N Engl J Med

November 7, 2013

Almost all health care is voluntary: patients choose when to engage in care, when to take their medicine (if they choose to take it), and whether to return for follow-up visits. In human immunodeficiency virus (HIV) infection and other chronic diseases, the benefits of medication adherence for the patient and public health are tremendous. Mobile health — the use of mobile devices such as cell phones to improve health outcomes and health care services — has been shown to be effective in promoting adherence to treatment for HIV infection. The World Health Organization has strongly recommended text messaging as a reminder tool to increase adherence to antiretroviral therapy.

However, the potential of mobile health is much greater than just reminders. A randomized, controlled trial in Kenya that showed the effectiveness of text messaging to improve outcomes of HIV treatment used weekly interactive check-ins to ask patients how they were doing, with follow-up phone calls to those reporting a problem.1 This model involved a weekly text message to patients with a single word — “Mambo?” (“How are you?”). The intention was to promote self-care rather than issue timed medication reminders. The patients reported that they felt cared for and supported. Clinic staff indicated that the intervention made their work more effective and efficient, since they could focus on patients who needed and wanted their help. Text-messaging services with frequent medication reminders increase costs and result in user fatigue.2 In separate trials, neither medication alarm devices3 nor daily text-message reminders4 improved adherence.

The provision of health information through mobile phones offers the opportunity to improve health literacy. But does it translate into improved adherence? Although this may be possible, effectiveness has not yet been shown in controlled studies. A randomized, controlled trial showed that longer motivational text messages with words of encouragement were no more effective at improving adherence than short messages.4 A separate trial of motivational messaging showed no effect on adherence.5 Imagine that patients are feeling sick, and a unidirectional text-messaging service keeps telling them they are important and cared for. It is better to show patients you care, rather than just tell them.

My experience and interpretation of the evidence support an “Ask, don’t tell” approach. Although patients may eventually tire of being reminded and told things they had not specifically asked about, they do not seem to tire of being asked how they are doing. Instead, they feel cared for. Patients also do not seem to tire of having access to their health care providers in times of need; this is the true power of having their health in their own hands through their mobile phones.

Richard T. Lester, M.D.
University of British Columbia Centre for Disease Control, Vancouver, BC, Canada


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