Application of short message service to control blood cholesterol: a field trial

Coronary heart disease (CHD) is among the main causes of morbidity and mortality across the world; Iran is no exception [1, 2]. High cholesterol level is a major cause of disease burden in both the developed and developing countries, which roughly causes 2.6 million deaths (4.5% of total deaths) and 29.7 million disability-adjusted life years (DALYS) [3]. That is why a diagnosis of dyslipidemia is important, especially in individuals at higher risk of CHD, because dyslipidemia is associated with increased risk of cardiovascular events [4, 5]. Although the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) recommends starting universal screening for high cholesterol levels at the age of 20 [6], many adults between the ages 20 and 44 years have missed the opportunity to get their blood cholesterol levels checked in their past 5 years [4].

Some studies have demonstrated that a well-designed health education program can enhance people’s adherence to screening programs by means of raising their awareness and increasing their knowledge of health [7]. The past decade has witnessed the increasing popularity of cell phones in most countries. The vast majority of adult Iranians own cell phones and texting (by using short message service, or SMS) is a very common practice among cell phone users in Iran. Therefore, SMS could be utilized for educational interventions for a large segment of the population at any time or place. Simplicity, low cost, widespread use and instant delivery are the rewarding features of employing this particular method [8, 9].

SMS-related improvements in healthcare outcomes have been reported in form of improved outpatient clinic attendance, encouragement for weight loss, compliance with taking medication, growing support for diabetic and asthmatic patients, increased smoking quit rates and increased sunscreen application [8, 10]. However, most of these studies have focused on clinical care interventions in sick individuals and there has been a paucity of information in the domain of prevention in healthy individuals. As an example of the latter group, a recent study showed that a telemonitoring program via SMS was an effective strategy in the secondary prevention of acute coronary syndrome survivors [11]. Park et al. also reported improved control of blood pressure, body weight, waist circumference and HDL-C levels in patients with concomitant obesity and hypertension after eight weeks of SMS intervention [12].

In the present study, we studied the cost-effectiveness of SMS as a tool to encourage people to check their blood cholesterol levels. To the best of the authors’ knowledge, this is the first published study that focuses on the cost-effectiveness of SMS in encouraging people to control a CHD risk factor.

Regardless of the study group, women were significantly more aware of their blood cholesterol levels than men were (68.7% vs. 53.6%, P < 0.001).

Screening young adults for serum lipid disorders is recommended by numerous specialties, particularly young adults with CHD, CHD equivalents or individuals with one or more cardiac risk factors [13, 14]. Nevertheless, convincing healthy people to take action and check their blood lipid levels appears to be almost a farfetched achievement [10]. As found in our study, 39% of the respondents had not checked their blood cholesterol levels during the two-year period leading up to our study.

We used cellular texting (SMS) as a tool for the reminder strategy in order to increase knowledge and attitude toward the important role that cholesterol plays in developing CHD, as well as increasing healthy people’s adherence to a preventive behavior toward CHD. We noted that this strategy inspired one out of twenty-five people in the general population to actually check his/her blood cholesterol level. We also found that the NNT for this intervention was less for people with a positive family history of CHD; therefore, the effectiveness of this strategy could be enhanced by focusing on the relatives of CHD patients.

During the intervention period, the attitude of the intervention group toward checking their cholesterol levels, regardless of the required time and money, was improved and this result was in accordance with the improvement in the preventive practice of testing the blood cholesterol level. Improvement in healthcare outcomes has been reported in previous studies examining the use of SMS [8, 10]; however, when Cocosila et al. evaluated the usefulness of SMS, they found non-significant improvement in healthy people’s adherence to taking vitamin C [9].

In the context of health economics, the cost of motivating a person in the general population to actually check his/her blood cholesterol level was 4.9 (25_NNT × 0.195_{cost of successful SMS delivery}) USD. The cost-effectiveness of this strategy could be augmented by restricting the target population to the relatives of high-risk CHD patients. With this restriction in mind, it would cost 2.1 USD per person to inspire a healthy relative of a high-risk CHD patient to do a screening for blood cholesterol level. A few studies in the existing literature have evaluated the cost-effectiveness of texting. Chen et al. [15] showed that reminding each patient of an appointment via SMS was significantly cheaper (0.31 Yuan per SMS) than telephone (0.48 Yuan per call). Koshy et al. [16] also used SMS reminders for ophthalmology outpatient appointments and concluded it was more cost-effective and less demanding than traditional methods.

The cost-effectiveness of the texting strategy also depends on the optimum number of messages, which demands further studies.

In the present study, female respondents were more aware of their cholesterol level and also checked their blood cholesterol levels twice as much as male participants. Considering the role of the male gender as an independent CHD risk factor [17], specific interventions are required, in order to propel men to enhance their health awareness. Furthermore, this result regarding gender as a factor can be interpreted as a sign of women having more sensitivity and attention to their health concerns [18].

In this study we randomly texted general population. Since higher blood cholesterol levels are expected in certain populations such as males, diabetics and smokers [19–21], stratification of the target group according to sex, existence of diabetes mellitus and smoking may yield better results. For this reason, these specific groups must be prioritized for screening programs.

During the study period, we addressed two important reasons for non-adherence within the participants: forgetfulness that was addressed by means of sending reminders every two weeks, and lack of knowledge, which was addressed by sending texts, which pointed the importance as well as one serious side effect of having high blood cholesterol levels [8].

In the light of our study results, we would postulate that SMS could affect people’s adherence to preventive programs for several reasons. As stated before, cell phones are widely used across Iran, and texting by using SMS is a common practice. Simplicity, efficiency, confidentiality [22], affordability and feasibility are also among the reasons why SMS use should be considered for preventive programs [8, 10].

In spite of these unique features of SMS, we should bear in mind that certain groups are less likely to access cell phones or be adequately educated to read texts. Those groups including, though not limited to, the unemployed, the destitute, the illiterate and the elderly need further education or assistance regarding the use of SMS. Another important limitation of this strategy was highlighted by our study; in the sense that the correct recollection of the message content was only 55.3% of the intervention group’s participants.

In this study, we were able to document the effectiveness of utilizing SMS as a preventive strategy for CHD. However, further research is needed to determine the optimal number of SMS messages to be sent, the optimal interval between the messages, and the most efficacious content and wording of the messages when accounting for different populations (for instance, people with dissimilar occupations and educational background).