Evaluation of a Text Messaging Intervention to Promote Preconception Micronutrient Supplement Use: Feasibility Study Nested in the Healthy Life Trajectories Initiative Study in South Africa

Abstract

Background Social messaging strategies such as SMS text messaging and radio are promising avenues for health promotion and behavior change in low- to middle-income settings. However, evidence of their acceptability, feasibility, and impact in the context of young women’s health and micronutrient deficiencies is lacking. Objective This study aimed to evaluate the feasibility of an automated 2-way text messaging intervention nested in an ongoing preconception health trial, the Healthy Life Trajectories Initiative (HeLTI; HeLTI Bukhali) in Soweto, South Africa. Second, we aimed to evaluate the acceptability of a health promotion radio serial, which aired concurrently in the region. Methods In this feasibility study, 120 participants enrolled in HeLTI Bukhali between November 2020 and February 2021 received the 6-month 2-way text messaging intervention. Quantitative and qualitative data on intervention acceptability, usability, interaction, perceived benefit, and fidelity were collected during 5 focus group discussions (FGDs) and from study data logs. During the FGDs, data were collected on the acceptability of the radio serial. Following the text messaging intervention, capillary hemoglobin levels were assessed, and a participant questionnaire provided information on adherence and attitudes toward supplements. The text messaging control group comprised the first 120 women recruited from November 2019 to February 2020, who received the Bukhali intervention but not the text messages. Statistical significance testing and a linear mixed model were used for indicative effect comparisons between the text message–receiving and control groups. Results The text messaging intervention was found to be acceptable and to have perceived benefits, including being reminded to take supplements, gaining knowledge, and feeling supported by the study team. The use of the 2-way text messaging reply function was limited, with only a 10.8% (13/120) response rate by week 24. Barriers to replying included a lack of interest or phone credit and technical issues. Regarding the indicative effect, participants receiving the text messages had higher self-reported adherence at follow-up than the text messaging control group (42/63, 67% vs 33/85, 39% taking supplements every time; P=.02), and altitude-adjusted hemoglobin increased more between baseline and follow-up in the SMS text message–receiving group than in the text messaging control group (1.03, 95% CI 0.49-1.57; P<.001). The radio serial content was acceptable, although few participants reported exposure before the FGD. Conclusions Women reported that the text messaging intervention was useful and described the benefits of receiving the messages. Examination of hemoglobin status indicated a promising beneficial effect of text messaging support on adherence to micronutrient supplementation, requiring further exploration through randomized controlled studies. Health promotion through radio and text messages were both found to be acceptable, although more research into the radio serial reach among young women is needed. Trial Registration Pan African Clinical Trials Registry (PACTR) PACTR201903750173871; https://tinyurl.com/4x6n32ff

Mobile Technology Use in Clinical Research Examining Challenges and Implications for Health Promotion in South Africa: Mixed Methods Study

“…The quantitative results of this study showed that a large proportion of individuals owned a mobile phone. This result is in line with previous literature, which has shown that mobile connectivity in South Africa has grown rapidly with a mobile penetration rate of >95%, with 91% of all phones being smartphones [1,17,24]. Although this was also corroborated by the qualitative findings, a key finding was that some participants were mobile phone sharers, whereas others had no phones at all and thus relied on their social networks who had phones and often depended on using these phones for a short while to be in touch with other individuals.…”

“…These number changes were tracked from randomization to the trial. The number changes were categorized as (1) no number change, (2) 1 number change, or (3) >2 number changes.…”

“…The use of mobile technologies in engaging people and communities to choose healthy behaviors and to improve their health is becoming an increasingly common phenomenon in global health programs [1][2][3][4]. Mobile technologies have increasingly become a common mode of delivering telemedicine in sub-Saharan Africa and other low-and middle-income countries (LMICs) given improvements in coverage [5], with the prospects of improving access to information pertaining to health care services in areas where health care systems lag in meeting minimum health standards [6,7].…”

“…Mobile phone technology use in clinical studies is a potential avenue for both the follow-up of participants in research [8][9][10] and the provision of targeted and tailored messaging to facilitate behavior change support. For instance, patients now progressively receive reminders regarding clinic appointments [11], medication uptake [12], health promotion [13,14], medical treatment or diagnosis [15], and accessing information on disease outbreaks and other health-related data [16] through SMS text messaging systems and telephone calls; all these methods have collectively contributed to better health [1,17]. These digital interventions are reinforced by the high level of mobile phone penetration in many LMICs.…”

“…This is caused, for instance, by theft and loss of phones, which results in connectivity loss with respondents and loss to follow-up [28]. Although several scholars have investigated the effectiveness of mobile phones in follow-up studies [1,[6][7][8]13,24,[27][28][29], there is a dearth of literature in South Africa that has qualitatively explored the challenges that participants experience in terms of being contactable through mobile technologies. Gaining insight into these challenges will help in developing targeted strategies to facilitate ways for research staff and researchers to remain in contact with participants over time and for follow-up research.…”