Text Message Reminders for Malaria Treatment

Increasing mobile phone ownership in developing countries presents exciting new opportunities for delivering public health and other social programs. Mobile phone subscriptions in developing countries increased from 7.9 per 100 inhabitants in 2001 to 78.8 per 100 inhabitants in 2011[1]. Rigorous studies of health promotion efforts delivered by mobile phones and other technologies can inform effective and efficient health programs. The impact of text message reminders on patient adherence to short-term treatments, such as that for malaria, remains largely unexplored. This study is a first attempt to evaluate the impact of text message reminders on patient adherence to malaria treatment through a randomized controlled trial in Tamale, Ghana, from May to October 2011.

Results from this study along with those from studies in Uganda (here and here), Kenya, and Zambia conducted in partnership with the Clinton Health Access Initiative, will be used to inform global policy on malaria diagnosis and treatment.

Despite the massive international efforts made over the past decades, malaria continues to be one of the primary causes of under-5 mortality worldwide. An estimated 1.24 million malaria deaths occurred in 2010, more than half of which were among children[2]. Of malaria deaths, 92% occurred in sub-Saharan Africa, where Plasmodium falciparum, the most virulent form of the malaria parasite, is most common[3]. P. falciparum has developed widespread resistance to several classes of antimalarial drugs, leaving artemisinins as the only known class of antimalarials that are effective at the population level.

P. falciparum becomes resistant to antimalarial treatments when parasites develop rare, random genetic mutations that prevent drugs from being effective. Artemisinin-based combination therapies (ACTs) are the first line treatment recommended by the World Health Organization because combination therapies lessen the likelihood that P. falciparum will develop resistance; parasites that mutate to become resistant to one drug should be killed by the other drug and there is a substantially lower likelihood that random mutations will confer resistance to both treatments.  Patients must complete the full dose of ACTs to most effectively prevent P. falciparum from developing resistance to artemisinins, but many patients do not finish their drugs. This study investigates the impact of text message reminders on adherence to ACT regimens. 

Malaria is one of the predominant causes of illness in Ghana, especially among young children. Ghana is a pilot country for the Global Fund’s Affordable Medicines Facility – malaria (AMFm), which aims to expand access to ACTs by highly subsidizing their cost. Ghana has also been rolling out a National Health Insurance Scheme since 2004, which allows registered members to receive ACTs free of charge. This study took place in and around Tamale, the capital of Ghana’s Northern Region.

Data enumerators recruited respondents at public and private hospitals, clinics, pharmacies, licensed chemical sellers, and other vendors and followed up all patients that could be reached by motorcycle within 30 minutes of leaving the town center. Vendors identified individuals purchasing malaria medicine and gave them a flyer to enroll in a mobile malaria information system and directed them to data enumerators. Willing and eligible participants received baseline participation questionnaire soliciting the participant’s mobile number, directions to his/her home and possible times to locate the patient (or his/her primary caretaker) at home. Participants who enrolled in the text messaging system were randomized to a treatment group or a comparison group. Participants randomized to the treatment group received one reminder for each of the six doses of ACT over the course of 60 hours. Those assigned to the treatment group were randomized to receive a short message, “'Please take your MALARIA drugs!” or a long message, “'Please take your MALARIA drugs! Even if you feel better, you must take all the tablets to kill all the malaria.”

Data enumerators made home visits between 72 and 96 hours after the in-vendor recruitment, when the course of the ACT treatment was supposed to be completed. The main outcome of the study was adherence, which was assessed by detailed, per-dose self-report and by data enumerator observation of pill packets. Enumerators also asked respondents about malarial symptoms, care-seeking patterns, awareness of malaria and malaria medications. In cases when a home-visit could not be made in the requisite time frame, participants were followed-up over the phone.