A randomized controlled behavioral intervention trial to improve medication adherence in adult stroke patients with prescription tailored Short Messaging Service (SMS)-SMS4Stroke study.
BACKGROUND
The effectiveness of mobile technology to improve medication adherence via customized Short Messaging Service (SMS) reminders for stroke has not been tested in resource poor areas. We designed a randomized controlled trial to test the effectiveness of SMS on improving medication adherence in stroke survivors in Pakistan.


METHODS
This was a parallel group, assessor-blinded, randomized, controlled, superiority trial. Participants were centrally randomized in fixed block sizes. Adult participants on multiple medications with access to a cell phone and stroke at least 4 weeks from onset (Onset as defined by last seen normal) were eligible. The intervention group, in addition to usual care, received reminder SMS for 2 months that contained a) Personalized, prescription tailored daily medication reminder(s) b) Twice weekly health information SMS. The Health Belief Model and Social Cognitive theory were used to design the language and content of messages. Frontline SMS software was used for SMS delivery. Medication adherence was self-reported and measured on the validated Urdu version of Morisky Medication Adherence Questionnaire. Multiple linear regression was used to model the outcome against intervention and other covariates. Analysis was conducted by intention-to-treat principle.


RESULTS
Two hundred participants were enrolled. 38 participants were lost to follow-up. After 2 months, the mean medication score was 7.4 (95 % CI: 7.2-7.6) in the intervention group while 6.7 (95 % CI: 6.4-7.02) in the control group. The adjusted mean difference (Δ) was 0.54 (95 % CI: 0.22-0.85). The mean diastolic blood pressure in the intervention group was 2.6 mmHg (95 % CI; -5.5 to 0.15) lower compared to the usual care group.


CONCLUSIONS
A short intervention of customized SMS can improve medication adherence and effect stroke risk factors like diastolic blood pressure in stroke survivors with complex medication regimens living in resource poor areas.


BACKGROUND
Clinicaltrials.gov NCT01986023 last accessed at https://clinicaltrials.gov/ct2/show/NCT01986023.
Stroke Services, Section of Neurology, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center, National Institutes of Health) and Aga Khan University, Stadium Road, 74800, Karachi, Pakistan. ayeesha.kamal@aku.edu.
Ayeesha Kamran
AK
Kamal
Fogarty Cerebrovascular Research Fellow, The International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center, National Institutes of Health) and Aga Khan University, Karachi, Pakistan. quratulain.shaikh@aku.edu.
Quratulain
Q
Shaikh
Epidemiology and Biostatistics Program, Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan. omrana.pasha@aku.edu.
Omrana
O
Pasha
Department of Community Health Sciences, Biostatistics, Aga Khan University, Karachi, Pakistan. iqbal.azam@aku.edu.
Iqbal
I
Azam
Department of Community Health Sciences, Biostatistics, Aga Khan University, Karachi, Pakistan. muhammad.islam@aku.edu.
Muhammad
M
Islam
SMS4Stroke Study, The International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center, National Institutes of Health) and Aga Khan University, Karachi, Pakistan. adeel.ali.memon@gmail.com.
Adeel Ali
AA
Memon
Stroke Service, Aga Khan University, Karachi, Pakistan. hasanrehman89@gmail.com.
Hasan
H
Rehman
Stroke Service, Aga Khan University, Karachi, Pakistan. masood.ahmed.akram@gmail.com.
Masood Ahmed
MA
Akram
SMS4Stroke Study, The International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center, National Institutes of Health) and Aga Khan University, Karachi, Pakistan. muhammad.affan87@gmail.com.
Muhammad
M
Affan
SMS4Stroke Study, The International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center, National Institutes of Health) and Aga Khan University, Karachi, Pakistan. drsumairapk@yahoo.com.
Sumaira
S
Nazir
SMS4Stroke Study, The International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center, National Institutes of Health) and Aga Khan University, Karachi, Pakistan. memon.salman@gmail.com.
Salman
S
Aziz
Stroke Services, Section of Neurology, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center, National Institutes of Health) and Aga Khan University, Stadium Road, 74800, Karachi, Pakistan. muhammad.jan@aku.edu.
Muhammad
M
Jan
Stroke Services, Section of Neurology, Department of Medicine, The International Cerebrovascular Translational Clinical Research Training Program (Fogarty International Center, National Institutes of Health) and Aga Khan University, Stadium Road, 74800, Karachi, Pakistan. anita.andani@aku.edu.
Anita
A
Andani
eHealth Innovation, Global, eHealth Resource Center, Aga Khan Development Network, Karachi, Pakistan. abdul.muqeet@akdn.org.
Abdul
A
Muqeet
Epidemiology and Biostatistics, Department of Medicine, Aga Khan University, Karachi, Pakistan. bilal.ahmed@aku.edu.
Bilal
B
Ahmed
Tech4Life Enterprises, and Technical Advisor-Evidence, Capacity & Policy mHealth Alliance, United Nations Foundation, Washington, USA. khojashariq@gmail.com.
Shariq
S
Khoja
D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001521:Behavior Therapy / Q000379:methods*; D001794:Blood Pressure; D040421:Cell Phone; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010154:Pakistan; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011582:Psychological Theory; D017010:Reminder Systems; D055502:Secondary Prevention; D016037:Single-Blind Method; D020521:Stroke / Q000188:drug therapy*; D060145:Text Messaging
D000959:Antihypertensive Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors