With the rise of cell phone usage, smart and otherwise, many health care providers, researchers and entrepreneurs alike have assumed that this ubiquitous technology can be used to improve health and wellbeing. Entrepreneurs have led the charge and so the common catch phrase “there’s an app for that” underscores the fact that nearly 17, 000 health related apps are available either for free or a small charge for Android or Apple users.  Young people in the US are perhaps the best targets of our mhealth efforts because they are eager users of mobile technology. However two questions arise naturally: 1) does data show that these apps lead to improved outcomes? 2) is there a theory of how we might use cell phones to improve health outcomes?

In a series of studies, we found that simply responding to text messages over a 3-month period led to improved quality of life and pulmonary function in pediatric asthma patients. In both studies, the researchers randomly assigned 30 asthmatic children, 10 to 17 years old, into three groups – a control group that did not receive any SMS messages; a group that received text messages on alternate days and a group that received texts every day. The children that received messages everyday between two scheduled appointments had the improved psychological and physical outcomes. Thus, our data does indicate that cell phones can be used effectively to improve health outcomes.

Perhaps more compelling is that we may have evidence of a possible mechanism that can lead to improved outcomes. The Health Belief Model is a cognitive theory of behavior change that espouses the notion that a critical pillar of behavior modification is that the individual must make the connection between the severity of the symptoms and the disease itself. In the case of asthmatic patients, we found that many times they attributed their symptoms to other causes. For example, they would say that they couldn’t exercise in the afternoon because they had a heavy lunch or that they couldn’t sleep the night before because they had seen a movie that had made them anxious— rather than attributing these symptoms (inability to exercise or sleep) to their asthma. The Health Belief Model also places value on acquiring knowledge about the disease. Thus, we sent patients texts messages that either asked about symptoms they had experienced or about asthma myths. Thus, our studies also indicate that improving symptom awareness and knowledge about their disease led them to have better medication adherence which in turn led to improved health outcomes.

While our data are far from conclusive they do provide an interesting roadmap for other researchers to pursue. Among the open hypotheses that we are investigating is whether this simple text-based system leads to improved outcomes in other chronic diseases such as diabetes or whether symptom awareness and knowledge improvement lead to improvements for patients suffering from mental health issues. Since the data stream from the text-messages serve as a continuous assessment of the patients symptoms. A related set of research questions aim to understand whether the patient’s text based responses (in the time between office visits) can be provided to the healthcare professional to improve point of care interaction.

Rosa L. Arriaga, PhD is the director of pediatric research at the Health Systems Institute, a multi-institutional and interdisciplinary initiative based at Georgia Tech and Emory University. Some of Arriaga’s current research focuses on developing an SMS text messaging system for asthma management.

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7 Responses for “Why Texting Patients Works: The Health Belief Model”

  1. koko says:

    umm, why is this better than an email? a phone call?
    I am bothered by the robotic nature of the interaction and the impression that you have proven something beyond shadow of doubt.
    How many subjects? What were criteria for improved health conditions? how much different? Did you do the study again? Did the text senders know the hoped for outcome? Were the tests sent all the same?

  2. the dude says:

    Very interesting

    I’m guessing that the more is better rule with texts hits a point of diminishing returns. And there is clearly a generational effect. I’m guessing we’d have a different response from a group of geriatric patients. Although come to think of it, it would be FASCINATING to see what happened

    So lets create a text based pilot practice somewhere and use texts to communicate creatively and with patients with key chronic conditions and other stuff . E.G.

    Dr. Tom’s office misses you. Schedule your follow up.

    Are you remembering to take your meds? Just checking. Dr. Tom

    Call us if you don’t feel better. We want to keep you around. Dr Tom’s Office

    Stress is bad. If you’re worried about your test result. Call us.

    Etc etc etc

  3. BV says:

    Koko: here’s the full paper — it’s also linked in the GT summary.

    http://www.cc.gatech.edu/~arriaga/YunArriagaCHI13.pdf

    (and there seem to be other relevant ones in the references to this one)

  4. RN says:

    Why is this better than an email? Have you seen how many people are tethered to their smart phones these days…and believe it or not, most of them definitely aren’t emailing. This seems like an honest attempt to adapt to the times, and connect with patients via a medium that they actually use. Of course phone calls and face-to-face interactions are still vitally important, but you can’t realistically expect a doctor to counsel the same patient in person every day — but you can get them the information they need through an automated text messaging system. Win-win.

  5. DCPatient says:

    How does this health belief model work ( or does it) with silently progressing (few overt symptoms) diseases. It seems that most adherence problems are with patients who cannot see or feel the effects of their condition until it is too late or when there is a long lag time between taking the medication and seeing a positive effect.

  6. NHW says:

    What works is communicating in the patient’s preferred and normal method of communicating. For many, that is phone or email, especially for those under 40. Anything more than a brief statement soliciting a yes or no answer can be too much for texting. I think using a short message system may do nothing more than allow checking a box that a patient has been cared for when nothing could be more wrong. So, general health messages are fine for texting. But not for dealing with an acute situation, and I would hope I deserve more than 140 characters. Personally, I can say when I am not well the last thing I can do is “thumb type”. And a lot of communication goes on beyond just written words.

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