responses. This study evaluated the quality of ChatGPT responses to real-world urology patient messages. METHODS: One hundred electronic patient messages were collected from a practicing urologist's inbox and categorized based on the question content. Individual responses were generated by entering each message into ChatGPT. The questions and responses were independently evaluated by 5 urologists and graded on a 5-point Likert scale. Questions were graded based on difficulty, and responses were graded based on accuracy, completeness, harmfulness, helpfulness, and intelligibleness. Whether or not the response could be sent to a patient was also assessed. RESULTS: Overall, 47% of responses were deemed acceptable to send to patients. ChatGPT performed better on easy questions with 56% of responses to easy questions being acceptable to send as compared to 34% of difficult questions (P = .03). Responses to easy questions were more accurate, complete, helpful, and intelligible than responses to difficult questions. There was no difference in response quality based on question content. CONCLUSIONS: ChatGPT generated acceptable responses to nearly 50% of patient messages with better performance for easy questions compared to difficult questions. Use of ChatGPT to help respond to patient messages can help to decrease the time burden for the care team and improve wellness. Artificial intelligence performance will likely continue to improve with advances in generative artificial intelligence technology.

Novel Machine Learning HIV Intervention for Sexual and Gender Minority Young People Who Have Sex With Men (uTECH): Protocol for a Randomized Comparison Trial.

BACKGROUND: Sexual and gender minority (SGM) young people are disproportionately affected by HIV in the United States, and substance use is a major driver of new infections. People who use web-based venues to meet sex partners are more likely to report substance use, sexual risk behaviors, and sexually transmitted infections. To our knowledge, no machine learning (ML) interventions have been developed that use web-based and digital technologies to inform and personalize HIV and substance use prevention efforts for SGM young people. OBJECTIVE: This study aims to test the acceptability, appropriateness, and feasibility of the uTECH intervention, a SMS text messaging intervention using an ML algorithm to promote HIV prevention and substance use harm reduction among SGM people aged 18 to 29 years who have sex with men. This intervention will be compared to the Young Men's Health Project (YMHP) alone, an existing Centers for Disease Control and Prevention best evidence intervention for young SGM people, which consists of 4 motivational interviewing-based counseling sessions. The YMHP condition will receive YMHP sessions and will be compared to the uTECH+YMHP condition, which includes YMHP sessions as well as uTECH SMS text messages. METHODS: In a study funded by the National Institutes of Health, we will recruit and enroll SGM participants (aged 18-29 years) in the United States (N=330) to participate in a 12-month, 2-arm randomized comparison trial. All participants will receive 4 counseling sessions conducted over Zoom (Zoom Video Communications, Inc) with a master's-level social worker. Participants in the uTECH+YMHP condition will receive curated SMS text messages informed by an ML algorithm that seek to promote HIV and substance use risk reduction strategies as well as undergoing YMHP counseling. We hypothesize that the uTECH+YMHP intervention will be considered acceptable, appropriate, and feasible to most participants. We also hypothesize that participants in the combined condition will experience enhanced and more durable reductions in substance use and sexual risk behaviors compared to participants receiving YMHP alone. Appropriate statistical methods, models, and procedures will be selected to evaluate primary hypotheses and behavioral health outcomes in both intervention conditions using an α<.05 significance level, including comparison tests, tests of fixed effects, and growth curve modeling. RESULTS: This study was funded in August 2019. As of June 2024, all participants have been enrolled. Data analysis has commenced, and expected results will be published in the fall of 2025. CONCLUSIONS: This study aims to develop and test the acceptability, appropriateness, and feasibility of uTECH, a novel approach to reduce HIV risk and substance use among SGM young adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT04710901; https://clinicaltrials.gov/study/NCT04710901. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/58448.

Factorial randomised controlled trial to examine the potential effect of a text message-based intervention on reducing adolescent susceptibility to e-cigarette use: a study protocol.

INTRODUCTION: Adolescent e-cigarette use, globally and within Australia, has increased in recent years. In response, public health agencies have called for the development of education and communication programmes targeting adolescents. Despite such recommendations, few rigorous evaluations of such interventions currently exist. The main objective of this study is to examine the potential effect of a text message intervention targeting parents and adolescents on adolescent susceptibility to e-cigarette use (eg, intentions towards using e-cigarettes). Secondary objectives are to (1): examine the effect of the intervention on adolescent e-cigarette and combustible tobacco use and (2) examine the acceptability of the intervention. METHODS AND ANALYSIS: A randomised controlled trial employing a 2×2 factorial design will be conducted with parent-adolescent dyads (aged 12-15 years). Dyads will be randomly allocated to one of four arms: arm 1-a text message intervention delivered to adolescents only; arm 2-a text message intervention delivered to the parents of adolescents only; arm 3-a text message intervention delivered to both the parents and adolescents; and arm 4-an information only control, consisting of an e-cigarette factsheet provided to parents only. Participant recruitment commenced in March 2023 with the aim to recruit 120 parent-adolescent dyads. Data collection to assess study outcomes will occur at baseline, 6, 12 and 24 months post the commencement of the intervention. The primary endpoint will be 6-month follow-up. The primary outcome will be adolescent susceptibility to e-cigarette use, assessed using validated items. Analyses of trial outcomes will be undertaken under an intention-to-treat framework, with all participants included in the analysis in the group they were allocated. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the human research ethics committee of the University of Newcastle (H-2022-0340). Findings will be disseminated in peer-reviewed journals and at conferences. TRIAL REGISTRATION NUMBER: The trial was registered prospectively with Australian New Zealand Clinical Trials Registry (ACTRN12623000079640).

An Automated Text Messaging Intervention to Reduce Substance Use Self-Stigma (Project RESTART): Protocol for a Feasibility and Acceptability Pilot Study.

BACKGROUND: Stigma is a barrier to treatment and harm reduction seeking in people who use drugs. Most stigma reduction interventions offer psychotherapy or psychoeducation in group-based clinical settings, failing to reach people who are not in treatment. SMS text messaging is an effective and acceptable modality for delivering health information to people who use drugs and may be a suitable conduit for providing information and advice to understand and cope with stigma. OBJECTIVE: This paper presents the protocol for a study that aims to determine the feasibility, acceptability, and preliminary effectiveness of a 4-week automated SMS text message intervention to increase stigma resistance and reduce self-stigma in people who use drugs. METHODS: We designed a novel automated SMS text message intervention to address the four personal-level constructs of stigma resistance: (1) not believing stigma and catching and challenging stigmatizing thoughts, (2) empowering oneself through learning about substance use and one's recovery, (3) maintaining one's recovery and proving stigma wrong, and (4) developing a meaningful identity and purpose apart from one's substance use. Theory-based messages were developed and pilot-tested in qualitative elicitation interviews with 22 people who use drugs, resulting in a library of 56 messages. In a single-group, within-subjects, community-based pilot trial, we will enroll 30 participants in the Resisting Stigma and Revaluating Your Thoughts (RESTART) intervention. Participants will receive 2 daily SMS text messages for 4 weeks. Implementation feasibility will be assessed through recruitment, enrollment, retention, and message delivery statistics. User feasibility and acceptability will be assessed at follow-up using 23 survey items informed by the Theoretical Framework of Acceptability. Primary effectiveness outcomes are changes in self-stigma (Substance Abuse Self-Stigma Scale) and stigma resistance (Stigma Resistance Scale) from baseline to follow-up measured via a self-administered survey. Secondary outcomes are changes in hope (Adult Dispositional Hope Scale) and self-esteem (Rosenberg Self-Esteem Scale). Feasibility and acceptability will be assessed with descriptive statistics; effectiveness outcomes will be assessed with paired 2-tailed t tests, and group differences will be explored using ANOVA. Overall, 12 participants will also be selected to complete acceptability interviews. RESULTS: This pilot study was funded by the National Institute on Drug Abuse in April 2023 and received regulatory approval in January 2024 by the University of North Carolina-Chapel Hill Institutional Review Board. Recruitment and enrollment began in March 2024. Follow-up visits are expected to conclude by May 2024. Results will be disseminated in relevant peer-reviewed journals. CONCLUSIONS: To the best of our knowledge, this is the first study to address substance use stigma via a self-help SMS text messaging program. Results will add to the nascent literature on stigma reduction in people who use drugs. This protocol may interest researchers who are considering text messaging to address psychosocial needs in hard-to-reach populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT06281548; https://clinicaltrials.gov/ct2/show/NCT06281548. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/59224.

Harnessing the power of mobile and messaging apps for risk communication and intervention during the COVID-19 pandemic: lessons from the Western Pacific.

Problem: The spread of mis- and disinformation on mobile and messaging apps during the COVID-19 pandemic not only fuelled anxieties and mistrust in health authorities but also undermined the effectiveness of the overall public health response. Context: Mobile and messaging apps help users stay informed and connected to their families, friends, colleagues and communities. However, during the COVID-19 pandemic, these apps were also one of the primary channels where mis- and disinformation were circulated. Action: Recognizing the importance of including mobile and messaging apps in risk communication and emergency response strategies, the World Health Organization (WHO) and some countries in the WHO Western Pacific Region independently piloted initiatives to reach messaging app users, meet their evolving information needs, and streamline health ministry communication. Outcome: The enhanced use of mobile and messaging apps enabled consistent and timely communication and improved coordination during the COVID-19 pandemic. Leveraging their features also helped identify and potentially fill crucial information gaps, mitigating the harms of mis- and disinformation and fostering stronger trust in health authorities. Discussion: The findings from the work carried out by WHO and countries in the Western Pacific Region identified some promising innovative communication interventions using mobile and messaging apps. While these interventions should be further explored and evaluated, they have demonstrated that interventions need to be proactive, flexible, and able to adapt to changes in mis- and disinformation content being shared through messaging apps.

Preferences for Text Messaging Supports During Youth Transition to Adult Mental Health Services: Theory-Informed Modified e-Delphi Study.

BACKGROUND: For many young people, the transition from child to adult mental health services is a vulnerable time associated with treatment disengagement and illness progression. Providing service information and options to youth, appealing to them, and tailoring to their needs during this period could help overcome systematic barriers to a successful transition. We know little about how SMS text message-based interventions might be leveraged to support the motivational, informational, and behavioral needs of youth during this time. Ascertaining youth preferences for the content and functionality of an SMS text message service could inform prototype development. OBJECTIVE: This study investigated consensus preferences among youth on important content, technology features, and engagement supports to inform a transition-focused SMS text message service. METHODS: A modified e-Delphi survey design was used to collect demographics, current levels of technology use, importance ratings on message content, preferred technical features, and barriers and enablers to engagement for youth in Canada aged 16-26 years who have accessed mental health services within the past 5 years. Survey items on content were categorized according to the information-motivation-behavioral skills (IMB) model. Survey items on technical features were categorized according to the persuasive system design (PSD) model. A predefined consensus rating matrix and descriptive statistics were used to characterize the sample. The high consensus threshold was 70%. RESULTS: A total of 100 participants, predominantly non-White (n=47, 47%), aged 20-26 years (n=59, 59%), and who had first accessed mental health services between the ages of 13 and 19 years (n=60, 60%), were selected. The majority (n=90, 90%) identified as daily SMS text message users. A high level of consensus on importance ratings was reported in 45% (9/20) of content items based on the IMB model. There were higher levels of consensus on importance ratings related to behavior domain items (3/3, 100%) than information domain items (4/9, 44%) or motivation domain items (2/8, 25%). A high level of consensus on importance ratings was reported in only 19% (4/21) of feature and functionality items based on the PSD model. Among PSD model categories, there was a high level of consensus on importance ratings in 8% (1/12) of the primary task support domain items and 100% (3/3) of the system credibility support domain items. None of the dialogue-support and social-support domain items met the high level of consensus thresholds. In total, 27% (27/100) of youth indicated that the most significant enabler for engaging with a transition-focused SMS text message intervention was the personalization of text messages. CONCLUSIONS: Scientists developing next-generation SMS text messaging interventions for this population need to consider how levels of consensus on different features may impact feasibility and personalization efforts. Youth can (and should) play an integral role in the development of these interventions.

Deceptively Simple yet Profoundly Impactful: Text Messaging Interventions to Support Health.

This paper examines the use of text message (SMS) interventions for health-related behavioral support. It first outlines the historical progress in SMS intervention research publications and the variety of funds from US government agencies. A narrative review follows, highlighting the effectiveness of SMS interventions in key health areas, such as physical activity, diet and weight loss, mental health, and substance use, based on published meta-analyses. It then outlines advantages of text messaging compared to other digital modalities, including the real-time capability to collect information and deliver microdoses of intervention support. Crucial design elements are proposed to optimize effectiveness and longitudinal engagement across communication strategies, psychological foundations, and behavior change tactics. We then discuss advanced functionalities, such as the potential for generative artificial intelligence to improve user interaction. Finally, major challenges to implementation are highlighted, including the absence of a dedicated commercial platform, privacy and security concerns with SMS technology, difficulties integrating SMS interventions with medical informatics systems, and concerns about user engagement. Proposed solutions aim to facilitate the broader application and effectiveness of SMS interventions. Our hope is that these insights can assist researchers and practitioners in using SMS interventions to improve health outcomes and reducing disparities.

Utilizing technology for diet and exercise change in complex chronic conditions across diverse environments (U-DECIDE): feasibility randomised controlled trial.

BACKGROUND: Diet and exercise are important components of treatment for complex chronic conditions, however access to allied health support is limited. When available, support is often siloed and fragmented. Digital health incorporating patient choice may help to align health care services with preferences and goals. This study evaluated the implementation of a ubiquitously accessible patient-centred digital health diet and exercise service. METHODS: U-DECIDE was a single-centre, 26-week randomised controlled trial set in kidney and liver disease clinics in a tertiary hospital in Brisbane, Australia. Participants were adults with a complex chronic condition referred for dietetic consultation with at least one feature of the metabolic syndrome. All participants received a dietary consultation, an activity monitor and usual care. Intervention participants were offered one text message per week and access to additional digital health options (increased text message frequency, nutrition app, exercise app, group-based diet and/or exercise video consultations). The primary outcome of feasibility was determined by safety (study-related serious adverse events: SRSAEs), recruitment (≥ 50% eligible patients), retention (≥ 70%), exposure uptake (≥ 75% of intervention group had greater access to health professional contact than comparator) and video consultation adherence (≥ 80% attendance). Secondary outcomes included process evaluation metrics and clinical outcomes. RESULTS: Of 67 participants (intervention n = 33, comparator n = 34), 37 (55%) were men, median (IQR) age was 51 (41-58) years. The most chosen digital health options were the nutrition app (n = 29, 88%) and exercise video consultations (n = 26, 79%). Only one participant chose no additional digital health options. The intervention group had no SRSAEs. The study exceeded targets for recruitment (52%), retention (81%) and exposure uptake (94%). Video consultation adherence was 42%. Engagement across digital health options was inconsistent. CONCLUSIONS: Digital health options incorporating patient choice were feasible and can be offered to people with complex chronic disease as a service model option. TRIAL REGISTRATION: Australia and New Zealand Trials Register: Trial Registration Number: ACTRN12620001282976. Registered 27th November 2020.

Effectiveness of a Mobile Phone Messaging-Based Message Framing Intervention for Improving Maternal Health Service Uptake and Newborn Care Practice in Rural Jimma Zone, Ethiopia: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Ethiopia has high rates of maternal and neonatal mortality. In 2019 and 2020, the maternal and newborn mortality rates were estimated at 412 per 1,000,000 births and 30 per 10,000 births, respectively. While mobile health interventions to improve maternal and neonatal health management have shown promising results, there are still insufficient scientific studies to assess the effectiveness of mobile phone messaging-based message framing for maternal and newborn health. OBJECTIVE: This research aims to examine the effectiveness of mobile phone messaging-based message framing for improving the use of maternal and newborn health services in the Jimma Zone, Ethiopia. METHODS: A 3-arm cluster-randomized trial design was used to evaluate the effects of mobile phone-based intervention on maternal and newborn health service usage. The trial arms were (1) gain-framed messages (2) loss-framed messages, and (3) usual care. A total of 21 health posts were randomized, and 588 pregnant women who had a gestational age of 16-20 weeks, irrespective of their antenatal care status, were randomly assigned to the trial arms. The intervention consisted of a series of messages dispatched from the date of enrolment until 6-8 months. The control group received existing care without messages. The primary outcomes were maternal health service usage and newborn care practice, while knowledge, attitude, self-efficacy, iron supplementation, and neonatal and maternal morbidity were secondary outcomes. The outcomes will be analyzed using a generalized linear mixed model and the findings will be reported according to the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth) statement for randomized controlled trials. RESULTS: Recruitment of participants was conducted and the baseline survey was administered in March 2023. The intervention was rolled out from May 2023 till December 2023. The end-line assessment was conducted in February 2024. CONCLUSIONS: This trial was carried out to understand how mobile phone-based messaging can improve maternal and newborn health service usage. It provides evidence for policy guidelines around mobile health strategies to improve maternal and newborn health. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR202201753436676; https://tinyurl.com/ykhnpc49. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52395.

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.

Feasibility and Preliminary Effects of a Social Media-Based Peer-Group Mobile Messaging Smoking Cessation Intervention Among Chinese Immigrants who Smoke: Pilot Randomized Controlled Trial.

BACKGROUND: Chinese immigrants experience significant disparities in tobacco use. Culturally adapted tobacco treatments targeting this population are sparse and the use is low. The low use of these treatment programs is attributed to their exclusive focus on individuals who are ready to quit and the wide range of barriers that Chinese immigrants face to access these programs. To support Chinese immigrant smokers at all levels of readiness to quit and address their access barriers, we developed the WeChat Quit Coach, a culturally and linguistically appropriate WeChat (Tencent Holdings Limited)-based peer group mobile messaging smoking cessation intervention. OBJECTIVE: This study aims to assess the feasibility, acceptability, and preliminary effects of WeChat Quit Coach. METHODS: We enrolled a total of 60 Chinese immigrant smokers in 2022 in New York City for a pilot randomized controlled trial (RCT) and a single-arm pilot test. The first 40 participants were randomized to either the intervention arm (WeChat Quit Coach) or the control arm (self-help print material) using 1:1 block randomization stratified by sex. WeChat Quit Coach lasted 6 weeks, featuring small peer groups moderated by a coach, daily text messages with text questions, and chat-based instant messaging support from the coach in response to peer questions. The next 20 participants were enrolled in the single-arm pilot test to further assess intervention feasibility and acceptability. All 60 participants were offered a 4-week supply of complimentary nicotine replacement therapy. Surveys were administered at baseline and 6 weeks, with participants in the pilot RCT completing an additional survey at 6 months and biochemical verification of abstinence at both follow-ups. RESULTS: Of 74 individuals screened, 68 (92%) were eligible and 60 (88%) were enrolled. The majority of participants, with a mean age of 42.5 (SD 13.8) years, were male (49/60, 82%) and not ready to quit, with 70% (42/60) in the precontemplation or contemplation stage at the time of enrollment. The pilot RCT had follow-up rates of 98% (39/40) at 6 weeks and 93% (37/40) at 6 months, while the single-arm test achieved 100% follow-up at 6 weeks. On average, participants responded to daily text questions for 25.1 days over the 42-day intervention period and 23% (9/40) used the chat-based instant messaging support. Most participants were satisfied with WeChat Quit Coach (36/39, 92%) and would recommend it to others (32/39, 82%). At 6 months, self-reported 7-day point prevalence abstinence rates were 25% (5/20) in the intervention arm and 15% (3/20) in the control arm, with biochemically verified abstinence rates of 25% (5/20) and 5% (1/20), respectively. CONCLUSIONS: WeChat Quit Coach was feasible and well-received by Chinese immigrants who smoke and produced promising effects on abstinence. Large trials are warranted to assess its efficacy in promoting abstinence in this underserved population. TRIAL REGISTRATION: ClinicalTrials.gov NCT05130788; https://clinicaltrials.gov/study/NCT05130788.

Effectiveness and Acceptability of Targeted Text Message Reminders in Colorectal Cancer Screening: Randomized Controlled Trial (M-TICS Study).

BACKGROUND: Mobile phone-based SMS text message reminders have the potential to improve colorectal cancer screening participation rates. OBJECTIVE: This study assessed the effectiveness and acceptability of adding targeted SMS text message reminders to the standard procedure for those who picked up but did not return their screening kit at the pharmacy within 14 days in a colorectal cancer screening program in Catalonia, Spain. METHODS: We performed a randomized control trial among individuals who picked up a fecal immunochemical test (FIT) kit for colorectal cancer screening at the pharmacy but did not return it within 14 days. The intervention group (n=4563) received an SMS text message reminder on the 14th day of kit pick up and the control group (n=4806) received no reminder. A 30-day reminder letter was sent to both groups if necessary. The main primary outcome was the FIT completion rate within 30, 60, and 126 days from FIT kit pick up (intention-to-treat analysis). A telephone survey assessed the acceptability and appropriateness of the intervention. The cost-effectiveness of adding an SMS text message reminder to FIT completion was also performed. RESULTS: The intervention group had higher FIT completion rates than the control group at 30 (64.2% vs 53.7%; P<.001), 60 (78.6% vs 72.0%; P<.001), and 126 (82.6% vs 77.7%; P<.001) days. Participation rates were higher in the intervention arm independent of sex, age, socioeconomic level, and previous screening behavior. A total of 339 (89.2%) interviewees considered it important and useful to receive SMS text message reminders for FIT completion and 355 (93.4%) preferred SMS text messages to postal letters. We observed a reduction of US $2.4 per participant gained in the intervention arm for invitation costs compared to the control arm. CONCLUSIONS: Adding an SMS text message reminder to the standard procedure significantly increased FIT kit return rates and was a cost-effective strategy. SMS text messages also proved to be an acceptable and appropriate communication channel for cancer screening programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04343950; https://www.clinicaltrials.gov/study/NCT04343950. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1371/journal.pone.0245806.

Efficacy of an mHealth-delivered behavioral intervention on weight loss and cardiometabolic risk in African American postpartum people with overweight or obesity: the SnapBack randomized controlled trial.

OBJECTIVE: The objective of this study was to evaluate the efficacy of a mobile health (mHealth)-delivered behavioral intervention on changes in postpartum weight and cardiometabolic risk factors (blood pressure [BP], lipids, and hemoglobin A1c) over 12 months. METHODS: A randomized controlled trial of 300 African American postpartum people with overweight and obesity enrolled in Philadelphia Women, Infants, and Children (WIC) clinics was conducted. Participants were randomized to usual WIC care (n = 151) or a 12-month mHealth-delivered intervention (n = 149) comprising behavior change goals, interactive self-monitoring text messages, and counseling support. RESULTS: Intervention and usual-care participants did not significantly differ in 12-month mean postpartum weight change (1.1 vs. 1.6 kg, p = 0.5; difference -0.6 kg, 95% CI: -2.3 to 1.2). However, high intervention engagement led to weight loss compared with weight gain among those who were less engaged (-0.6 vs. 2.4 kg, p = 0.01; difference -3.0 kg, 95% CI: -5.4 to -0.6). The intervention reduced systolic BP relative to usual care (-1.6 vs. 2.4 mm Hg, p = 0.02; difference -4.0 mm Hg, 95% CI: -7.5 to -0.5), but this effect did not extend to other cardiometabolic risk factors. CONCLUSIONS: Among African American postpartum people enrolled in WIC, an mHealth-delivered intervention reduced systolic BP but not additional cardiometabolic risk factors or weight. Intervention participants with high engagement had significantly better postpartum weight outcomes, and thus, next steps include addressing barriers to engagement.

Experimenting to increase the effectiveness of a national campaign on hygiene behavior in Tanzania.

Through Tanzania's National Sanitation Campaign, we study the effectiveness of two common elements of behavior change campaigns: endorsements from celebrities and testimonials. Using four experiments in Tanzania in early 2021 as part of the national campaign, we find that including endorsements and testimonials in text messages sent to individuals significantly increases self-reported hygiene behavior. These results mask important heterogeneity based on the source of endorsement or framing of the testimonial and provide insights into cost-effective approaches for changing behavior at scale.

Effects of delay and reminders on time-based prospective memory in a naturalistic task.

The current study examined the effect of a delay on naturalistic time-based prospective memory (PM) tasks. Two experiments were performed to compare PM performance on a texting task with delays of 1 to 6 days after an initial session. In the first experiment, half of the participants were asked to repeat their response with the same delay to test whether requiring a second response (i.e., a repeated PM task, such as taking medication at the same time each day) would affect time-based PM performance. In the second experiment, participants were given an implicit or an explicit reminder several hours before their time to respond to examine the effect of type of reminder on this PM task. The results of both experiments showed a significant decline in PM performance between the 1-day and multi-day delays. Repeating responses (Experiment 1) had no effect on accuracy of the PM task, but in Experiment 2, explicit experimenter-initiated reminders significantly increased time-based PM performance compared with implicit reminders. These results are discussed in the context of previous studies that have tested delay effects on time-based PM and current theoretical descriptions of time-based PM.

Treating young adult cannabis use disorder with text message-delivered peer network counseling.

BACKGROUND: Approximately 16.5% of U.S. young adults have a cannabis use disorder (CUD) and are at risk for negative outcomes. Treatment can reduce cannabis use, but young adults are less likely to seek help than older adults. Peer Network Counseling-txt (PNC-txt) is a brief, text-delivered, Motivational Interviewing-informed substance use intervention focusing on peer relations and activity spaces as mechanisms for behavioral change. PNC-txt has shown evidence of reducing tobacco and cannabis use with adolescents and young adults, but it has not been tested in the context of legal cannabis use. The current randomized controlled trial sought to expand the evidence regarding the context of PNC-txt effects, comparing one state in which cannabis is legal (Colorado) and one state in which it is not (Tennessee). We hypothesized that participants randomized to PNC-txt would show significant reductions in cannabis use compared to controls, with larger reductions for females and those in Colorado, and that peer relations and activity space would mediate effects. METHODS: One thousand, seventy eight 18-25 year olds (CO: 551; TN: 527) who met screening criteria for CUD and biologically-verified cannabis use were randomly assigned to PNC-txt or waitlist control condition. Every other day for 4 weeks, participants assigned to PNC-txt received pre-programmed text conversations, tailored via data from the baseline assessment. Self-report and biological indicators of cannabis use were measured at 1-, 3-, and 6-months. DISCUSSION: Data analysis is underway. Results will provide evidence regarding whether, and how, PNC-txt reduces cannabis use in young adults with CUD. TRIAL REGISTRATION: This trial was prospectively registered on September 28, 2020 with ClinicalTrials.gov (NCT04567394).

Rationale, Design and Baseline Characteristics of a Randomized Controlled Trial of a Cardiovascular Quality Improvement Strategy in India: The C-QIP Trial.

BACKGROUND: Quality of chronic care for cardiovascular disease (CVD) remains suboptimal worldwide. The Collaborative Quality ImProvement (C-QIP) trial aims to develop and test the feasibility and clinical effect of a multicomponent strategy among patients with prevalent CVD in India. METHODS: The C-QIP is a clinic-based, open randomized trial of a multicomponent intervention vs usual care that was locally developed and adapted for use in Indian settings through rigorous formative research guided by Consolidated Framework for Implementation Research (CFIR). The C-QIP intervention consisted of 5 components: 1) electronic health records and decision support system for clinicians, 2) trained nonphysician health workers (NPHW), 3) text-message based lifestyle reminders, 4) patient education materials, 5) quarterly audit and feedback reports. Patients with CVD (ischemic heart disease, ischemic stroke, or heart failure) attending outpatient CVD clinics were recruited from September 2022 to September 2023 and were randomized to the intervention or usual care arm for at least 12 months follow-up. The co-primary outcomes are implementation feasibility, fidelity (ie, dose delivered and dose received), acceptability, adoption and appropriateness, measured at multiple levels: patient, provider and clinic site-level, The secondary outcomes include prescription of guideline directed medical therapy (GDMT) (provider-level), and adherence to prescribed therapy, change in mean blood pressure (BP) and LDL-cholesterol between the intervention and control groups (patient-level). In addition, a trial-based process and economic evaluations will be performed using standard guidelines. RESULTS: We recruited 410 socio-demographically diverse patients with CVD from 4 hospitals in India. Mean (SD) age was 57.5 (11.7) years, and 73.0% were males. Self-reported history of hypertension (48.5%) and diabetes (41.5%) was common. At baseline, mean (SD) BP was 127.9 (18.2) /76.2 (11.6) mm Hg, mean (SD) LDLc: 80.3 (37.3) mg/dl and mean (SD) HbA1c: 6.8% (1.6%). At baseline, the GDMT varied from 62.4% for patients with ischemic heart disease, 48.6% for ischemic stroke and 36.1% for heart failure. CONCLUSION: This study will establish the feasibility of delivering contextually relevant, and evidence-based C-QIP strategy and assess whether it is acceptable to the target populations. The study results will inform a larger scale confirmatory trial of a comprehensive CVD care model in low-resource settings. TRIAL REGISTRATION: Clinical Trials Registry India: CTRI/2022/04/041847; Clinicaltrials.gov number: NCT05196659.

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.