C-CHANGE
C-Channel:
Issue 24 | OCTOBER 2010
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Text messaging and behavior change

Of Interest…

C-Hub

C-Change has launched C‑Hub, an online resource of communication materials for development. C‑Hub showcases media and materials, (posters, outdoor displays, pamphlets, flip charts, radio & TV programs/spots, training materials) along with research, testing and evaluation reports developed for health campaigns. Visit C‑Hub.

C-Channel 24 highlights the use of text messaging in public health interventions, with particular emphasis on communication for behavior change. Two articles describe literature reviews on text messaging as a behavior change tool and five look at uses of text messaging across various health care issues, e.g., sexual health, communicable diseases, healthcare gaps, etc. A final three examine gender and cultural norms in the context of family planning, gender violence, and HIV prevention. Research for these articles was conducted in Malawi, Nicaragua, South Africa, Taiwan, Uganda, and the United States. The literature reviews include studies across multiple countries.

In support of the Government of Kenya's Male Circumcision (MC) Program and working with local partners, C‑Change developed innovative communication materials, tools, and guiding documents on voluntary medical male circumcision (VMMC) that emphasize safe healing and continued HIV prevention practices. Visit C-Hub to download these MC communication materials. See the C‑Change website for further information about C‑Change work in Kenya.

 

In this issue

Using Text Messaging in Health - Literature Reviews

1. Behavior change interventions delivered by SMS

2. Text messaging for disease prevention and management

Text Messaging: Uses in Health Care and to Assist Behavior Change

3. Sexual health text messaging service for youth - United States
ONLINE FULL TEXT

4. Multi-channel mass risk communication program - Taiwan
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5. Text message-based intervention for healthcare communication - Malawi

6. Mobile phones to improve clinic attendance - Uganda

7. Text message-based intervention for weight loss - United States
ONLINE FULL TEXT

Gender and Cultural Norms

8. Overt and covert use of HIV prevention methods - South Africa

9. Determinants of the desire for children among sero-discordant couples - Uganda
ONLINE FULL TEXT

10. Ending intimate partner violence after pregnancy - Nicaragua
ONLINE FULL TEXT


Using Text Messaging in Health - Literature Reviews

1. Behavior change interventions delivered by mobile telephone short-message service

Authors: Fjeldsoe BS 1; Marshall AL 2; Miller YD 1
Institutions: 1 School of Psychology, The University of Queensland, Brisbane, Australia; 2 School of Public Health, Queensland University of Technology, Brisbane, Australia
Source: American Journal of Preventive Medicine, Feb 2009; 36(2): 165-73. [PubMed]

ABSTRACT
CONTEXT: The expansion and adoption of new methods of communication provide new opportunities for delivering health behavior change interventions. This paper reviews the current research examining mobile telephone short-message service (SMS) for delivering health behavior change interventions via text messages. This service has wide population reach, can be individually tailored, and allows instant delivery with asynchronous receipt, suggesting potential as a delivery channel for health behavior interventions.
EVIDENCE ACQUISITION: An electronic database search was conducted for studies published between January 1990 and March 2008. Studies were included in the review if they (1) evaluated an intervention delivered primarily via SMS, (2) assessed change in health behavior using pre-post assessment, and (3) were published in English in a peer-reviewed scientific journal.
EVIDENCE SYNTHESIS: Of 33 studies identified, 14 met the inclusion criteria. Four of the 14 studies reviewed targeted preventive health behaviors (e.g., smoking cessation), and ten focused on clinical care (e.g., diabetes self-management). Positive behavior change outcomes were observed in 13 of the 14 reviewed studies. Intervention initiation (researcher or participant), SMS dialogue initiation, tailoring of SMS content, and interactivity were found to be important features of SMS-delivered interventions. Methodological issues with current SMS research were also identified.
CONCLUSIONS: This review suggests that SMS-delivered interventions have positive short-term behavioral outcomes. Further research is required to evaluate interventions for preventive health behaviors that incorporate features found to affect behavioral outcomes and participant acceptance. The quality of studies in this emerging field of research needs to improve to allow the full potential of this medium to be explored.

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2. Text messaging as a tool for behavior change in disease prevention and management

Authors: Cole-Lewis H; Kershaw T
Institution: Yale University School of Epidemiology and Public Health, New Haven, CT
Source: Epidemiologic Reviews, Apr 2010; 32(1): 56-69. [Epub before print; PubMed]

ABSTRACT
Mobile phone text messaging is a potentially powerful tool for behavior change because it is widely available, inexpensive, and instant. This systematic review provides an overview of behavior change interventions for disease management and prevention delivered through text messaging. Evidence on behavior change and clinical outcomes was compiled from randomized or quasi-experimental controlled trials of text message interventions published in peer-reviewed journals by June 2009. Only those interventions using text message as the primary mode of communication were included. Study quality was assessed by using a standardized measure. Seventeen articles representing 12 studies (5 disease prevention and 7 disease management) were included. Intervention length ranged from 3 months to 12 months, none had long-term follow-up, and message frequency varied. Of 9 sufficiently powered studies, 8 found evidence to support text messaging as a tool for behavior change. Effects exist across age, minority status, and nationality. Nine countries are represented in this review, but it is problematic that only one is a developing country, given potential benefits of such a widely accessible, relatively inexpensive tool for health behavior change. Methodological issues and gaps in the literature are highlighted, and recommendations for future studies are provided.

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Text Messaging: Uses in Health Care and to Assist Behavior Change

3. SEXINFO: A sexual health text messaging service for San Francisco youth

Authors: Levine D 1; McCright J 2; Dobkin L 3; Woodruff AJ 1,3; Klausner JD 2
Institutions: 1 Internet Sexuality Information Services, Oakland, CA; 2 San Francisco Department of Public Health, San Francisco, CA; 3 School of Public Health, University of California, Berkeley, CA
Source: American Journal of Public Health, Mar 2008; 98(3): 393-5. [Epub before print; free text]

ABSTRACT
In response to rising gonorrhea rates among African American youth in San Francisco, Calif, Internet Sexuality Information Services, Inc, in partnership with the San Francisco Department of Public Health, developed SEXINFO, a sexual health text messaging service. SEXINFO is an information and referral service that can be accessed by texting "SEXINFO" to a 5-digit number from any wireless phone. A consortium of community organizations, religious groups, and health agencies assisted with identifying culturally appropriate local referral services. We conducted focus group sessions among youth aged 15 to 19 years to discuss the viability of the service. Usage of the service has been greater than expected, and an initial evaluation to assess the impact of SEXINFO on increasing access to sexual health services among at-risk adolescents has had promising results.

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4. Taipei's use of a multi-channel mass risk communication program to rapidly reverse an epidemic of highly communicable disease

Authors: Yen MY 1,2; Wu TS 3,4; Chiu AW 1,5; Wong WW 1; Wang PE 6; Chan TC 3; King CC 3
Institutions: 1 Department of Disease Control and Prevention, Taipei City Hospital, Taipei City Government, Taipei, Taiwan; 2 Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan; 3 Institute of Epidemiology, College of Public Health, National Taiwan University, Taipei, Taiwan; 4 Luke International Norway, Nøtterøy, Norway; 5 Department of Urology, National Yang-Ming University, Taipei, Taiwan; 6 Department of Health, Keelung City Government, Keelung, Taiwan
Source: PLoS One, 23 Nov 2009; 4(11): e7962. [Open Access]

ABSTRACT
BACKGROUND: In September 2007, an outbreak of acute hemorrhagic conjunctivitis (AHC) occurred in Keelung City and spread to Taipei City. In response to the epidemic, a new crisis management program was implemented and tested in Taipei.
METHODOLOGY AND PRINCIPAL FINDINGS: Having noticed that transmission surged on weekends during the Keelung epidemic, Taipei City launched a multi-channel mass risk communications program that included short message service (SMS) messages sent directly to approximately 2.2 million Taipei residents on Friday, October 12th, 2007. The public was told to keep symptomatic students from schools and was provided guidelines for preventing the spread of the disease at home. Epidemiological characteristics of Taipei's outbreak were analyzed from 461 sampled AHC cases. Median time from exposure to onset of the disease was 1 day. This was significantly shorter for cases occurring in family clusters than in class clusters (mean+/-SD: 2.6+/-3.2 vs. 4.39+/-4.82 days, p = 0.03), as well as for cases occurring in larger family clusters as opposed to smaller ones (1.2+/-1.7 days vs. 3.9+/-4.0 days, p<0.01). Taipei's program had a significant impact on patient compliance. Home confinement of symptomatic children increased from 10% to 60% (p<0.05) and helped curb the spread of AHC. Taipei experienced a rapid decrease in AHC cases between the Friday of the SMS announcement and the following Monday, October 15, (0.70% vs. 0.36%). By October 26, AHC cases reduced to 0.01%. The success of this risk communication program in Taipei (as compared to Keelung) is further reflected through rapid improvements in three epidemic indicators: (1) significantly lower crude attack rates (1.95% vs. 14.92%, p<0.001), (2) a short epidemic period of AHC (13 vs. 34 days), and (3) a quick drop in risk level (1 approximately 2 weeks) in Taipei districts that border Keelung (the original domestic epicenter).
CONCLUSIONS AND SIGNIFICANCE: The timely launch of this systematic, communication-based intervention proved effective at preventing a dangerous spike in AHC and was able to bring this high-risk disease under control. We recommend that public health officials incorporate similar methods into existing guidelines for preventing pandemic influenza and other emerging infectious diseases.

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5. A text message-based intervention to bridge the healthcare communication gap in the rural developing world

Authors: Mahmud N 1,2; Rodriguez J 2,3; Nesbit J 2
Institutions: 1 Stanford University School of Medicine, Stanford, CA; 2 FrontlineSMS: Medic, Palo Alto, CA; 3 Stanford University School of Medicine Office of Global Health, Stanford, CA
Source: Technology and Health Care, Jan 2010; 18(2): 137-44. [PubMed]

ABSTRACT
Healthcare delivery in the rural developing world is limited by a severe shortage of health workers as well as profound communicative and geographic barriers. Understaffed hospitals are forced to provide care for patients that reside at a great distance from the institutions themselves, sometimes more than 100 miles away. Community health workers (CHWs), volunteers from local villages, have been integral in bridging this patient-physician gap, but still lose enormous of amounts of time in transit between hospital and village. We report the results of a retrospective mobile health (mHealth) pilot at St. Gabriel's Hospital in Malawi designed to eliminate many of these trips in favor of communication via text messages. A group of 75 CHWs were supplied with cell phones and trained to utilize the network for a variety of usage cases, including patient adherence reporting, appointment reminders, and physician queries. At the end of the pilot, the hospital saved approximately 2,048 hours of worker time, $2,750 on net ($3,000 in fuel savings minus $250 in operational costs), and doubled the capacity of the tuberculosis treatment program (up to 200 patients). We conclude that mHealth interventions can provide cost-effective solutions to communication barriers in the setting of rural hospitals in the developing world.

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6. Using mobile phones to improve clinic attendance amongst an antiretroviral treatment cohort in rural Uganda: A cross-sectional and prospective study

Authors: Kunutsor S 1,4; Walley J 1; Katabira E 2; Muchuro S 2; Balidawa H 3; Namagala E 3; Ikoona E 3
Institutions: 1 Nuffield Centre for International Health and Development, Institute of Health Sciences, Leeds University, Leeds, UK; 2 Communicable Disease Research Programme Consortium, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; 3 Uganda National Aids Control Programme, Kampala, Uganda; 4 Malaria Consortium, COMDIS MUK, Kampala, Uganda
Source: AIDS and Behavior, 11 Aug 2010; doi 10.1007/s10461-010-9780-2. [Epub ahead of print]

ABSTRACT
We aimed to assess the patterns and dynamics of mobile phone usage amongst an antiretroviral treatment (ART) cohort in rural Uganda and ascertain its feasibility for improving clinic attendance. A cross-sectional study of clients on ART exploring their access to mobile phones and patterns of use was employed. Clinic attendances for antiretroviral drug refills were then monitored prospectively over 28 weeks in 176 patients identified in the cross-sectional survey who had access to mobile phones and had given consent to be contacted. Patients were contacted via voice calls or text messages to remind them about their missed clinic appointments. Of the 276 patients surveyed, 177 (64%) had access to mobile phones with all but one were willing to be contacted for missed visits reminders. Of the 560 total scheduled clinic appointments, 62 (11%) were missed visits. In 79% of episodes in which visits were missed, patients presented for treatment within a mean duration of 2.2 days (SD = 1.2 days) after mobile phone recall. Access to mobile phones was high in this setting. Privacy and confidentiality issues were not considered deterrents. Mobile phones have a potential for use in resource-constrained settings to substantially improve the clinical management of HIV/AIDS.

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7. A text message-based intervention for weight loss: randomized controlled trial

Authors: Patrick K 1; Raab F 1; Adams MA 1,2; Dillon L 1; Zabinski M; Rock CL 1; Griswold WG 3; Norman GJ 1
Institutions: 1 Department of Family and Preventive Medicine and the California Institute of Telecommunications and Information Technology (Calit2), University of California, San Diego, La Jolla, CA; 2 Graduate School of Public Health, San Diego State University, San Diego, CA; 3 Department of Computer Sciences and Engineering, University of California, San Diego, La Jolla, CA
Source: Journal of Medical Internet Research, 13 Jan 2009; 11(1): e1. [free text]

ABSTRACT
BACKGROUND: To our knowledge, no studies have evaluated whether weight loss can be promoted in overweight adults through the use of an intervention that is largely based on daily SMS (Short Message Service: text) and MMS (Multimedia Message Service: small picture) messages transmitted via mobile phones.
OBJECTIVE: This paper describes the development and evaluation of a text message-based intervention designed to help individuals lose or maintain weight over 4 months.
METHODS: The study was a randomized controlled trial, with participants being exposed to one of the following two conditions, lasting 16 weeks: (1) receipt of monthly printed materials about weight control; (2) an intervention that included personalized SMS and MMS messages sent two to five times daily, printed materials, and brief monthly phone calls from a health counselor. The primary outcome was weight at the end of the intervention. A mixed-model repeated-measures analysis compared the effect of the intervention group to the comparison group on weight status over the 4-month intervention period. Analysis of covariance (ANCOVA) models examined weight change between baseline and 4 months after adjusting for baseline weight, sex, and age.
RESULTS: A total of 75 overweight men and women were randomized into one of the two groups, and 65 signed the consent form, completed the baseline questionnaire, and were included in the analysis. At the end of 4 months, the intervention group (n = 33) lost more weight than the comparison group (-1.97 kg difference, 95% CI -0.34 to -3.60 kg, P = .02) after adjusting for sex and age. Intervention participants' adjusted average weight loss was 2.88 kg (3.16%). At the end of the study, 22 of 24 (92%) intervention participants stated that they would recommend the intervention for weight control to friends and family.
CONCLUSIONS: Text messages might prove to be a productive channel of communication to promote behaviors that support weight loss in overweight adults.

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Gender and Cultural Norms

8. Managing men: Women's dilemmas about overt and covert use of barrier methods for HIV prevention

Authors: MacPhail C a; Terris-Prestholt F b; Kumaranayake L b; Ngoako P c; Watts C b; Rees H a
Institutions: a Reproductive Health and HIV Research Unit, University of the Witwatersrand, South Africa; b Health Policy Unit, London School of Hygiene and Tropical Medicine, UK; c Progressus CC Research and Development Consultancy, Sunward Park, South Africa
Source: Culture, Health & Sexuality, Jun 2009; 11(5): 485-97. [PubMed]

ABSTRACT
Women in sub-Saharan Africa are at high risk of HIV infection and may struggle to negotiate condom use. This has led to a focus on the development of female-controlled barrier methods such as the female condom, microbicides and the diaphragm. One of the advantages of such products is their contribution to female empowerment through attributes that make covert use possible. We used focus groups to discuss covert use of barrier methods with a sample of South African women aged 18-50 years from Eastern Johannesburg. Women's attitudes towards covert use of HIV prevention methods were influenced by the overarching themes of male dislike of HIV and pregnancy prevention methods, the perceived untrustworthiness of men and social interpretations of female faithfulness. Women's discussions ranged widely from overt to covert use of barrier methods for HIV prevention and were influenced by partner characteristics and previous experience with contraception and HIV prevention. The discussions indicate that challenging gender norms for HIV prevention can be achieved in quite subtle ways, in a manner that suits individual women's relationships and previous experiences with negotiation of either HIV or pregnancy prevention.

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9. My partner wants a child: A cross-sectional study of the determinants of the desire for children among mutually disclosed sero-discordant couples receiving care in Uganda

Authors: Beyeza-Kashesya J 1,2; Ekstrom AM 2; Kaharuza F 1; Mirembe F 1; Neema S 3; Kulane A 2
Institutions: 1 Department of Obstetrics/Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda; 2 Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden; 3 Makerere University Institute of Social Research, Kampala, Uganda
Source: BMC Public Health, 13 May 2010; 10:247. [Open Access]

ABSTRACT
BACKGROUND: The percentages of couples in HIV sero-discordant relationships range from 5 to 31% in the various countries of Africa. Given the importance of procreation and the lack of assisted reproduction to avoid partner transmission, members of these couples are faced with a serious dilemma even after the challenge of disclosing their HIV status to their spouses. Identifying the determinants of the decision to have children among sero-discordant couples will help in setting reproductive intervention priorities in resource-poor countries.
METHODS: We conducted a survey among 114 mutually disclosed sero-discordant couples (228 individuals) receiving HIV care at four centres in Greater Kampala, between June and December 2007. The data we collected was classified according to whether the man or the woman was HIV-positive. We carried out multivariate logistic regression modelling to determine factors (age, gender, and the influences of relatives and of health workers, ART knowledge, and disclosure) that are independently associated with a desire for children.
RESULTS: The majority, 59%, of the participants, desired to have children. The belief that their partner wanted children was a major determinant of the desire to have children, irrespective of the HIV sero-status (adjusted odds ratio 24.0 (95% CI 9.15, 105.4)). Among couples in which the woman was HIV-positive, young age and relatives' expectations for children were significantly associated with increased fertility desire, while among couples in which the man was positive; knowledge of ART effectiveness was associated with increased fertility desire. Availability of information on contraception was associated with decreased fertility desire.
CONCLUSIONS: The gender of the positive partner affects the factors associated with a desire for children. Interventions targeting sero-discordant couples should explore contraceptive choices, the cultural importance of children, and partner communication.

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10. Ending intimate partner violence after pregnancy: Findings from a community-based longitudinal study in Nicaragua

Authors: Salazar M 1,3; Valladares E 1,2; Ohman A 3,5; Högberg U 3,4
Institutions: 1 Centre for Demography and Health Research, Nicaraguan National Autonomous University, León, Nicaragua; 2 Department of Obstetrics and Gynaecology, Nicaraguan National Autonomous University, León, Nicaragua; 3 Epidemiology and Public Health Sciences, Department of Public Health and Clinical Medicine, Umeå University, Sweden; 4 Obstetrics and Gynaecology, Department of Clinical Sciences, Umeå University, Sweden; 5 Umeå Centre for Gender Studies, Challenging Gender Excellence, Umeå University, Umeå, Sweden
Source: BMC Public Health, 18 Sep 2009; 9:350. [Open Access]

ABSTRACT
BACKGROUND: Although reducing intimate partner violence (IPV) is a pervasive public health problem, few longitudinal studies in developing countries have assessed ways to end such abuse. To this end, this paper aims to analyze individual, family, community and societal factors that facilitate reducing IPV.
METHODS: A longitudinal population-based study was conducted in León, Nicaragua at a demographic surveillance site. Women (n = 478) who were pregnant between 2002 and 2003 were interviewed, and 398 were found at follow-up, 2007. Partner abuse was measured using the WHO Multi-country study on women's health and domestic violence questionnaire. Women's socio demographic variables, perceived emotional distress, partner control, social resources, women's norms and attitudes towards IPV and help-seeking behaviours were also assessed. Ending of abuse was defined as having experienced any abuse in a lifetime or during pregnancy but not at follow-up. Crude and adjusted odds ratios were applied.
RESULTS: Of the women exposed to lifetime or pregnancy IPV, 59% reported that their abuse ended. This finding took place in a context of a substantial shift in women's normative attitudes towards not tolerating abuse. At the family level, no or diminishing partner control [ORadj 6.7 (95%CI 3.5-13)] was associated with ending of abuse. At the societal level, high or improved social resources [ORadj 2.0 (95%CI 1.1.-3.7)] were also associated with the end of abuse.
CONCLUSION: A considerable proportion of women reported end of violence. This might be related to a favourable change in women's norms and attitudes toward gender roles and violence and a more positive attitude towards interventions from people outside their family to end abuse. Maintaining and improving social resources and decreasing partner control and isolation are key interventions to ending abuse. Abuse inquiring may also play an important role in this process and must include health care provider's training and a referral system to be more effective. Interventions at the community level are crucial to reducing partner violence.

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