Our findings showed that simple one-way communication of text-message reminders sent to health workers' personal mobile phones improved the quality of artemether-lumefantrine management. We recorded not only a short-term effect of the intervention but also a long-term improvement 6 months afterwards.
We are not aware of any other studies that have assessed text-message reminders on health workers behaviour (panel 3
). However, according to early results of a large systematic review of strategies to improve health worker performance in developing countries (213 effect sizes from 172 studies with robust designs and none including text-message interventions), the median improvement was just 9% (IQR 3–23%).24
Of direct relevance for malaria case-management practices in Kenya, a study that measured case-management indicators similar to those in our study showed only slight (and not statistically significant) positive effects of in-service training and passive distribution of job aids on health workers' adherence to treatment guidelines.25
In the context of broader health applications of mobile phone technology in developing countries, our results complement the findings of trials in Kenya in which text-message communication between health workers and patients substantially improved patients' adherence to antiretroviral treatment3,4
and HIV treatment outcomes.3
Panel 3. Research in context
On April 1, 2011, we searched a list of references from the Health Care Provider Performance (HCPP) review,23
a systematic review of studies of health worker performance in low-income and middle-income countries. The HCPP review included more than 105 000 studies that were identified by a search of 15 electronic databases (eg, Medline, CINHL, EPOC specialised register), the bibliographies of 510 previous reviews and other articles, document inventories, and websites of 29 organisations involved with health worker performance (eg, the US Centers for Disease Control and Prevention, World Bank, WHO), the bibliography of the International Network for Rational Use of Drugs, and the WHO Rational Use of Drugs database. Electronic databases were searched without language restrictions in May, 2006, and other sources were searched between 2006 and 2010. Adequate study designs were defined as studies before and after interventions with a control group (with or without randomisation), studies done after intervention with a randomised control group, and interrupted time series. The HCPP review list (dated March 31, 2011) included 2430 references, 852 of which were studies with an adequate study design. To complement the search of electronic databases since 2006, on April 4, 2011 we also searched the Medline database with search terms “text-messaging” and screened 174 citations.
We know of no other study to examine the effectiveness of mobile phone text-message reminders to improve health worker performance in a developing country. In our study, text-message reminders were associated with substantial improvements in health workers' adherence to national guidelines for the management of outpatient paediatric malaria. In resource-limited settings, malaria control programmes should consider use of text-messaging to improve health workers' case-management practices.
The intervention had a substantial effect on the completion of four dispensing and counselling tasks that were rarely done before this study. First, giving of the first artemether-lumefantrine dose at a health facility improved by more than 20%. Completion of this task ensures prompt antimalarial treatment for children presenting to facilities but, as shown in Tanzania,9
is also associated with better adherence to the full course of artemisinin-based combination treatment. Second, improvements in counselling tasks related to the correct timing of the second artemether-lumefantrine dose (nearly 30%) and the giving of the drug after a meal (nearly 20%) are encouraging findings that are important to ensure successful treatment outcomes in view of the poor oral bioavailability of artemether-lumefantrine and varied absorption between doses.26–28
Third, febrile children with malaria often vomit after swallowing bitter antimalarial tablets. Therefore, the recorded 24·5% improvement in counselling on what to do if vomiting occurs offers further encouragement.
We do not fully understand why the intervention was successful.29
Our main assumption is that text-message reminders address health workers' forgetfulness,30
emphasise the clinical importance of doing tasks described in the messages, and increase the priority of doing the tasks because the text messages represent the voice of authority of the health workers' employer (the Ministry of Health). However, whether the intervention in our setting also involves the communication of new or corrective information, or the enhancement of health workers' feeling that someone is paying attention to their work (ie, the Hawthorne effect31
), is not clear. The intervention's effect could have had little to do with the malaria-related content of the messages but with increased motivation from the famous quotes and sayings. We are examining these questions with qualitative research methods, and hope to publish our findings by the end of 2011.
From a programmatic perspective, our findings have important implications for malaria case-management implementers in Kenya and elsewhere in Africa. Despite the encouraging results of our study against frequent reports of unsuccessful interventions to change clinical practices across the continent,15,16,24
we do not argue that text messaging should replace a traditional package of case-management interventions such as in-service training, supervision, and dissemination of guidelines and job aids. Our intervention provided large and sustained improvements in the quality of care given to children with malaria, but resulted in only about half the children being correctly managed. Therefore, we recommend that text-message reminders should be used to complement existing interventions—which themselves should be qualitatively improved—to target weak points in malaria case-management practices. In the Kenyan context, with 22 million people who subscribe to a mobile phone service32
and 86% of the population with access to mobile network coverage,33
and an even higher likelihood of health facilities having network coverage, the pending large-scale implementation of a universal diagnostic policy for febrile patients34
offers an opportunity for the government to implement behaviour change through text-messaging.34
As part of this activity, text-message reminders can be used to strengthen antimalarial treatment and dispensing and counselling practices, but also to reinforce testing of febrile patients, antimalarial treatment for only test-positive patients, and the need to assess children who test negative for malaria for other causes of fever. Across Africa, the network coverage will ultimately establish the feasibility of the intervention. Findings from remote districts in Tanzania suggest that large scale text-message applications in health are feasible.35
Because sending text-messages seemed like an insubstantial intervention, we hypothesised that frequent, repetitive reminders during a long period (6 months) would be needed for the intervention to be effective. Moreover, because the study was intended to provide proof of concept, we thought that the testing of the intervention at a high dose would be best. Qualitative research with health workers exposed to the intervention should help reveal how burdensome the intervention was, and whether the intervention could be delivered for a period shorter than 6 months and expanded to other disease areas without losing effectiveness.
The simplicity and low cost of text messaging means that widespread implementation of an intervention that uses this technology can be done quickly and successfully. For example, the cost of a text message in Kenya is about US$0·01,36
resulting in the cost of full exposure to our intervention of $2·6 per health worker, or $39 000 if scaled up to an estimated 15 000 health workers in all rural facilities nationwide.37
However, despite the low cost of sending a text message, additional costs and complexities exist in the establishment and maintenance of the distribution systems. We are undertaking a cost-effectiveness analysis under our trial conditions. In collaboration with the Kenyan Ministry of Health, we are also assessing the cost and operational requirements for the deployment and effective maintenance of the text-message distribution system on a national scale. These findings, together with better understanding of health workers' views on the intervention's modalities and underlying motivators that affect their behaviour, will be crucial when considering national scale-up and replication of this intervention elsewhere.