Text Messaging or SMS for Improved Health

In a recent blog we introduced the concept of mobile health or mHealth (“the delivery of healthcare services via mobile communication devices”).  mHealth interventions can be divided into two types, depending on the user of the intervention:  doctors or patients.  mHealth programs directed at doctors are used as aids in data collection or to support decision-making, while patient-directed mHealth programs are aimed at facilitating and supporting behavior change and disease management1.  While a number of different mHealth technologies have been utilized (video messaging, voice calling, internet connectivity) the focus of today’s blog is on text messaging, also known as short-message service (SMS), since it is the most accessible and frequently used mHealth feature.  Additionally, it has been the focus of two recent reviews that highlight the potential of text messaging for improved health2,3.

Published mHealth studies have generally used text messaging in one of two ways: i) to prevent disease and/or promote positive health behaviors or ii) to manage disease and/or provide clinical care.  Examples of the former include interventions to aid in quitting smoking, weight loss, and increasing knowledge about sexually transmitted diseases.  Examples of the latter include programs to help manage diabetes, asthma, and HIV treatment.  However, by far the most commonly addressed health issues in the SMS research literature are diabetes management and weight loss3.

The earlier of the two reviews, published in 2009, identified 33 studies of text messaging interventions but only closely examined 14 of these studies.  The authors found that 13 out of 14 studies reported positive behavior outcomes2!  That’s a 93% rate of success, although the amount of ‘success’ varied across studies.  The second review, published in 2010, was a bit more rigorous in the criteria used to evaluate the published studies (i.e., it tended to look at studies with a higher caliber of research).  This review identified 12 studies but looked more closely at the best 9 studies and found that 8 out of 9 “found evidence to support text messaging as a tool for behavior change3 (an 89% success rate).

These two reviews were also helpful in identifying key points to keep in mind as we move forward in this area.  Specifically, they highlight what has worked particularly well in the past and what areas need improvement.  There appear to be some aspects of text messaging interventions that make them more successful than others such as tailoring to the individual patient’s needs and interactivity2.  An area that could use some improvement is that of the length of time that patients were followed up.  To date, follow-up has ranged from 3 to 12 months3 and in order to get a better understanding of how far-reaching the intervention effects may be future studies should extend beyond 12 months.  I would like to point out, however, that this problem is not unique to studies of text messaging in health or to mHealth interventions.  Following up patients is extremely time consuming and expensive and is therefore limited in research of many different health-related interventions.

Overall, the research to date shows that text messaging has been successful in promoting healthy behaviors.  Considering the widespread ownership and use of cellular phones and the cost-effectiveness of this kind of intervention, this is clearly an extremely promising and exciting are of mHealth.

References:

  1.  Free C, Phillips G, Felix L, Galli L, Patel V, Edwards P.  2010.  The effectiveness of M-health technologies for improving health and health services: a systematic review protocol.  BMC Research Notes 3:  250-256. doi:10.1186/1756-0500-3-250
  2. Fjeldsoe BS, Marshall AL, Miller YD.  2009.  Behavior change interventions delivered by mobile telephone short-message service.  Am J Prev Med 36:  165-173.
  3. Cole-Lewis H, Kershaw T.  2010.  Text messaging as a tool for behavior change in disease prevention and management.  Epidemiol Rev 32:  56-69.