Odeny TA, Bailey RC, Bukusi EA, Simoni JM, Tapia KA, Yuhas K, Holmes KK, McClelland RS. Text messaging to improve attendance at post-operative clinic visits after adult male circumcision for HIV prevention: A randomized controlled trial. PLoS One. 2012;7(9):e43832. Epub 2012 Sep 5.
To determine the effect of text messaging on men's attendance at scheduled post-operative clinic visits seven days after circumcision.
Twelve clinics providing male circumcision (MC) services in Nyanza province, Kenya.
Randomized controlled trial.
Men aged ≥18 years who had undergone circumcision on the day of screening, owned a mobile phone, had the phone in their possession at the time of enrollment, and were able and willing to respond to a questionnaire administered by phone 42 days after circumcision.
Attendance at the scheduled seven-day post-operative clinic visit.
Men who had undergone circumcision were approached by study staff during the 30-minute post-operative recovery period. The purpose of the study was described, and those who agreed to be screened were asked questions to determine eligibility. For eligible men, study procedures were described in detail. Those interested in participating were invited to provide written informed consent prior to enrollment. Eligible men were interviewed for baseline characteristics, then randomized to receive either the intervention (daily text messages for seven days) or control condition (no text message).
The investigators used automated text-messaging software to send pre-programmed text messages each day to members of the intervention group, at each man's preferred time of day and in his preferred language (English, Kiswahili or Dholuo). The messages were adapted from a pilot study conducted in Nyanza province to assess their acceptability among circumcised men. The message sent each day changed to address the typical post-operative needs of that day, as relevant to each individual. For example, on the first day the message was "This is your MC provider. It is normal to feel a bit of pain and swelling, but if there is severe swelling, bleeding or pain please come back to the clinic." On the second day the message was "This is your MC provider. Remember do not allow water to soak the dressing before removal on the 3rd day." On the third day the message was "Remove the dressing today. Make sure you review the post-op instructions and use the blade provided. Throw away the blade after use." The messages continued to evolve in this way, so that each day they would be relevant to the man's post-operative recovery. On the sixth day the message was "This is your MC provider. Don't forget to come back to the clinic for your day 7 follow-up visit. You will be checked to be certain the healing is going well." On the seventh day the message was "This is your MC provider. See you at the clinic today for your follow-up visit."
Between September 2010 and April 2011, 1200 men were randomly assigned to receive either the intervention or standard care. The median age was 24.9 years (inter-quartile range [IQR] 21.5 to 30.7). The majority of participants were from the Luo ethnic group (n=1153; 96.3%). Most of the participants (n=870, 72.5%) reported having at least one sexual partner in the preceding month. Most (n=1093, 91%) had previously been tested for HIV infection. The median age at first sex was 16.0 years (IQR 14.0 to 18.0), and 672 (56%) participants were married or had a regular live-in partner. The median time taken to travel to and from the clinic was one hour (IQR 0.5 to 1.0), and the median time taken away from work in order to attend clinic was 3.0 hours (IQR 0.0 to 6.0). The median cost of travelling to and from the clinic was equivalent to USD $0.75 (IQR 0.38 to 1.25). There were minor differences in the proportions of men reporting zero versus one partner in the past month in the intervention versus control arms. However, the proportion reporting multiple partners was similar. Other baseline characteristics were similar in both study arms.
Outcome data were available for 592 (98.7%) participants in the intervention group, and 596 (99.3%) in the control group. Overall, 743 men (62.5%) returned at day 7. In the intent-to-treat analysis, the proportion of men who returned was higher in the intervention group (387/592; 65.4%) than in the control group (356/596; 59.7%; relative risk [RR] 1.09, 95% confidence interval [CI] 1.00 to 1.20; p=0.04).
The key factor associated with men's failing to return for the seventh-day follow-up visit was higher transportation costs. Men who paid more than 100 Kenyan shillings (about USD $1.25) to travel to and from the clinic had a higher risk of failure to return compared to those who spent ≤100 shillings (adjusted relative risk [aRR] 1.35, 95% CI 1.15 to 1.58; p<0.001). Educational level was of marginal significance. Men with secondary or higher education had a statistically non-significant lower risk of missing their follow-up visit compared to those with primary or less education (aRR 0.87, 95% CI 0.74 to 1.01; p=0.07). Among participants who returned for the seventh-day visit, 23/387 (6%) in the intervention group had had an adverse event compared with 19/356 (5%) in the control group (RR 1.12, 95% CI 0.6 to 2.1; p=0.7).
The authors conclude that mobile phone text messaging led to a modest increase in attendance at the seventh-day post-operative clinic visit compared to a control condition with standard care.
The overall risk of bias in this trial is low. The randomization sequence was developed by a statistician in the United States, using a block randomization scheme with variable blocks of size 4-16. Randomization was stratified by clinic. Investigators and study staff were blinded to the block number, block size, and sequence in the block. Participants were assigned to intervention arms using pre-prepared sequentially numbered, sealed, opaque envelopes containing group assignment. It was not possible to mask participants to group assignments. However, clinicians and nurses performing the circumcision procedure and follow-up were not aware of study group assignment. Patients excluded or lost to follow up are accounted for appropriately.
There appear to be missing outcome data, though it is possible that these will be presented in a different paper. No data are presented on the proportion of men resuming sexual activity before post-circumcision day 42, which was pre-specified in the trial's protocol as a primary outcome. This outcome is not specifically mentioned in the present article (apart from delayed resumption being promoted at follow-up visits).
This trial adds to a growing body of evidence on the efficacy of mobile phone text messaging as a means of enhancing compliance in follow-up care and medication adherence.(1, 2) A recent Cochrane review (2) found moderate quality evidence that mobile phone text message reminders are more effective than no reminders in promoting attendance at healthcare appointments. Mobile phone ownership is expanding rapidly in sub-Saharan Africa, with 22 million of Kenya's 38 million people subscribing to mobile phone service as of 2009;(3) the number may now be significantly higher. Additional high quality studies are needed of this intervention.
Clinics offering MC services should consider implementing pilot programs of mobile phone text messaging to enhance post-circumcision care and clinic attendance.
- Horvath T, Azman H, Kennedy GE, Rutherford GW. Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection. Cochrane Database Syst Rev. 2012 Mar 14;3:CD009756.
- Car J, Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database Syst Rev. 2012 Jul 11;7:CD007458.
- The 2009 Kenya Population and Housing Census. Kenya National Bureau of Statistics. [accessed 15 September 2011]