BMJ 2014;349:g6158 doi: 10.1136/bmj.g6158 (Published 24 October 2014)
Page 1 of 2
Editorials
EDITORIALS Mobile phone messaging to improve health We still have a lot to learn about what makes it work Kanav Kahol head of division Division of Affordable Health Technologies, Public Health Foundation of India, C11 Qutub Institutional Area, New Delhi 110016, India
Mobile technologies are fascinating. In the past two decades, our lives have been transformed by mobile services that not only allow us to get connectivity anywhere anytime but also allow us to ease our lives in an unprecedented manner. There are many successes in the mobile technologies space. Google Android, Facebook, WhatsAPP, and Instagram are some of the examples of companies and efforts that got it right. However, behind every success there are several failures. These failures do not attract the same global media attention as the successes, but they provide an important insight into what makes certain efforts successful and others not so successful. It is imperative for us to analyse objectively both successes and failures and the reasons behind them so we can improve existing methodologies and approaches.
The linked study by Shet and colleagues (doi:10.1136/bmj. g5978) is an important evaluation of the use of mobile phone messaging to improve adherence to HIV treatments and decrease virological failure.1 The paper details a randomised controlled trial in which the intervention group of adults infected with HIV received conventional antiretroviral therapy plus customised and interactive motivational voice calls and reminder messages to their mobile phones, while the control group received only conventional antiretroviral therapy. Detailed analysis found no significant differences between the groups in adherence to drug regimen, virological failure, or other outcomes even in pre-specified subgroups, including those defined by age, location, and disease severity at baseline.
The results tend to suggest that there was no additional benefit associated with sending automated reminders. The authors also question similar studies conducted in Africa, where it was noted that automated reminders could improve adherence.2 3 Shet and colleagues’ study suggests we need to reassess the role of mobile phone reminders in improving management of patients with HIV. This becomes critical given the current WHO guidelines which recommend mobile phone messaging for improving implementation of nationwide HIV treatment programmes. Effective mobile messaging, including voice messaging, is a complex activity. The theory behind mobile messaging is in its infancy and is emerging from various related fields, including persuasive computing,4 advertising theories,5 and social network theories.6 Studies from these disciplines suggest that
entertainment, informativeness, irritability, credibility, frequency of exposure, and attitude towards privacy are just some of the factors5 that influence the acceptability of messaging. Each of these dimensions has a non-linear relation to messaging acceptance. Take, for example, the frequency of messaging. In advertising, the informativeness and entertainment value of promotional information declines with repetition because the information is soon learnt by the audience and subsequent repetitions lower its value.5 7 Similarly, as the quantity of promotional messages rises, the attitude of the individual towards the promotional vehicle worsens.8 9 These studies tell us that the frequency of messaging needs to be designed meticulously to obtain the desired effect. In Shet and colleagues’ study, the same voice calls and pictorial messages were repeated once a week for nearly two years. Could such messages suffer from the same loss of value suggested by studies in advertising? Similar complex relationships can be found between messaging effectiveness and other dimensions mentioned above. Shet et al, by their own admission, take a simplistic approach to messaging patients. Their intervention may not have been designed to take account of the many dimensions of messaging and their potential impact on delivery and acceptance. The authors also raise the issue of having a control arm that gets effective and high quality care through conventional therapy, thereby leaving little room for improvement. But even if we look beyond this methodological limitation, the study points to a more general and larger problem with most studies of mobile phone messaging.
Mobile health messaging studies tend to focus mostly on the clinical or procedural effect of the intervention rather than carefully studying the art of messaging itself. Messaging design for appropriate health promotion needs to be scientifically analysed and documented. We know very little about questions such as what health messages are perceived as informative by populations, or what health messages are irritating for the recipients and may have a negative impact. Answers to these questions require careful and detailed research. We need a multidisciplinary approach to the study of messaging design that critically analyses both successes and failures of mobile health messaging and develops theoretical models on the
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BMJ 2014;349:g6158 doi: 10.1136/bmj.g6158 (Published 24 October 2014)
Page 2 of 2
EDITORIALS
creation of health messages. This body of literature will help researchers, practitioners, and policy makers leverage the mobile media to reach out to patients and ultimately to improve public health. In conclusion, I urge the readers to not draw generic conclusions either way on the effectiveness of mobile health messaging. When we download a bad application onto a mobile phone, we don’t blame the entire mobile phone ecosystem, we simply call that app an inadequately designed application. WHO has recognised the potential of mobile technology in it its recommendations for using mobile messaging to reach out to patients, encourage adherence, and improve health. It is now up to researchers to develop a body of literature exploring what makes a mobile health message effective or ineffective to guide ongoing implementation of messaging systems. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none. Provenance and peer review: Commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
1 2 3
4 5 6 7 8 9
Shet A, DeCosta A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, et al. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014;349:g5978. Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 2010;376:1838-45. Pop-Eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, de Walque D, et al. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011;25:825-34. Fogg B. Persuasive technology: using computers to change what we think and do (interactive technologies) . Morgan Kaufmann, 2003. Haghirian P, Madlberger M, eds. Consumer attitude toward advertising via mobile devices—an empirical investigation among Austrian users. Proceedings of ECIS (European Conference on Information Systems) 2005, Regensburg, Germany. Mesch GS, Talmud I, Quan-Haase A. Instant messaging social networks: individual, relational, and cultural characteristics. J Soc Personal Relation 2012;29:736-59. Ducoffe RH. How consumers assess the value of advertising. J Curr Iss Res Advertising 1995;17:1-18. Ha L. Observations: advertising clutter in consumer magazines: dimensions and effects. J Advertis Res 1996;36:76-84. Tellis GJ. Effective frequency: one exposure or three factors? J Advertis Res 1997;37:75-80.
Cite this as: BMJ 2014;349:g6158 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Editorials
EDITORIALS Mobile phone messaging to improve health We still have a lot to learn about what makes it work Kanav Kahol head of division Division of Affordable Health Technologies, Public Health Foundation of India, C11 Qutub Institutional Area, New Delhi 110016, India
Mobile technologies are fascinating. In the past two decades, our lives have been transformed by mobile services that not only allow us to get connectivity anywhere anytime but also allow us to ease our lives in an unprecedented manner. There are many successes in the mobile technologies space. Google Android, Facebook, WhatsAPP, and Instagram are some of the examples of companies and efforts that got it right. However, behind every success there are several failures. These failures do not attract the same global media attention as the successes, but they provide an important insight into what makes certain efforts successful and others not so successful. It is imperative for us to analyse objectively both successes and failures and the reasons behind them so we can improve existing methodologies and approaches.
The linked study by Shet and colleagues (doi:10.1136/bmj. g5978) is an important evaluation of the use of mobile phone messaging to improve adherence to HIV treatments and decrease virological failure.1 The paper details a randomised controlled trial in which the intervention group of adults infected with HIV received conventional antiretroviral therapy plus customised and interactive motivational voice calls and reminder messages to their mobile phones, while the control group received only conventional antiretroviral therapy. Detailed analysis found no significant differences between the groups in adherence to drug regimen, virological failure, or other outcomes even in pre-specified subgroups, including those defined by age, location, and disease severity at baseline.
The results tend to suggest that there was no additional benefit associated with sending automated reminders. The authors also question similar studies conducted in Africa, where it was noted that automated reminders could improve adherence.2 3 Shet and colleagues’ study suggests we need to reassess the role of mobile phone reminders in improving management of patients with HIV. This becomes critical given the current WHO guidelines which recommend mobile phone messaging for improving implementation of nationwide HIV treatment programmes. Effective mobile messaging, including voice messaging, is a complex activity. The theory behind mobile messaging is in its infancy and is emerging from various related fields, including persuasive computing,4 advertising theories,5 and social network theories.6 Studies from these disciplines suggest that
entertainment, informativeness, irritability, credibility, frequency of exposure, and attitude towards privacy are just some of the factors5 that influence the acceptability of messaging. Each of these dimensions has a non-linear relation to messaging acceptance. Take, for example, the frequency of messaging. In advertising, the informativeness and entertainment value of promotional information declines with repetition because the information is soon learnt by the audience and subsequent repetitions lower its value.5 7 Similarly, as the quantity of promotional messages rises, the attitude of the individual towards the promotional vehicle worsens.8 9 These studies tell us that the frequency of messaging needs to be designed meticulously to obtain the desired effect. In Shet and colleagues’ study, the same voice calls and pictorial messages were repeated once a week for nearly two years. Could such messages suffer from the same loss of value suggested by studies in advertising? Similar complex relationships can be found between messaging effectiveness and other dimensions mentioned above. Shet et al, by their own admission, take a simplistic approach to messaging patients. Their intervention may not have been designed to take account of the many dimensions of messaging and their potential impact on delivery and acceptance. The authors also raise the issue of having a control arm that gets effective and high quality care through conventional therapy, thereby leaving little room for improvement. But even if we look beyond this methodological limitation, the study points to a more general and larger problem with most studies of mobile phone messaging.
Mobile health messaging studies tend to focus mostly on the clinical or procedural effect of the intervention rather than carefully studying the art of messaging itself. Messaging design for appropriate health promotion needs to be scientifically analysed and documented. We know very little about questions such as what health messages are perceived as informative by populations, or what health messages are irritating for the recipients and may have a negative impact. Answers to these questions require careful and detailed research. We need a multidisciplinary approach to the study of messaging design that critically analyses both successes and failures of mobile health messaging and develops theoretical models on the
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g6158 doi: 10.1136/bmj.g6158 (Published 24 October 2014)
Page 2 of 2
EDITORIALS
creation of health messages. This body of literature will help researchers, practitioners, and policy makers leverage the mobile media to reach out to patients and ultimately to improve public health. In conclusion, I urge the readers to not draw generic conclusions either way on the effectiveness of mobile health messaging. When we download a bad application onto a mobile phone, we don’t blame the entire mobile phone ecosystem, we simply call that app an inadequately designed application. WHO has recognised the potential of mobile technology in it its recommendations for using mobile messaging to reach out to patients, encourage adherence, and improve health. It is now up to researchers to develop a body of literature exploring what makes a mobile health message effective or ineffective to guide ongoing implementation of messaging systems. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none. Provenance and peer review: Commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
1 2 3
4 5 6 7 8 9
Shet A, DeCosta A, Kumarasamy N, Rodrigues R, Rewari BB, Ashorn P, et al. Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India. BMJ 2014;349:g5978. Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 2010;376:1838-45. Pop-Eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, de Walque D, et al. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011;25:825-34. Fogg B. Persuasive technology: using computers to change what we think and do (interactive technologies) . Morgan Kaufmann, 2003. Haghirian P, Madlberger M, eds. Consumer attitude toward advertising via mobile devices—an empirical investigation among Austrian users. Proceedings of ECIS (European Conference on Information Systems) 2005, Regensburg, Germany. Mesch GS, Talmud I, Quan-Haase A. Instant messaging social networks: individual, relational, and cultural characteristics. J Soc Personal Relation 2012;29:736-59. Ducoffe RH. How consumers assess the value of advertising. J Curr Iss Res Advertising 1995;17:1-18. Ha L. Observations: advertising clutter in consumer magazines: dimensions and effects. J Advertis Res 1996;36:76-84. Tellis GJ. Effective frequency: one exposure or three factors? J Advertis Res 1997;37:75-80.
Cite this as: BMJ 2014;349:g6158 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
