April, 2017 - SUPPORT Summary of a systematic review | print this article |

Does mobile phone messaging improve self- management of long-term illnesses?

Diseases such as diabetes, hypertension and asthma are long-term illnesses. Mobile phone messaging can be used as a tool to help people control and self-manage these conditions.

Key messages

  • Mobile phone messaging support probably leads to little or no difference in people’s knowledge about their diabetes but may improve people’s self-efficacy in relation to their diabetes.
  • Mobile phone messaging support probably leads to little or no difference in adherence to diabetes medication in young people with diabetes or care plan adherence in people with asthma but probably improves medication adherence in people with hypertension.
  • Mobile phone messaging support for people living with diabetes probably leads to little or no difference in glycaemic control and may lead to little or no difference in diabetes complications.
  • Mobile phone messaging support for people living with asthma or hypertension may lead to little or no difference in control of these conditions.
  • It is uncertain whether mobile phone messaging support changes health service utilisation by people living with diabetes and asthma.
  • All of the studies were conducted in high-income countries and the applicability of the findings to low income countries is likely to vary, depending on the availability of the technological infrastructure required and factors such as levels of patient literacy and the acceptability of this intervention among different groups.

 

Background

The effective self-management of long-term diseases can play an important role in preventing and controlling complications associated with these diseases. Mobile phone messaging tools such as Short Message Service (SMS) (also known as text messages) and Multimedia Message Service (MMS) may help people to self-manage their conditions. This can be done by sending medication reminders to people with long-term illnesses, sending supportive care messages, or helping people communicate with healthcare providers and receive feedback from them. The extent to which mobile phone messaging applications can improve self management, increase the utilisation of services, and consequently enhance people’s health outcomes, is unknown.



About the systematic review underlying this summary

Review objectives: To assess the effects of mobile phone messaging applications designed to facilitate self-management of long-term illnesses, on health outcomes and the capacity of patients to self-manage their conditions.
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non-randomised trials, controlled before-after studies, or interrupted time series studies with at least three time points before and after the intervention.

Four randomised trials were included. Text messaging was used as an intervention in all the included studies. Multimedia Message Services (MMS) were not used in any of the included studies.

 

Two studies of interventions for diabetes and hypertension respectively used one-way communication between an automated system and the study participants. One study about diabetes used two-way communication between patients and an automated system, and one study about asthma used two-way communication between patients and their physicians.


Participants Patients with long-term illnesses
182 participants: people with diabetes aged between 8 and 25 years (2 studies, 99 people); people over 18 years with hypertension (1 study, 67 people); people of any age with asthma (1 study, 16 people)
Settings Any Outpatient services in the USA, the UK, Spain and Croatia
Outcomes

Primary outcomes: Health outcomes as a result of the intervention, including physiological measures (e.g. blood pressure) and capacity to self-manage long-term conditions (e.g. lifestyle modification).

 

Secondary outcomes: User (patient, carer or healthcare provider) evaluation of the intervention (e.g. satisfaction); health service utilisation following the intervention; costs (direct and indirect) of the intervention; user perceptions of safety; potential harms or adverse effects of the intervention, such as misreading or misinterpretation of data.


Primary outcomes: Glycaemic Control (Hb1Ac) in people with diabetes (2 trials); diabetic ketoacidosis (DKA) (1 trial), severe hypoglycaemia (1 trial), systolic and diastolic blood pressure(1 trial), forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) in people with asthma (1 trial). The following outcomes were also evaluated across the 4 trials: self-efficacy for diabetes, diabetes social support interview, diabetes knowledge scale, hypertension treatment adherence at six months, diabetes treatment adherence, adherence of people with asthma to peak expiratory flow measurement.

 

Secondary outcomes: participant evaluation of the intervention and health services utilisation were evaluated in one trial.


Date of most recent search: June 2009
Limitations: This is a well-conducted systematic review with only minor limitations.
de Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone messaging for facilitating self-management of long-term illnesses. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD007459.

Summary of findings

The review identified four studies that included 182 participants. None of the studies was conducted in a low-income country.

1) Effects of mobile phone messaging support on capacity to self-manage diabetes, hypertension, and asthma

Four studies examined the effects of mobile phone messaging support on people’s capacity to self-manage their diabetes, hypertension or asthma. This was compared with usual care or usual care with self-management support by email.

 

  • Mobile phone messaging support p robably leads to little or no difference in people’s knowledge about their diabetes . The certainty of this evidence is moderate. 
  • Mobile phone messaging support may improve people’s self-efficacy in relation to their diabetes. The certainty of this evidence is low. 
  • Mobile phone messaging support p robably leads to little or no difference in adherence to diabetes medication in young people with diabetes or care plan adherence in people with asthma but probably improves medication adherence in people with hypertension. The certainty of this evidence is moderate. 
  • Mobile phone messaging support m ay result in a higher number of self-testing results sent back by people with diabetes. The certainty of this evidence is low.

 

 

 

Effects of mobile phone messaging support on capacity to self-manage long-term illnesses

People            People with long-term illnesses including diabetes, hypertension, and asthma

Settings          Outpatient services in the USA, the UK, Spain and Croatia

Intervention   Mobile phone messaging support for self-management of diabetes, hypertension and asthma

Comparison    Usual care, or usual care with self-management support delivered by email

Outcomes

Mean Difference

(MD) (95% CI) / Impact

Number of participants (studies)

Certainty

of the evidence

(GRADE)

Self-efficacy for diabetes

MD 6.10 (0.45 to 11.75)

59

(1 study)

Low

Knowledge of diabetes

MD -0.5 (-1.60 to 0.60)

59

(1 study)

Moderate

Adherence to medication or care plans

Probably leads to little or no difference in adherence to diabetes medication in young people with diabetes or care plan adherence in people with asthma but probably improves medication adherence in people with hypertension

142

(3 studies)

Moderate

Number of blood glucose results sent back

May result in a higher number of results sent back

40

(1 study)

Low

Mean Difference (MD): Difference of means between the intervention and control group for the continuous variable. In the meta-analysis, the difference in means from each study was weighted by the precision of its estimate of effect and a pooled mean reported.
CI: Confidence interval GRADE: GRADE Working Group grades of evidence (see above and last page)

2) Effects of mobile phone messaging support on health outcomes

Three studies examined the effects of mobile phone messaging support for self-management, compared with usual care or usual care with self-management support by email, on health outcomes for diabetes, hypertension and asthma.

 

  • Mobile phone messaging support for people living with diabetes probably leads to little or no difference in glycaemic control. The certainty of this evidence is moderate.
  • Mobile phone messaging support for people living with diabetes may lead to little or no difference in diabetes complications. The certainty of this evidence is moderate.
  • Mobile phone messaging support for people living with hypertension may lead to little or no difference in blood pressure control, including diastolic and systolic blood pressure and the number of people with blood pressure not under control. The certainty of this evidence is low.
  • Mobile phone messaging support for people living with asthma may lead to little or no difference in asthma control. The certainty of this evidence is low.

Effects of mobile phone messaging support on health outcomes

People              Patients with long-term illnesses including diabetes, hypertension, and asthma

Settings            Outpatient services in the USA, the UK, Spain, and Croatia

Intervention     Mobile phone messaging support for self-support of diabetes, hypertension and asthma

Comparison       Usual care, or usual care with self-management support delivered by email

Outcomes

With usual care

With mobile phone messaging

Relative

effect

(95% CI)

Number of participants

(studies)

Certainty

of the evidence

(GRADE)

Absolute effect* (95% CI) / Impact

Diabetes complications

– diabetic ketoacidosis

111 per 1000

62 per 1000

(11 to 347)

RR 0.56

(0.10 to 3.12)

59

(1)

Low

Diabetes complications

- severe hypoglycaemia

148 per 1000

31 per 1000

(4 to 264)

RR 0.21

(0.03 to 1.78)

59

(1)

Low

Diabetes – glycaemic control

Probably leads to little or no difference in glycaemic control

-

88

(2)


Moderate

Hypertension control

May lead to little or no difference in blood pressure control, including diastolic and systolic blood pressure and the number of people with blood pressure not under control

-

67

(1)

Low

Asthma control

May lead to little or no difference in asthma control, based on a range of measures

-

8

(1)

Low

CI: Confidence interval RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

* The risk WITHOUT the intervention is based on the median control group risk across studies. The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall relative effect (and its 95% confidence interval).


3) Effects of mobile phone messaging support on the utilisation of diabetes and asthma services

Two studies examined the effects of mobile phone messaging support for self-management, compared with usual care or usual care with self-management support by email, on utilisation of health services for diabetes, hypertension and asthma.

 

  • It is uncertain whether mobile phone messaging support changes health service utilisation by people living with diabetes and asthma. The certainty of this evidence is very low.

Mobile phone messaging and utilisation of services for diabetes, hypertension, and asthma

People          Patients with long-term illnesses including diabetes, hypertension, and asthma

Settings         Patients with long-term illnesses including diabetes, hypertension, and asthma

Intervention   Outpatient services in the USA, the UK, Spain, and Croatia

Comparison    Mobile phone messaging support for self-management of diabetes, hypertension and asthma

                       Usual care, or usual care with self-management support delivered by email

Outcomes

Impact

Number of participants

(studies)

Certainty

of the evidence (GRADE)

Service utilisation by people with diabetes

It is uncertain whether mobile phone messaging support changes the number of clinic visits (MD 0.30 (CI: -0.22 to 0.82)) or calls to an emergency hotline (RR 0.32 (CI: 0.09 to 1.08)) as the certainty of the evidence is very low

75

(2)


Very low

Service utilisation by people with asthma

It is uncertain whether mobile phone messaging support changes health service utilisation (outpatient visits, hospitalisations) as the certainty of the evidence is very low

16

(1)


Very low

Mean Difference (MD): Difference of the means between the intervention and control group for the continuous variable. In the meta-analysis, the difference in means from each study was weighted by the precision of its estimate of effect and the pooled mean reported.
RR: Risk Ratio CI : Confidence Interval GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
All of the included studies were conducted in high income countries.

The applicability of the findings to low-income countries is likely to vary, depending on the availability of the technological infrastructure required (including, for example, computerised patient record systems for providers). Consideration will also need to be given to additional factors such as the level of patient literacy and the acceptability of this intervention among different groups.

Where resources are limited, phone messaging services are poor, or people with long-term illnesses do not have adequate access to health services, support via mobile phone messaging is unlikely to be a useful option.


EQUITY
The included studies did not provide data regarding differential effects of the interventions across genders or across various levels of advantage

The intervention relies on technology that may be less affordable for or less accessible to disadvantaged groups, such as people with low levels of literacy or low incomes. The use of this technology may therefore exacerbate health inequalities if these aspects are not taken into account, for example by developing messaging that is accessible to people with low levels of literacy.

The use of mobile phone messaging may be less acceptable to groups, such as older people, that are less familiar with this technology. Such groups may be disadvantaged if this intervention is widely relied on to support people with long-term illnesses.


ECONOMIC CONSIDERATIONS
The review reports few data on the costs of the intervention or the resources used to implement it.

Although mobile phone messages are generally considered low cost interventions, their implementation at scale may require the provision of expensive infrastructure including linking messaging and computerised patient record systems and creating electronic back-up systems.

Where systems are implemented in which people can, or are expected to, respond to messages from the health services, this may result in additional costs for service users.


MONITORING & EVALUATION

The certainty of the evidence for many outcomes was low or very low, including for impacts on health service utilisation and health outcomes

Few data are available on the costs of these interventions.


Larger and more rigorous studies, including studies in low-income countries, are needed. These studies should evaluate the full range of outcomes, including impacts on people’s capacity to self-manage their long-term condition, their use of health services and the extent to which their health condition is controlled. These studies should explore the extent to which effects are sustained over time and whether there are differential impacts across different groups, such as poorer people or the elderly.

The acceptability, feasibility and costs of these interventions for both people living with long-term conditions and the health services should also be evaluated.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods


 

Additional information

Related literature

Berrouiguet S, Baca-García E, Brandt S, Walter M, Courtet P. Fundamentals for Future Mobile-Health (mHealth): A Systematic Review of Mobile Phone and Web-Based Text Messaging in Mental Health. J Med Internet Res. 2016;18(6):e135

 

Car J, Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database of Systematic Reviews. 2013; 12:CD007458.

 

Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone messaging for communicating results of medical investigations. Cochrane Database of Systematic Reviews. 2012; 6: CD007456.

 

Thakkar J, Kurup R, Laba TL, Santo K, Thiagalingam A, Rodgers A, Woodward M, Redfern J, Chow CK. Mobile Telephone Text Messaging for Medication Adherence in Chronic Disease: A Meta-analysis. JAMA Intern Med. 2016;176(3):340-9

 

Vodopivec-Jamsek V, de Jongh T, Gurol-Urganci I, Atun R,Car J. Mobile phone messaging for preventive health  care.Cochrane Database of Systematic Reviews. 2012;12:CD007457.

 

 

This summary was prepared by

Hossein Joudaki, Tehran University of Medical Sciences, Tehran, Iran.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Thyra de Jongh, Ola Kdouh, Simon Goudie and Simon Lewin.

 

This review should be cited as

de Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone  messaging for facilitating

self-management of long-term illnesses. Cochrane  Database of Systematic Reviews 2012, Issue 12. Art.
No.:CD007459.

 

The summary should be cited as

Joudaki H. Does mobile phone messaging improve self-management of long-term illnesses? A SUPPORT Summary of systematic review. April 2017.www.supportsummaries.org

 

Keywords

Evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, text messaging, SMS, mobile phone messaging, long-term illnesses. 



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