Using text messages to improve medication adherence
The teenager's cell phone rang telling him he was getting a text message. He opened it and read, "Hi. Remember to take your medication." Then he closed his phone and went back to whatever it was he was doing. And oh yes, he also took his asthma medication.
This is a daily occurrence for some teenagers who have asthma. They're patients of Dr. Maria Britto at the Children's Hospital Medical Center in Cincinnati, Ohio. Britto is a primary care physician working in the Division of Adolescent Medicine and the Center for Innovation in Chronic Disease Care. Britto, Jennifer Knopf, who is a project specialist, and others are developing new ways to deliver healthcare and to communicate with teens who have chronic illnesses. A common problem for many teens is medication adherence (or lack thereof). Knopf says that teens often forget to take their medication or, if they do remember, plan on taking it later. According to Knopf, the daily text message reminders are a way to get teens to stop for a second and say, "Hey, I need to take my medication."
Before this program began, hospital staff noticed that, during both clinical and research encounters, teens were often text messaging their friends and parents. This was happening whether they were getting blood drawn, having a shot, or even talking with doctors. Teens opened their ringing phones, read the message, either deleted it or responded, and then "moved on with their lives," Knopf says.
- The daily text message reminders are a way to get teens to stop for a second and say, 'Hey, I need to take my medication.'
Since the fall of 2007, about 20 teens with asthma (ages 12 to 21) have been receiving a text reminder message once or twice a day. The frequency depends on how often they need medication. The message contains no additional information about which medicine to take or who sent the message. Knopf says that teens already know these things. They also know that the message is about taking routine "controller" medications to prevent asthma attacks and not about "rescue" medications needed only when attacks occur.
Anecdotal evidence, Knopf says, already indicates that this program is helping teenage patients who simply have trouble remembering to take medication. Text messaging isn't likely to be as effective, though, with teens who are in denial about their illness, don't know why they need medication, or are not interested in taking it. "Text messaging won't help those individuals because they have more going on than just forgetting," Knopf says.
Beyond day-to-day medication management, Knopf says that this project is helping teens with chronic diseases develop good self-care habits. Some are learning how much better they feel when taking medication as prescribed, rather than just waiting for emergency situations. Others find this a comfortable and convenient way of communicating - much better than being bugged, lectured at, or nagged to take medication. In a recent conversation, Knopf shared specifics about how this text messaging program works and what steps professionals can take to implement it.
Offer the option of text messaging. Whether teens are newly diagnosed or have been dealing with asthma for many years, clinicians are usually the ones to initiate a discussion about text message medication reminders. Of course, the timing of this discussion and choice about whether to use text messaging is up to the providers, teens, and their parents. Sometimes there are more pressing concerns and text messaging may seem like one of too many issues to consider. But more often, teens and their parents respond well when clinicians say, "We have this program that can help you remember to take medications. If you're interested, we can start right away."
Obtain consent from teens and, if teens are under the age of 18, their parents. At the hospital in Cincinnati, teens are given a simple one-page form specifying that they will receive a text message (either once or twice a day) and agree to pay any phone-related charges that may accrue. For teens under 18, their parents must also agree. For many teens, there is no additional cost. Their cell phone plans already include unlimited text messaging. If the teen or parent can't afford or doesn't want text messaging, there are alternative suggestions to help them remember their medication. For example, setting a phone alarm is a possibility.
Designate someone to send daily messages. Initially, the program started with a small trial in which the "Parent Coordinator," a hospital staff member, sent messages manually from her own phone. The Parent Coordinator sent messages at pre-determined times to all the teens. Unlike email when people can see who else is receiving the same message, there is no concern about privacy. Each teen only reads the message that comes to his or her phone. The hospital is now also testing a commercial system for automated text messaging.
Make the message clear, but brief. The Teen Advisory Board talked about how to word the reminder message. They cautioned adults not to be cool and use slang or text shorthand. They wanted all words spelled out so as not to be confusing. So the message uses terms like "forget," not "4get." Sometimes the Parent Coordinator writes something extra, such as a friendly or timely, "Have a great day," or, "Happy Halloween."
Teens see text messaging as a helpful, non-intrusive reminder. All they have to do is pick up their phone and it's there. By self-report, teens say they are taking medications more regularly as a result of getting the messages. Knopf is a big fan of using text messaging this way and encourages other healthcare professionals to give it a try. "Absolutely they should do this," she says. "We haven't seen any downsides yet."
The text messaging program is completing its pilot phase, and the staff is preparing for a larger study. Knopf, Britto, and others already see its far-reaching possibilities not just for teens with asthma but also for people of all ages dealing with chronic disease.
Ways to learn more:
Jennifer Knopf is a project specialist working in the Division of Adolescent Medicine and the Center for Innovation in Chronic Disease Care at Children's Hospital Medical Center in Cincinnati, Ohio. You can reach her by email at Jennifer.Knopf@cchmc.org.
Britto MT, DeVellis RF, Hornung RW, DeFriese GH, Atherton HD, Slap GB, "Health Care Preferences and Priorities of Adolescents With Chronic Illnesses." Pediatrics, November 2004; Vol. 115(5):1272-1280. Available online at www.pediatrics.org.
Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. She received two "Gold" 2008 Plain Language awards from NIH for her work on the NCI booklets "Radiation and You" and "Chemotherapy and You." Her column appears regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.