Background Patients at increased risk of sexually transmitted infections (STIs)/HIV acquisition are advised to reattend for retesting. A previous study showed that ‘generic’ text reminders did not improve reattendance.
Aim To assess if a personalised text message with increased contact information would increase reattendance rates of at-risk patients.
Methods Patients who are at risk of future STIs, defined by having a current acute STI, attending for emergency contraception, commercial sex workers (CSWs) or men who have sex with men (MSM), were sent a text reminder to reattend for retesting 6 weeks after initial visit. Reattendance rates were measured for September to December 2012 (control group who received a generic text message) and February to May 2014 (intervention ‘personalised message’ group who received a text message containing their first name and ways to contact the clinic). Reattendance was counted within 4 months of the end of the initial episode of care.
Results The reattendance rate was significantly higher for the intervention group: 149/266 (56%) than the control group: 90/273 (33%) (p=0.0001) and was also significantly higher in the intervention group than the control group in patients with the following risks: recent chlamydia (64/123 (52%) vs 43/121 (36%)) (p=0.03), recent gonorrhoea (41/64 (64%) vs 4/21 (19%)) (p=0.0003) and MSM (26/45 (58%) vs 3/18 (16%)) (p=0.006). New STI rates in the reattending intervention group and controls were 26/ 149 (17%) and 13/90 (14%) (n.s), respectively.
Conclusions Sending a personalised text message with increased contact information as a reminder for retesting increased reattendance rates by 23% in patients who are at higher risk of STIs.
- COMMUNICATION TECHNOLOGIES
- SEXUAL HEALTH
- CHLAMYDIA INFECTION
- HEALTH SERV RESEARCH
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Globally the incidence of sexually transmitted infections (STIs) is rising.1 Current evidence shows that patients testing positive for STIs are more likely to reacquire an STI in the future.2 Several guidelines recommend routine retesting after being diagnosed with an STI, but the time interval when retesting should reoccur is debateable.2 ,3 Methods such as verbally advising patients to reattend for retesting at the time of diagnosis have not been shown to be effective.4 Telephone and text reminders have been trialled with success. In one study 67% of patients questioned preferred text messaging as a means of reminding them of appointments compared with emails, letters and automated voicemail reminders.5 Reattendance rates when using text messaging remain variable. An Australian sexual health clinic showed that sending short message service (SMS) messages with or without incentives resulted in an increase in reattendance rates in patients diagnosed with Chlamydia.6 However a study in Swaziland where a majority of patients (71.8%) had mobile phones showed no improvement in reattendance (80.1% vs 83.3%).7 This was similar to a study in our clinic which showed no improvement in attendance when high-risk patients were sent SMS messages to attend for retesting with 33% reattendance in the text group and 35% in the control group.8
Patients with acute STIs, commercial sex workers (CSWs), men who have sex with men (MSM) and women receiving emergency contraception are all at higher risk of acquiring STIs.2 Strategies to improve reattendance and retesting in these populations are likely to be an effective use of resources.
Sending generic SMS texts to patients at higher risk of STI and HIV acquisition had previously not improved reattendance in our clinic. Reattendance was defined as attending within 4 months following the end of an episode of clinical care irrespective of whether they received a text message. We sought to see if sending a more personalised SMS text, with increased clinic access details, to remind such patients to reattend for testing, would increase reattendance.
The clinic has approximately 15 000 sexual health attendances each year in either booked (15%) or walk-in (85%) appointments. Patients are from diverse ethnic backgrounds with over 50% of attendees being black British/Caribbean/African.
Planning the intervention
In September 2012 the clinic introduced SMS text reminders for patients at higher risk of STIs and those in the window period for HIV to try and improve reattendance. Higher-risk patients were defined as patients that had been diagnosed with an STI such as Chlamydia, Gonorrhoea, acute viral hepatitis and Syphilis. Other patients considered at risk were those receiving emergency contraception, CSWs and MSM. Patients who consented to recall were booked into an SMS text reminder virtual clinic, usually 6 weeks after the initial episode. The text read “It is time for you to have a routine test. Walk in during opening hours or ring xxxxxx for an appointment”.9 This was shown not to improve reattendance in the clinic. In February 2014 we introduced a more personalised text message to include the patient's first name and additional clinic contact details to see if this improved attendance. The text message read “Hi (Patient Forename) It’s time for a routine test. Walk-in, call xxxxxx or email xxxxxxxx for appt”.
Planning the study of the intervention
This was a controlled before and after study.
Control Group: patients at higher risk of STIs and who had been listed for SMS text reminders to reattend between September and December 2012.
Intervention Group: patients at higher risk of STIs and who had been listed for text reminders between February and May 2014.
Study size: a minimum of 266 patients were needed in each group to detect a rise in reattendance rate of 6% using a 5% α-error level and 50% β-error level. A change of 5–6% in reattendance is what has been seen in other studies.6 ,7
Method of evaluation
Reattendance was counted if it was within 4 months of the end of a previous clinical episode.
The Wald method was used to calculate the CI. A two-tailed Fisher's exact test was used to assess the difference in reattendance rates between the intervention group and the control group.
They were 273 patients in the control group and 266 patients in the intervention (personalised SMS text) group.
Reattendance rates were significantly higher for the intervention group than the control group and for most of the demographic and risk categories including Chlamydia, Gonorrhoea and MSM (table 1). Reattendance rates in other risk categories (CSWs, patients with high number of sexual partners, Trichomonas vaginalis, equivocal HIV results and Syphilis) improved by 34% but this was not statistically significant. New STI rates were high in the reattending intervention and control groups (17% vs 14%). The rate of new STIs in the intervention group was highest in the patients recalled after a diagnosis of Gonorrhoea and in the control group in patients who had an initial diagnosis of Chlamydia. STIs diagnosed at reattendance included Chlamydia, Gonorrhoea, non-specific urethritis, Molluscum contagiosum, HIV, pelvic inflammatory disease and recurrences of warts and genital herpes. Of the text messages 90% were confirmed as delivered in both groups.
Booking appointments by email remained at a low level during this second period with patients using this facility less than once a day. Patients were not sent information that could have affected reattendance.
This study shows that changing the content of the SMS text reminders inviting patient to retest, increased reattendance rates in higher-risk patient groups by an average of 23% (from 33% to 56%) when compared with our previous impersonal text message.9 The two major changes were the addition of the patient’s first name (compared with no name used previously) and the addition of an email address for clinic contact. Of these two changes, the addition of the patient’s name seems to have been the biggest factor as the number of email appointment bookings did not rise significantly after the introduction of this service. We found high rates of STIs in patients who reattended.
Relation with other evidence
SMS messages are one of the most widely used methods of communication. To reduce non-attendance and for prevention of STIs, text messages have been used in different healthcare settings with variable results. A majority of studies show an improvement in outpatient attendance. A study in a Sydney Sexual Health Clinic showed an increase in attendance by 9% (21% vs 30%) among patients diagnosed with Chlamydia.6 Automated messaging in MSM led to an increase in attendance and detection of STIs.10 Our previous study and a study in Swaziland in patients returning for HIV test results showed no difference in reattendance.8 These studies were in services with already high reattendance rates. Previously there were no studies assessing the impact of personalising the content of text messages.
The group of patients we included for recall was a mixture of different risk groups and the case mix was different between the two time periods surveyed. One of the reasons for an increase in attendance of MSM was the introduction of human papillomavirus vaccine for MSM under the age of 27 years. This could suggest unintentional bias by clinicians only selecting patients who were more likely to return to add to the recall list in the second period. However, the rise in reattendance rate was seen across a range of demographic and risk-factor groups and suggests that there was no significant bias. All acute STIs were systematically recalled. Chlamydial infection as a risk factor was similar in proportion in both time periods and a 16% rise in reattendance was seen in the second period, supporting the contention that the improved reattendance rate was a real phenomenon. The only risk group in which a rise was not seen was in women receiving emergency contraception who started with a high baseline return rate (45%).
This was a retrospective before and after study and in such studies it cannot be proved that any changes in outcomes that occurred were directly related to the change being measured, although no other changes in clinic process happened during this period.
Interpretation of results
After publication of our original paper it was suggested that our relatively high reattendance rate (35%) might have meant that reattendance had reached a ‘saturation point’ beyond which reminders were of diminishing or no value. An alternative possibility was that the original text message could be improved through personalisation and adding extra access details. The use of the patients’ first name appears to have made the main difference as email or on-line booking rates did not change between the study periods.
This study demonstrates a 23% increase in reattendance rates in higher-risk patients following the introduction of new SMS text reminders to retest containing the patients’ first name, as compared with more impersonal text reminders. This suggests that the personalised nature of the text recall message is very important to patients.
The authors thank the clinic staff who were key to the success of texting outcomes.
Handling editor Jackie A Cassell
Contributors I can confirm that all others mentioned were involved in all four aspects required for them to be considered as authors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data regarding patients that attended prior to receiving text message is available and has been submitted as a response to reviewers’ questions. This study was represented as a poster at the British Association of Sexual Health and HIV spring conference June 2015. The abstract was in the conference programme.