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The objective of this study was to determine racial and ethnic minority patient receptiveness to health reminders, and preferences for media channels and messengers for preventive health reminders.
A pen and paper survey was administered to patients in the waiting room of a publicly funded clinic serving predominately racial and ethnic minorities.
Three-fourths of participants said they would like to receive health reminders. The top three preferred methods of receiving health reminders were via text message, phone call, and letter by mail. About half of participants wanted their doctor or nurse to send them the health reminder.
Health reminders could be a tool to successfully encourage racial and ethnic minority patients to participate in their own health. If physicians or nurses use a cell phone text message, a phone call, or a letter to send these health reminders they may be particularly effective at improving patient health outcomes.
Studies have found that physicians demonstrate poor adherence to national guidelines for recommending and performing preventive health practices.1–3 For example, physicians’ adherence rates are low for HIV testing,4–6 influenza vaccinations,2 and cancer screenings1 – all conditions with considerable morbidity and mortality that benefit from early screening and care. This lack of adherence may be particularly important for racial and ethnic minority patients, traditionally underserved patient populations who are less likely to receive timely preventive care and, therefore, disproportionately suffer poorer health outcomes.7–10 There are many physician barriers to following guidelines. Cabana et al. have highlighted barriers including a lack of knowledge of guidelines, competing clinical priorities, and an inability to reconcile patient preferences with guideline recommendations.3 Activating patients to initiate discussion with their physicians about preventive health services could be an effective method to overcome physician barriers to providing recommended care. Furthermore studies have found that patients who are more active communicators with their healthcare providers have better health outcomes.11,12
One method to activate patients could be through the use of health reminders, or messages sent to patients with reminders or cues to action. Previous studies have found that sending health reminders to patients is effective in increasing the number of patients who receive recommended preventive services, such as mammograms, post-partum gestational diabetes screenings, and cancer screenings.14–17 These health reminders could include pertinent health information. For example, a health reminder could give patients information on HIV testing guidelines or remind patients to ask their physicians for the annual flu shot. Health reminders can be sent using many forms of traditional media and new media including letters in the mail, phone calls, text messages, or e-mails. Health reminders also could be tailored to meet the needs of individual patients. This could include using the name of the patient, giving screening reminders based on the patient’s demographic information, or including the name of the patient’s actual doctor or nurse. Health campaign tailoring has been shown to be an effective strategy for changing health behaviors.13,14 Finally, health reminders could prompt patients to better engage with their physicians. This would enable patients to be more active participants in discussions about preventive health practices. These features could make health reminders a useful tool to help overcome the problem of physicians not following guidelines.
The objective of this study was to determine racial and ethnic minority patients’ receptiveness to health reminders and their preferences for traditional media and new media channels and messengers for preventive health reminders.
This study was conducted in the waiting room of a primary care clinic in the Harris Health System in Houston, TX. The Harris Health System is the nation’s fifth largest publically funded healthcare system18 and serves a predominantly low-income, African-American and Hispanic patient population.19 The Baylor College of Medicine Institutional Review Board approved this study.
Participants were eligible for this study if they were: 1) over 18 years old 2) fluent in English 3) finished with their physician’s appointment (to not interrupt clinic workflow) and 4) a patient at the clinic. Participant recruitment occurred between June 2014 and February 2015. Fliers advertising the study were posted around the clinic to inform patients of the location of the research booth. Also, a research assistant stood by the clinic exit door asking patients if they wanted to participate in the study. Finally, patients passing by the research booth stopped to learn about the research study. A nominal incentive of a $10 gift card to a local grocery store was offered to study participants.
After consenting to participate, participants completed a self-administered, pen-and-paper survey in the clinic waiting room. This survey was created by the research team and was used to determine patient preferences for and characteristics of health reminders. Prior to study recruitment, the survey was pilot tested by patients in the target population for readability and understandability. The survey first introduced the topic of health reminders with the following statement: “Health reminders are brief reminders to help you and your doctor take care of your health. For example, a reminder might say, ‘it’s time to have your cholesterol checked’ or ‘your prescription refill is ready.’” Following this description, three questions were asked regarding preferences for health reminders. These questions pertained to acceptability of health reminders and preferences for health reminder campaign channels and messengers (see Appendix A for survey questions and answer choices). Participants could select more than one option for channel and messenger preferences. Finally, standard demographic questions were included in the survey.
Two research assistants independently abstracted paper surveys into a Microsoft ACCESS database (Microsoft Corporation; Redmond, WA). All data were subsequently imported into Stata 13 (StataCorp; College Station, TX). Discrepancies between the two abstractors were systematically catalogued and were mediated by the research team. For the statistical analysis, standard descriptive statistics were calculated. All demographic questions in the survey were multiple-choice; responses of subjects were thus described as simple proportions. Differences in the outcomes of interest between demographic groups were compared using χ2 or Fisher’s exact test, as appropriate.
A total of 285 participants agreed to complete the survey. The participants were 67.7% female and had a median age of 54 years. Additionally, 41.4% of participants were African American and 21.8% were Hispanic. A majority of participants (72.6%) had an annual household income of less than $20,000 (see Table 1).
Three-fourths (75.1%) of participants said they would like to receive health reminders.
The top three preferred methods of receiving health reminders were text message (44.9%), phone call (30.2%), and letter by mail (31.8%). All other health reminder channel options were selected by fewer than 30% of participants. (see Table 2). Males preferred receiving health reminders via email (n=30, 33.0%) significantly more than females (n=41, 21.2%) (p < 0.05). Further analyses were completed to determine significant differences in channel preferences across racial or ethnic groups. No significant differences among these groups were found.
Because age differences in exposure to and preferences for media channels may have influenced responses – particularly in this study, which included traditional media and new media, we stratified the data by ages 49 and younger and ages 50 and older (the latter of which are commonly referred to as “older adults”). Older adults preferred health reminders via cell phone mobile application (n=9, 5.03%) or email (n=38, 21.2%) significantly less than participants who were 49 years or younger (cell phone mobile application, n=12, 11.7%; email, n=33, 32.0%) (p < 0.05). No other significant differences in channel preferences were found between the two age groups.
About half of participants wanted their doctor (54.0%) or nurse (47.0%) to send them the health reminder, although the clinic secretary was a viable option to 30.5% of participants. All other messengers were selected by fewer than 30% of participants. When comparing between preferences for doctor versus nurse, there were significantly more participants who wanted only their doctor, but not their nurse, to send health reminders (n=62, 40.3%) compared to those who wanted only their nurse, but not their doctor, to send health reminders (n=42, 31.3%) (p < 0.05). See Table 2 for health reminder messenger preferences. White participants preferred receiving health reminders from a secretary (n=35, 41.7%) or their nurse (n=48, 57.1%) significantly more than Blacks participants did (n=25, 24.5% and n=42, 41.2%, respectively for secretary and nurse) (p < 0.05). There were no other significant differences in preferences for messengers across gender or racial/ethnic groups.
Notably, older adults, when compared with younger adults, were significantly less likely to prefer health reminders from their doctor (n=89, 49.7% vs. n=65, 63.11%), their social worker (n=14, 7.8% vs. n=21, 20.4%), or their case manager (n=15, 8.4% vs. n=20, 19.4%) (p < 0.05 for all three comparisons).
Our study of predominantly racial and ethnic minority, low-income patients found that the majority would be amenable to receiving reminders about their healthcare needs. Developing campaigns to educate patients about their needs – and ensuring that the campaigns prompt patients with a cue to action20 – may help overcome physician barriers to adhering to clinical guidelines and recommendations.3 For example, a campaign may inform the patient of the latest HIV screening guidelines – guidelines vastly under-adhered to by physicians21 – and include a prompt such as, “Your doctor wants you to ask for the HIV test. Don’t forget to add this to a list of things to discuss with your doctor at your next visit!”22 These campaigns may be particularly important for racial and ethnic minority patients who suffer worse health outcomes23,24 in part because they do not receive timely preventive health interventions7–9,25 and because they have poorer communication with their physicians.11,26 It is noteworthy that studies have found that patients want to be active participants and communicators during the healthcare encounter;27 health reminder campaigns may be a way to activate them.
The way in which physicians and patients communicate depends, in part, on patients’ media exposure.28 Our study suggests that health reminder media campaigns using text messages, phone calls, or letters by mail may prompt racial and ethnic minority patients to become more active participants in preventing disease and determining their own health outcomes. It is notable that text message was the most preferred medium for receiving health reminders, with almost 50% of patients selecting this medium. A recent study conducted by Zallman et al. among a similar population also found that text message was the most preferred channel for health reminders.29 One survey found that racial and ethnic minorities, compared to non-minority populations, are more likely to use their phones for finding health information which may help explain why text messages are a preferred health campaign channel.30 Additionally, a national survey found that over 85% of African Americans and Hispanics use text messaging.31 Thus, mobile phone text messaging could be an ideal campaign channel for sending health reminders to these traditionally hard-to-reach populations.32,33 We have previously described the opportunistic benefit of using text messages for health reminders.34,35 Unlike static media such as billboards and posters which may contain health information that is not tailored and may not present messages at a time when patients are in a setting to act upon them, text messages can be personalized (e.g., include the patient’s name, physician’s name) and delivered immediately before a clinic appointment. Many electronic medical record (EMR) systems have the capability to send text messages. As such, the EMR can be programmed to send patient-specific alerts based on health services due for that patient (e.g., HIV test, influenza vaccination), timed to their appointment time with their physician, and can include the patient’s name and physician’s name for personalization. It is worth noting that approximately one-third of our patient participants also preferred health reminders to be in letters by mail. Saville et al. also found that patients prefer reminders sent via mail.36 Preference for this method may be due to the fact that patients are familiar with this method as it is already commonly used for reminders related to both healthcare and other subjects. Alternatively, this preference may be due to cost. Receiving a mailing would be free to patients; text messages may incur cell phone charges for some patients.
As highlighted by McGuire’s communication-persuasion matrix, the credibility of the messenger impacts adoption of health campaign messages.37 Our study found that patients want health reminders sent by their healthcare providers. Further, among patients that selected only doctor or only nurse, significantly more patients selected physician. This preference may be because patients feel confident in their physicians’ medical advice.38 One study found that patients heed their physician’s recommendation to complete a preventive health screening because they trust their physician.39 Additionally, when physicians give health information and recommend a behavior, patients are more likely to remember the information, pass it along to friends, and attempt to change their behavior.40 Therefore, a health reminder sent by a physician could be effective in creating behavior changes, such as starting the discussion about preventive health services, among patients. Nurses also can be a credible source of health information and influence patients to take health action, which may explain why nurses also were a preferred messenger in our study. A national poll found that 85% of Americans think that nurses have very high or high honesty and ethical standards. In the same poll nurses were the most highly ranked medical professionals for perceived honesty and ethical standards and have consistently ranked highest since 2002.41,42 This favorable view of nurses could be capitalized when using health reminders to engage patients; health campaign messages could be sent or delivered by nurses familiar to the patients. Finally, clinic secretary was chosen as the preferred messenger by nearly one-third of the participants in our study. To our knowledge, there is no published literature on patients’ trust in clinic secretaries. However, it is possible that patients come to know the clinic support staff more than the healthcare providers because of time and nature of interactions. That is, patients may interact with the staff to make appointments, during clinic check-in and check-out, while waiting in the waiting room, and to file insurance claims and process payments.
While patient-preferred channels and messengers are important to understand for development of health reminders campaigns, equally important is ensuring the message content is understandable and salient and promotes action. Involving patients in content development (i.e., by conducting interviews or focus groups) can help achieve this.43,44 Barriers and facilitators to engaging in a preventive health service can be explored and accounted for in final message content. Additionally, attention can be paid to age, gender, and cultural norms For example, a 24-year-old male may have different motivations for asking for and obtaining the influenza vaccine compared to a 63-year-old grandmother living with small grandchildren. Even patients of the same age will have different needs based on their gender. Thus, message development should also take gender-specific health recommendations into consideration. Additionally, cultural norms should be considered when creating messages. Parents from more conservative cultures may not ask for the Human papillomavirus vaccine for their children if it is perceived to be for prevention of sexually transmitted infections rather than cancer prevention. Notably, as noted by the National Institutes of Health, health messages containing a cue to action can affect successful behavior change.20 The cue could be as simple as, “Talk to Dr. Jones today about if you need any new vaccines” and could accompany a health fact about how vaccines help prevent infections or cancer. Importantly, as suggested by the American Medical Association Foundation, health messages should be no higher than a 5th grade reading level so patients of all ages and health literacy levels can access the information.45 Finally, as recommended by the National Institutes of Health, prior to campaign launch message pretesting should be conducted with members of the target patient population to ensure that the final message is understandable and acceptable to the patient population.43
Despite the insight this study offers, there are some limitations. This study was conducted in one publically funded clinic in a large metropolitan area. Thus, these results may not be generalizable to patients at other clinics in Houston or patients in other non-metropolitan areas. However, our relatively large sample size from an urban clinic serving predominantly racial and ethnic minority, low-income patients in a large city may offer insight to other similar settings in the U.S. Additionally, this was an opt-in survey so selection bias may have influenced participation rates and responses. These responses were also self-reported so some answers may reflect social desirability and not actual patient preferences. However, since the survey was anonymous, participants may have felt more comfortable providing candid responses. Finally, while subject-matter experts helped develop the survey questions, construct and external validity have not been tested.
In conclusion, our study suggests that health reminders sent via a text message by a patient’s healthcare provider could be an effective tool at improving the health of low-income racial and ethnic minorities, populations that generally suffer the worst health outcomes. Research has found that healthcare providers accommodate patients who are engaged and ask questions.28 A patient-facing health reminders campaign designed with patient preferences in mind may be the catalyst needed to attenuate physician barriers to adhering to preventive health guidelines and recommendations. Further research is needed to determine what messages would successfully activate patients to discuss preventive health with their physicians. Additionally, the timing of receipt and preferences for message repetition need to be better understood. Finally, further research is needed to determine if health reminders targeting patients that prompt patient engagement do, indeed, improve physician adherence to preventive health guidelines and increase services offered. Health reminders – delivered in a way patients prefer – could achieve the Healthy People 2020 goal of increasing the proportion of patients that feel involved in making their own healthcare decisions and may help address health disparities.46
Sajani Patel, Address: 10518 Windwalker Trail Houston, TX 77095; Telephone: 713-409-9304.
Vagish Hemmige, Address: 6620 Main Street, #1375, Houston, TX 77030; Telephone: 713-798-2900.
Richard L. Street, Jr, Address: Houston VA Medical Center (Mailstop 152), 2002 Holcombe Blvd, Houston, TX 77030.
Kasisomayajula Viswanath, Address: Dana-Farber Cancer Institute, 450 Brookline Avenue, LW 601, Boston, Massachusetts 02215; Telephone: 617.632.2225.
Monisha Arya, Address: Houston VA Medical Center (Mailstop 152), 2002 Holcombe Blvd, Houston, TX 77030; Telephone: 713 794-8601.