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Effect of mobile phone reminders on follow-up medical care of children exposed to or infected with HIV in Cameroon (MORE CARE): a multicentre, single-blind, factorial, randomised controlled trial

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Summary

Background

Missed scheduled HIV appointments lead to increased mortality, resistance to antiretroviral therapy, and suboptimum virological response. We aimed to assess whether reminders sent to carers by text message, mobile phone call, or concomitant text message and mobile phone call increase attendance at medical appointments for HIV care in a population of children infected with or exposed to HIV in Cameroon. We also aimed to ascertain the most cost-effective method of mobile-phone-based reminder.

Methods

MORE CARE was a multicentre, single-blind, factorial, randomised controlled trial in urban, semi-urban, and rural settings in Cameroon. Carers of children who were infected with or had been exposed to HIV were randomly assigned electronically in blocks of four and allocated (1:1:1:1) sequentially to receive a text message and a call, a text message only, a call only, or no reminder (control). Investigators were masked to group assignment. Text messages were sent and calls made 2 or 3 days before a scheduled follow-up appointment. The primary outcomes were efficacy (the proportion of patients attending a previously scheduled appointment) and efficiency (attendance/[measures of staff working time × cost of the reminders]), as a measure of cost-effectiveness. The primary analysis was by intention to treat. This study is registered with the Pan African Clinical Trials Register, number PACTR201304000528276.

Findings

The study took place between Jan 28 and May 24, 2013. We randomly assigned 242 adult–child (carer–patient) pairs into four groups: text message plus call (n=61), call (n=60), text message (n=60), and control (n=61). 54 participants (89%) in the text message plus call group, 51 (85%) in the call group, 45 (75%) in the text message group, and 31 (51%) in the control group attended their scheduled appointment. Compared with control, the odds ratios for improvement in the primary efficacy outcome were 7·5 (95% CI 2·9–19·0; p<0·0001) for text message plus call, 5·5 (2·3–13·1; p=0·0002) for call, and 2·9 (1·3–6·3; p=0·012) for text message. No significant differences were seen in comparisons of the three intervention groups with each other, and there was no synergism between text messages and calls. For the primary efficiency outcome, the mean difference for text message versus text message plus call was 1·5 (95% CI 0·7 to 2·4; p=0·002), for call versus text message plus call was 1·2 (0·7 to 1·6; p<0·0001), and for call versus text message was 0·4 (−1·3 to 0·6; p=0·47).

Interpretation

Mobile-phone-based reminders of scheduled HIV appointments for carers of paediatric patients in low-resource settings can increase attendance. The most effective method of reminder was text message plus phone call, but text messaging alone was the most efficient (ie, cost-effective) method.

Funding

No external funding.

Introduction

In central Africa, vertical transmission of HIV from mother to child occurs in nearly 30% of children born to HIV-infected women, partly because of inadequate implementation of post-natal preventive strategies, especially during breastfeeding.1 Furthermore, in Cameroon only 13% of children who require antiretroviral therapy actually receive it.2

Mortality in infants with HIV has been greatly reduced in the era of effective antiretroviral therapy, but sporadic clinic attendance, poor compliance with co-trimoxazole prophylaxis or antiretroviral therapy in infants born to HIV-infected women, and late presentation of infants identified as having been exposed to or infected with HIV after birth are major contributors to persistent childhood mortality.3 Poor attendance at medical follow-up visits can also lead to suboptimum virological response to treatment and contribute to the development of drug resistance. Bastard and colleagues4 have defined an adherence indicator based on timeliness of clinic attendance. The indicator is strongly predictive of virological response to antiretroviral therapy and the occurrence of drug resistance, and can be used to identify non-adherent patients in a timely manner in settings where viral load monitoring is not available.

Inadequate attendance at medical follow-up visits in infancy is thus an important and potentially reversible factor contributing to increased mortality, resistance to antiretroviral therapy, and suboptimum virological response. In Cameroon, only 65% of infants born to HIV-seropositive mothers are brought to the recommended medical visit at age 6 weeks.5

WHO encourages the use of new technologies to assist health-care delivery in resource-limited settings,6 and UNAIDS encourages the use of wireless communication technologies to tackle morbidity and mortality related to HIV infection.7 Africa has seen a large increase in the use of mobile phone technology over the past decade.8 In Cameroon, mobile phone subscriptions have increased by 270% per year since 2000,9 and 43% of adults were reported to own a mobile phone in 2010,10 allowing for the potential use of mobile communication technology for medical appointment reminders.

Research has shown that mobile phone text messages and phone calls can be used to improve attendance at medical appointments in the general population and in adults with HIV/AIDS.11 Evidence from randomised controlled trials12, 13 also suggests that mobile phone text messaging at weekly intervals is effective at improving adherence to antiretroviral therapy and enhancing suppression of HIV viral load. Several studies14, 15, 16, 17, 18, 19, 20, 21 of mobile phone reminders to improve attendance at medical appointments have been done in adults, including one in adults with HIV.17 Studies22, 23, 24, 25, 26, 27 have also been done to assess the use of mobile phone appointment reminders in paediatric settings, but none have been done for paediatric HIV follow-up care. The investigators of a Cochrane review20 concluded that appointment reminders sent via text message and by phone call are effective at improving attendance compared with no reminders. They also noted that text messages are as effective as phone calls at increasing attendance and that the effect is greater when both text messages and phone calls are used. These findings are consistent with those of other studies.28, 29

To the best of our knowledge, the potential effect of delivering medical appointment reminders by text message, mobile phone call, or both on the clinic attendance of babies and children who require HIV-related care in low-income and middle-income countries has not previously been investigated. In the MORE CARE (mobile reminders for Cameroonian children requiring HIV treatment) study, we aimed to assess whether reminders sent to carers by text message, mobile phone call, or concomitant text message and mobile phone call increased attendance at medical appointments for HIV care in a population of children infected with or exposed to HIV in Cameroon. We also aimed to ascertain the most efficient (ie, cost-effective) method of mobile-phone-based reminder.

Section snippets

Study design and participants

MORE CARE was a multicentre, single-blind, randomised controlled trial with a two-by-two factorial design to assess the use of mobile-phone-based reminders to improve attendance at HIV medical appointments in a paediatric population in Cameroon. The study protocol has been reported in detail previously.30 The three MORE CARE study research sites are located in two regions of Cameroon. The Essos National Insurance Fund Hospital is in Yaoundé, the administrative headquarter of the Centre region

Results

We screened 301 adult–child pairs for enrolment between Jan 28 and May 24, 2013; 119 from the Goulfey District Hospital, 142 from the Kousséri Regional Hospital, and 40 from the Essos National Insurance Fund Hospital. After exclusions, we randomly allocated 242 participant pairs who met the enrolment criteria (figure). All randomly allocated participants were included in the analysis. Some baseline characteristics (ages of children and carers, carers' education, and time to appointment) were

Discussion

Our findings from two regions in Cameroon show that mobile-phone-based appointment reminders for carers of paediatric patients can increase attendance at scheduled HIV medical visits. The most effective method of appointment reminder in our study was a text message followed by a phone call, but a text message alone was the most cost-effective method (panel).

Previous studies of the use of mobile phone technology for the provision of appointment reminders have had similar designs to ours.14, 15,

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