Jennifer D. Uhrig

Beyond reminders: a conceptual framework for using short message service to promote prevention and improve healthcare quality and clinical outcomes for people living with HIV

Abstract The availability of effective antiretroviral therapy has altered HIV from being an acute disease to being a chronic, manageable condition for many people living with HIV (PLWH). Because of their ubiquity and flexibility, mobile phones with short message service (SMS) offer a unique opportunity to enhance treatment and prevention for people managing HIV. To date, very few US studies using SMS for HIV self-management have been published. In this article, we review the published SMS-based intervention research that aimed to improve healthcare quality and outcomes for PLWH and other chronic health conditions, and propose a conceptual model that integrates the communication functionality of SMS with important psychosocial factors that could mediate the impact of SMS on health outcomes. We posit that an SMS-based intervention that incorporates the elements of interactivity, frequency, timing, and tailoring of messages could be implemented to encourage greater medication adherence as well as impact other mutually reinforcing behaviors and factors (e.g., increasing patient involvement and social support, reducing risk behaviors, and promoting general health and well-being) to support better healthcare quality and clinical outcomes for PLWH. We recommend that future studies explore the potential linkages between variations in SMS characteristics and these mediating factors to determine if and how they influence the larger outcomes.

Similarities and Differences in Choosing Health Plans

Background. Increasingly, consumers have multiple health insurance options. New information is being developed to help consumers with these choices. Objectives. To study similarities and differences in how the publicly and privately insured choose health plans. To explore the effect of traditional enrollment materials and reports developed by the Consumer Assessment of Health Plans Study (CAHPS) on consumers’ perceptions and decision-making. Research Design. Using data from eight CAHPS demonstrations, we tested for significant differences across consumers with employer-sponsored insurance, Medicaid, and Medicare. Subjects. Approximately 10,000 consumers with employer-sponsored, Medicaid, and Medicare health plans. Measures. Perceptions of the health plan selection process, use of information sources, and reactions to and use of traditional enrollment materials and CAHPS reports. Results. Most consumers with all types of insurance thought that choosing a health plan was important and obtained information from multiple sources. Choosing a plan was more difficult for Medicare and Medicaid recipients than for the privately insured. When choosing a plan, Medicaid recipients cared most about convenience and access, whereas the privately insured emphasized providers and costs. The percentage of consumers who looked at and remembered the CAHPS report varied widely from 24% to 77%. In all but one of the demonstration sites, most consumers spent less than 30 minutes looking at the CAHPS report. Conclusions. Group sponsors and the developers of information interventions such as CAHPS may need to invest in developing and testing different reporting approaches for Medicare, Medicaid, and privately insured consumers.

Do Content and Format Affect Older Consumers’ Use of Comparative Information in a Medicare Health Plan Choice? Results from a Controlled Experiment

We assessed the efficacy of materials that integrated comparative information on cost, benefits, and quality for employer-based retiree health plans and Medicare Advantage plans in a randomized experiment to test the impact of content and format. Results indicate that older consumers who received the intervention materials found the materials easier to use, gained greater knowledge about Medicare from them, were more likely to value comparative quality information, were more likely to select higher quality plans, and were more likely to choose a plan that reflected the dimensions they found most important compared to older consumers receiving the control materials.

Efficacy Methods to Evaluate Health Communication and Marketing Campaigns

Communication and marketing are growing areas of health research, but relatively few rigorous efficacy studies have been conducted in these fields. In this article, we review recent health communication and marketing efficacy research, present two case studies that illustrate some of the considerations in making efficacy design choices, and advocate for greater emphasis on rigorous health communication and marketing efficacy research and the development of a research agenda. Much of the outcomes research in health communication and marketing, especially mass media, utilizes effectiveness designs conducted in real time, in the media markets or communities in which messages are delivered. Such evaluations may be impractical or impossible, however, imiting opportunities to advance the state of health communication and marketing research and the knowledge base on effective campaign strategies, messages, and channels. Efficacy and effectiveness studies use similar measures of behavior change. Efficacy studies, however, offer greater opportunities for experimental control, message exposure, and testing of health communication and marketing theory. By examining the literature and two in-depth case studies, we identify advantages and limitations to efficacy studies. We also identify considerations for when to adopt efficacy and effectiveness methods, alone or in combination. Finally, we outline a research agenda to investigate issues of internal and external validity, mode of message presentation, differences between marketing and message strategies, and behavioral outcomes.

Addressing HIV Knowledge, Risk Reduction, Social Support, and Patient Involvement Using SMS: Results of a Proof-Of-Concept Study

Men who have sex with men continue to be severely and disproportionately affected by the HIV/AIDS epidemic in the United States. Effective antiretroviral therapy has altered the HIV epidemic from being an acute disease to a chronic, manageable condition for many people living with HIV. The pervasiveness, low cost, and convenience of short message service suggests its potential suitability for supporting the treatment of conditions that must be managed over an extended period. The purpose of this proof-of-concept study was to develop, implement, and test a tailored short message service–based intervention for HIV-positive men who have sex with men. The messages focused on reducing risk-taking behaviors and enhancing HIV knowledge, social support, and patient involvement. Participants reported strong receptivity to the messages and the intervention. The authors detected a statistically significant increase in HIV knowledge and social support from baseline to follow-up. Among participants who received sexual risk reduction messages, the authors also detected a statistically significant reduction in reported risk behaviors from baseline to follow-up. Results confirm the feasibility of a tailored, short message service–based intervention designed to provide ongoing behavioral reinforcement for HIV-positive men who have sex with men. Future research should include a larger sample, a control group, multiple sites, younger participants, and longer term follow-up.

Applying core principles to the design and evaluation of the ‘Take Charge. Take the Test’ campaign: What worked and lessons learned

OBJECTIVES To describe the application of seven core principles to the design and evaluation of a human immunodeficiency virus (HIV) testing social marketing campaign as a case study example. STUDY DESIGN The Centers for Disease Control and Prevention (CDC) used a structured social marketing approach, informed by the Ecological Model, the Theory of Planned Behaviour and the Health Belief Model, to develop and evaluate a two-city campaign with print, radio and outdoor advertising; HIV telephone hotlines; an HIV website; community partnerships; and events to promote information seeking and HIV testing. METHODS The CDC applied seven core principles to design and evaluate the campaign, including formative research, the use of behavioural theories, audience segmentation, message design and pretesting, channel selection, process evaluation and outcome evaluation. RESULTS Over 200 partners in both cities contributed significantly to campaign efforts. Key informant interviews indicated that, due to increased coordination, city infrastructures for HIV testing improved. More than 9600 individuals attended campaign events in both cities, with 1492 rapid HIV tests administered and 14 newly-identified HIV individuals. Overall, event attendees responded positively to campaign materials and events, and free HIV testing opportunities. The campaign significantly increased information-seeking behaviours in the form of hotline calls and web searches. Audience reaction and receptivity to the final campaign materials was very high. Exposure to campaign messages was associated with increases in key knowledge items, intentions to get tested, and peer-to-peer communication. CONCLUSIONS The seven core principles, including formative research, behavioural theories and extensive partnerships, acted synergistically to help a campaign reach its target audience with compelling, relevant messages and motivate them to seek information and get an HIV test. Rapid testing removes many barriers by providing a testing process that can be accessed and acted upon quickly in response to media exposure. Findings suggest that modifying the campaign in future implementations to encourage the target audience to attend and participate in rapid testing events, while expanding the number and reach of such events, may have considerable potential to measurably increase testing behaviours.

Beneficiary knowledge of original Medicare and Medicare managed care.

Background:Previous research on beneficiary knowledge of the Medicare program has shown that the beneficiary population is not well informed about Medicare. The Centers for Medicare & Medicaid Services (CMS) implemented the National Medicare Education Program in 1998 to educate Medicare beneficiaries about program benefits; choices, rights, responsibilities and protections, and health behaviors. Objectives:We sought to measure beneficiary knowledge of the Medicare program and to assess how knowledge varies by beneficiary subgroups and topic areas. Research Design:We conducted psychometric analyses of survey data from Round 36 of the Medicare Current Beneficiary Survey to construct knowledge indices and estimated regression models with each knowledge index as the dependent variable, controlling for sociodemographic characteristics, self-reported health status, and insurance. Subjects:The study sample included 2634 noninstitutionalized Medicare beneficiaries. Measures:There were 2 separate knowledge indices representing the 2 primary avenues for receiving Medicare benefits: Original Medicare and Medicare managed care. Results:Beneficiaries ages 75 or older, nonwhite, with lower incomes, lower education levels, and public insurance had lower levels of knowledge on both indices. Enrollment in Medicare managed care was positively associated with knowledge about Medicare managed care but negatively associated with knowledge about Original Medicare. Areas of low program knowledge included coverage and benefits, enrollment/disenrollment, and plan choice. Conclusions:Our findings suggest the need to develop educational campaigns targeting vulnerable beneficiaries who have continued to demonstrate low levels of Medicare program knowledge.

Testing the Effect of Quality Reports on the Health Plan Choices of Medicare Beneficiaries

This article describes a laboratory experiment that used a convenience sample of 225 Medicare beneficiaries to test the effects of comparative quality information on plan choice. Providing information about quality did not significantly influence the choice between Original Medicare and a health maintenance organization (HMO), but did affect the choice of HMO. Results from this experiment suggest that information about plan quality may not be effective in encouraging beneficiaries to leave Original Medicare and join HMOs that are rated high in quality. Furthermore, beneficiaries choosing among HMOs were not inclined to select a low-cost HMO, even when it was rated higher in quality. Implications for policy are discussed.

Technical implementation of a multi-component, text message-based intervention for persons living with HIV

Background Men who have sex with men (MSM) continue to be severely and disproportionately affected by the HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) epidemic in the United States. Effective antiretroviral therapy has altered the HIV epidemic from being an acute disease to a chronic, manageable condition for many people living with HIV. The pervasiveness, low cost, and convenience of Short Message Service (SMS) suggests its potential suitability for supporting the treatment of conditions that must be managed over an extended period. Objective The purpose of this proof-of-concept study was to develop, implement, and test a tailored SMS-based intervention for HIV-positive MSM. Prior studies do not routinely provide sufficiently detailed descriptions of their technical implementations, restricting the ability of subsequent efforts to reproduce successful interventions. This article attempts to fill this gap by providing a detailed description of the implementation of an SMS-based intervention to provide tailored health communication messages for HIV-positive MSM. Methods We used archives from the SMS system, including participant responses to messages and questions sent via SMS, as the data sources for results reported in this article. Consistent with the purpose of this article, our analysis was limited to basic descriptive statistics, including frequency distributions, means and standard deviations. Results During the implementation period, we sent a total of 7,194 messages to study participants, received 705 SMS responses to our two-way SMS questions of participants, and 317 unprompted SMS message acknowledgements from participants. Ninety two percent of participants on antiretroviral therapy (ART) responded to at least one of the weekly medication adherence questions administered via SMS, and 27% of those had their medication adherence messages changed over the course of the study based on their answers to the weekly questions. Participants who responded to items administered via SMS to assess satisfaction with and use of the messages reported generally positive perceptions, although response rates were low overall. Conclusions Results confirm the technical feasibility of deploying a dynamically tailored, SMS-based intervention designed to provide ongoing behavioral reinforcement for HIV-positive MSM. Lessons learned related to text programming, message delivery and study logistics will be helpful to others planning and implementing similar interventions.

Exploring African American women's perceptions of a social marketing campaign to promote HIV testing

We tested the reliability of a new perceived effectiveness scale for HIV testing media messages and examined whether perceived effectiveness of the Take Charge. Take the Test campaign is predictive of downstream outcomes. We used data from an online survey of young, single, African American women (N = 428), collected from October 2007 to March 2008. Participants were recruited from online web panels maintained by Knowledge Networks and Survey Sampling International. The survey included a baseline and two longitudinal follow-ups at 2 and 6 weeks post-baseline. African American women aged 18 to 24 years, with annual incomes of less than