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
April, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
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
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.
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.
| 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. | ||
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.
The review identified four studies that included 182 participants. None of the studies was conducted in a low-income country.
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.
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Effects of mobile phone messaging support on capacity to self-manage long-term illnesses |
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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 |
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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. |
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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.
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Effects of mobile phone messaging support on health outcomes |
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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 |
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|
Outcomes |
With usual care |
With mobile phone messaging |
Relative effect (95% CI) |
Number of participants (studies) |
Certainty of the evidence (GRADE) |
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|
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) |
|
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|
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 |
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|
Asthma control |
May lead to little or no difference in asthma control, based on a range of measures |
- |
8 (1) |
Low |
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|
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). |
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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.
|
Mobile phone messaging and utilisation of services for diabetes, hypertension, and asthma |
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|
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 |
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|
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) |
|
|
|
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) |
|
|
|
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. |
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| 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. |
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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 see: www.supportsummaries.org/methods |
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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.
Hossein Joudaki, Tehran University of Medical Sciences, Tehran, Iran.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Thyra de Jongh, Ola Kdouh, Simon Goudie and Simon Lewin.
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.
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.
