Background

Mobile phone Short Message System (SMS) text messaging as a strategy to promote healthy behaviors has proved promising in terms of feasibility and effectiveness.  SMS is perceived as convenient, time-saving, cost-effective, and non-disruptive to patients or caregivers and physicians.  Further implementation of SMS utilities in various settings and for various health goals should shed continued light on its potential and its limitations.

 

Objectives

This Practice Inquiry Project sought to evaluate, at a community family clinic: (1) the effectiveness of SMS in increasing fruit and vegetable intake (FVI) among adult patients with hyperlipidemia with no more than one co-morbidity, excluding diabetes; and, (2) SMS’s effect on participant perceptions of their own health and the quality of care they receive at the clinic.  Positive project results would directly impact the use of SMS text messaging as a standard for patient contact at the test location.

 

Design

Main outcome measures were patient responses to pre-, interim-, and post-intervention questionnaires.

 

Results

Participant fall-off in the project was high, resulting in areas of poor data reliability.  Some interim measures, however, were still statistically significant.  At 3 months, 85% of respondents reported an increase in the number of servings consumed, per day, of fruits and vegetables; 92% reported a higher percentage of their meals included servings of fruits and/or vegetables.  Patient attitudes toward the clinic increased as well for 92% of the interim respondents.  All 14 interim respondents reported an improvement in their overall sense of health.

 

Conclusions 

Despite indications that the project was too long and that data reliability was suspect in part, some project results appear positive enough to recommend using SMS as a clinic standard for patient contact on the caveat that SMS interventions similar to the one in this project may have optimal time spans for effective use.

The quality of food intake is directly linked to chronic conditions such as diabetes, cardiovascular disease, obesity, and some forms of cancer; improved dietary habits can ease such conditions and the health care costs related to them [1].  Inadequate fruit and vegetable intake (FVI) can exacerbate chronic conditions and lead to increased health costs (US Department of Health and Human Services, 2010).  More specifically, the 2013 joint guidelines of the American Heart Association (AHA) and the American College of Cardiologists (ACC) recommend a dietary profile emphasizing FVI for improved overall cardiovascular health including reduced hypertension, reduced risk for coronary artery disease, and, germane to this project, the reduction of lipids [2].  Based on data from the Behavioral Risk Factor Surveillance System (BRFSS), however, only 32.5% of Americans consumed fruit two or more times per day and only 26.3% consumed vegetables three or more times per day, falling short of the national targets of 50% and 75% respectively. 

 

New interventions to increase FVI are in order, but finding effective ways to change patient health behaviors is a challenge [3].  One approach that has a track record of effectiveness for changing patient health behaviors in a wide range of conditions is the use of Short Message System (SMS) text messaging utilities sent via patient mobile/cell phones.  SMS is perceived as convenient, time-saving, cost-effective, and non-disruptive to patients or caregivers and physicians [4].  Reports of its apparent benefits for appointment reminders; clinical data collection; and, the sending of informative, educational, personalized and motivational messages for patients with a wide range of chronic conditions is now almost taken for granted [5].  One recent study [6] focusing specifically on FVI found that SMS messaging created a context for “active engagement” among patients in an intervention.  Adolescent participants sending more than 50% of the messages available in a provided routine increased their FVI.

 

This Practice Inquiry Project seeks, first, to evaluate via questionnaire and patient self-report, the effect of SMS technology on increased FVI among patients with hyperlipidemia at the Spring Family Clinic (SFC).  The objective is to see a 20% increase in the number of participants eating the recommended minimum 5-servings/day (RDA) of fruits and vegetables per day and a 20% increase in the number of participants who eat fruits and vegetables with at least 75% of their meals.  A second purpose of the project is to see if SMS text messaging affects how patients rate their overall sense of satisfaction with the SFC via perceptions of how personal and accessible SFC care is.  Positive results will directly impact considerations to use SMS text messaging as a standard for patient contact and care at SFC.

 

2. Review of SMS Literature
2.1 Data Sources

A review of the literature was performed using the following electronic databases:  PubMed, Cinahl, Nurse Reference Center, OVID, and Scopus.  Search terms used included:  “text messaging,” “SMS text messaging,” “intervention,” “compliance,” “patient compliance,” “preventive health,” “health behavior,” “healthy behavior,” “medical regimen,” “diet,” “fruit and vegetable intake,” and “dietary intake.”  In addition, reference lists for selected articles were also reviewed for pertinent reference sources.

 

2.2 Selection Criteria

Included studies were randomized controlled trials (RCTs), controlled studies (CSs) that evaluated use of SMS text messaging for its influence in changing health care processes and/or health outcomes, systematic reviews (SRs), and one “review of reviews.”  Some studies which used SMS in tandem with other utilities such as “beepers,” paging devices, or Internet e-mail messaging were included.  Only studies in English and available in full-text were included.

Excluded were studies focusing on non-adult populations, the use of SMS between doctors/nurses rather than caregivers and patients, studies that used smart phones for video communication more than text messaging, and any studies judged as having inadequate relevance to the PICOT question guiding the Practice Inquiry Project based on the study’s abstract.

Appendix A presents the Consort Diagram summarizing the search process.  Appendix B identifies the included 35 relevant studies in a series of tables separated according to the three types of studies and with data extraction categories.  Of the 35 included studies, 22 were RCTs, 7 were CSs, and 6 were systematic reviews (SRs).

 

2.3 Data Extraction Results

After reviewing titles and abstracts of the identified citations and applying the inclusion/exclusion criteria noted above, data were collected from each eligible article.  For RCTs and CSs, the following data categories were used: Citation Details, Research Questions/Hypotheses; Design/Level of Evidence; Independent Variables & Measures; Dependent Variables & Measures; Sample Size & Population; Results; Strengths, and Weaknesses.  For SRs, the following categories were used:  Citation Details; Research Questions/Hypotheses; Search Methods; Selection Criteria; Data Collection & Analysis; and Conclusions.

A total of 16,494 adults (some parents of child patients) participated in the combined studies.  Study durations ranged from 6 weeks to one year, most lasting for 6 months.  In the RCTs and CSs (a total of 29 studies), SMS messaging was used as a reminder intervention, either alone  or in conjunction with motivational messages a total of 20 times [7-27].  Five were motivational only [28-31].   There were three SMS feasibility studies, [32-35] and one qualitative assessment of text-messaging  [36].  SMS was applied to various clinical areas: sunscreen application regimens [37], health promotion appointment attendance [15-22] recall of traumatic brain injury therapy goals [38], HIV ART regimens [39], low back pain treatment [40], physical activity for post-natal mothers, weight loss, [41-42] smoking cessation (Rodgers et al., 2005) [43], bulimia nervosa relapse [44], asthma treatment [45], diabetes [46], alcohol abuse treatment  [47],  malaria treatment guidelines [48], mammogram testing  [49], and hepatitis treatment adherence  [50].  Over a third of the studies (38%) were from outside the United States.  Three studies were from China [51-52] one from Australia [53], one from Finland  [54], three from [22-26], one from Germany  [14], one from Singapore  [16], one from Kenya  [15], one from Denmark  [18], and one from Lebanon [20].

 

All 29 RCTs and CSs used SMS text messaging technology either alone (23 of 29) or in conjunction with a similar technology [25].  Three studies used programmed messages [45-49].  Five studies used multiple sorts of messages (e.g., advice, support, distraction) [51-55].  Personalized messages were used in six studies [25-31].  One of those studies had the patients compose their own personalized messages [6].  Two studies used bi-directional texting [15-17].

 

Not all studies specified message frequency, and frequency, when specified, varied greatly.  Appointment reminder studies sent a single reminder SMS message 24-72 hours before a scheduled appointment.  Treatment reminders were sent daily in some studies [17-20] multiple times per week in others [12,15,45] and multiple times daily in others [14,25,30].  Specific message content was available in the lower back pain study [25] and unavailable in all other studies.

 

2.4 Studies Measuring Processes of Care

Process of care studies included appointment reminder SMS messages.  In all such studies, SMS reminders reduced failure to appear percentages; when the SMS utility was being compared to telephone or email or postal reminders, SMS appearance numbers were not appreciably better than phone or email or post, but researchers in eleven of the studies were quick to point out that the cost of SMS messaging was significantly lower than any of the alternatives [14,25,36,39]. 

 

2.5 Outcomes of Care Studies

In reference to change in disease-specific outcomes or changed behaviors toward those promoting better health, SMS messaging was reported as ineffectual in only 3 of the 18 outcomes-of-care studies [25,48,54], specifically studies on sunscreen regimen, mammogram screening, and in bulimia nervosa follow-up treatment.  In the sunscreen study, SMS was perceived as favorable, but that had little effect on the patient motivation to attend to SMS messages.  In the mammogram screening study, short messages were being compared to longer messages, and no appreciable differences were noted between the effects of the two.  Participants in the bulimia nervosa study seemed to have little interest or connection at all to the SMS utility.  Even though participation was viewed by most as easy, messages were considered inappropriate and impersonal to many participants.  SMS had a favorable effect in 15 studies (83%).

 

Some study limitations were explicitly noted.  The most common was inadequate sample size and the inability to guarantee generalizability with confidence.  Ten studies mentioned this inability [17,19,25].  Another mentioned limitation was the reliance in several studies on self-reporting [25,29,45,51].  While SMS increases caregiver-patient contact opportunities as well as opportunities for information and educational exchange (all deemed favorable by patients), SMS messaging cannot guarantee, finally, the reliability of patient reports on their conditions or treatment regimen adherence.  Other limitations included: study length too short to reach dependable general conclusions [25] quantity of response cannot guarantee quality of engagement by patient [15] possibility of confounding factors rather than SMS causes in some favorable outcomes [17-23]; inadequate tracking of cell phone ownership and use and ability to verify if SMS messages have been received by intended participants [45-48].

 

2.6 Systematic Reviews    

Six SRs of SMS technology were included in this study, one of them a systematic “review of reviews.”  Three were general investigations into the interface of health care and the mobile phone/SMS capability, and one focused specifically on SMS as a patient-physician interaction tool [5-9], one on SMS as a tool for behavior change in disease management [48], and one aimed specifically at the role SMS plays in antiretroviral therapy adherence in HIV+ patients [25].   The conclusions drawn by the reviewers about the SMS utility and its use in health care processes and clinical outcomes were very favorable across the board [47]. See it as a technology to reduce the global burden on health care accessibility and cost; along the same lines [48], say that SMS is possibly the first technology to increase the chances of delivering health interventions to hard-to-reach populations, going completely against the grain, in their opinion, of the history of technical innovation in medicine.  According to Wallwiener et al., (2009), SMS is deemed to have broad positive effects for health care mainly due to:
Negatives mentioned were:

•              Possible mobile phone health risks [45]
•              The fact that studies are in early stages and heterogeneous; more studies are necessary to fill in information gaps [26]
•              Lack of detailed studies on cost-effectiveness of SMS [19]

While maintaining a critical eye, reviewers seem to agree that clinics should adopt SMS interventions in their practices as soon as practicable [14,36,45].  The main worries expressed had to do with legal issues regarding patient privacy [13] and a concern that the technology still may not be able to reach all segments of the population in need of health care (Patrick et al., 2008) [14].  Finally, one recent “review of reviews” noted that SMS intervention generally brought about desired outcomes but found only limited evidence across populations to recommend, reliably, which SMS intervention characteristics are, in fact, crucial to success [17].

 

3. PIP Design and Methodology
3.1 Participants

This project selected, by open recruitment over a 3-month period, a convenience sample from the patient population at the SFC in spring, Texas.  Participants were healthy adults between the ages of 18-65 with hyperlipidemia.
•              Inclusion criteria:
o              >18 and <65 years of age
o              Diagnosed with hyperlipidemia
o              No more than 1 co-morbidity (e.g., hypertension; dysmetabolic syndrome)
o              Smart phone owner
•              Exclusion criteria:
o              <18 and >65 years of age
o              Diagnosed with diabetes mellitus
o              Had more than 1 co-morbidity

The study did not differentiate qualified participants according to age, gender, presence or absence of a non-disqualifying co-morbidity, or which single non-disqualifying co-morbidity a participant may have had.  
Prior to the proposed SMS text messaging intervention, the Primary Investigator (PI) culled clinic patients meeting the inclusion criteria from among her regular clientele.  Qualified potential recruits were informed of and invited to participate in the clinic’s SMS project.  Prospective participants were told that they would have to have personal access to smartphones, share their cell phone numbers with the SFC, sign an agreement to receive text messages from the SFC on their smartphones, and could voluntarily retire from the SMS intervention at any time.  Thirty qualified patients of the SFC agreed to participate.

 

4. Intervention

The project employed a client-based software utility for text-messaging services, MessageMedia.  The application made it possible to send text messages to groups or individuals via smartphone at any time of day or night.  In this study, messages were sent once daily to each study participant.  On any given day, the same message was sent to each individual.  Times at which each daily message were sent varied somewhat, but, time of day was not an independent variable for the study.  In general, messages were sent in the afternoons during the week and late morning on the weekends.

Both outbound messages (from SFC to subject) and inbound messages (from subject to SFC) were possible with the particular SMS utility employed, but participants were not prompted one way or another to respond to the daily messages they received.  Message Media informed the PI if messages were undeliverable.  Throughout the study, subjects could indicate via the text messaging system whether they wished to continue receiving messages; they could opt out at any time.

The PI composed the content of the messages sent via smart phone to the study participants.  A total of 30 different messages were composed.  Messages varied in terms of information content, but message content always included references to fruit and/or vegetable intake.  Some messages highlighted FVI health benefits; others reminded that fruits and vegetables could be convenient replacements for less healthy foods; some focused on convenient or appealing fruit and vegetable preparation; some tied fruits and vegetables to the holidays.  Message tone was designed to be engaging.  Some messages were conversational, others playful, others were encouraging, some a friendly challenge.

 

5. Assessment

Three questionnaires were the basis for assessment in this pilot study.  Questionnaire data results can be seen in Appendix C.  Sample questions included:
•              How many servings of fruits and vegetables do you eat per day?  
•              How many times per week do you eat “junk food” (e.g., fast food, chips, ice cream, etc.)?
•              Which best describes the level of personalized care you receive from caregivers at the SFC?

 

6. Data Analysis

This pilot study has one set of subjects and one independent variable: SMS text messaging.  At the same time, the project has more than one outcome measure: (1) participant changes in FVI habits, and (2) participant perceptions about their health care experiences at the SFC.  Multivariate data analysis is recommended when more than one outcome measure exists-provided outcome measures are related to each conceptually or in some other important way [25].  However, given the overall practical purpose of this study, which was to give the SFC good reason to employ SMS messaging with its patients, it wasn’t necessary to conceptually relate the FVI and the patient care satisfaction threads of this study.  Consequently, data analysis consisted of multiple discrete applications of paired sample t-tests using Statistical Package for the Social Sciences (SPSS) software.  Paired sample categories were as follows: (1) changes in FVI intake; (2) changes in patient perceptions of satisfaction of care provided by the SFC; and, (3) changes in patient perceptions of the personal nature of the care given by providers at the SFC; and, (4) changes in patients’ perceptions of the state of their personal health.  Paired samples were analyzed relative to the pre-intervention questionnaire and the 3-month questionnaire and between the 3-month questionnaire and the post-intervention questionnaire at 6 months.

 

7. Implementation

The PI, and SFC employee, implemented all facets of the SMS project at the SFC.  Except for initial permission from the SFC’s supervising physician to carry out the project, no SFC staff other than the PI was involved in its implementation and oversight.  This included:

 

• Research on and selection of SMS text messaging utility
• Questionnaire design
• Participant inclusion/exclusion criteria
• Patient chart review and recruitment
• Questionnaire distribution at pre-, interim-, and post-intervention
• Payment of fees for the MessageMedia utility ($600: $100 monthly for 6 months; from PI’s own pocket)
• Original composition of daily text messages sent to participants
• Sample Messages
• Dump the chips!  Dip with veggies!
• It takes the brain a couple minutes to tell the body it’s not hungry anymore.  Eat a carrot or half an avocado…THEN WAIT!
• Did you know that people eat less when they eat with others?  So, invite some friends over for that new vegetable casserole you decided to make.
• Eating healthy isn’t a sacrifice; it’s more like treating yourself as a friend.
• Acting liaison with Message Media in case of technology breakdowns
• Selecting and sending daily messages via the utility to all participants
• Responsibility for any other incidental costs (e.g., copying questionnaires)

 

 

 

            Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS (n=22)

 

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Armstrong, A. et al. (2009). Text-message reminders to improve sunscreen use Archives of Dermatology, 145(11), 1319-1321.	Do SMS reminders help adherence to sunscreen use?	Level II	Daily reminders for 6 weeks 1. A “hook” text 2. A prompt	Sunscreen application adherence; Number of days participants applied sunscreen	N=70 >18 Recruited from general community	No statistically significant differences between study vs. control groups	Revealed SMS as a favorable (attractive, easy, low cost) mode of reminder	Population too small?
Chen, Z. W., Fang, L. Z., Chen, L. Y., & Dai, H. L. (2008). Comparison of an SMS text messaging and phone reminder to improve atten-dance… Journal of Zhejiang University Science, 9(1), 34-38.	How does SMS compare to phone reminders for attendance rates at health promotion center?	Level   Single blind   3 Groups: -Control -Phone -SMS	Reminder sent 72 hrs before appointment	Measure of attendance rates	N = 1,859 w/ scheduled appoint-ments   w/ active cell phones	Phone and SMS rates significantly higher than control   No difference between phone/SMS	-Population size; -Study ethically approved -Sound statistical analysis	No clear weaknesses

 

Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Cho, S. J. et al. (2010). A randomized controlled trial of SMS text messaging versus postal reminder…  Korean Journal of Family Medicine, 31(4), 284-293.	How does SMS compare with postal  reminders attendanceand cost-effective-ness?	Level   Single-blind   3 Groups: -Control -Post -SMS	Reminders sent at 16 weeks	Patients who attended by week 24	N = 918 - hospital based fam.  practice >20 -Hyperlip-idemic	SMS rate significantly better than control   Cost per attendance much lower for SMS	-Pop. size; -Ethically approved -Sound statistical analysis -clinic attendance a sound outcome measure	No apparent weaknesses
Culley, C., & Evans J. J. (2010).  SMS text messaging as a means of increasing recall of therapy goals... Neuropsychological Rehabilitation, 20(1), 103-19.	Does SMS help traumatic brain injury patients remember rehab. Goals?	Level   Single-blind   Within-subjects	SMS messages sent 3x/day for 14 days	Recall assessed via free recall and cued recall procedures at baseline, 7 days and 14 days	N = 11   -from community rehab. centers	-Goals in the “text” condi-tion recalled better than in “no text” condition -SMS: quick -Socially acceptable -Inexpensive	-Focused population   -sound statistical method	Not easily generalizable to other populations   Potential that Pop. Size too small

 

 

Summary Table For Research Critiques – Randomized Control Trials

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Fjeldsoe, B. S. et al. (2010). Mobile Mums… Annals of Behavioral Medicine, 39, 101-111.	Are SMS messages feasible and effective for a physical interven-tion for post-natal women?	Randomized, single blind	SMS part of other strategies over 12 wk period -3-5 SMS/wk -2 SMS/wk for support person -Personal-ized	# days/wk participants reported at least 30 mins of MVPA or walking.	N = 88   -post  natal women	SMS significant positive effect	One of first RCT + SMS + physical activity study   -Tested personalized SMS content	Sample size inadequate to measure exercise duration increase.   Self-reporting
Haapala, I. et al. (2009). Weight loss by mobile phone: a 1-year effectiveness study. Public Health Nutrition, 12(12), 2382-91.	How effective is SMS for reducing food intake and daily weight reporting?	Randomized, double- blind   1 year w/ Assessments at 0, 3, 9 & 12 mos.	Use of a pre-designed weight loss program: WEIGHT BALANCE -patient initiated -auto calculations -advisory SMS	-Changes in body weight   -Waist circumference	N = 125 -healthy   -BMI = 26-36   > 25 < 44	Experimental group significantly better   Predictors of weight loss: -early loss -contact frequency -like SMS -changes in eating habits	Ethically approved	Effect of in-person weigh-ins at 3 mos intervals may lead to overestima-tion of program effectiveness   Report of possible bias-subsidy

 

summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

 

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Hardy, H. et al. (2011).  …Personalized Cellular Phone Reminder System to Enhance Adherence to Antiretroviral Therapy. AIDS Patient Care, 25(3), 153-163.	Is SMS more effective than a “beeper” for adherence to antiretroviral therapy in the HIV infected?	-RCT Single blind   -Beeper Group   -SMS Group   -3/6 wk interview	-Daily personalized SMS   Vs. Beepers   *SMS repeated until attended to *Beepers, no repeat	Composite adherence score resulting from:   -MEMS -pill count -self-report	N = 23   10 male 9 female   -On ART   -Self-repor- Ted <85% adherence	N = 19 completed study   Adherence higher in SMS reminder group	Statistical analysis	Short length of study   Small pop.   No clinic outcome data collected   Limited generaliz-ability

 

 

 

 

Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Harris, L. T. et al. (2010). Two-Way Text Messaging for Health Behavior Change Among Human Immunodeficiency Virus–Positive Individuals. Telemedicine and eHealth, 16(10), 1024-29.	What are the… -overall use ability -user-evaluation -demographics/ppsycho-socials -benefits as adherence tool	Data Analysis of an RCT	-1-8 person-alized mes-sages daily   -reminders -questions -informative -educational	-Overall useability -User-evaluation -Demo-graphics/ppsycho-socials -Benefits as adherence tool	N = 107   >18 -HIV posi-tive -85% male	-System evaluated positively; -Response rate low, drop over time -Technical complaints -Interest over time wanes		-Response rate used as measure of user engagement; -Lack of tailored educational content -Device hard to carry
Kim, H-S, et al. (2006). Impact of a Nurse Short Message Service Intervention for Patients With Diabetes Journal of Nursing Care Quality, 21(3), 266-271.	Effect of SMS from nurses on diabetic patient adherence to HbA1c levels	Quasi-experimental, 1-group, pretest and post test design	Weekly optimal and tailored recommendations to each patient via SMS for 12 wks.	(HbA1c < 7%).	N = 45   >30 yrs -Internet access -diabetic	Improved (HbA1c < 7%) levels via SMS   -Satisfied patient need for desired contact with caregiver		Self-report
Koshy, E. et al. (2008). Effectiveness of mobile-phone short message service (SMS) reminders for ophthalmology outpatient appoint-ments… BMC Opthamology, 8, 9.	Effect of SMS on appointment adherence: Ophthalmology outpatients	RCT 1-blind 2-arm	Appointment reminder sent to patients with scheduled appts.	Attendance at scheduled appointment	N = 447   -had scheduled appoint-ments	38% lower non-attendance rates with SMS		Presence of confounding factors: -sociodemo-graphics -clinical conditions

 

 

 

Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Lakkis, N. A. et al. (2011). The effect of two types of sms-texts on the uptake of screening mammo-gram…. Preventive Medicine, 53(4-5), 325-327.	Compare: SMS “invitation” to a mammogram vs. a “benefits” of mammogram message	RCT:   6 month	Group 1: “Invitation” SMS   Group 2: “Invitation + “benefit info” SMS   Similar mean ages		N = 2010   -female   >40 <75   -On health insurance plan at Amer. Univ. Beirut	No significant positive SMS results (see weaknesses)   High preference for SMS as medium over email	Ethically sound   No cost	Inadequate update of mobile phone numbers   No definitive SMS statistics
Leong, K. C. et al. (2006). The use of text messaging to improve attendance in primary care… Family Practice, 23 (6), 699-705.	Compare Phone message to SMS reminder to improve attendance in primary care.   Assess cost-effect	Three-arm randomized con-trolled trial.   Group I: Control Group II: SMS GroupIII: phone	-Same message sent verbally or via text. Max. 3 reminders -No clinic or lab info included. -Contact defined as ‘message sent’ or if participant responded.	Attenders:   Arrived at clinic on appointed day	N =1111   -required follow-up   appointments between 48hrs to 3 mos from recruit date   SMS ready	N = 933 SMS rate and phone rate equal   Each significantly higher than no reminder group   SMS cost almost 50% less than phone group	SPSS version 11.5	No way  to confirm if participants got reminders   Attenders definition too restricted   Low general- Izabilty?

 

 

 

Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Liew, S. et al.. (2009). Text messaging reminders to reduce non-attendance in chronic disease follow-up… British Journal Of General Practice, 59(569), 916-920.	SMS reminders compared to telephone reminders and no reminders	RCT   Three-arm -control -phone -SMS	Reminders sent 24-48 hrs before scheduled appt.	Attendance: -attended on appropriate date	N = 931   -on at least 6 mos of follow-up	Attendance rates much lower in intervention groups (see weaknesses column for possible explanation)   No difference for SMS v. phone		Unequal availability of mobile phones in 3 groups
Prabhakaran, L. et al. (2010). The use of text  messaging to improve asthma control… Journal Of Telemedicine & Telecare, 16(5), 286-290.	Does SMS help with asthma control?	RCT 2-arm Double blind	Software sends alerts if detected increased use of reliever compared to patient baseline	Chi-square performed to assess:   -ACT >20; -nebulization reduction -reduced # of ED visits	N = 497 (n=120) -60 control -60 intervention Admitted to hospital for asthma during 11 mo period	Improved asthma control scores   Did not reduce ED vists or hospital admissions	Ethically approved	Sample too small and  not generalizable --+55 age  excluded   Response message cost to participant

 

 

 

 

Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Robinson, S. R. et al. (2006).  Aftercare Intervention Through Text Messaging in the Treatment of Bulimia Nervosa—Feasibility Pilot. (Int) eating Disorders, 39, 633-638.	How feasible is SMS for aftercare or relapse prevention for bulimia nervosa?	RCT – Pilot   6 mo. span	Send a pre programmed, personally tailored feedback message	Personal text response rate	N = 21	-Program use was low   -Limited acceptance of intervention	Aims at value of personalized SMS content	Small pop.   Intervention inadequately designed   No indication of frequency of SMS
Rodgers, A. et al. (2005). Do u smoke after txt? Tobacco Control, 14(4), 255-261.	Test effectiveness of SMS in a smoking cessation program	RCT 2-arm Single blind (staff) Control & Intervention groups 6 mos with follow-up	Intervention:   Receipt of regular, personalized SMS including -advice-support-distraction-free of charge	Not smoking in the past week 6-weeks after randomization	N = 1700   -smokers ->15 -want to quit -58% female -mean age 25	SMS doubled quit rates at 6wk   Difference between control and intervention less notable at end of 26 weeks	Measured across ethnographic categories	Incomplete follow-up   Over-reporting of quitting

 

 

 

Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Stockwell, M. S. et al. (2012). Text4Health: Impact of Text Message Reminder–Recalls for Pediatric and Adolescent Immunizations. American Journal of Public Health, 102(2), e15-e21.	Determine impact of SMS reminders on immunization receipt and recall session attendance	RCT   2-blind 2-arm   Reminders	SMS immunization reminders	Receipt of immunization at 4 wks. And 24 wks.	N = 195 -parents of children 11-18 -low income -have cell phones -need MCV4 and/or Tdap at 4, 12, and 24 wks.	Intervention parents significantly higher		Focused on parents with a recorded cell phone #   Race/ethnicity Stats. Subject to inaccuracy
Strandbygaard, U. et al. (2010). A daily SMS reminder increases adherence to asthma Treatment… Respiratory Medicine, 104, 166-171.	Will daily SMS reminders help asthma treatment adherence?	RCT   2-arm	Daily short SMS reminders to take medication	PRIMARY: Adherence to asthma treatment SECOND-ARY:-Reimbursement of asthma meds.-change in exhaled nitric oxide -airway clarity	N = 26 >18 <45 -clinical history of asthma -pos. methacho-line challenge test	Almost an 18% improvement of adherence in intervention groups. SMS over time tends to take on a simple ‘alarm clock’ effect and content is ignored	Elicited responses about favorable and unfavoravle times for participants to receive SMS.	Limited sample size

 

 

Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Taylor, N. F. et al. (2012). Short Message Service Reminders Can Reduce Nonattendance in Physical Therapy Outpatient clinics… Arch Phys Med Rehabil 93, 21-26.	Do SMS help reduce non-attendance in physical outpatient clinics?	Prospective RCT   2-arm 1-blind	Receipt of SMS reminder before scheduled appt.	Rate of non-attendance without cancellation	N = 679   SMS-=342 Control=337	Non-attendance higher for control group	Indicated other factors influencing attendance:   -type of phys. therapy needed   -Monday/Friday appts. Often high non-attendance	Failed to reach target sample size   No data kept for patients who could not provide a mobile phone #   No formal health economic analysis
Vervolet, et al. (2011). Improving medication adherence in diabetes type II…with SMS reminders. BMC Health Science Research 11(5), 1-9.	Evaluate effectiveness of RTMM monitoring + SMS messaging for improving adherence rates	RCT Protocol   3-arm 2-blind   6 mo. duration	Combines real-time monitoring of meds. Use with SMS reminders if meds. Are forgotten	Pharmacy refill data.	Minimum N = 69   -Diabetes Type II   -<80% adherence to antidiabet-ics	None yet.		Sample size too small?   Potentially non-general-zable because participation limited to one pharmacy chain

 

Summary Table for Research Critiques – RANDOMIZED CONTROL TRIALS

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Weitzel, J. A. et al. (2007). Using wireless handheld computers and tailored text messaging to reduce negative consequen-ces of drinking alco-hol. Journal of Studies on Alcohol and Drugs, 68(4), 534-537.	What are outcomes and feasibility for SMS tailored messages to reduce alcohol-related consequences among college students/	RCT- 2 blind 2 arm Follow-up -Control: complete daily surveys -Inter-vention:Receipt of messages tailored to respondent behavior	Students sent messages for 12-14 days	Self-reported drinking data	N = 40   -college students	Treatment group reported fewer drinks per drinking day   T-group had fewer trouble worries re drinking   Volunteered positive and negative feedback about SMS content	Info about positive and negative reactions to SMS content	Convenience sample   Small sample size   Self-report   Short study span, follow-up data may not be informative
Zurovac, D. et al. (2011).  The eff ect of mobile phone text-message reminders on Kenyan health workers’ adherence… Lancet, 378, 795–803	Do SMS help health workers stick to treatment guidelines for helping pediatric malaria patients?	Cluster RCT   1-blind (patients)   2-arm   Receipt vs. non-receipt of SMS	-1-way SMS reminders about malaria case management -10 different process management messages -M-F 9am & 2pm weekly for 6 mos. -160 charcters max.	Correct artemetherlumefantrine management	N = 119   -health workers	Adherence improved by 23.7%	Unique population: Applies SMS to health workers rather than patients as target participants	No clear analysis of the characteristics of SMS that influenced desired outcomes

 

 

 

Summary Table for Research Critiques – Controlled Studies (n=7)

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Axén, I. A ., et al. (2012). The use of weekly text messag-ing over 6 months was a feasible method.... Journal of Clinical Epidemiology, 65 (4), 454-461.	Does SMS help with data collection from patients about low back pain (LBP)?	Level II:   OBSERVATION-AL STUDY	Weekly SMS over 6 month period ‘‘How many days this week has your low back pain been bother-some?’’	Measures: response rate; user friendliness; compliance	N=262 w/ non-specific LBP	Mean response rate = 82.5%   Found to be user friendly   CONC: SMS useful for LBP data collection in primary care setting	Useful, relevant outcomes	Problems with generalizing to other populations;   Doesn’t isolate other factors that might influence willingness to respond
Downer, S. R. et al. (2005).  Use of SMS text messaging to improve outpatient attendance. Medical Journal of Australia, 183, 366-368.	Test SMS appointment reminders to improve outpatient attendance	Cohort Study with historical control	Reminders:   160 character max   Sent 3 days before appt.	Appointment attendance	N = 1382 9/2004 N=1482 8/2004 -had scheduled appts. At any of 5 out-p clinics -gave cell #’s	Failure rates lower for all SMS compared to control groups.   14% vs. 23%		Use of historical control groups (results may be due to monthly variation)   Couldn’t verify receipt of SMS by correct recipients

 

Summary Table for Research Critiques – Controlled Studies

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Foley, J & O’Neill, M. (2009). Use of SMS as a reminder: the effect on Patient Attendance. European Archives of Pediatric Dentistry,10(1), 15-18.	Do SMS reminders help patient attendance?	Control-led study   Historical control group	Reminder of appt. 24 hr. prior to appt.	Attendance at appt.	N = 276 in 2006 (control)   N=433 in 2007 (inter-vention)   -gave mobile contact #s	24% failure for control   10.4% failure for SMS		Those who provide cell #s may be more motivated than other patients
Gerber, B. S. et al. (2009).  Mobile Phone Text Messaging to Promote Healthy Behaviors and Weight Loss Maintenance: A Feasibility Study. Health Informatics, 15(1), 17-25.	Can SMS promote healthy behaviors and weight loss maintenance?	Pilot Study -3 SMS per week to each participant -Personal messages received at specific time of day	Used Hiplink XS. -Can send SMS to individuals or groups -3 general SMS weekly -Personalized received 2 personal + 1 generalized	Questionnaire follow-up	N = 95   -female   >30 <65   -Min 14 yrs educ.	Most welcomed text messages   Many looked forward to messages and said it positively affected their behavior		Self- report   Inconsistent delivery of messages   No clear cause/effect of SMS <span style="font-size:10.0pt;font-family:Wingdings;mso-ascii-font-family:" times="" new="" roman";="" mso-hansi-font-family:"times="" roman";mso-bidi-font-family:"times="" mso-char-type:symbol;mso-symbol-font-family:wingdings"="">à desired behaviors

 

Summary Table for Research Critiques – Controlled Studies

 

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/Limitations/Bias
Neville, R. G. et al. (2008). Early experience of the use of short message service (SMS) technology in routine clinical care. Informatics in Primary Care, 16, 203-211.	What is the technical effectiveness and qualitative response to SMS text messaging?	Observation of SMS service + In-depth, semi-structured interviews		Service utilization and patient views	N = 180 registered patients	-SMS technically feasible for:   -appts.   -prescrip.     refill   -remote     access -SMS user friendly, especially for meds. -No adverse effect on SFC staff workload	Ongoing adaptive redesign of SMS messag-ing during course of study	Small pop. sample
Person, A. K. et al. (2011).  Text Messaging for Enhancement of Testing and Treatment for Tuberculosis, Human Immunodeficiency Virus, and Syphilis: A Survey of Attitudes Toward Cellular Phones and Healthcare Telemedicine and eHealth, 189.	Assess knowledge, attitudes, behaviors re health care related SMS use among persons at risk for or infected with TB or HIV.	Anonymous survey		Results by:   -demo-graphics   -barriers   -attitudes toward cell phones and SMS	Survey respondents = 315   241 with cell phones   142 preferred cell phone communication	SMS availability growing   Requires literacy (barrier for some)   Too frequent reminders not good   Appt. reminders preferred

 

Summary Table for Research Critiques – Controlled Studies

Citation	Research Questions/ Hypothesis	Design/ Level of Evidence	Independent Variables and Measures	Dependent Variables and Measures	Sample Size Pop’n	Results	Strengths	Weaknesses/ Limitations/ Bias
Vilella, A. et al. (2004). The role of mobile phones in improving vaccination rates in travelers. Preventive Medicine, 38, 503-509.	Do SMS reminders help adherence to hepatitis A/B vaccination schedules?	Quasi RCT   -3-arm -2 controls: 2000, 2001		Second hepatitis A + B dose administered 30  days of first vaccine and when the third dose of A + B and second dose of hepatitis A administered within 6 mos.  of the primary dose.	N = 2348   Control (2001) = 1610   Inter=738	SMS aided compliance for third dose of Hep A + B and for second dose of Hep A.	Few studies aimed at compliance of travelers

 

 

 

Summary Table for Research Critiques – SYSTEMATIC REVIEWS (n=6)

 

Citation	Research Questions/ Hypothesis	Search Methods	Selection Criteria	Data Collection & Analysis	Results	Conclusions
Cole-Lewis, H. & Kershaw, T. (2010). Text Messaging as a Tool for Behavior Change in Disease Prevention and Management. Epidemiological Review, 32, 56-69.	To determine text-messaging is good for  enhancing adherence to ART in patients with HIV infection.	- A comprehensive electronic literature search   -Including MEDLINE, Cochrane, Google Scholar, et al.	-RCT or Quasi-RCT   -Required to measure the impact of text message interventions by assessing change in health behavior, health outcomes, and/or clinical outcomes using pre-/posttests   -Peer reviewed	-Participant characteristics, Intervention details, dose and duration of text messaging, follow-up times, outcome measures, and results. Quality of study design was assessed and a score assigned based on 9 characteristics: individual randomization, use of a control group for comparison, isolation of text messaging technology, use of pre-/posttest design, retention, equivalence of baseline groups, consideration of missing data, power analysis for sample size consideration, and validity of measures.	-Majority found short term SMS effects related to various conditions (e.g., diabetes, weight loss, smoking) and to meds. adherence   - no clear differences in intervention outcomes based on age, gender, or length of messages.   -Only one RCT in a developing country   -May marginalize illiterate   -Behavioral theory-based SMS best   -Often failure to isolate the SMS technology	Text messaging may be an important tool to reduce the global burden on health care by providing more effective disease prevention and management support.

 

 

Summary Table for Research Critiques – SYSTEMATIC REVIEWS

 

Citation		Research Questions/ Hypothesis	Search Methods	Selection Criteria	Data Collection & Analysis	Results	Conclusions
	Hall, A. K., Cole-Lewis, H. & Bernhardt, J. M. (2015). Mobile text messaging for health:  A systematic review of reviews. Annual Review of Public Health, 18, 393-415.	Meta-review:   Identify SMS interventions designed for health improvement to derive recommendations for practice	Find and identify all existing SMS systematic reviews through various databases	English only, Narratives, Literature reviews, systematic and meta analytic reviews   Adult targets Adolescents not targeted	SMS effectiveness, behavior/health outcomes, intervention components   3-author data extraction redundancy   PRISMA checklist used	N=15 Reviews Studies varied in complexity   SMS interventions good for diabetes self-management; weight loss, physical activity, smoking cessation.	SMS interventions work, but knowing which SMS characteristics guarantee  success are indeterminate
Horvath, T. et al. (2012).  Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection. The Cochrane Collabor-ation		To determine whether mobile phone text-messaging is efficacious in enhancing adherence to ART in patients with HIV infection.	Cochrane, MEDLINE, EMBASE, WHO, et al.   01 January 1980 to 01 November 2011	Randomised controlled trials (RCTs) in which patients or their caregivers (in the case of infants and children) of any age, in any setting, and receiving ART were provided with mobile phone text messages as a means of promoting adherence to ART.	Seventeen full-text articles were closely reviewed. Both authors abstracted data independently	There is high-quality evidence from the two RCTs that mobile phone text-messaging at weekly intervals is efficacious in enhancing adherence to ART, compared to standard care.	Practice: Should consider funding programs proposing to provide weekly SMS as a means for promoting adherence to antiretroviral therapy. Need for research into: -adolescent populations -SMS acceptability -optimal message length

 

 

Summary Table for Research Critiques – SYSTEMATIC REVIEWS

 

 

Citation	Research Questions/ Hypothesis	Search Methods	Selection Criteria	Data Collection & Analysis	Results	Conclusions
Krishna, S. et al. (2008). Health care via cell phones: a systematic review. Telemedicine and eHealth, 15(3), 231-240.	What does the empirical evidence about the role of cell phones and text messaging say about improving health outcomes and processes of care?	MEDLINE (1950-2008)   MeSH   Key words: cellular phone; text messaging; mobile phone   2735 citations	RCTs & Controlled Studies   -cell phone use for educational or informative interventions for health outcomes or processes of care	-Final Set of Studies:   -20 RCT -5 Controlled Studies   Abstracted Data: -study design -clinic areas -country -patient sample -technology -duration -delivery frequency -intervention -processes and outcome   measures -statistical significance   “Successful Trial” = p < 0.05	-RCTs ranged from 3wks to 12 months -Cell phone use applied to 12 different clinical areas including (diabetes, asthma, hepatitis, physical activity) -Took place internationally -9 studies used SMS alone -Message frequency: from daily to once/wk -60% successful process or outcome measures -84% change in health outcomes because of SMS (alone or in combo) -Small sample size limitations (low generalizability) -One study was abstract only -Only two studies provided cost info	-SMS is possibly first technology to increase chances of delivering health interventions to hard-to-reach pops.   -Cost-effectiveness studies needed   -clinics should adopt SMS

 

  

Summary Table for Research Critiques – SYSTEMATIC REVIEWS

 

Citation	Research Questions/ Hypothesis	Search Methods	Selection Criteria	Data Collection & Analysis	Conclusions
Patrick, K. et al. (2008). Health and the Mobile Phone. American Journal of Preventive Medicine,35(2), 177-181.	Overview of the implications of the introduction of mobile phone technology on health care delivery	Not given	Not given	Not given	-SMS broad positive effects for health care delivery   -May not be sufficient to reach all segments of the population
Wallwiener, M. et al. (2009). Impact of electronic messaging on the patient-physician interaction. Royal Society of Medicine Press Limited	Review of Literature on Text Messaging	MEDLINE/Pub-Med   ‘Electronic mail’ ‘patient’ ‘messag*’ ‘electroni* ‘internet’   1065 publications/ 71 relevant	-Evaluate an SMS system Re patients, physicians, efficacy of care, user satisfaction, etc.   -Exclusion: did not address benefits, shortcomings or impact of SMS; failed to provide outcome measures; not English	Screened by 2 independent investigators CATEGORIES: -expectations -benefits -quant. Advantages -qual. Advantages -patient satisfaction -barriers to implementation -legal -econ. Benefits -available SMS systems	-Patients satisfied w/ SMS (convenient, time-saving) -No adverse effects reports f/ physicians -Only legal concerns are about privacy -Economic benefits to large health-care groups -Cost-effective overall

  

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3. Armstrong AW, Watson AJ, Makredes M, Frangos JE, Kimball AB, et al. (2009) Text-message reminders to improve sunscreen use: A randomized, controlled trial using electronic monitoring. Archives of Dermatology 145: 1319-1321.

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6. Chen ZW, Fang LZ, Chen LY, Dai HL (2008) Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: A randomized controlled trial. Journal of Zhejiang University Science 9:34-38.

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8. Clark SJ, Butchart A, Kennedy A, Dombkowski KJ (2011) Parents' experiences with and preferences for immunization reminder/recall technologies. Pediatrics 128: e1100-5.

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11. Cole-Lewis H, Kershaw T (2010) Text messaging as a tool for behavior change in disease prevention and management. Epidemiological Review 32: 56-69.

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