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Short message service (SMS) interventions for the prevention and treatment of sexually transmitted infections:… Lunny, Carole; Taylor, Darlene; Memetovic, Jasmina; Wärje, Orion; Lester, Richard; Wong, Tom; Ho, Kendall; Gilbert, Mark; Ogilvie, Gina Jan 16, 2014

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PROTOCOL Open AccessShort message service (SMS) interventions for theprevention and treatment of sexually transmittedinfections: a systematic review protocolCarole Lunny1,2*, Darlene Taylor1,2, Jasmina Memetovic1,2, Orion Wärje1, Richard Lester1,2, Tom Wong3,Kendall Ho2,4,5, Mark Gilbert1,2 and Gina Ogilvie1,2AbstractBackground: Globally, the incidence of sexually transmitted infections (STI) is rising, posing a challenge to itscontrol and appropriate management. Text messaging has become the most common mode of communicationamong almost six billion mobile phone users worldwide. Text messaging can be used to remind patients aboutclinic appointments, to notify patients that it is time for STI re-testing, and to facilitate patient communication withtheir health professionals with any questions and concerns they may have about their sexual health. While thereare a handful of systematic reviews published on short message service (SMS) interventions in a variety of healthsettings and issues, none are related to sexual health. We plan to conduct a systematic review to examine theimpact text messaging might have on interventions for the prevention and care of patients with STIs.Methods/Design: Eligible studies will include both quantitative and qualitative studies published after 1995 thatdiscuss the efficacy and effectiveness of SMS interventions for STI prevention and management using textmessaging. Data will be abstracted independently by two reviewers using a standardized pre-tested data abstractionform. Inter-rater reliability scores will be obtained to ensure consistency in the inclusion and data extraction of studies.Heterogeneity will be assessed using the I2 test and subgroup analyses. A nonhypothesis driven inductive reasoningapproach as well as a coding framework will be applied to analyze qualitative studies. A meta-analysis may beconducted if sufficient quantitative studies are found using similar outcomes.Discussion: For this protocol, we identified ten related systematic reviews. The reviews were limited to a particulardisease or setting, were not exclusive to SMS interventions, or were out of date. This systematic review will be the firstcomprehensive examination of studies that discuss the effectiveness of SMS on multiple outcomes that relate to STIprevention and management, covering diverse settings and populations. Findings of the systematic review and anyadditional meta-analyses will be published and presented to our key knowledge users. This information will providethe evidence that is required to appropriately adopt text messaging into standard practice in STI care.Keywords: short message service, cell phones, mobile health, HIV, chlamydia, gonorrhea, syphilis, hpapillomavirus,herpes simplex virus, Sexually transmitted infections* Correspondence: carole.lunny@bccdc.ca1BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BritishColumbia V5Z 4R4, Canada2University of British Columbia, 2329 W Mall, Vancouver, British Columbia V6T1Z4, CanadaFull list of author information is available at the end of the article© 2014 Lunny et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (, which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedicationwaiver ( applies to the data made available in this article, unless otherwisestated.Lunny et al. Systematic Reviews 2014, 3:7 rates of reported sexually transmitted infections(STIs) remain a major public health challenge worldwide.Despite active and passive surveillance activities and mul-tiple interventions aimed at increasing case finding andtreatment, human immunodeficiency virus (HIV), chla-mydia (CT), gonorrhea (GC), syphilis, herpes, and humanpapillomavirus (HPV) infections impose a large burden onhealth resources [1,2].In the past two decades, the population use of newtechnologies such as mobile phones and the internet hasexploded. The Canadian Wireless Telecommunications As-sociation figures showed that almost 27 million Canadians,representing more than 81% of the Canadian population,subscribed to mobile phones in 2012 [3]. Of those whoown smart phones in Canada, according to RogersCommunications survey in 2012, text messaging wasnoted to be the top application (88% users) [4]. Further-more, a Statistics Canada 2010 survey revealed that 78%of Canadian have a cell phone, and wireless-only homesincreased to 13% from 8% in 2008 [5].Text messaging is commonly used in a variety of med-ical contexts. Text messaging allows patients and pro-viders to ‘interact’ via two-way communication [6], whichcan allow for enhanced support by health-care providersto confirm medication taking [7,8], to enable patients toask medication questions to pharmacists [9], and to alertclinic staff of problems [10]. SMS messages can be cus-tomized to fit the needs of specific individuals by deliver-ing tailored messages that are more likely to catch theindividual’s attention and be perceived as personally rele-vant and interesting [11]. Moreover, because messages ex-changed between health-care providers and clients arestored on the device, there is the potential for them to be-come part of the client’s health-care record.SMS has been used in other health contexts in the formof smoking cessation [12-14], cancer [15], diabetes[16-23], asthma [24-34], diet or weight management [35],obesity [36], and reminder programs [37-43]. In the con-text of sexual health services, SMS has been used in theform of appointment reminders [44,45], STI rescreeningreminders [46,47], provision of STI results [48-51], commu-nication of STI information [10,52], sexual health promo-tion [53,54], and assistance with contact-tracing [55-58]. Ithas also been shown to decrease the amount of time fromdiagnosis to treatment among positive chlamydia patients[49], increase the rate of retesting among high risk groups[59], and reduce the amount of missed clinic appoint-ments [10,44]. Others report that sexual health knowledgeand behavior is increased by delivering educational mes-sages via text message [53,54]. Because younger peoplehave higher risk of acquiring STIs such as GC and CT,text messaging, which is commonly used by this segmentof the population, can be an effective tool to reach andhelp them in STI management and care. Today, text messa-ging and email managed on handheld devices are overtak-ing traditional voice calling for personal communicationin Europe and North America. However, despite wide-spread use, there is little consensus about the actual im-pact that SMS interventions have on the prevention andcontrol of STIs. The purpose of this systematic review isto examine the use of SMS to improve the treatment andprevention of STIs. Our research will attempt to answerthe following questions: (a) What are the various waysthat SMS use has been proposed to improve STI preven-tion and management in quantitative studies with controlgroups? (b) What are the potential benefits and harms forparticipants of SMS interventions related to STI pro-grams? (c) What are the experiences and perceptions ofpeople involved in STI-related SMS interventions? and (d)Why does an intervention work (or not), for whom, andin what circumstances?Methods/DesignInclusion/exclusionThe following inclusion/exclusion criteria are based onPatient and Problem, Intervention, Comparison and Out-come (PICO) domains.Study designEligible studies will include randomized and non-randomized controlled trials, pre- and post-test de-signs, non-experiment observational (cross-sectional,case-series, case studies) and qualitative papers thatexamine the benefits and other impacts of SMS inter-ventions on STIs.PopulationIndividuals of any age who use cell phones and have beeninvolved in an intervention that uses text messaging as pa-tient support to improve the treatment and prevention ofSTIs will be included.InterventionSMS or text messaging interventions that are deliveredthrough a mobile electronic device to improve the treat-ment and prevention of STIs will be included.ComparatorThe comparison is the usual standard of care, or in thecase of a randomized control trial, the comparison is thecontrol condition.OutcomeThe a priori primary outcomes of interest include: (a)clinical outcomes (HIV viral suppression, STI clearance,STI re-infections); (b) adherence (for example, percent-age of missed appointments, adherence to medication),Lunny et al. Systematic Reviews 2014, 3:7 Page 2 of 8 STI testing (for example, rates of primary testing, re-testing), (c) changes in STI knowledge or risk behavior(for example, increased condom use), (d) uptake of SMSfor partner notification, (e) acceptability of SMS for STIinterventions, and (f ) any cost-effectiveness assessments.Secondary outcomes are: notification of test results, con-dom use, mental health outcomes (for example, anxietyand depression scores), quality of communication withclinicians, quality of care, feasibility of program deliveryand privacy impact of SMS messages (for example, contentof messages). Outcomes that are similar will be groupedfor quantitative synthesis. Outcomes will be grouped basedon an objective or subjective class (Table 1). We will in-clude other outcomes of interest identified during theliterature review.Exclusion criteriaThe following data will be excluded: commentary oropinion publications without new data, publications be-fore 1996, research that does not include use of SMS/text messaging, research that uses PDAs other than PDAphones, and studies with an email/social network-based/landline telephone intervention. Studies using PDAsonly (and not PDA phones) will be excluded because oftheir relatively uncommon use with most populationsduring their peak popularity (for example, often used byphysicians but not their patients).Search strategyThe databases that will be searched for journal articles,reports, editorials and abstracts include Ovid (for example,Cochrane Database of Systematic Reviews, Medline,Embase), Web of Knowledge (for example, Biosis, Web ofScience), and EBSCO (for example, PsycINFO, ERIC,CINHAL, etcetera). The gray literature will be searchedfor reports, dissertations, conference proceedings andmobile health-related websites. Our search will includeEnglish and non-English-based databases. Since SMS isrelatively new, the search will be limited to articles pub-lished between 1996 to August 2013. The following STIjournals will be hand-searched by an inhouse librarian:Sexually Transmitted Diseases, Sexually TransmittedInfections, and AIDS Patient Care and STDs.Search termsMedical Subject Headings (MeSH), subject headings andkeywords will be created by using language that describestext message interventions for STIs. Search terms will in-clude but will not be limited to: mobile health, mHealth,cell phone, mobile phone short message service, SMS,MMS, communication technologies, patient monitor-ing devices, wireless technologies, STI testing, sexuallytransmitted diseases, sexually transmitted infections,HIV, chlamydia, gonorrhea, herpes, Trichomonas vagi-nalis, and syphilis. Boolean combinations will createmore specific searches using Ovid MeSH terms as thestandard for developing a search strategy for each database.A health librarian will be consulted to ensure the opti-mal search strategy is being conducted. In addition, back-ward and forward citation searches of included studies,relevant evidence reviews and reports will also be done.Email letters will be sent out to scholars in leadership andother related fields to ask them to review the list of studiesthat we included and to suggest other studies that theythought might be missed. This list will be expanded uponduring the data collection phase.Table 1 Outcomes classified on objective or subjective criteriaObjective/semi-objective Subjective● Mortality ● Mental health outcomes● Suppression of HIV viral load ● Quality of life/functioning● Sexually Transmitted Infection (STI) clearance ● Satisfaction with/Quality of care● STI re-infection ● Quality of communication● Withdrawals/drop-outs ● General physical health● Time to testing for an STI or HIV ● Adverse events● Time of symptom onset to seeking medical treatment (first time, recurrence) ● Continuation of condition● Time to uptake of diagnosis or treatment ● Cost-effectiveness● STI testing rates ● STI knowledge and behaviour● Correct clinical diagnosis or assessment ● Communication uptake regarding STIs● Improvement in condition (i.e. signs and symptoms) ● Feasibility of program delivery● Number and proportion of partners notified by short message service (SMS) ● Privacy impact/assessment● Cost savings/reduction ● Notification of test results● Condom useLunny et al. Systematic Reviews 2014, 3:7 Page 3 of 8 selection and extraction processOne reviewer will be responsible for creating a searchstrategy and will store all identified references in ashared RefWorks account. Once duplicates are manuallyremoved, all publications found will be exported into anMS Access database. Two reviewers will then independ-ently read the titles and abstracts of the identified arti-cles and determine eligibility based on the specifiedinclusion/exclusion criteria. Any disagreements betweenthe reviewers will be resolved by a third reviewer. Oncethe subset of publications meeting inclusion criteria is fi-nalized, each publication will be reviewed and its charac-teristics documented using a standardized pre-testeddata extraction form. These forms will capture: the pur-pose of the SMS intervention, duration of the interven-tion, delivery frequency of text messages, study design,setting and outcomes. The reviewers will attempt tocontact the authors of studies that are missing key data.The reviewers (CL, JM, and OW) will translate includedstudies written in French, Spanish. German, Mandarinor Korean, or use online translation software.Two reviewers will assess the studies with disagreementresolved by a third reviewer, and inter-rater reliability willbe measured using kappa statistics. An inter-rater Kappascore will be assessed during the inclusion/exclusion phaseof review, to ensure that a Kappa score at or above 0.8 isreached as measured by Cohen’s Kappa (k) statistical test[60]. If the measure falls below our threshold for high cor-respondence (0.8), the three reviewers will discuss untilagreement is reached.Methodological qualityThe methodological quality will be assessed using appro-priate tools, including the Cochrane Collaboration’s Riskof Bias tool for randomized controlled trials, the CochraneEffective Practice and Organization of Care group’s toolfor quasi-experimental designs, and the risk of bias tooldeveloped in Waddington et al. [61] study for regression-based studies (with special attention to confounding) [61].Other observational studies will be assessed using theNOS score (Newcastle-Ottawa Quality Assessment Scale)[62]. The NOS score rates quality based on high risk(1 to 3 stars), medium risk (4 to 5 stars), or low risk(6 to 9 stars) NOS score [62]. If data allows, we will ratethe overall quality of body of evidence using the GRADEsystem as it incorporates ratings for consistency, direct-ness, and precision per outcome across multiple studies inaddition rating the overall validity and risk of bias ( is usually necessary to consider the reliability or val-idity of the actual outcome measure being used (for ex-ample, several different scales can be used to measurequality of life or psychological outcomes). The reviewerswill meet to discuss any differences in the interpretationof the scales measuring semi-objective and subjectiveoutcomes. For bodies of evidence that include observa-tional research, we will also systematically assess the char-acteristics of each outcome, including dose–responseassociation, plausible confounding that would change theobserved effect, and the strength of association. We haveregistered our protocol with the Preferred Reporting Itemsfor Systematic Reviews and Meta-Analyses (PROSPEROregistration number CRD42013006503).Data analysisQualitative synthesis of studies We will describe theclinical and methodological characteristics of the in-cluded studies, including their size, inclusion or exclu-sion of important subgroups, timeliness, and otherrelevant factors, both qualitatively and by using tables ofstudy characteristics [63]. The strengths and limitationsof individual studies and patterns across studies will beassessed and we will explain how design weaknesses orexecution of the study (or groups of studies) could biasthe results.Quantitative analysis If the systematic review includesrandomized controlled trials or observational studies, wewill conduct meta-analysis and the Cochrane Collabora-tion’s Review Manager 5.0 will be used [64]. In the firstanalysis, a fixed-effects model will be used, and a random-effects model will check against it to ascertain its robust-ness. We will extract comparable effect size estimates fromincluded studies, together with 95 percent confidence in-tervals. Where possible, we will calculate standardizedmean differences (SMDs) for continuous outcome vari-ables, and risk ratios (RRs) for dichotomous outcomevariables.Treatment effects will be calculated as the ratio of, ordifference between, treated and control observations in aconsistent way, such that outcome measures are com-parable across studies. Thus, an SMD greater than zero(RR greater than 1) will indicate an increase in the out-come under the intervention as compared to the com-parison. An SMD less than zero (RR between 0 and 1)will indicate a reduction under the intervention as com-pared to the comparison. An SMD equal to (or insignifi-cantly different from) zero (RR equal to 1) will indicateno change in outcome over the comparison. Whetherthese relative changes represent positive or negative im-pacts will depend on meaning of the outcome in thecontext of the program being evaluated. We will onlyinclude one effect estimate per study. Where studies re-port multiple effect sizes according to subgroups of par-ticipants, we will report data on subgroups separately.If statistical heterogeneity is observed, a random-effectsmodel will be used. Statistical heterogeneity between studiesLunny et al. Systematic Reviews 2014, 3:7 Page 4 of 8 be examined visually using a I2 statistic and a chi-squared test (a chi-squared P value of less than 0.10 or anI-squared (I2) value equal to or more than 50% will beconsidered indicative of heterogeneity [65]. Furthermore,if heterogeneity is detected, subgroup analyses and meta-regression will be performed to identify factors that ex-plain the heterogeneity. The factors we identify a prioriare: (a) type of study design, (b) type of intervention, (c)purpose of the SMS intervention, (d) duration of interven-tion, (e) study setting, (f) sex ratio, (g) age groups (for ex-ample, adolescents, young adults, older adults), (h) qualityrating, (i) type of outcome (for example, STI type, type ofdevice used (Apple android, etcetera), number of re-minders, number of appointments missed, contraceptiveused), (j) English versus non-English literature, and (k)published versus unpublished literature. To evaluate thepossibility of publication bias, we will use the Peters testand a color-enhanced funnel plot that will be done usingSTATA software (StataCorp. 2011. Stata Statistical Soft-ware: Release 12. College Station, TX: StataCorp LP.)[66,67].Qualitative analysis We will employ interpretive de-scription to answer the qualitative questions in our re-view [68]. Interpretive description, developed by Thorneet al. in 1997, is applied to qualitative research findingsto solve a clinical problem as opposed to exploring atopic as an end goal (Thorne [68]). This strategy has twophases: (a) deriving findings inductively from data with-out imposing predetermined hypotheses, and (b) gener-ating results that apply to a real-world clinical practice.We will review qualitative data from included studies,develop a coding framework to code data using NVivo,and hold weekly discussions to resolve conflicts and ar-rive at final conclusions.DiscussionWhile there has been an explosion in the number of ar-ticles and studies on text messaging use in health inter-ventions, few reviews have conglomerated the literaturerelated directly to SMS and STIs. Ten systematic reviewsabout mobile interventions for promoting sexual healthwere identified ([69-78]; Additional file 1). The reviewswere limited to a particular disease or setting, were notexclusive to SMS interventions, or were out of date.SMS technology and use has evolved and has ex-panded in multiple health-care settings, and the numberof studies related to SMS interventions for STI has dra-matically increased since previous reviews were done.Although the reviews by Horvath et al. [69], Chavezet al., Zou et al. and Velthoven et al. [70-72] present im-portant findings with respect to text messaging and sex-ual health outcomes, they do not cover multiple efficacyand effectiveness outcomes of SMS interventions for abroad spectrum of STI prevention and control. Broad re-views such as the one by Sørensen et al. [73] and byChavez et al. [70] on the impacts of eHealth and otherdigital media may be useful; however, the girth of infor-mation on non-SMS information and communicationtechnologies often overshadows the focused questions thathealth providers may seek on mHealth specific interven-tions. There have been a number of recent research papersspecific to SMS and STIs with higher quality evidence.Therefore, an up-to-date review with a synthesis of currentevidence is warranted.Significance of this reviewA host of new remote monitoring and communicationtechnologies are available, allowing providers to interactwith patients anywhere and anytime, and patient engage-ment is key to managing STIs [79-81]. Cell phones, per-sonal devices that are highly convenient to use, areparticularly suited for leveraging the time and expertiseof providers in communication with their patients. Thisprompt and personal communication can effectively en-gage patients in their knowledge acquisition and motiv-ate them towards effective self-care. Like any consumers,patients as the primary users of health services prefer tohave many options for communicating with their pro-viders. Text messaging via mobile phones could not onlyprovide a convenient option [82], but could also decreasethe need for booking repeat appointments through timelydoctor-patient communication, thereby reserving scarcehealth resources for those who need face-to-face encoun-ters with clinicians.This synthesis is particularly important as there is alack of quality evaluations of SMS interventions on mul-tiple outcomes affecting STI management. Researchershave attempted to empirically assess the effectiveness ofSMS interventions but the data are sparse and have beencollected with small sample sizes. Furthermore, manysystematic reviews attempting to assess SMS interven-tions were conducted before randomized controlled tri-als on key outcomes were published. Synthesizing datafrom numerous studies will provide greater confidencein the effectiveness of these interventions, especially ifthe data allows for a meta-analysis. Moreover, there areconflicting results about the acceptability of some SMSinterventions such as receiving results of laboratory testsas well as interventions for partner notification. A know-ledge synthesis will provide more power to assess theseconflicting reports and provide a pooled estimate of ac-ceptability with reduced uncertainty.Text messaging shows immense potential for preven-tion and management of STIs. However, there is a lackof consensus on its acceptability, feasibility and cost-effectiveness for different STIs, populations, settings anduses. The systematic review will be the first evaluation ofLunny et al. Systematic Reviews 2014, 3:7 Page 5 of 8 scope of SMS use in clinical and community settingsfor all levels of STI prevention and treatment. This infor-mation will provide the evidence that is required to maketext messaging standard practice in STI care.Additional fileAdditional file 1: Summary of ten systematic reviews foundthrough a scoping review [83].AbbreviationsCT: Chlamydia; GC: Gonorrhea; HPV: Human papillomavirus;NOS: Newcastle-Ottawa quality assessment scale; PICO: Patient andproblem, intervention, comparison and outcome; PROSPERO: Preferredreporting items for systematic reviews and meta-analyses; RR: Risk ratio;SMD: Standardized mean difference; SMS: Short message service;STI: Sexually transmitted infection.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsCL drafted, edited and finalized the manuscript. DT, JM and OW edited themanuscript. JM and OW did the literature searching. GO, RL, and MGcontributed to the research design. DT, GO, MG, KH, MK, TW participated inwriting the grant application. All authors read and approved the finalmanuscript.AcknowledgementsThis project is funded by the Canadian Institutes of Health Research forsystematic reviews (201210KSH-297706).Author details1BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BritishColumbia V5Z 4R4, Canada. 2University of British Columbia, 2329 W Mall,Vancouver, British Columbia V6T 1Z4, Canada. 3Public Health Agency ofCanada, 130 Colonnade Road, AL 6501H, Ottawa, Ontario K1A 0 K9, Canada.4Department of Emergency Medicine, UBC Faculty of Medicine, Room 3300,910 West 10th Avenue, Vancouver, British Columbia V5Z 1 M9, Canada.5eHealth Strategy Office, UBC Faculty of Medicine, Room 215, 855 West 10thAvenue, Vancouver, British Columbia V5Z 1 L7, Canada.Received: 17 October 2013 Accepted: 16 December 2013Published: 16 January 2014References1. Workowski KA, Berman SM: Centres for Disease Control and Preventionsexually transmitted diseases treatment guidelines. Clin Infect Dis 2007,44(Sup 3):S73–S76.2. 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Pop-Eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP,de Walque D, MacKeen L, Haberer J, Kimaiyo S, Sidle J, Ngare D,Bangsberg DR: Mobile phone technologies improve adherence toantiretroviral treatment in a resource-limited setting: a randomizedcontrolled trial of text message reminders. AIDS (Hagerstown) 2011,25:825–834.doi:10.1186/2046-4053-3-7Cite this article as: Lunny et al.: Short message service (SMS)interventions for the prevention and treatment of sexually transmittedinfections: a systematic review protocol. Systematic Reviews 2014 3:7.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at et al. Systematic Reviews 2014, 3:7 Page 8 of 8


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