A bidirectional texting intervention to improve communication between clinicians and patients to increase HAART adherence.
Clinicians using WelTel send patients automated texts once a week inquiring about their wellbeing. Patients can respond that they are doing well or that there is a problem. Indication of problem triggers clinician outreach. If users do not respond to clinicians’ texts within 48 hours, clinicians attempt to call the user. WelTel is focused on improving communication. Research has examined impact on highly active antiretroviral therapy (HAART) Adherence.
Young Adults (18-30)
Effects of a mobile short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): A randomized trial.
Lester RT, Ritvo P, Kariri A, et al. The Lancet. 2010. 376: 1838-1845. PMID: 21071074
Summary: Clinicians from three clinics recruited 538 patients initiating HAART to participate in the study. Eligible participants had to be initiating HAART for the first time, have near daily access to a mobile phone, and use short messaging service (SMS) to communicate. Clinics were chosen to represent regional diversity of health settings in Kenya. Participants were randomized to receive the WelTel intervention (n=273) or treatment as usual (TAU) (n=265). TAU included counseling sessions and encouragement to seek outside support. All communications between clinicians and participants through WelTel were recorded in a study log. Participants’ self-reported HAART adherence was assessed at six and 12-month follow-up appointments. Viral load was assessed at 12 months. Focus groups with 10 to 20 participants were conducted before, during, and after the study at two study clinics. Attrition rates were 19% in the intervention group and 23% in the control group. Participants who received WelTel had significantly better rates of HAART adherence than the TAU group. Those who received WelTel had their viral loads suppressed below detectable levels than participants in the control group. About 98% of participants who received WelTel reported that they would like to continue and 98% reported that they would recommend it to a friend.
Take Away: WelTel shows promise as a way to improve patients’ adherence to HAART and, subsequently, suppression of HIV viral loads.
The HAART cell phone adherence trial (WelTel Kenya I): A randomized controlled trial protocol. Lester TL, Mills EJ, Kariri A, et al. Trials. 2009. 10(87). PMCID: PMC2760542
In-depth analysis of patient-clinician cell phone communication during the WelTel Kenya1 antiretroviral adherence trial.
van der Kop ML, Karanja S, Thabane L, et al. PLoS ONE. 2012. 7(9): e46033. PMCID: PMC3457960
Summary: Interviews with participants conducted at 12 months after enrollment assessed benefits and barriers of WelTel. Clinicians recorded 11,873 responses to their messages, 7,766 of which indicated that the participant was fine, 377 indicated the participant has a problem, and 3,730 were non-responses. The problem responses significantly decreased as the study progressed. 52% of participants who received the intervention indicated that they had a problem at least once. Patients most often cited health problems as reasons for problem responses. 260 participants who received the intervention did not respond to clinicians at least once; 62% of the reasons for not responding could not the determined. The most common reasons for non-response were phone problems, often related to exceeding limitations of the phone plan. When participants could not be contacted, 89% contacted the clinic later. Participants from rural and low-income clinics had higher rates of non-response than those from the urban clinics. Participants commonly described being reminded to take their medication (54%) and feeling like someone cares (22%) as benefits of the intervention. Most participants (66%) responded that there were no barriers to the intervention; listed barriers included lack of cellular network (20%).
Take Away: WelTel was a reminder to take their medication and a source of support for participants. Clinicians reported high rates of response. In cases of non-response, patients often contacted the clinic themselves.
A qualitative study investigating the use of a mobile phone short message service designed to improve HIV adherence and retention in care in Canada (WelTel BC1).
Smillie K, Van Borek N, Abaki J, et al. Journal of the Association of Nurses in AIDS Care. 2014. 25(6):614-625. PMID: 24768442
Summary: Researchers analyzed data from 20 participants recruited by staff at an HIV clinic in British Columbia, Canada to receive WelTel for six months. Eligible participants were youth (14-24) and older (50+) patients receiving or initiating HAART. Mobile phones were provided to participants. Researchers assessed patients’ perceptions of HIV care and support and the WelTel technology itself. Common barriers were loss of the phone, loading the phone with credit for texting, and coordinating phone plan and provider. Most participants did not experience difficulty sending or receiving texts and believed they received the right amount of texts. Participants who did not respond to the texts reported not doing so because of depression, being asleep, having their phone turned off, forgetting, being too busy, or running out of credit. Participants reported that WelTel made it easier to communicate with their HCP and improved their psychosocial wellbeing, but did not change their perceptions of adhering to medication and care. All participants indicated that they would recommend WelTel to a friend.
Take Away: WelTel was a valuable source of support for HIV patients but patients generally did not feel that it helped with their adherence to HIV care.
Health care providers’ perspectives on a weekly text-messaging intervention to engage HIV-positive persons in care (WelTel BC1).
Murray MCM, O’Shaughnessy S, Smillie K, et al. AIDS and Behavior. 2015. 19: 1875-1887. PMID: 26297567
Summary: Researchers recruited five health care providers (HCPs) at the clinic to participate in focus groups after a presentation about WelTel. Four HCPs closely involved with the study were asked to participate in individual interviews post-intervention. HCPs discussed how WelTel was a good fit to the clinic’s patient-centered model of care. While some HCPs already texted with patients, others felt they were unable to because of privacy concerns, and felt that WelTel was an appealing augment to their current model of care by way of streamlining outreach efforts, helping connect with difficult-to-reach patients, and increasing patients’ agency in clinical care. HCPs described how WelTel required more time, but likely reduced the amount of time spent dealing with crises. HCPs reported that WelTel was an effective way to engage patients, improve relationships with patients, provide individualized care, and improve utilization of HIV and community services. HCPs were unsure whether some of the improvements they described, such as utilization of outside services and support, was a result of the WelTel or the provision of cell phones to participants for the study.
Take Away: WelTel was well suited to clinic involved in the pilot and was acceptable and feasible to HCPs at that clinic, despite the time commitment involved. Provision of phones to patients may have independent influence on patient access to services and supports.
Operationalizing mHealth to improve patient care: A qualitative implementation science evaluation of the WelTel texting intervention in Canada and Kenya.
Bardosh KL, Murray M, Khaemba AM, Smilie K, Lester R. Globalization and Health. 2017. 13(87). doi: 10.1186/s12992-017-0311-z
Summary: Researchers interviewed 32 stakeholders involved in 6 WelTel projects in Canada (4) and Kenya (2) to evaluate implementation of the intervention. Stakeholders included researchers (10), WelTel staff (8), clinic staff (12), a clinic manager (1), and a government official (1). Interviews were semi-structured, with questions about impressions before and during early implementation, intervention-health system interactions, functionality of intervention technology, and scale-up. Researchers were guided by the Consolidated Framework for Implementation Research. Common topics that emerged from interviews included: positive intervention impacts on patient-provider relationships, service provision, and clinic structure, desire for adaptability of WelTel, the positive role of evidence supporting WelTel in obtaining financial support and clinic buy-in, and barriers and facilitators to scale-up. Participants reported WelTel empowered patients by improving access to care and connection to clinicians and giving them control over communication with clinicians. Kenyan participants noted more structural barriers (e.g., geographic, cultural, economic, and political barriers) to enrollment of patients than Canadian participants. High clinical staff workload and lack of experience with technology were barriers to implementation and staff perceptions of WelTel impacted sustainability. Local champions to oversee implementation and operation of WelTel could facilitate implementation. Clinicians often requested changes to WelTel to better fit practice workflow and patient populations and researchers found they had to balance making changes and maintaining feasibility and simplicity of WelTel. The evidence base supporting WelTel could influence decision-making on large (national) and small (clinic) scales. Participants emphasized the importance of cost data in determining sustainability of WelTel. Scale-up would rely on partnerships with non-government organizations and policy making to provide funding.
Take Away: Stakeholders in 6 WelTel projects reported that WelTel was beneficial to patients with a strong supporting evidence base, but there are a number of barriers to implementation and sustainability, especially in Kenyan projects.
Mobile text messaging to improve medication adherence and viral load in a vulnerable Canadian population living with human immunodeficiency virus: A repeated measures study.
King E, Kinvig K, Stief J, et al. Journal of Medical Internet Research. 2017. 19(6): e190. doi: 10.2196/jmir.6631
Summary: Researchers analyzed chart data from 80 patients at a Canadian HIV clinic who received WelTel for one year to determine how viral load and treatment adherence differed between the year before using WelTel and the year of WelTel use. Participants had attended the clinic with a detectable viral load for the past year, were indicated for combined antiretroviral therapy (cART), and were at high risk for disengagement from care. High risk for disengagement from care was indicated by one of the following: intimate partner violence, unstable housing, advanced HIV or AIDS, poor treatment adherence, hard to contact, substance use, distant from care settings, or recent incarceration. Patients were initiated into WelTel upon recruitment. Participants without a mobile phone were provided with a traditional cell phone. Researchers extracted participant CD4 count and percentage, viral load, cART dosage, emergency department visits, hospital admissions, self-reported medication adherence, medication refills, and appointment attendance from medical records in the past year (control year) and during the year of WelTel use. WelTel sent 3,674 initial inquiry messages and participants replied with 1,753 “OK” responses, 362 “problem messages, and 1,559 instances of non-response. Between the control year and study-year participant viral loads decreased significantly. cART adherence also improved significantly between the control year and study end. Attendance at clinic appointments significantly decreased between the control year and study end.
Take Away: Participants with HIV were more adherent to cART and had lower viral load after a year of using WelTel than in the year before WelTel initiation.
Effect of an interactive text-messaging service on patient retention during the first year of HIV care in Kenya (WelTel Retain): An open label, parallel-group study.
van der Kop ML, Muhula S, Nagide PI, et al. Lancet Public Health. 2018. 3(3): e143-e152. doi: 10.1016/S2468-2667(17)30239-6
Summary: Researchers recruited 700 patients at 2 Kenyan health centers who had recently tested positive for HIV for the first time by referral. Participants were randomized to receive usual care (UC) alone or UC plus WelTel for about 1 year. Researchers used medical records to determine participant retention in care at 12 months, retention in care after first ART eligibility assessment, ART initiation, 6-month clinic retention, and appointment attendance. Researchers also assessed participant social support, satisfaction with care, and health-related quality of life at baseline, 6, and 12 months. Over the course of the study, WelTel sent 17,422 initial messages. Participants sent 9,303 “OK” responses and 401 “problem” responses, participants did not respond to 7,718 messages. There were no intervention effects on retention in care after first ART eligibility assessment, ART initiation, 6-month clinic retention, appointment attendance, or retention in care at 12 months. Participants were similarly satisfied with their HIV care. Participants who received WelTel reported significantly higher social support and health-related quality of life than participants who received UC only, on average. Most participants who received WelTel liked WelTel (93%) and found it helpful (94%). Participants reported wanting to continue using WelTel after the study (97%) and reported that they would recommend it to someone with HIV (91%).
Take Away: WelTel did not impact participant retention in care, but showed some evidence of improving social support and quality of life relative to usual care alone.