At first glance, the text message seems like the perfect reminder for just about anything. It’s an automated nudge, a way to say, “Hey, remember to do this thing right now.” And given the inundation of text messages and push notifications from every app and service imaginable, you’d assume they must work.
But a deep-diving, three-year study of breast cancer patients just published in the Journal of Clinical Oncology found something else entirely.
“No matter how we looked at [the data] in our study, the text messaging was not effective,” says Dawn Hershman, Professor of Medicine and Epidemiology at Columbia University Medical Center, who helped lead the study. “What we found was you could see absolutely no benefit from the intervention.”
It seems that text messages make lousy reminders over the long term.
Hershman’s team set up the study to be definitive and bulletproof. It followed 702 women taking breast cancer medication for three years, and it texted them each twice a week to take their medication. Very few people dropped out of the study. Rather than collect prescription fulfillment data from pharmacists or ask people if they took their pills as they were supposed to, as many medication studies do, this study actually analyzed the urine of patients to determine whether the treatments were consumed.
For the reminders to have failed entirely is a surprising finding. As part of her study, Hershman reviewed dozens of papers that analyzed how text-message reminders could help patients take their medications reliably. Whether these patients were battling tuberculosis or HIV, the text messaging tended to work. When people were reminded to take their pills, they did so more often. But as Hershman explains, these studies were focused on short-term, highly targeted treatments that generally lasted no longer than 12 weeks. Breast cancer survivors, on the other hand, are asked to take a daily hormone pill for 5 to 10 years as part of a long-term treatment plan. Despite the seriousness of this treatment, and the fact that a hormone pill is easy to take as far as medicines go, only about 50% of people stay on their regimen over the long term.
Truth be told, Hershman was skeptical that the text messages would move the numbers all that much, anticipating that people would begin to write off the messages over time. “We didn’t think this would be effective long-term . . . but even if it was a little effective, it would be worth it, because it was so inexpensive!” she says.
But it turned out the text messaging wasn’t effective in any measurable way, in the early or the later days of the study.
Hershman agrees that we see this same phenomenon play out with apps, which send an endless barrage of messages, and we just swipe them aside every time. “What ends up happening is you just become numb to it all,” says Hershman. “Without any kind of engagement, it just becomes noise.”
It’s possible companies aren’t getting much engagement from the messages, but again, these notifications are cheap to send. So even if you get only .001% of users’ attention, why not send out another blast? In healthcare, however, the stakes are much higher. And Hershman believes that the problem with health-related text messages is potentially solvable with a bit more effort.
“The reality is, you have to understand the reason someone is not adherent [to taking medication] and tailor the intervention toward whatever that may be,” says Hershman. “In this particular circumstance, it’s less that people are forgetting their medicine, and it’s other reasons people don’t take it.” Medications cost money. They come with unpleasant side effects. And many people just don’t believe they work. For a text message to be effective, then, it needs to address these concerns. But how? Turn the one-way text message into a two-way conversation.
With the boom of telemedicine in response to COVID-19, Hershman imagines that automated text messages will be used to set up chats with doctors, who can get to the root of why someone is or isn’t taking their medication. “It’s much more accessible to engage with patients through videoconferencing,” she says, “to make sure people are staying on track without dragging them into the office.”