SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
November, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
Failure to attend healthcare appointments impacts on patient health and health system costs. Sending patients appointment reminders using mobile phone text messages (Short Message Service (SMS) and Multimedia Message Service (MMS)) could improve attendance compared to no reminders, or other types of reminders, such as postal or phone call reminders.
The broad penetration of mobile phones in several low-income countries makes this intervention particularly promising.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Different communication methods can be used to remind patients about healthcare appointments, including face-to-face reminders, postal messages, calls to landlines, calls to mobile phones, messages via web-based electronic health records, emails and mobile phone text messages (SMS/MMS).
Mobile phones have penetrated rapidly in many low-income countries, and this growth is expected to continue. The use of mobile phone reminders to increase healthcare appointment attendance rates and for a range of other healthcare purposes, is therefore of particular interest.
| Review objectives:To assess the effects of mobile phone messaging reminders on attendance rates at healthcare appointments | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials evaluating the use of reminders for healthcare appointments sent from a healthcare provider to a patient using SMS or MMS compared with no intervention, or other modes of communication. |
Eight randomised trials involving a total of 6,615 people evaluated a text messaging intervention compared to usual practice (in 7 studies, the usual practice was no reminders). The messages were sent 24 to 72 hours before the appointment, and included the participant's name and appointment details. Two studies included instructions (i.e. to call a specified number if the patient was unable to attend), and two emphasised the importance of attending the appointment. Three studies used a web-based platform to send the messages, one used a modem linked to electronic medical records, and three did not describe the platform used. In one study, messages were sent either manually or through an automated delivery system |
| Participants | Any type of participants regardless of age, gender and ethnicity; patients with any type and stage of disease. |
Patients that required an appointment in the clinic or practice (3 studies), middle- and high- income employees or owners of local companies (1 study). |
| Settings | Any setting |
Australia (1), China (2), Kenya (1), Malaysia (2) and the United Kingdom (UK) (2). The settings were: one hospital health promotion centre; one inner-city general practice; six ENT clinics (in one hospital); nine primary care clinics; and 12 governmental health clinics. |
| Outcomes | The primary outcome was the rate of attendance at healthcare appointments. Secondary outcomes included health outcomes (e.g. blood pressure, clinical assessments), user evaluation of the intervention, user perceptions of safety, costs, and potential harms. |
All studies reported attendance rates at healthcare appointments. The costs of the interventions were reported in two studies. None of the included studies reported health outcomes, user perceptions of safety, or potential harms of the intervention. Only one study measured some form of user evaluation (proportion of participants contacted who had a mobile phone and who were willing to be contacted by SMS). |
| Date of most recent search: August 2012 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R, Car J. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD007458. DOI: 10.1002/14651858.CD007458.pub3
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
ight studies evaluated mobile phone text messaging compared to no reminder, or other types of reminders. The messages were either sent manually, through an automated delivery system, a web-based platform, or via a modem linked to electronic patient medical records, 24 to 72 hours before an appointment. The studies were conducted in four upper-middle or high-income countries (Australia, China, Malaysia and the United Kingdom (UK)), and 1 low‑income country (Kenya), and in different settings (primary, hospital, community, and outpatient). All studies reported attendance rates, but no studies reported health outcomes.
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Mobile phone message reminders compared to no reminders |
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People |
Patients with healthcare appointments |
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Settings |
All settings (primary, hospital, community, outpatient) |
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Intervention |
Mobile phone text message reminders |
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Comparison |
No reminders |
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Outcomes |
Absolute effect* |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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Without |
With |
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Attendance at healthcare |
678 per 1,000 |
773 per 1,000 (698 to 854) |
RR 1.14 (1.03 to 1.26) |
Moderate |
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Difference: (Margin of error: 20 to 176 more patients) |
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Other |
None of the included studies reported on health outcomes, user evaluation of the intervention, user perceptions of safety, costs, potential harms or adverse events of the intervention. |
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- |
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Margin of error = Confidence Interval (95% CI) GRADE: GRADE Working Group grades of evidence (see above and last page) * The risk WITHOUT the intervention is based on the risk of attendance in the control group of the studies identified in the review. 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). |
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Mobile phone message reminders compared to phone call reminders |
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People |
Patients with healthcare appointments |
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Settings |
All settings (primary, hospital, community, outpatient) |
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Intervention |
Mobile phone message reminders |
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Comparison |
Phone call reminders |
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Outcomes |
Absolute effect* |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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With phone call reminder |
With |
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Attendance at healthcare |
803 per 1,000 |
795 per 1,000 (763 to 819) |
RR 0.99 (0.95 to 1.02) |
Moderate |
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Difference: (Margin of error: 40 fewer to 16 more patients) |
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Other |
None of the included studies reported on health outcomes, user evaluation of the intervention, user perceptions of safety, costs, potential harms or adverse events of the intervention. |
- |
- |
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Margin of error = Confidence Interval (95% CI) * The risk WITHOUT the intervention is based on the risk of attendance in the control group of the studies identified in the review. 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). |
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Mobile phone message plus postal reminders compared with postal reminders alone |
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People |
Patients with healthcare appointments |
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Settings |
All settings (primary, hospital, community, outpatient) |
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Intervention |
Mobile phone message plus postal reminders |
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Comparison |
Postal reminders |
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Outcomes |
Absolute effect* |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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With postal reminder |
With mobile plus postal reminder |
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Attendance at healthcare |
858 Per 1,000 |
944 per 1,000 (875 to 1,000) |
RR 1.1 (1.02 to 1.19) |
Low |
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Difference: (Margin of error: 17 to 163 more) |
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Other |
The included study did not report on health outcomes, user evaluation of the intervention, user perceptions of safety, costs, potential harms or adverse events of the intervention. |
- |
- |
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Margin of error = Confidence Interval (95% CI) RR: Risk Ratio GRADE: GRADE Working Group grades of evidence (see above and last page) * The risk WITHOUT the intervention is based on the risk of attendance in the control group of the studies identified in the review. 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). |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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The review identified 8 studies with a total of 6,615 participants that evaluated the use of mobile phone text messages reminders to increase healthcare appointments attendance.
è Seven studies were conducted in upper middle- or high-income countries, and 1 in a low-income country è All of the reminders were simple. They did not indicate whether the user had read it, the message did not facilitate the cancellation of the appointment, or any other form of user-sender interaction. |
There was moderate uncertainty about the effects of all of the mobile phone reminders tested in these studies. w Simple reminders are designed to address a single factor (i.e. patients forgetting an appointment) that explains non-attendance. However, the reasons for non-attendance may vary in different settings. w Other factors besides the scale of mobile phone penetration must be considered when evaluating the applicability of these findings to specific low- income countries. These include phone number portability and which devices are available. w In low-income countries, mobile phone penetration is increasing rapidly. As more sophisticated devices become available, there is greater opportunity for more meaningful interaction with users. |
| EQUITY | |
| The included studies did not directly address equity issues. |
This intervention may increase health inequities, by not supporting people without cell phones, those who live in remote areas that do not have signal coverage, those with low literacy levels, or people reluctant to use these forms of technology w However, where mobile phone reminders are more available or acceptable than other forms of reminders, using them could help to decrease health inequities. |
| ECONOMIC CONSIDERATIONS | |
| Two studies reported that the costs per text message per attendance were lower than the costs per phone call reminder. |
Considering there is uncertainty for most of the critical outcomes for decision-making, the cost-benefit of this intervention is difficult to anticipate. Mobile phone reminders may decrease the costs of a reminder service compared to other methods. |
| MONITORING & EVALUATION | |
| The intervention is potentially ineffective |
Additional randomised trials are needed to evaluate if more intensive reminders, or messages that allow different types of interactions are effective in specific groups. |
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*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 please see: www.supportsummaries.org/methods |
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Guy R, Hocking J, Wand H, Stott S, Ali H, Kaldor J. How effective are short message service reminders at increasing clinic attendance? A meta-analysis and systematic review. Health Serv Res. 2012 Apr;47(2):614-32. doi: 10.1111/j.1475-6773.2011.01342.x
James J. Penetration and Growth Rates of Mobile Phones in Developing Countries: An Analytical Classification. Soc Indic Res. 2010 Oct;99(1):135-145. doi: 10.1007/s11205-009-9572-0
van Velthoven MH, Brusamento S, Majeed A, Car J. Scope and effectiveness of mobile phone messaging for HIV/AIDS care: a systematic review. Psychol Health Med. 2013;18(2):182-202. doi: 10.1080/13548506.2012.701310. Epub 2012 Jul 12.
Rada G. Evidence-Based Health Care Program, Pontificia Universidad Católica, Chile.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Willem Odendaal and Josip Car.
Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R, Car J. Mobile phone messaging reminders for
attendance at healthcare appointments. Cochrane Database of Systematic Reviews 2013, Issue 12. Art.
No.: CD007458. DOI: 10.1002/14651858.CD007458.pub3
Rada G. Does the use of mobile phone messaging reminders increase attendance at healthcare appointments? A SUPPORT Summary of a systematic review. November 2016. 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
