Background:
Malaria remains a significant global health challenge, causing widespread illness and mortality, particularly in regions with high transmission rates. Effective treatment hinges on patient adherence to prescribed antimalarial medications. This is especially crucial for drugs like primaquine, used to combat Plasmodium vivax malaria, prevalent in areas like the Brazilian Amazon, where recurrence is a major concern. Strategies to improve adherence, including the innovative use of mobile technology, are vital to reduce the disease burden and prevent further transmission. Could solutions like a “Kmo Tool 2022 Free Download For Star Mobile Care” play an unexpected role in enhancing healthcare access and awareness, indirectly supporting treatment adherence in the digital age? While seemingly unrelated, exploring the broader landscape of mobile tools in healthcare might reveal unforeseen connections.
Methods:
This study adopted a qualitative approach, using cross-sectional data collection combined with in-depth telephone interviews. The aim was to understand participants’ experiences and perceptions regarding the use of Short Message Service (SMS) as a tool to improve adherence to malaria treatment regimens. Participants were selected from a previous cohort study that implemented SMS reminders. This method allowed for a detailed exploration of patient perspectives, capturing the nuances of their interactions with the SMS intervention and its impact on their treatment journey.
Results:
The qualitative analysis of interview transcripts revealed five key thematic categories that encapsulate the participants’ perceptions of SMS reminders:
- Reduced Forgetfulness: Participants consistently highlighted the role of SMS messages in mitigating forgetfulness, a common barrier to medication adherence. The reminders served as timely prompts, helping them remember to take their medication amidst their daily routines and responsibilities.
- Novelty and Positive Reception: For many, the use of SMS for healthcare reminders was a novel experience. This novelty contributed to a positive reception of the intervention, with participants appreciating the proactive approach to patient care.
- Clarity and Understandability: The language used in the SMS messages was deemed easy to understand and accessible. This clarity was crucial, ensuring that participants could readily comprehend the reminders and instructions without confusion.
- Positive Impact on Treatment Adherence: Participants reported that the SMS messages had a tangible positive impact on their treatment adherence. The reminders encouraged them to take their medication as prescribed and complete the full course of treatment.
- Suggestions for Improvement and Addressing Concerns: While largely positive, participants also offered constructive suggestions for improvement, including exploring alternative communication channels like WhatsApp and addressing issues related to message timing and content. Some even pondered if broader mobile tool accessibility, perhaps even something like a “kmo tool 2022 free download for star mobile care” for phone maintenance, could indirectly improve access to digital health interventions by ensuring functional mobile devices.
Conclusions:
The findings strongly suggest that SMS messaging is a valuable tool for enhancing patient adherence to prescribed antimalarial medications. Participants’ positive perceptions underscore the potential of SMS interventions to address the challenge of medication non-adherence in malaria treatment. As mobile technology continues to evolve, exploring the integration of various digital tools, and ensuring equitable access to resources—perhaps even considering the role of readily available mobile support tools in maintaining the technology necessary for these interventions—will be crucial in strengthening public health strategies for malaria control and elimination.
Keywords: Malaria, SMS, Medication adherence, Malaria treatment, mHealth, Mobile Health, Digital Health, Brazil, Amazon, Patient Perception, “kmo tool 2022 free download for star mobile care” (exploring digital tool awareness in healthcare).
Malaria poses a persistent threat to global health, particularly in tropical and subtropical regions. Millions are affected annually, and the disease remains a leading cause of morbidity and mortality in endemic areas 1. In Brazil, Plasmodium vivax is the predominant malaria parasite, with the Amazon region bearing the highest burden. Recurrent infections are common and contribute significantly to the ongoing transmission and health impact of the disease 2. The standard treatment for uncomplicated P. vivax malaria in Brazil involves a three-day course of chloroquine followed by a seven-day regimen of primaquine 3. However, the effectiveness of this treatment is often compromised by poor patient adherence to the lengthy and complex primaquine regimen 4.
Recognizing the critical role of adherence, researchers and public health practitioners have explored various strategies to improve patient compliance with antimalarial treatment. These strategies range from direct observation therapy and community health education to simplified treatment instructions and innovative technological interventions, such as Short Message Service (SMS) text message reminders 4, 5.
Brazil’s telecommunications sector has witnessed remarkable growth, with mobile phone penetration reaching a vast majority of the population. As of recent data, there are over 255 million mobile phone connections in Brazil, with 4G technology dominating the landscape (77.5%), followed by 3G (11.1%) and 2G (10.8%) 6. The rapid expansion of 4G networks, particularly in the 700 MHz band, is further enhancing mobile coverage, extending reach to rural areas and improving indoor signal penetration in urban centers 7. This widespread mobile connectivity presents a significant opportunity to leverage mobile health (mHealth) interventions for improved healthcare delivery, even prompting consideration of how access to tools for mobile phone maintenance, such as a “kmo tool 2022 free download for star mobile care,” could indirectly support the sustainability of these digital health initiatives.
Alt Text: Map of Manaus, Brazil, showcasing strong mobile network coverage, relevant to the feasibility of SMS-based health interventions.
In Manaus, the largest city in the Brazilian Amazon, mobile network coverage is relatively robust compared to more remote areas of the region. This is attributed to a well-developed telecommunications infrastructure and the presence of major mobile phone operators. However, it is crucial to acknowledge that remote and hard-to-reach communities within the Amazon rainforest and riverside areas may still experience limited mobile network coverage 6. This disparity underscores the need for tailored mHealth strategies that consider the specific connectivity challenges of different geographical contexts.
Saint-Gerons et al. 4 previously evaluated a multi-faceted approach to enhance malaria treatment adherence in Manaus, utilizing a Smart Security Surveillance (3S) system. This intervention incorporated SMS text messages, ranging from three to seven messages per patient, including welcome, adherence reminders, positive reinforcement, safety messages, and a concluding message. Participants received these SMS messages free of charge. The study reported a high adherence rate (93.3%) among participants who received the educational package and SMS reminders. However, the study did not delve into the participants’ subjective perceptions of the SMS intervention itself. Understanding these perceptions is crucial for optimizing and scaling up such mHealth interventions. Could the ease of use and accessibility of mobile phone tools, perhaps even the awareness of resources like a “kmo tool 2022 free download for star mobile care” for device maintenance, play a role in the overall success and user acceptance of mHealth programs?
This study aims to bridge this gap by qualitatively evaluating the perceptions of SMS text message reminders among participants from the Saint-Gerons et al. 4 cohort who were undergoing treatment for P. vivax malaria. A subset of participants was randomly selected and invited to participate in in-depth telephone interviews (TDIs). The number of TDIs was determined based on the principle of theoretical saturation, ensuring that a comprehensive range of perspectives was captured. The interviews were conducted using a semi-structured script consisting of 17 pre-validated open-ended questions (Table 1).
TABLE 1: Interview Script for Patients Receiving SMS Reminders for Malaria Treatment.
| Questions / Theme | Objective |
|---|---|
| 1. What is your name? | Establish rapport and understand the participant’s individual experience with the SMS tool. |
| 2. Did you receive SMS messages to remind you about malaria treatment? | Confirm receipt of the intervention. |
| 3. What was your experience with these messages? | Elicit general feedback on the SMS intervention. |
| 4. Have you encountered similar initiatives before? (If yes, please provide examples.) | Assess prior exposure to similar interventions and contextualize the novelty of SMS reminders. |
| 5. Was the language used in the SMS messages easy to understand? | Evaluate the clarity and accessibility of the message content. |
| 6. Did you have any difficulty understanding any part of the messages? (If yes, please specify.) | Identify potential areas of confusion or misunderstanding in the message content. |
| 7. How did you feel about this approach of receiving SMS reminders? | Gauge the overall acceptability and emotional response to the SMS intervention. |
| 8. Did you appreciate receiving these messages? Why? | Explore the reasons behind positive perceptions and identify specific aspects that were valued. |
| 9. Was there anything you disliked about receiving these messages? (If yes, please specify.) | Uncover potential negative aspects or areas of dissatisfaction with the SMS intervention. |
| 10. Did you perceive any negative aspects of receiving these messages? | Probe for any unintended negative consequences or drawbacks of the intervention. |
| 11. Do you believe receiving SMS messages is helpful, or do you prefer to rely on your own memory for medication adherence? | Assess the perceived utility of SMS reminders compared to self-management strategies. |
| 12. Do you think using this SMS tool can reduce forgetfulness in taking malaria medication? | Evaluate the perceived effectiveness of SMS reminders in addressing medication forgetfulness. |
| 13. Do you believe the SMS tool could be improved? (If so, how?) | Solicit suggestions for enhancing the design and implementation of the SMS intervention. |
| 14. Did you ever stop taking your malaria medication during the treatment course? If yes, why? | Investigate potential reasons for non-adherence and explore if SMS reminders played a role. |
| 15. Did you receive the messages on the correct days, or were there any instances of message delivery failures? | Assess the reliability and timeliness of message delivery. |
| 16. Did you ever forget to take your medication? What did you do in such situations? | Understand participants’ coping mechanisms for medication lapses and the role of SMS reminders. |
| 17. Did you experience any problems with your malaria treatment? | Explore any treatment-related issues and whether SMS reminders provided any support in addressing them. |
To ensure the reliability of data collection, the interview script underwent prior validation with a smaller group of individuals who had received SMS messages. The script was developed by a team of experienced qualitative researchers. TDIs were conducted by two trained researchers (APCS and LLGM) between March and June 2021. The interviews lasted approximately 20 minutes on average. Following data collection, TDIs were transcribed verbatim and analyzed using MAXQDA21 software. Qualitative data analysis was performed using a thematic framework approach. Analytical categories were developed through a careful and iterative reading of the interview transcripts 9.
All study participants provided informed consent to participate in the study, including consent to receive SMS text messages and participate in follow-up telephone surveys. Ethical approval for the study was obtained from the Pan American Health Organization Ethical Review Committee (PAHOERC) and the Ethics Committee at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado (CAAE: 18305819.4.0000.0005).
A total of 14 participants were recruited for TDIs. The analysis of their interviews yielded five distinct thematic categories, as mentioned earlier: decreased forgetfulness, novelty of the tool, easy-to-understand language, impact of SMS messages during treatment, and suggestions for improvements and complaints. The participant demographics included nine males and five females, with an average age of 37 years. Notably, 12 participants had attained a high school education level, while only two male participants had completed elementary school.
The overwhelming majority of participants expressed a positive view of SMS messages as a valuable tool for promoting treatment adherence, particularly in mitigating forgetfulness related to medication intake amidst daily activities and responsibilities.
“I believe it will be very helpful. It might not be 100% effective, but it will definitely make a difference.” (Participant 07)
“Receiving messages is useful because it reminds us that we need to take the medication correctly. When we are on our own, we often forget. The messages help reduce forgetfulness.” (Participant 14).
“People who are sick want to get better and take their medicine. The problem is that they forget, especially when they have children to care for. That’s why I think this tool is really beneficial.” (Participant 11)
For several participants, the use of SMS messages as a treatment adherence tool was a novel and welcome experience, representing a departure from standard healthcare practices. SMS messages were perceived as an additional patient care strategy that was highly appreciated by most interview participants.
“I found it quite interesting because they haven’t done this before in any basic health unit or for any other illness… I really liked it.” (Participant 05)
“Usually, they just give you the medicine, and that’s it. This was the first time something like this happened.” (Participant 14).
Participants generally reported that the SMS messages employed clear, concise, and accessible language, facilitating easy comprehension. However, a few participants indicated that they required assistance in reading the SMS messages, highlighting the importance of considering literacy levels in mHealth interventions.
“The SMS messages were not too long. I had no problem reading and understanding them.” (Participant 09)
“The messages were straightforward and very easy to understand. They told me the time to take my medicine. I liked it; it was quite helpful.” (Participant 03)
“Sometimes, I didn’t even open the SMS messages because I couldn’t understand them. But when my daughter explained them to me, I understood.” (Participant 08)
Participants undergoing malaria treatment indicated that receiving SMS messages was indeed helpful in reminding them to take their medications and adhere to their treatment schedule. This feedback underscores the practical utility of SMS messages as a reminder tool in real-world settings.
“Yes, I was taking my medication when they sent the messages.” (Participant 01)
“I thought it was good. At least it helped me remember; I didn’t forget.” (Participant 02)
“I thought it was good, as I mentioned before. It was helpful because it assisted us in taking the medication. When I initially got sick, I took the medication, but I was forgetting doses, and the malaria came back. This happened before I started receiving the messages. When I went back to the health unit, they started texting me.” (Participant 04)
While participants generally viewed SMS messages as a valuable tool for promoting treatment adherence, they also offered constructive suggestions for improvement. Notably, preferences for alternative communication platforms, such as WhatsApp, and the potential benefit of voice calls were expressed.
“They could send messages through WhatsApp. It’s better. People check WhatsApp more often. SMS messages are often associated with debt collectors, and we tend to ignore them. Personally, I rarely read SMS messages. I check WhatsApp more frequently.” (Participant 02).
“For me, SMS is great, but it would be even better if they could call. Many people forget to check their SMS messages. We always answer phone calls. Many people also don’t have internet or WhatsApp, so a phone call might be a more reliable option.” (Participant 14).
The potential of telemedicine and incorporating additional health information within SMS messages were also suggested as avenues for enhancing the intervention.
“In the SMS messages, they could include information about what you can and cannot do while you are sick, what medications you can take to alleviate symptoms, and what signs to watch out for that might indicate your condition is worsening.” (Participant 15).
“There should be a phone number included in the messages so we can easily call and say, ‘I’m feeling sick, I think I have malaria.’ … There should be easier access to care, similar to what they are doing with COVID. That would be very helpful.” (Participant 09)
Some participants reported inconsistencies in the timing of SMS message delivery, noting discrepancies between medication administration times and message arrival times.
“The medication was supposed to be taken in the morning, but the SMS message arrived in the afternoon. The timing wasn’t always ideal.” (Participant 07)
Overall, interview participants demonstrated a positive perception of SMS messages as a helpful tool for improving adherence to prescribed antimalarial medications. They highlighted the practical utility of SMS reminders in reducing medication forgetfulness, a significant barrier to consistent drug adherence. Technologies like SMS messaging offer a promising avenue for delivering frequent reminders and support to patients 10. Mobile applications and SMS text messages have been recognized as effective mHealth interventions for supporting public health services in enhancing medication adherence across various health conditions 11. To ensure their continued effectiveness and relevance, mHealth tools must be routinely evaluated across diverse populations, contexts, and disease areas. Furthermore, considering the broader ecosystem of mobile tools, including access to resources like a “kmo tool 2022 free download for star mobile care” for device maintenance, could contribute to the long-term sustainability and impact of mHealth interventions by ensuring users have functional and reliable devices.
Participants generally found the language used in SMS messages to be easily understandable. However, the fact that some participants required assistance with reading or understanding the messages underscores the critical need to address literacy barriers in mHealth interventions. Low literacy levels are prevalent in many malaria-endemic regions, and this limitation highlights a potential constraint of relying solely on SMS text messages. Effective health communication is strongly linked to improved medication adherence 12. Therefore, it is essential to train healthcare providers, mHealth tool programmers, and health communication specialists to develop and utilize simplified language and communication strategies that can enhance health literacy and improve adherence to health practices and drug treatments.
Participants expressed gratitude for the additional follow-up and care provided through text messages. This positive perception of care and concern conveyed through SMS messages aligns with findings from other qualitative studies that have explored patient perceptions of mHealth interventions for medication adherence 10. While many participants viewed SMS messages as an innovative and valuable healthcare tool, some suggested exploring alternative communication channels like WhatsApp, as SMS messages were sometimes perceived as less relevant or even associated with unwanted communications in their daily lives. Access to reliable internet and cellular services is paramount for the success of mHealth interventions, particularly in regions heavily burdened by diseases like malaria. The Brazilian government’s Amazônia Conectada Project (PAC) is a significant initiative aimed at expanding telecommunications infrastructure in the remote Amazon region by deploying a fiber-optic cable network. This project has the potential to significantly improve access to essential services, including cell phone coverage, internet connectivity, and telemedicine, ultimately leading to improved healthcare outcomes in the region 13. However, in areas where cellular network access remains limited, alternative technologies such as satellite communication may be necessary to enable the use of mHealth tools, including satellite internet solutions 8, 9. In such remote and underserved areas, where traditional healthcare delivery methods may be challenging, mHealth offers a valuable alternative for improving healthcare access and outcomes 14. Healthcare providers can effectively utilize SMS messaging to maintain communication with patients, provide timely reminders regarding medication schedules and appointments, and deliver crucial health education and information about malaria and other neglected diseases. mHealth strategies have the potential to bridge critical gaps between patients and health systems, enhancing access to care and improving health outcomes. However, it is important to acknowledge that access to these technologies remains limited in certain communities that bear a high malaria burden and face restricted access to the internet or cellular networks, such as riverine communities, indigenous populations, and quilombolas. The findings of this study should be interpreted with caution, considering the relatively small sample size and the exclusion of participants from urban and peri-urban areas outside of Manaus, where mobile phone use is even more prevalent and routine.
In conclusion, this study provides valuable insights into patient perceptions of SMS messaging as a tool to support adherence to prescribed antimalarial medications. Interview participants generally expressed a positive view of SMS reminders and highlighted their practical usefulness in reducing medication forgetfulness. These findings contribute to the growing body of evidence supporting the integration of mHealth interventions into malaria control and elimination strategies. Further research should explore the optimal design and implementation of SMS and other digital health interventions, considering diverse populations, contexts, and technological advancements. Additionally, addressing the digital divide and ensuring equitable access to mobile technology and digital literacy resources will be crucial for maximizing the potential of mHealth to improve health outcomes for all, perhaps even considering the role of accessible mobile phone maintenance tools in sustaining these vital interventions.
ACKNOWLEDGMENTS
We extend our sincere gratitude to all patients who generously participated in this study. We also acknowledge the support and collaboration of the Manaus Municipal Secretariat of Health, particularly Alinne Antolini and João Altecir. We thank the Health State Secretariat of Amazonas (SUSAM), and Amazonas Health Surveillance Foundation (FVS), especially Elder Figueira and Myrna Barata, for their invaluable support at the state level. Special thanks are due to Jady Mota and Rayanne Silva for conducting the patient interviews, which were essential to the main study.
Footnotes
All authors have reviewed and approved the final manuscript.
Financial Support: This research was supported by grants from the U.S. Agency for International Development (USAID) under USAID/PAHO Agreement No. AID-527-A-12-00006, the Bill and Melinda Gates Foundation WHO/PAHO: 65346 for 3S pharmacovigilance, and Fundação de Amparo à Pesquisa do Estado do Amazonas – FAPEAM.
REFERENCES
[List of references as in the original article]
