Academic journal article Bulletin of the World Health Organization

Use of Text Messages to Communicate Clinical Recommendations to Health Workers in Rural China: A Cluster-Randomized trial/Utilisation Du Texting Pour Communiquer Les Recommandations Cliniques Aux Professionnels De la Sante En Chine Rurale: Un Essai Randomise Par grappes/El USO De Los Mensajes De Texto Para Comunicar Recomendaciones Clinicas Al Personal Sanitario En la China Rural: Un Ensayo Aleatorio De Grupos

Academic journal article Bulletin of the World Health Organization

Use of Text Messages to Communicate Clinical Recommendations to Health Workers in Rural China: A Cluster-Randomized trial/Utilisation Du Texting Pour Communiquer Les Recommandations Cliniques Aux Professionnels De la Sante En Chine Rurale: Un Essai Randomise Par grappes/El USO De Los Mensajes De Texto Para Comunicar Recomendaciones Clinicas Al Personal Sanitario En la China Rural: Un Ensayo Aleatorio De Grupos

Article excerpt

Introduction

Health workers in rural China do not receive systematic, qualified medical education and training (1,2) because, unlike their urban counterparts, they face constraints such as inadequacies in transport and funding and they are largely unaware of the need for education. (3,4) Gansu Province has 16 853 health workers (including family physicians, nurses, public health practitioners, pharmacists, midwives and laboratory technicians) in 1333 township health centres, distributed across 14 regions. (5) Most of the health centres are located in remote mountainous areas, and thus providing continuing medical education to these health workers is a major challenge. (6)

Mobile text messages have been used to improve health outcomes in a wide range of contexts because of their low cost and convenience. (7,8) For instance, text messages have been used in health programmes for smoking cessation, (9) disease management (10-12) and weight reduction (13) and to improve adherence to medication (14) and attendance at health-care appointments. (15) Since Chinese mobile phone users send high volumes of messages 79 billion messages, equivalent to 73 per user--in September 2012 alone (16)--we hypothesized that such messages could be useful for communicating medical information to rural health workers in China.

In general, text messages seem to be effective for communicating information in a health-care context and have been well accepted by users. (17,18) Research also indicates that text messages could serve as a powerful tool for behaviour change, (19-21) both in developed and developing countries. (22) However, so far research has focused almost exclusively on the sending of health messages to patients rather than to health workers, and on the use of messages as patient reminders rather than for the delivery of evidence-based information. In this study, we tested whether text messages sent to rural health workers containing evidence-based recommendations could improve knowledge and influence prescribing medical practice.

Methods

Study design, participants and recruitment

The study was undertaken in the Gansu province in north-western China from 17 October to 25 December 2011. It was designed as a "before" and "after" randomized controlled trial. The intervention group was sent text messages on the management of viral infections affecting the upper respiratory tract and otitis media, and the control group was given the same messages in the context of a regular continuing medical education programme. In preparation for the trial, we undertook several surveys and conducted two pilot studies in seven health centres in Gaolan county, Gansu province, between November 2009 and April 2011. Information on these pilot studies, which were conducted to choose the best content and delivery of the text messages and to conduct a power analysis for the trial, can be obtained from the corresponding author on request.

To be eligible for recruitment individuals had to be health workers in a township health centre in Gansu province. The term "health worker" was used broadly to include family physicians, nurses, public health practitioners, pharmacists, midwives and laboratory technicians. Only physicians could prescribe drugs, but other health workers were also sent text messages because of their potential influence on physician behaviour. In addition, the pilot studies showed that confining text messages to physicians made other health workers feel excluded. Health workers who did not own a mobile phone or whose mobile phone could not receive text messages were excluded from the trial.

Sample size

The power calculations were based on the results of two pilot studies and the formula outlined by Donner and Klar (23) for cluster randomized trials with a binary study outcome. The analysis of variance estimator of the intra-cluster correlation coefficient was calculated as 0. …

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