SMS Interventions: Fundamentals for Future Mobile-Health

Automated text messaging offers an innovative, cost-effective way to improve self-care and wellbeing. It has been discovered that text-only interventions are an excellent way to encourage health self-management (Willcox et al, 2019; Whittaker et al., 2019). In this case, it helps patients feel connected with their healthcare providers (Berrouiguet et al., 2016). It increases patients’ health-related awareness and knowledge for a wide variety of issues (Sahin et al., 2018). Because text messages allow for real-time information exchange, are accessible even in rural locales, and can be sent to many recipients simultaneously, they are suitable tools for public health outreach (Schwebel & Larimer, 2018).

A growing percentage of US veterans also agree that text messaging is a desirable modality for communicating health-related information (Erbes et al., 2014; McInnes et al., 2014; Whealin et al., 2015). Among 600 ethnoculturally diverse Veterans and National Guard members, 32.2% indicated that they would be willing to receive text messages to support their well-being (Whealin et al., 2016). Among 290 Veterans with spinal cord injuries and disorders, only 26.2% reported the use of text messaging (Hogan et al., 2016). A survey of 106 homeless veterans found that most were interested in receiving mobile phone communications from their healthcare providers, with 93% interested in receiving a mobile phone calls or text message appointment reminders (McInnes et al., 2014).

A survey of 77 veterans with a mental health diagnosis found that most reported having a cell phone (97%), but fewer than half reported having a smartphone (35/74, 47%). However, most were interested in using technology for some types of healthcare-related communications. (Miller et al., 2016). Among 149 veterans who attended another VA for mental healthcare, 79.2% used texting technology, and 10.7%used mental health-related app (Erbes et al., 2014). Last, a study of 77 older veterans (mean age = 69 years) found that, when questioned about the mode of delivery, about a quarter (28.6%) preferred receiving messages via mobile apps (28.6%), compared to about a third (35.1%) who preferred mailed paper materials (Gould et al., 2020).

Despite widespread interest and growing use, very little research has examined veterans’ preferences for text message interventions (Iversen et al., 2014). One study that examined 100 veterans who had attended an appointment at a single Veterans Health Administration facility found that veterans expressed interest in mobile support and increased physical activity. It amounted to (79.8%), get better sleep via CBT techniques (73.1%), change negative/self-critical thinking (72.3%), increase activities (72.3%), track mood/stress/anxiety/PTSD symptoms (67.2%), speak to a coach (66.4%), learn more about your mental health condition (psychoeducation (64.7%), improve your social skills (63.0%), medications reminders (61.3%), and connect with others who have similar problems (51.3%) (Lipschitz et al., 2019).

In a different study, focus groups were conducted with 28 elderly patients (mean age = 69.5, 14 of whom were veterans) using antiplatelet medication. The majority of participants viewed text message reminders favorably (Rubeis, 2022). Most participants preferred that text messages be sent from their healthcare providers and be personalized to their condition or procedure. They chose a two-way texting interface to engage with the text’s information more thoughtfully. A few individuals recognized the possibility of text message fatigue, which might lead to disregard for SMS reminders (Schwebel & Larimer, 2018). Some also reported negative reactions to messages that would praise them for adhering to their medication regimen, calling them “condescending” (Park et al., 2020).

Method

Sample

Every VA patient is eligible to use the Annie platform and at any given time, 5,000-6,000 veterans are actively subscribed to a protocol (such as CPD and Coping). Annie users reside in all 50 states and range from the 18 to over 74 years old, with the most significant percentage (29%) between 65-74 years (compared to the US veteran mean average age of 58 years, with most between 45-64 years (Planning, 2010).

The VA Annie Platform

The VA has developed a variety of eHealth interventions to enable patients to self-manage their health (Iversen et al., 2014). The Coping and CPP subscriptions are part of the VA Office of Connected Care (OCC) automated SMS tool ‘Annie.’ (Rogal et al., 2019). The platform was hosted on Amazon Web Services Veterans Affairs Enterprise Cloud–Mobile Applications Platform. The platform allows the delivery of various protocols comprising short message service text messages to practically all cell phones. The Annie application is accessible to any Veteran enrolled in the VA, although typical texting charges may have applied depending on a veteran’s texting plan (Planning, 2010).

Project Design

The open-ended survey response data collected as part of a nationwide quality improvement program was retrospectively analyzed for this study (Schmidt et al., 2020). This project evaluated data collected from veterans enrolled in one or both of two population-scale automated text interventions (Schmidt et al., 2020). The first, called Coronavirus Precautions (CPP), was a 60-day text subscription that delivered educational content on coronavirus precautions, In addition, it guided Veterans in monitoring their clinical symptoms, and, based on their responses, advised them to call their care team or a nurse triage line when appropriate (Saleem et al., 2020). Educational tips (e.g., “Annie again. If you are ill, use a separate bedroom and bathroom if possible.”) were sent Monday, Wednesday, and Friday and wellness questions (“Annie here. Are you feeling well today?”) were sent Monday, Wednesday, Friday, and Sunday. The protocol was accessible on the VA’s “Annie” text messaging app starting in March 2020. Any Veteran registered as a VA patient could self-enroll free or be assigned by a VA staff member.

The second, called “Coping during COVID” (Coping) was a 60-day subscription that sent one of four rotating message prompts on Tuesdays, Thursdays, and Saturdays (Whealin et al., 2021). In these messages, “Annie” prompts veterans to take steps daily to prevent stress and states that veterans can “type TIP YES to request a coping tip now or whenever you want one.” Veterans could receive one of 60 motivational/educational text messages designed to encourage proactive efforts to manage COVID-19-related stress, such as setting a new goal for something you’d like to accomplish in the month ahead. What aspects of your life would you like to alter? and “It is bad for your health to think about bad things all the time.” Focus on positive thoughts to counterbalance bad news (Rubeis, 2022). The subscription became available in May 2020. Any Veteran registered as a VA patient could self-enroll for free in either/both subscription(s) or be assigned by a VA staff member.

Project Approval

This project was a retrospective analysis of open-ended item survey response data captured as part of a national quality improvement initiative. Approval for the procedure was completed through the Clinical Coordination Cell, a VHA Emergency Management Coordination Cell function. In this project, further research is needed to evaluate ways of combining qualitative comments and statistical data, which could be utilized for public reporting and quality improvement.

References

Berrouiguet, S., Baca-García, E., Brandt, S., Walter, M., & Courtet, P. (2016). Fundamentals for future Mobile-Health (mHealth): A systematic review of mobile phone and web-based text messaging in Mental Health. Journal of Medical Internet Research, 18(6). Web.

Erbes, C. R., Stinson, R., Kuhn, E., Polusny, M., Urban, J., Hoffman, J., Ruzek, J. I., Stepnowsky, C., & Thorp, S. R. (2014). Access, utilization, and interest in mhealth applications among veterans receiving outpatient care for PTSD. Military Medicine, 179(11), 1218–1222. Web.

Gould, D., Lindström, H., Purssell, E., & Wigglesworth, N. (2020). Electronic hand hygiene monitoring: Accuracy, impact on the Hawthorne Effect and efficiency. Journal of Infection Prevention, 21(4), 136–143. Web.

Hogan, T. P., Hill, J. N., Locatelli, S. M., Weaver, F. M., Thomas, F. P., Nazi, K. M., Goldstein, B., & Smith, B. M. (2016). Health information seeking and technology use among veterans with spinal cord injuries and disorders. M & R: The Journal of Injury, Function, and Rehabilitation, 8, (2), 123–130. Web.

Iversen, H. H., Bjertnæs, Ø. A., & Skudal, K. E. (2014). Patient evaluation of hospital outcomes: An analysis of open-ended comments from extreme clusters in a national survey. BMJ Open, 4(5). Web.

Lipschitz, J., Miller, C. J., Hogan, T. P., Burdick, K. E., Lippin-Foster, R., Simon, S. R., & Burgess, J. (2019). Adoption of mobile apps for depression and anxiety: Cross-sectional survey study on patient interest and barriers to engagement. JMIR Mental Health, 6(1). Web.

McInnes, D. K., Sawh, L., Petrakis, B. A., Rao, S. R., Shimada, S. L., Eyrich-Garg, K. M., Gifford, A. L., Anaya, H. D., & Smelson, D. A. (2014). The potential for health-related uses of mobile phones and internet with homeless veterans: Results from a multisite survey. Telemedicine and e-Health, 20(9), 801–809. Web.

Miller, C. J., McInnes, D. K., Stolzmann, K., & Bauer, M. S. (2016). Interest in use of technology for healthcare among veterans receiving treatment for mental health. Telemedicine and e-Health, 22(10), 847–854. Web.

Park, L. G., Ng, F., K Shim, J., Elnaggar, A., & Villero, O. (2020). Perceptions and experiences of using mobile technology for medication adherence among older adults with coronary heart disease: A qualitative study. DIGITAL HEALTH, 6, 205520762092684. Web.

Planning, O. of P. and. (2010). Veterans Affairs. Go to VA.gov. Web.

Rogal, S. S., Yakovchenko, V., Waltz, T. J., Powell, B. J., Gonzalez, R., Park, A., Chartier, M., Ross, D., Morgan, T. R., Kirchner, J. A. E., Proctor, E. K., & Chinman, M. J. (2019). Longitudinal assessment of the association between implementation strategy use and the uptake of hepatitis C treatment: Year 2. Implementation Science, 14(1). Web.

Rubeis, G. (2022). IHealth: The ethics of artificial intelligence and big data in mental healthcare. Internet Interventions, 28. Web.

Sahin, C., Courtney, K. L., Naylor, P. J., & Rhodes, R. E. (2020). Patients’ evaluations of mobile text messaging studies for type 2 diabetes management: A systematic review and a meta-synthesis. Journal of Technology in Behavioral Science, 6(1), 54–73. Web.

Saleem, J. J., Read, J. M., Loehr, B. M., Frisbee, K. L., Wilck, N. R., Murphy, J. J., Vetter, B. M., & Herout, J. (2020). Veterans’ response to an automated text messaging protocol during the COVID-19 pandemic. Journal of the American Medical Informatics Association, 27(8), 1300–1305. Web.

Schwebel, F. J., & Larimer, M. E. (2018). Using text message reminders in health care services: A narrative literature review. Internet Interventions, 13, 82–104. Web.

Whealin, J. M., Jenchura, E. C., Wong, A. C., & Zulman, D. M. (2016). How veterans with post-traumatic stress disorder and comorbid health conditions utilize eHealth to manage their health care needs: A mixed-methods analysis. Journal of Medical Internet Research, 18(10). Web.

Whealin, J. M., Saleem, J. J., Vetter, B., Roth, J., & Herout, J. (2021). Development and cross-sectional evaluation of a text message protocol to support mental health well-being. Psychological Services. Web.

Whealin, J. M., Seibert-Hatalsky, L. A., Howell, J., & Tsai, J. (2015). Telehealth preferences in ethno-racially diverse Veterans and National Guard members. Journal of Rehabilitation Research and Development, 52(6), 725-738. Web.

Whittaker, R., McRobbie, H., Bullen, C., Rodgers, A., Gu, Y., & Dobson, R. (2019). Mobile phone text messaging and app-based interventions for Smoking Cessation. Cochrane Database of Systematic Reviews. Web.

Willcox, J. C., Dobson, R., & Whittaker, R. (2019). Old-fashioned technology in the era of “Bling”: Is there a future for text messaging in Health Care? Journal of Medical Internet Research, 21(12). Web.