Electronic reminders for cancer prevention: Factors associated with preference for automated voice reminders or text messages☆
Highlights
► Automated voice reminders (AVR) and SMS text prompts may increase intervention use. ► 598 participants assigned to receive prompts selected reminder modality (AVR, SMS). ► We examined associations between participant characteristics and selected modality. ► 28% picked SMS: age, computer comfort and SMS use were associated with this choice. ► Both AVR and SMS reminders should be available so all can benefit from prompting.
Introduction
Escalating healthcare costs have placed greater emphasis on prevention and encouraging patient activation regarding healthful lifestyle choices and decisions (Honore et al., 2011, Koh and Sebelius, 2010). Given that most patients seen in the primary care setting have more than one behavioral risk factor (Pronk et al., 2004), this setting is an important venue in which to promote behavior change.
eHealth, as defined by the World Health Organization (2012) is “the use of information and communication technologies (ICT) for health”, while mHealth, a subset of eHealth, is defined by U.S. Health Resources and Service Administration (HRSA) (2012) as “the use of mobile and wireless devices to improve health outcomes, health care services, and health research”. Both can bring behavior change interventions to people who have access to some technology, such as a telephone or a smartphone, but do not have access to a computer. Furthermore, self-guided and e- and mHealth interventions may be more economical to implement at the population level than those involving person-delivered components: however, interventions must be well utilized to lead to population-level health improvement. Active intervention engagement is associated with greater behavior change, and there is concern about the relatively low use of web-based interventions (Bennett and Glasgow, 2009, Leslie et al., 2005). Email and telephone contact may promote return visits to websites (Brouwer et al., 2011). Prompting may also help initiate (Fry and Neff, 2009) and maintain (Fjeldsoe et al., 2011) behavior change efforts.
In the U.S., just 2.4% of households do not have telephone access (U.S. Census, 2000), and recent data indicate that 87% of adults own a cell phone, and 46% have smartphones (Smith, 2012) making automated voice response (AVR) messages and short message service (SMS) text messages inexpensive and readily available modalities to deliver automated reminders to prompt behavioral action. SMS are brief written messages transmitted to cell phones, and AVR are automated telephone calls; both are easy to implement and to tailor. Research examining the use of reminders to promote behavior change is promising (Fry and Neff, 2009), but to our knowledge no research has been conducted discerning what reminder modality people prefer or what characteristics are associated with preferred modality. These questions must be answered to ensure that offered options meet the needs of the audience and to understand the impact of reminders. Thus, we examined the relationship of socio-demographics, health status, and factors associated with technology use and selected reminder modality.
Section snippets
Study design
Healthy Directions 2 (HD2) was a cluster randomized controlled trial of a multiple risk behavior intervention conducted in two urban health centers in the Boston area. Briefly, HD2 had three arms: 1) usual care; 2) HD2 intervention materials, delivered via print or web; or 3) HD2 intervention materials plus coaching calls. Randomization occurred at the primary care provider (PCP) level. The intervention was designed to simultaneously target physical activity, fruit and vegetable intake, red
Results
The sample was 59.3% female, had a mean age of 50.8 years (SE = 0.58), and was racially/ethnically diverse, with 44.5% identifying as non-white (Table 1). Over half of participants reported having a college degree and most were comfortable using computers. Almost all owned a cell phone, and about one-third reported sending or receiving SMS 5 + times a week, although 38.9% reported never doing so.
Discussion
Fewer than one-third of participants chose SMS over AVR as a prompting modality. To our knowledge, this is the first study to examine the association between participant-level factors and preferred reminder modality. Predictors of SMS preference included younger age, computer comfort, and use of SMS. The lack of association between perceived health or weight status and selected modality suggests that these technologies could be widely used across a range of interventions, and that the use of
Conclusion
Providing participants with an opportunity to self-select prompting modality may promote intervention engagement. Limiting reminders to AVR may inhibit intervention engagement by younger individuals and those who are more technologically savvy, as evidenced by frequency of sending/receiving SMS. Conversely, limiting reminders to SMS could preclude older individuals who are not adept with SMS. Both options should be offered to benefit as many individuals as possible.
Acknowledgments
This work was supported by NIH grants R01 CA123228 and 1K05 CA124415. We thank Harvard Vanguard Medical Associates for the opportunity to conduct our research in their clinical sites, and all of the health care providers who participated in this study. We would like acknowledge Jess Haines, PhD, RD, an HD2 co-investigator, as well as the HD2 staff: Louisa Bloomstein, Joanne Chin, Lindsay ElShazly, Emma Issenberg, Fatima Shahzad, Kim Skeete, Kristie Usher, and Val Varner. We also would like to
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ClinicalTrials.gov registration number: NCT01415492.