Effect of Short Message Service Reminders on Clinic Attendance Among Outpatients With Psychosis at a Psychiatric Hospital in Nigeria

In Nigeria, where many patients with mental illnesses present first to tertiary services, the burden of care is largely borne by relatives (1–3). For patients with first-episode psychosis (FEP), appropriate treatment early in the course of the illness reduces the morbidity that otherwise occurs rapidly during the first few years of the psychotic disorder (4,5). Clinic appointments are an opportunity for patients to receive regular advice and monitoring regarding psychological and general medical health (6). Missed appointments, however, have been found to be common in psychiatry clinics in Nigeria, as in other parts of the world (7–9).

Patients who do not attend follow-up appointments are likely to adhere poorly to prescribed medications, have a poorer prognosis, and have an increased likelihood of relapse, adding to the financial and emotional burden on caregivers. Missed follow-up appointments also waste physician and clerical time, contribute to decreased levels of empathy by clinicians, and contribute to poor quality of patient-doctor communication (10,11).

Telephone call reminders have been shown to dramatically improve outpatient attendance rates at general medical and mental health clinics (12–14). Telephone calls, however, are expensive, and repeated calls may be necessary in order to make contact with a single patient. Short message service (SMS) text messages are equally as effective as phone calls (14), yet are cheaper, easier, and less time consuming. They have been found to be particularly useful in managing the treatment of persons with serious mental illness (15,16). There are no previously published studies to examine the impact of SMS intervention on mental health care service delivery in Nigeria, the country with the largest population in Sub-Saharan Africa.

Methods

Study Design and Operational Definitions

This study was a randomized controlled trial (RCT) comparing outcomes among individuals with FEP who were assigned randomly to receive SMS reminders about an upcoming clinic appointment and those who did not receive SMS reminders. Individuals with FEP were defined as persons who present at a clinical setting with psychosis and who have never previously sought care for psychosis at an appropriate clinical setting (17–19). An appropriate clinical setting referred to an orthodox psychiatric treatment center where a certified psychiatrist makes a diagnosis and institutes treatment for mental illnesses. Attendance was defined as a participant’s attendance at the outpatient clinic on the scheduled appointment date. A caregiver was defined as the person who is responsible for the patient’s care and who ensures that the patient comes in for the next clinic appointment. Duration of untreated psychosis (DUP) was calculated as the difference between the age at presentation for FEP treatment and the age at onset of psychosis.

Intervention, Outcome, and Study Population

The intervention was an SMS reminder of the date and time of patients’ first clinic appointment. The SMS was sent five days and three days before the scheduled clinic appointment. The intervention was considered to have been received if “message delivered” was displayed on the bulk SMS platform Web page. Participants in the control and intervention groups received the current standard procedure for clinic reminders (appointment cards containing the appointment date written by hand). The outcome measured was the proportion of missed next clinic appointments.

The study population consisted of patients between the ages of 18 and 64 who sought appropriate treatment for a psychotic illness at the Federal Neuro-Psychiatric Hospital in Benin City, alone or accompanied by a caregiver, while experiencing a psychotic episode. All patients with FEP were identified with the Psychosis Module of the Mini-International Neuropsychiatric Interview (MINI Plus 5.0), a brief, structured interview for major axis I psychiatric disorders in DSM-IV and ICD-10. Patients were included if the MINI confirmed a diagnosis of psychosis and if the patient gave consent to participate in the study, had a functional mobile phone, and could read and understand text messages in the English language. Patients were excluded if they required immediate admission for inpatient care, required referral to another health facility because of a general medical comorbidity, or sought treatment at the hospital before their next scheduled appointment because of deteriorating health or because they required inpatient care.

Study Instruments

A questionnaire was used to obtain information about patients’ sociodemographic characteristics, such as age, gender, religion, level of education, employment status, marital status, and living status; patients’ mobile phone number; and information about the caregivers, such as relationship to patients, level of education, and mobile phone number. A second section of the questionnaire was designed to capture illness-related characteristics, such as DUP, ICD-10 diagnosis, and presence of general medical comorbidity. The second section included the MINI Plus 5.0, which has acceptably high validity and reliability in eliciting symptom criteria used in making ICD-10 diagnoses (20), and the Brief Psychiatric Rating Scale (BPRS), version 4.0 (24-question version). The BPRS is a clinician-rated scale used to assess severity of psychopathology and shows adequate validity (21,22) and interrater reliability (23). Ratings are made on a 7-point scale, ranging from 0 or 1, not present, to 7, extremely severe. Possible scores range from 13 to 168, with higher scores indicating greater severity of psychopathology.

Sample Size, Study Duration, and Ethical Approval

In a recent study conducted at the Federal Neuro-Psychiatric Hospital in Benin City, the prevalence rate of missed first outpatient appointments was 33% (24). It was hypothesized that an attendance rate of 85% may be achieved in the intervention arm. Employing the formula for proportions in RCTs (25), and allowing for 10% attrition, a sample of 100 patients was recruited into each arm. Therefore a total of 200 individuals were enrolled in the study.

Data for the study were collected over a period of six months and one week (June 2 to November 24, 2014). Ethical clearance was obtained from the Ethics Committee of the Federal Neuro-Psychiatric Hospital in Benin City.

Randomization

A simple, or unrestricted, randomization was used to randomly assign participants to two groups. An author (BJ) who was blind to the recruitment of the study participants generated the randomization codes by using the computer software Research Randomizer (www.randomiser.org) used in allocation of patients to the intervention and control groups, respectively. One hundred numbers from 1 to 200 were randomly generated and were allocated to the intervention group. The remaining numbers were assigned to the control group.

Procedure at Enrollment

Each patient with FEP who met the criteria for enrollment in the study, a caregiver, or both received a full explanation of the aim of the study, and informed consent was obtained. The questionnaire, MINI, and BPRS were administered by the first author before the patient was given the appointment date. A serial number was assigned to each patient on recruitment. The serial number, case file number, mobile phone number of the patient (or the appointed relative), and the patient’s scheduled appointment date were provided to the second author, who conducted the allocation on the basis of the predetermined randomization codes.

Using a bulk SMS platform, the first author sent an SMS reminder to patients in the intervention group five and three days before their scheduled appointment. The SMS stated, “Good day. This is to remind you of (your appointment/the appointment of your relative) at the Out-Patient Clinic of Federal Neuro-Psychiatric Hospital, Benin, at (time) (a.m. or p.m.) on (date). Thank you.” The first author also checked the case files of all the patients recruited for the study to ascertain if they attended the outpatient clinic on the scheduled date.

Data Management and Analysis

The data collected were analyzed by using the SPSS, version 21. The association between patient characteristics and receipt of SMS messages was determined by using Pearson’s chi-square test for categorical variables and Student’s t test (normally distributed data) and the Mann-Whitney U test (skewed data) for continuous variables. Significant associations in bivariate analyses were entered into a binary logistic regression model by using the forced entry method with subsequent clinic attendance as the dependent variable. The level of significance was set at p<.05, and 95% confidence intervals (CIs) were used.

Results

Sociodemographic Characteristics

Table 1 shows the sociodemographic characteristics of patients recruited into the study. Most (54%) were female. The mean±SD age was 33.7±11.9 years. Female participants were on average significantly older than males when they were first seen at the hospital (34.3±12.4 versus 30.3±10.5 years; t=7.60, df=189, p<.01). Females also had a significantly older age at onset of psychosis compared with males (34.3±12.4 versus 30.3±10.5 years, t=7.26, df=189, p<.02). Almost half of the patients (48%) were employed. [A flow diagram of participants’ progress through the phases of the RCT is available in an online supplement to the article.]

Clinical Characteristics

The most common ICD-10 diagnosis in this patient sample was schizophrenia (N=86, 45%); 62 patients in this subgroup (72%) were diagnosed as having paranoid schizophrenia. Thirty-four patients (18%) were diagnosed as having a severe depressive episode with psychotic symptoms, and 22 patients (12%) were diagnosed as having mania with psychotic symptoms. The DUP showed a wide range (one to 884 weeks), with a median of 12 weeks. A majority of the patients (N=114, 60%) had a DUP of less than 24 weeks. BPRS scores ranged from 15 to 87, with a mean score of 47.28±12.93.

The patients in the intervention and control arms were comparable at baseline in terms of age, gender distribution, educational status, median DUP, and severity of psychopathology symptoms (Table 2). Although DUP data were skewed, there was no significant difference in DUP across arms (U=4,198, p=.29, r=.07).

Sociodemographic Characteristics of Caregivers

Most patients (N=189, 99%) were accompanied by a caregiver, most often a parent (N=64, 34%), sibling (N=54, 29%), or spouse (N=33, 18%). Most caregivers (N=131, 69%) had received at least 12 years of formal education. A majority (N=160, 85%) were employed.

Primary Outcome for Intervention and Control Arms

The impact of the intervention was assessed by using per-protocol analysis. Thus eight persons were excluded because they required inpatient care before the outcome was measured (N=3) or because an outcome could not be determined objectively because of missing case files (N=5). Outcomes for 192 participants (N=95, intervention arm; N=97, control arm) were analyzed. Forty-five participants (47%) who received the SMS reminders and 60 participants (62%) in the control arm missed the clinic appointment (χ²=4.07, df=1, p=.04).

The odds of attending the appointment were significantly greater among participants who received an SMS reminder compared with the control group (odds ratio [OR]=1.80, CI=1.02–3.19). The relationship between receiving an SMS reminder and missing the first appointment was determined after adjusting for selected sociodemographic variables in a binary logistic regression model. The model was undertaken by using the forced entry method with missed first appointment as the dependent variable (0=yes; 1=no). Categorical and continuous variables were entered in a nonstepwise fashion into the regression model. The Hosmer–Lemeshow test (χ²=9.09, df=8, p=.34) showed that the model generated was a good fit, given that it had a p value of >.05. The variables in the model, however, explained only 7% of the variation in the outcome measure (Cox and Snell R²=.073, –2 log likelihood=249.947). In the regression model, receiving an SMS predicted clinic attendance (p<.03) (Table 3). Participants who received an SMS were significantly less likely to miss their first clinic appointment (OR=.50).

Discussion

To our knowledge, this is the first RCT from Nigeria to evaluate the effect of SMS reminders on clinic attendance. This study showed that patients who received an SMS reminder were almost twice as likely to attend their next scheduled outpatient clinic appointment. Furthermore, receiving an SMS reminder independently reduced the risk of missing the next scheduled appointment by 50%, according to a logistic regression that adjusted for age, gender, employment status, DUP, and illness severity. This result is consistent with other studies that showed a reduction in missed appointment rates associated with use of SMS reminders (14,15), and it suggests that SMS reminders could be an effective tool that can be targeted toward improving attendance of clinic appointments in Nigeria, keeping in mind that a large proportion of clients who commence treatment for psychiatric disorders do not attend their follow-up appointments (24).

This study also showed that the SMS reminders were effective irrespective of the recipient. In some instances, both the patient and the caregiver received the messages or only the caregiver received the message if the patient had no mobile phone. This study did not, however, assess the opinions and level of acceptability among patients and their caregivers regarding the SMS-reminder method. Future studies could examine the views of patients and caregivers, a necessary requirement before incorporating any new intervention strategy into a health care system (26).

It would be expected that a patient or a caregiver would be more likely to remember a reminder sent closer to the appointment date. A review of several studies on SMS reminders showed no significant difference in missed appointment rates on the basis of when the reminder was sent (27). Still, it could be argued that sending a reminder a week before would give the patient or caregiver time to prepare for the appointment (get funds or obtain permission from work), but the reminder could also be more easily forgotten compared with a reminder sent just a few days before the appointment date.

Some sociodemographic and clinical characteristics of participants in this study require some discussion. The age at onset of psychotic illnesses in this study was observed to be older compared with other populations. First, the long duration of untreated illness suggests that actual dates of onset of mental illness may be prone to recall bias. Second, some clients were too ill to provide exact time lines, and ascertainment of DUP was reported by caregivers, which may also be unreliable. Third, respondents may have attributed their symptoms to a general medical illness, stress, or spiritual problem. In addition, some patients in this study were diagnosed as having affective psychosis, which usually has an older age at onset compared with nonaffective psychosis, and this may have contributed to the later age at onset observed. Nevertheless, previous community surveys have noted the later onset of psychiatric illness in Nigerian populations (28,29). Nearly two-thirds of participants had a formal education. This is consistent with the level of educational attainment and occurrence of mental disorders reported by a previous community survey (30). This study was conducted at a tertiary facility, and thus the educational attainment of the patients may not be consistent with the true population of individuals with psychosis, who may have lower educational status and seek treatment at nonorthodox or primary health care centers. In Nigeria, health services are largely financed by out-of-pocket payment, given that the National Health Insurance Scheme does not adequately cover the cost of psychiatric consultations and medications for people with psychiatric disorders who are not employees of states, the federal government, or large corporations (31,32); the decision about inpatient admission depends largely on whether the caregiver can afford the cost.

Limitations of this study were that some participants may not have received the SMS reminders that were sent to them, although this was not verified. Although SMS texts as a reminder method are effective, manual telephone calls to the patient or caregiver have been shown in some cases to be more effective (27). In addition, considering the large treatment gap that exists in Sub-Saharan Africa between individuals with mental illness and those who actually access orthodox treatment (33), the findings from this study may be applicable only to individuals with psychosis who have access to care at a psychiatric hospital.

In spite of the aforementioned limitations, our findings have positive implications for improving mental health care in developing countries. First, the technology is easy to use and requires minimal training, which facilitates easy inclusion in health records systems. Second, it has beneficial effects in terms of improving productivity, decreasing wastage of scarce health resources, and improving overall quality of life. Further studies are also needed to test the effectiveness of this intervention among patients with other psychiatric diagnoses.

Conclusions

SMS reminders of clinic appointment dates could be an effective strategy in Nigeria to encourage patients with FEP to attend clinic appointments as scheduled.