Text message reminders improve healthcare practice in rural Africa, study finds

The study, published today in the 'Lancet', was carried out by researchers at the Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme in Nairobi.

Within Africa, the adherence to national malaria treatment guidelines by health workers is vital in making sure that patients stick to and correctly complete malaria treatment doses. Failure to do so can not only affect the patient's recovery from the disease but also increase the likelihood of the malaria parasites becoming resistant to the drugs.

Despite the relatively simple guidelines, however, failure by the health workers to adhere to them has been widely reported across the continent. To help improve health workers' practices, researchers at the KEMRI-Wellcome Trust Research Programme carried out a randomised controlled trial looking at the impact of sending SMS text message reminders to the health workers' personal mobile phones.

For five working days, two text messages (one at 09.00 and one at 14.00) were sent daily to every health worker's mobile phone. The same process was repeated every week for six months. The messages included both information from the guidelines and inspirational quotes. For example:

Message one (Monday morning)
Check ALL sick children <5yrs for any severe signs! Also check for fever, cough, diarrhea, pallor & any other problem. Quote: "Persistent work triumphs"

Message two (Monday afternoon)
Child has FEVER when complained by mother or child is hot or Temp is >=37.5 - Pls ask mother, touch child & take Temp! Quote: "Actions speak louder than words"

Message three (Tuesday morning)
TREAT with AL* all children under 5yrs weighing >=5kg coming with FEVER for first visit & without severe signs. Quote: "Opportunity seldom knocks twice"

*Artemether-lumefantrine, the recommended antimalarial.

Most randomised controlled trials from high-income countries have focused on reminders to improve patients' adherence to treatment, and all studies only assessed short-term effects of the intervention. This is believed to be the first study to assess the use of text messaging to target the behaviour of health workers.

The researchers evaluated the effectiveness of the intervention using a performance index on how health workers managed the children in clinic, by interviewing mothers of children as they left the clinic and by reviewing clinical records. The study showed a 25 per cent improvement in health workers practices in providing correct care to patients with malaria. The intervention resulted in a substantial increase in the number of patients who received prompt antimalarial treatment at the health facility and were correctly counselled to take remaining tablets when they were at home.

Lead author of the study Dr Dejan Zurovac says: "This trial, the first one using text messaging to target health workers' behaviour in developing countries, has shown that a simple intervention like SMS can improve health workers' adherence to malaria treatment guidelines by 25 per cent. Text messaging should complement traditional approaches to support clinical management such as in-service training of health workers, supportive supervision, or dissemination of job aids."

Dr Zurovac and colleagues believe the scheme may have been successful because text-message reminders address health workers' forgetfulness, emphasise the clinical importance of doing tasks described in the messages, and increase the priority of doing the tasks because the text messages represent the voice of authority of the health workers' employer (the Ministry of Health).

The simplicity and low cost of text messaging means that widespread implementation of an intervention that uses this technology can be done quickly and successfully. For example, the cost of a text message in Kenya is about US$0.01, resulting in the cost of full exposure to the intervention of $2.6 per health worker, or $39,000 if scaled up to an estimated 15,000 health workers in all rural facilities nationwide.

Professor Bob Snow, who heads the research group in Nairobi, says: "The role of the mobile phone in improving health providers' performance, health service management and patient adherence to new medicines across much of Africa has a huge potential to engage and promote health to many people, who despite being poor and often inaccessible nevertheless have access to cell phone communication."

Co-author and head of the Department of Disease Prevention and Control, Ministry of Public Health and Sanitation, Dr Willis Akhwale added: "This is an excellent example of high quality research responding to immediate needs of policy implementers who are continuously searching for simple and low cost solutions to strengthen weak health systems and provide better care for Kenyans. We need to explore ways of scaling up such intervention to all health workers in the country."