Preparing Short Message Service Reminders to Improve Treatment Adherence among Tuberculosis Patients in Sleman District, Indonesia

Abstract

Background: 

Modern tuberculosis (TB) treatment approaches require innovative adherence strategies.

Objectives: 

This study aimed to explore the feasibility of using short message service (SMS) reminders through mobile phones to improve treatment adherence among TB patients.

Materials and Methods: 

An exploratory sequential design was applied; initially, qualitative data collection was conducted among TB patients and TB program officers. A content analysis was done and messages were then developed. The messages were pretested using focus group discussions (FGDs), and a quantitative method using quasi-experiment on 120 TB patients. All the patients received a standard directly observed therapy short reminder, but only intervention group received daily SMS reminders (n = 60), the data were then analyzed using logistic regression.

Results: 

Reminder messages can be sent directly to young TB patients or indirectly to the relatives of elderly patients. There are four phases of emotional states, which TB patients go through during treatment starting with disappointment and desperation after being diagnosed, grievance during the initiation of treatment, high and then low desire to follow treatment. Reminder messages aimed at improving treatment adherence should correspond to those conditions and motivate, inform, and facilitate TB patients to overcome all the obstacles during treatment. SMS reminders should also be short, informal, and easy to understand. Treatment adherence was significantly higher among the intervention group compared to the control group (odds ratio = 10.73) after controlling for demographics, accessibility, and adverse drug reaction.

Conclusions: 

SMS through mobile phone is a feasible form of media to remind TB patients and to improve adherence to treatment in low-resource facilities.

INTRODUCTION

Globally, tuberculosis (TB) is one of the leading causes of death which is responsible for 1.7 million deaths in 2017.[¹] The long duration of TB treatment leads to a high level of nonadherence, especially during the first 2 months of the intensive treatment phase when patients should take anti-TB drugs daily.[²]

The nonadherence to treatment can increase transmission, drug resistance,[³] the need for more expensive treatment,[⁴] and mortality. A reminder system which uses innovative adherence strategies involving simple communication technology is important for managing nonadherence problems in low-resource facilities with limited numbers of health officers and incompetent direct observers.

The studies have shown that sending short message service (SMS) reminders through mobile phones could increase treatment adherence at a relatively low cost.[⁵] The percentage of people in Indonesia who own a mobile phone is high (84% in 2012).[⁶] Before a large-scale program is carried out, a pilot feasibility study must be done to ensure effectiveness. This study aimed to explore the feasibility of SMS reminders to improve treatment adherence among TB patients. We investigated the extent to which the SMS reminder was suitable and likely to be used by TB patients, developed appropriate messages and system to deliver the SMS reminder,[⁷] and to measure the effectiveness of the SMS reminder.

MATERIALS AND METHODS

This study uses an exploratory sequential design[⁸] using a qualitative study, followed by a quantitative study. Qualitative data were collected to explore the acceptability and demand of SMS reminders among TB patients and to identify suitable reminder messages. This was followed by a small-scale posttest only, quasi-experimental study to measure the effectiveness of the SMS reminder system on treatment adherence. This study was conducted in Government-Own Primary Health Cares, the Sleman District Hospital, and the Community Pulmonary Health Service Unit in Sleman District, the Northern part of Yogyakarta Special Province in Java Island, Indonesia.

Qualitative data were collected among informants who were selected purposively with maximum variation sampling according to sex and age. The informants were 32 TB patients (aged 18–61 years, consisting of 17 men and 15 women), 25 primary health center (PHC) staffs, 10 officers from public and private hospitals, and 1 staff from a community pulmonary health service unit. Overall, ten FGDs and five in-depth interviews were conducted.

After individual informed consent was granted, the FGD and interviews were conducted, recorded verbatim, then transcribed, and analyzed. From the transcript, meaning units were identified and open coded, then similar codes were put into categories.[⁹] With consideration to the results of the qualitative data analysis, the fourth author drafted the messages, all other authors were revised the language. The messages then were pretested in four FGDs with TB patients.

The researchers consisted of different backgrounds to enable triangulation: two physicians, two nurses, one social scientist, two undergraduate nursing students, and one postgraduate public health student who was also a district health officer in charge of TB program manager in Sleman.

SMS reminders were then pretested in a small-scale quasi-experimental study involving 60 TB patients in the intervention group receiving daily SMS plus standard directly observed therapy short (DOTS) reminders, and 60 patients in the reference group receiving only standard DOTS reminders. Source of 60 out of 120 participants from Sudiya S et al.[¹⁰] The sample size was determined based on the availability of resources. The samples were selected consecutively with the inclusion criteria of being newly diagnosed patients who started their treatment in a PHC in the Sleman District, were above 18 years of age, and agreed to participate in the study. The exclusion criteria were having complications. The selection of TB patients was done by systematic random sampling at the time of diagnosis in health services, while the allocation was done purposively. TB patients who were diagnosed from May 1, 2014, to June 30, 2014 were recruited as a control group, and the intervention group was recruited from November 1, 2014, to December 31, 2014 [Figure 1]. Researcher defined the random allocation of TB patients; the physician at the health facilities did the enrolment. The treatment adherence measurement was done by TB program officer in all health facilities who unaware of the random allocation of TB patient.

Figure 1: Participants flow of intervention and control groups

Treatment adherence was identified if the length of treatment was 56 days. To measure the effectiveness of SMS reminders on treatment adherence, some possible confounders were measured using questionnaire at the health-care facilities by health officer: demographic factors (age, sex, education, occupation, and income), accessibility (available mode of transportation and time to reach a health facility), and adverse drug reactions. A multivariate analysis with logistic regression was conducted using Stata version 14 (StataCorp LP, College station, Texas, USA) to test the relationships between the type of intervention and treatment adherence controlling for the possible confounders.

Ethical clearance was granted by the Ethical Committee, Faculty of Medicine, Public Health and Nursing, UGM number KE/FK/35/EC, and individual written informed consent was obtained from each recruited TB patients.

RESULTS

How do tuberculosis patients utilize mobile phones?

Four categories arose to describe how TB patients utilized their mobile phones: (1) purpose of using mobile phones, (2) perceived benefit of using mobile phones, (3) mobile phone dependency, and (4) ability to use mobile phones.[¹¹]

All of the informants used mobile phones as a means of communication. Elderly informants confessed to difficulty in reading messages, that is, reading small text in close proximity. They also admitted difficulties making regular phone calls and preferring instant calls instead. On the other hand, young informants used mobile phones as a means of building or maintaining their social networks, either through SMS messages, phone calls, or the use of various social media and entertainment.

In general, informants admitted to the benefits of using mobile phones such as supporting their jobs and getting in touch with social networks, but occasionally informants felt disturbed by their mobile phones, i.e., when there were untimely, inappropriate, or unauthorized phone calls or messages.

Dependency toward mobile phones and the ability to use them varied according to age. The younger were more dependent and had more advanced abilities to operate them. Older informants shared their mobile phones with other family members and needed help from their younger relatives to operate them.

Tailoring reminder messages

In structuring the messages, three subcategories emerged from the codes on how to design the message. These were the nature of the messages (short, easy to understand, and informal), motivating characteristics (inviting and positive statement), and words showing respect (salutation, using Mr/Mrs/Miss, and avoid “TB patient”).[¹²]

There were four emotional states, TB patients went through according to the treatment phase. After being diagnosed with TB, they felt disappointed and desperate, they were afraid of being labeled as TB victims. The feeling then changed into grievance during treatment initiation because of side effects from the anti-TB drugs. Once they managed their side effects well and believed that their illness was curable, TB patients had a high desire to follow the treatment regimen. Finally, a low desire to follow the treatment regimen as they experienced improved health.

This study found three different contents of messages that can be developed as reminders: motivational messages, regular reminders, and informational messages. The contents of these messages were mapped according to the TB patient's emotional state [Table 1]. For the first emotional stage of feeling disappointed and desperate, suitable messages should be motivating and convince the recipients that TB can be cured. The second phase, another pessimistic time. Therefore, informational messages about side effects and how to manage them was appropriate. The third phase of confidence is a time when information about regular treatment and prevention of transmission could be emphasized. Finally, the fourth phase of pessimism or low desire at the end of intensive phase treatment, which requires emphasis on information about long term and regular treatment.

Table 1: Pattern of emotional states of tuberculosis patients and suitable message content

We tailored and arranged 100 messages for daily delivery according to the emotional state of the patients. These messages were pretested among TB patients. Revisions were made. For example, the word “regular” was rewritten with capital letters as “REGULAR,” and the word “6-month treatment,” which may create a burden to the patient due to the long treatment duration, was paraphrased. After revision, 56 and one closing messages were ready to be sent daily to TB patients during the intensive phase [Table 2].[¹²]

Table 2: Message topics for tuberculosis patient during their intensive phase

Delivering short message service reminders

For the intervention group, a system was built by installing an SMS gateway application program in a PC, recording the mobile phone number of all TB patients, recording all messages, and scheduling messages to be delivered daily [Appendix]. Then, automatically reminder message was delivered daily to all TB patients’ mobile phone.

Effectiveness of short message service reminders on improving treatment adherence

A comparison done between the intervention and control group in terms of predictors: demographic characteristics, health-care accessibility, and whether the patients experienced side effects [Table 3].[¹⁰] Logistic regression shows that the only significant difference between groups was in the proportion of patients adhering to treatment (odds ratio [OR] = 7.88 ± 2.94–21.07). No significant differences were found in the other predictors. A greater likelihood of adhering to treatment among TB patients was found in the intervention group (OR 10.73 ± 3.64–31.66) compared to the control group after controlling for other predictors [Table 4].[¹⁰]

Table 3: Comparisons of characteristics: demographics, health-care accessibility, and side effects among the intervention and control groups

Table 4: Crude and adjusted odds ratios of predictors for treatment adherence

DISCUSSION

This study showed that TB patients had different emotional states requiring different type of messages. Desperation, fear, and grievance at the beginning of the treatment require motivational and informative messages about the treatment course and side effects. High motivation during the intensive phase treatment requires continuous information about taking medication regularly and how to prevent transmission. Finally, low motivation at the end of the intensive phase emphasizes the importance of taking drugs regularly and the long period of treatment. This finding is in line with the transtheoretical model by Prochaska who suggests to tailor a suitable intervention to certain psychological conditions of the client such as precontemplation, contemplation, preparation, action, and maintenance.[¹³]

Mittal and Gupta[¹⁴] emphasized that education should be given at the beginning of the treatment, describing the overall treatment, possible side effects, and other barriers that might hinder adherence during the long treatment period. This should be done periodically. This study also found that encouraging (positive) messages were more preferable for creating behavior adoption than discouraging (negative) messages, which create fear and might intensify the negative stigma of a TB patient. This finding is in line with the persuasive health message theory which underlines the importance of illustrating the possible health risks and treatment efficacy.[¹⁵] During the end of the intensive period, patients recognized that they felt better and usually considered the treatment to be sufficient. This misinterpretation was also identified by Cramm et al., especially during the continuation phase.[¹⁵] Raguenaud et al.[¹⁶] demonstrated that communication with TB patients on a daily basis by health-care workers yielded high-TB treatment compliance. Mkopi et al.[¹⁷] emphasized the importance of health education to improve awareness to cure the disease and foster adherence over the long period of treatment. Farooqi et al. found that SMS reminders for TB patients were feasible and considered as care and support for TB patients.[⁵] Similar results were found in SMS reminders for HIV/AIDS patients in Mozambique, an illness with stronger stigma.[¹⁸]

Stigma toward TB patients remains present, as reflected by the statement to avoid the used of “TB patient” in the SMS. Stigma creates an additional psychological burden, especially when the patient is first diagnosed. Fear of becoming the subject of gossip is another reason for TB stigma, and only 3.7% of the population in South Africa disregard that fear.[¹⁵] Health education is critical in convincing TB patients that TB can be cured.

This study showed that the age of the patient is an important factor influencing the ability to receive the reminder.[¹¹] This is in accordance with a study by Lei et al. which found age to be a factor in sending SMS reminders.[¹⁹] Age is related to the ability to operate a mobile phone, which in turn is related to the feasibility of sending SMS reminders.[²⁰]

Due to the disruption caused by unwanted promotions or fraud through mobile phones, it is important to show the credibility of the sender and gain permission to send the SMS. Previous studies have found that 65%–91% of cell phone users decline to receive SMS reminders.[¹⁹²⁰²¹] Approval to participate from the recipient is important, as Albino et al. found that a positive perception toward SMS reminder acceptance influences treatment adherence among TB patients.[²²]

This study showed that SMS reminders significantly improved treatment adherence among TB patients during the intensive phase. Although reminders are acceptable for most TB patients, direct communication is preferred.[²⁰] SMS reminders delivered through mobile phone is not intended to be a stand-alone intervention, but as an addition to the standard DOTS reminders given face to face.

This study is limited due to the few TB patient informants attending the FGDs, which might be related to the TB stigma. To overcome these challenges, further in-depth interviews were conducted. Another limitation is the measurement of treatment adherence based on the length of treatment due to limited resources. Electronic measurement devices or standardized measurement questionnaire such as Morisky Medication Adherence Scale-8[²³] is recommended for the future study. We tried to identify any harm and unintended consequences of being uncomfortable with receiving SMS every day, but this was not found in this study.

CONCLUSIONS

SMS reminders on mobile phones are feasible to improve treatment adherence among TB patients, however, for use on older patients need help from a younger relative. The messages for the reminders should be short, easy to understand, informal, and developed according to fluctuations in emotional states of TB patients, starting from disappointment and desperation, grievance, high desire, and low desire to complete treatment. Although SMS reminders are not popular nowadays, the emotional states and corresponding messages found in this study can be applied when developing reminder messages through other platform in a smartphone.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

This study would not have been possible without financial support from the the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia grant number UPPM/13/M/05/04/04.14 in 2014.