Image: CDC, 2016, https://www.cdc.gov/malaria/ A randomized trial on the impact of text message reminders on adherence to antimalarial treatment Julia Raifman, ScD Heather Lanthorn, ScD Slawa Rokicki, ScM Günther Fink, PhD SUMMARIZE: We look at the impact of sending a short or a long reminder message on self-reported ACT adherence Image: CDC, 2016, https://www.cdc.gov/malaria/

Study objectives Objectives Problem Low adherence to antimalarial treatment Objectives Assess the impact of text message reminders on adherence to ACT regimens Develop and test a scalable method of enrolling patients in a text message reminder system We have some reason to think that text message reminders might improve adherence Few studies on text message reminders among developing country populations Image: CDC, 2016, http://wwwnc.cdc.gov/travel/diseases/malaria

Study Setting & Population Tamale, capital of Northern Region Endemic malaria 85% mobile phone ownership1 Recruited from 69 public and private ACT vendors within 30 minutes of Tamale ACTs: AL and AS+AQ 3X2 regimen! 1. International Telecommunications Union, 2012 Image: Ghana Web, 2012

Enrollment in text message system Own phone “Flashing” Designed to represent feasible method of scale-up Self-enrollment and own phone differentiates this study from past studies of text reminders Outcome: Self-reported adherence validated by pill count Method: Logistic regression analysis

Randomization Enrollment 3 Days Day 5 All individuals purchasing ACTs from vendor Receive flyer for text message system enrollment Enrollment Study enrollment, Enrollment message: “Thank you for registering for mobile health information” Randomization Treatment 6 messages at 7:00 am and 7:00 pm for 60 hours Control No messages during ACT treatment Long message “Please take your MALARIA drugs. Even if you feel better, you must take all the tablets to kill all the malaria.” Follow up Interview Short message “Please take your MALARIA drugs” 3 Days Malaria prevention message: “Sleep under a bed net to prevent malaria” Day 5

Adherence among adults in the control group Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6 100% 80% 60% 40% 20% 0% Dose number Percent of respondents completing dose This is adherence among adults in the control group. 84% reported taking dose 4 74% reported taking dose 5 56% reported taking dose 6 Percent of respondents completing dose 95% Confidence Interval Percent of respondents completing dose 95% Confidence Interval Percent of respondents completing dose 95% Confidence Interval

Proportion completed treatment Intervention Impact N=1141 Proportion completed treatment Adjusted OR Control group 61.5% 331/538 Reference group Either text message 66.4% 380/572 1.21 (0.94 – 1.56) Short message 69.0%** 185/268 1.45** (1.03 – 2.04) Long message 64.1% 195/304 1.08 (0.80 – 1.47) Covariates: Patient sex, patient age, male household head, household head educational attainment, household wealth quintile, and whether participants sought care at private hospitals or clinics or public hospitals or clinics. * p < 0.1 ** p < 0.05 *** p <0.001

Discussion ACT adherence is low 58% of adults in control group Impact of text message reminders depends on content Short text message reminders increase the odds of ACT adherence by 38.5% Pharmacists distributing flyers is a feasible distribution method

Acknowledgements Clinton Health Access Initiative Innovations for Poverty Action-Ghana Jessica Cohen, Harvard School of Public Health