Mobile Phone Text Messages to Support Treatment Adherence in Adults With High Blood Pressure (SMS-Text Adherence Support [StAR]): A Single-Blind, Randomized Trial
Open accessAbstract
Background—: We assessed the effect of automated treatment adherence support delivered via mobile phone short message system (SMS) text messages on blood pressure. Methods and Results—: In this pragmatic, single-blind, 3-arm, randomized trial (SMS-Text Adherence Support [StAR]) undertaken in South Africa, patients treated for high blood pressure were randomly allocated in a 1:1:1 ratio to information only, interactive SMS text messaging, or usual care. The primary outcome was change in systolic blood pressure at 12 months from baseline measured with a validated oscillometric device. All trial staff were masked to treatment allocation. Analyses were intention to treat. Between June 26, 2012, and November 23, 2012, 1372 participants were randomized to receive information-only SMS text messages (n=457), interactive SMS text messages (n=458), or usual care (n=457). Primary outcome data were available for 1256 participants (92%). At 12 months, the mean adjusted change in systolic blood pressure compared with usual care was −2.2 mm Hg (95% confidence interval, −4.4 to −0.04) with information-only SMS and −1.6 mm Hg (95% confidence interval, −3.7 to 0.6) with interactive SMS. Odds ratios for the proportion of participants with a blood pressure <140/90 mm Hg were 1.42 (95% confidence interval, 1.03–1.95) for information-only messaging and 1.41 (95% confidence interval, 1.02–1.95) for interactive messaging compared with usual care. Conclusions—: In this randomized trial of an automated adherence support program delivered by SMS text message in a general outpatient population of adults with high blood pressure, we found a small reduction in systolic blood pressure control compared with usual care at 12 months. There was no evidence that an interactive intervention increased this effect. Clinical Trial Registration—: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02019823. South African National Clinical Trials Register, number SANCTR DOH-27-1212-386; Pan Africa Trial Register, number PACTR201411000724141.
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Digital health interventions have become a very effective, useful and available form of healthcare delivery in self-management and controlling hypertension compared with usual care.
“In recent years, digital health interventions have become a very effective, useful and available form of healthcare delivery in self-management and controlling hypertension,8, 9, 10, 11, 12 compared with usual care.”
From Effectiveness of digital health interventions on blood pressure control, lifestyle behaviours and adherence to medication in patients with hypertension in low-income and middle-income countries: a systematic review and meta-analysis of randomised controlled trials (2024) · cites this paper as [8]
The Results (Primary outcome and Secondary outcomes; page not provided) show that SMS adherence support improved medication adherence and that information-only messages produced a small reduction in systolic blood pressure compared with usual care. The Conclusion says the intervention may modestly decrease blood pressure and can be delivered automatically. This supports the claim for this specific intervention, but not the broader assertion that digital health interventions generally are “very effective” for hypertension self-management; the interactive arm’s blood-pressure difference was not statistically significant. (LLM, conf=0.89)
Experimental — accuracy not yet measuredDigital health technologies have the potential to deliver low-cost interventions aimed at supporting disease self-management.
“Digital health technologies have the potential to deliver low-cost interventions aimed at supporting healthier lifestyles [12] and disease self-management [13,14].”
In Bobrow et al 2016, the adjusted difference in change in systolic blood pressure for the interactive message group compared with usual care was -1.6 mm Hg (95% CI -3.7 to 0.6, p=0.16).
“for the interactive message group compared with usual care −1.6 mm Hg (−3.7 to 0.6, p=0.16).”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
In Bobrow et al 2016 in South Africa, the adjusted difference in change in systolic blood pressure for the information-only message group compared with usual care was -2.2 mm Hg (95% CI -4.4 to -0.04, p=0.046).
“The mean (95% CI, p value) adjusted difference in change for the information-only message group compared with usual care was systolic blood pressure −2.2 mm Hg (−4.4 to −0.04, p=0.046)”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
In Bobrow et al 2016, subgroup analysis showed no statistically significant heterogeneity in treatment effects.
“There was no statistically significant heterogeneity in the treatment effects and there was an indication that active interventions were more effective among older patients (55 years), patients in better control at baseline (<140 mm Hg) and among those with a shorter duration of hypertension (<10 years).”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
In Bobrow's study, the mHealth components were reminders and the opportunity to change appointment times, allowing patients to fit the intervention into daily life.
“In Bobrow’s study, the mHealth components were reminders, opportunity to make changes to appointment times so the patient was able to fit the intervention into their daily life.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
In Bobrow et al 2016, secondary outcomes did improve; proportion of days of medication covered was higher in both intervention groups, suggesting they were remembering to collect their medication because of the reminders.
“Yes—the secondary outcomes did improve. Proportion of days of medication covered (adherence to medication) was higher in both intervention groups suggesting that they were remembering to collect their medication because of the reminders: the two intervention groups were collecting the medication more regularly over the control groups.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
In Bobrow et al 2016, there was an indication that active interventions were more effective among patients in better control at baseline (<140 mm Hg).
“There was no statistically significant heterogeneity in the treatment effects and there was an indication that active interventions were more effective among older patients (55 years), patients in better control at baseline (<140 mm Hg) and among those with a shorter duration of hypertension (<10 years).”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
In Bobrow et al 2016, there was an indication that active interventions were more effective among older patients (55 years).
“There was no statistically significant heterogeneity in the treatment effects and there was an indication that active interventions were more effective among older patients (55 years), patients in better control at baseline (<140 mm Hg) and among those with a shorter duration of hypertension (<10 years).”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
In Bobrow et al 2016, there was an indication that active interventions were more effective among those with a shorter duration of hypertension (<10 years).
“There was no statistically significant heterogeneity in the treatment effects and there was an indication that active interventions were more effective among older patients (55 years), patients in better control at baseline (<140 mm Hg) and among those with a shorter duration of hypertension (<10 years).”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
In Bobrow et al 2016, among patients with adherence data, 63% in the information-only group, 60% in the interactive group, and 49% in the usual care group had 80% proportion of days covered for blood pressure lowering medication over 12 months.
“Out of the 86% of patients, the trial had adherence data available, 63% from the information only message intervention group, 60% for the interactive message intervention group and 49% from the usual care group, had 80% of proportion of days covered for blood pressure lowering medication for a 12-month period.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
In Bobrow et al 2016, the primary outcome did not improve; blood pressure levels in both intervention groups did not decrease during the trial period, suggesting the text message did not help reduce blood pressure control in adults with diagnosed high BP and on treatment.
“No—the primary outcome did not improve. Blood pressure levels in both intervention groups did not decrease during the trial period suggesting the text message (information and interactive) did not help to reduce blood pressure control in adults with diagnosed high BP and on treatment (partly because many of them were stable at baseline).”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as Bobrow et al, 2016
Bobrow's study found a non-significant reduction in systolic blood pressure control compared with usual care at both 6 and 12 months.
“Bobrow’s study found a non-significant reduction in systolic blood pressure control compared with usual care at both 6 and 12 months.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
In Bobrow's study, the mHealth intervention allowed patients to feel cared for by the nurse and to take more control of their management by changing appointments from their phones.
“The mHealth intervention allowed the patient to feel cared for by the nurse and to take more control of their management by having the option to change appointments from their phones.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
There was significant improvement in the secondary outcome of adherence to collecting medication from the clinic in Bobrow's study.
“There was significant improvement in their secondary outcome of adherence to collecting medication from the clinic.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
Bobrow's study found that patients who benefited the most from the mHealth intervention were those with high personal stress caused by multiple psychosocial stressors.
“Bobrow’s study found that patients who benefited the most from the mHealth intervention were those with high personal stress caused by multiple psychosocial stressors.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
In Bobrow's study, the intervention did not lead to a decrease in blood pressure.
“This did not lead to a decrease in blood pressure; however, adherence to medication improved.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
In Bobrow's and Lester's studies, the interventions were more effective for patients early in their disease trajectory.
“In Bobrow’s and Lester’s studies, the interventions were more effective for patients early in their disease trajectory.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
In Bobrow's study, text messages increased disease awareness and visibility.
“The text messages increase disease awareness and thus its visibility.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
In Bobrow's study, adherence to medication improved.
“This did not lead to a decrease in blood pressure; however, adherence to medication improved.”
From mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review (2018) · cites this paper as [45]
A text messaging intervention could elicit a small reduction in systolic blood pressure control compared with usual care at 12 months.
“A RCT by Bobrow et al. 56 included 1372 patients and demonstrated that a text messaging intervention could elicit a small reduction in systolic BP control compared with usual care at 12 months.”
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- Authors
- Bobrow, K., Farmer, A. J., Springer, D., Shanyinde, M., Yu, L.-M., Brennan, T., Rayner, B., Namane, M., Steyn, K., Tarassenko, L., & Levitt, N.
- Affiliations
- Western Cape Department of Health (ZA)
- From Institute of Biomedical Engineering, Department of Engineering Science (K.B., D.S., T.B., L.T.) and Nuffield Department of Primary Care Health Sciences (K.B., A.J.F., M.S., L.-M.Y.), University of Oxford, UK; Chronic Disease Initiative for Africa, Cape Town, South Africa (K.B., K.S., N.L.); Division of Nephrology and Hypertension, Groote Schuur Hospital, Cape Town, South Africa (B.R.); University of Cape Town, South Africa (B.R.); Western Cape Province Department of Health, Cape Town, South...
- Corresponding author
- Bobrow, Kirsten
- ORCID
- Venue
- Circulation
- Published
- 2016-02-09
- Volume
- 133
- Issue
- 6
- Pages
- 592-600
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- PMC
- PMC4750295
- OpenAlex
- W2262346340
- Cited by
- 295
- References
- 43
- Citations by year
- 2026: 17 · 2025: 22 · 2024: 30 · 2023: 24 · 2022: 32 · 2021: 39 · 2020: 31 · 2019: 37 · 2018: 32 · 2017: 20 · 2016: 11
- FWCI
- 62.09
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Wellcome Trust (088877)
- National Institute for Health and Care Research (NF-SI-0512-10077)
- Topics
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Health Sciences › Medicine › Family Practice › Medication Adherence and Compliance
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Keywords
- hypertension, antihypertensive treatment adherence, safety management systems, mobile health, systolic blood pressure control, antihypertensive therapy, South Africa
- MeSH terms
- Adult, Aged, Female, Follow-Up Studies, Humans, Hypertension, Male, Middle Aged, South Africa, Single-Blind Method, Telemedicine, Cell Phone, Medication Adherence, Text Messaging
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