Texting has grown from technological fad to a primary route of communication popular around the world. With cell phones in the pockets of people of all incomes and ages, the quick, no-frills conversations enabled by texting have made almost everyone more proficient with their thumbs. Due to such impressive ubiquity, people in health care are starting to ask whether text-messaging can be harnessed as a cheap and user-friendly tool for communicating with patients outside of the clinic – particularly hard-to-reach patients in urban and low income areas.
“People are ignoring that unlike every other technology, mobile phones reverse the digital divide,” said Shantanu Nundy, clinical instructor of medicine at the University of Chicago Medical Center. “More low income patients are using phones for text messaging and internet than other groups. So shouldn’t we then be developing technology for this type of population?”
Nundy and Jonathan Dick, a Pritzker graduate now in residency at Columbia University Medical Center, arrived independently at this same idea after separate trips overseas, where they saw clinics in Uganda and India using text messages as part of their operation. With texts, physicians could follow up with patients with chronic diseases, making sure they were taking medications and doing the types of self-examinations necessary to manage diabetes or HIV – tasks that are just as challenging at home as they are abroad. In some areas of Chicago the diabetes rate is as high as 25 percent, and African-American populations have much higher rates of diabetes complications such as blindness and amputation.
“It seemed to me that we had a lot of the same problems on the South Side of Chicago, so why not try it there?,” Dick said.
To test this premise, Nundy and Dick joined efforts with Medical Center faculty Monica Peek and Marshall Chin, who recently received grants from the Alliance to Reduce Disparities in Diabetes and the National Institutes of Health to look for new ways to improve outcomes in South Side neighborhoods. For a pilot study published last month in the Journal of Diabetes, Science, and Technology, the team recruited 18 African-American diabetes patients to try out a new automated text-messaging communication system that they programmed.
The study participants were not your typical teenage texters, instead reflecting an age range (38-72) more commonly afflicted with diabetes.
“If this is going to work, we needed to look at middle aged people and people in their 60s and 70s. I’m less interested in having this as a hip thing for teenagers with diabetes,” said Peek, assistant professor of medicine. “It needs to be able to work in people I see in clinic. A 55-year-old black woman with diabetes, if it works for her, I’m interested.”
Each participant was asked at the beginning of the study what kinds of text message they would like to receive, with candidates including reminders to take diabetes medications, check blood sugar, or conduct self-examinations to detect potential complications. Participants could also customize when they received the message, and how often they came in over the one-month pilot.
Some were purely notifications (i.e. “Please take your medications now.”) while others required a text response (“How many times did you check your feet this week?”). In one early sign that the messages were reaching their targets, participants often texted back whether a response was required or not, sending an “OK” or a “Thank you” message to what they knew was an automated system. The study reports, “Many participants found that they began anticipating the text messages and readying themselves to answer the questions in an affirmative way, such as preparing the insulin syringe ahead of the expected message.” That enthusiasm was reflected in surveys of the patients after the study period ended, where all but one participant said they were very satisfied with the text reminders.
“In the context of a population that typically has very few interactions with the health care system and may have experiences that are negative or bad or fearful, it was very fulfilling for them to have positive reinforcing messages where they really felt cared for by the system in a way they hadn’t in the past,” Peek said.
The patients also reported fewer missed medication doses and higher confidence about managing their diabetes, even one month after the text messages stopped. Though the numbers were small and the study short – some participants already requested more variety in the messages, even after only a month – the results suggested the potential of texting as a way to keep in touch with patients through the blind spots between doctor’s appointments.
“Doctors have very little insight as to what happens to people once they leave our clinic,” Nundy said. “The vast majority of care for diabetes happens outside of the clinic where we can’t see them. Just asking the question, ‘Did you take your medicine today?,’ gave us a piece of information none of us ever had before.”
Early next year, the research team will start a second, larger study of the text-messaging system, while Peek and Chin plan to add the tool to their broad spectrum of community interventions for diabetes. Non-physician “care managers” that help patients deal with the daily challenges of diabetes could be contacted by text message to help set up a clinic appointment or order a refill of medication, Peek said. Based on the pilot study results, the hope is that text messages can be more than just a trivial distraction, but a cheap, effective tool in improving health outcomes.
“What surprised and inspired us the most was how much people seemed to care about it, and how such a little thing as a text made such a big deal in somebody’s schedule,” Dick said. “It doesn’t take a whole lot to make people think that somebody cares about them, and that little thing can be enough to motivate behavior.”
Dick JJ, Nundy S, Solomon MC, Bishop KN, Chin MH, & Peek ME (2011). Feasibility and usability of a text message-based program for diabetes self-management in an urban african-american population. Journal of diabetes science and technology, 5 (5), 1246-54 PMID: 22027326