National Partnership for Women & Families

Monthly Women's Health Research Review

Study: Text Message Reminders Help Ensure Teen's Adherence to Contraceptive Injections

Summary of "Text Messaging Support for Urban Adolescents and Young Adults Using Injectable Contraception: Outcomes of the DepoText Pilot Trial," Trent et al., Journal of Adolescent Health, May 18, 2015.

While the U.S. teen pregnancy rate has significantly decreased, "many urban communities continue to report" high birth rates among teenagers and young adults, according to Maria Trent, of Johns Hopkins University School of Medicine's Department of Pediatrics' Section on Adolescent Medicine, and colleagues.

For example, the researchers noted that Baltimore has implemented programs aimed at reducing its teenage birth rate -- roughly 60.6 births per 1,000 girls between the ages of 15 and 19 in 2012 -- by "increas[ing] the number of sexually active teens who use highly effective long-acting reversible contraceptives." However, the researchers noted that about 30% of teenagers who do not use LARCs instead use "a moderately long-acting reversible contraceptive (MARC)," such as the Depo-Provera shot, "and/or more cumbersome and slightly less-effective" contraceptive methods. As a result, they wrote that public health programs "that optimize the use of MARCs, which have played a major role in reducing teen pregnancy in the [U.S.], should also be employed in the context of adolescent choice and the goal of reducing unplanned pregnancies among youth."

According to Trent and colleagues, "Using a text-messaging intervention with adolescents managing contraception would enable provision of self-management reminders, serve as a source of empowerment for adolescents to better self-manage, and provide the desired privacy for managing reproductive health issues." In this study, the researchers explore "the feasibility, acceptability, and preliminary effectiveness" of a text message reminder program, called DepoText, that aims "to improve [MARC] appointment attendance among young urban adolescent girls and young adult women using Depo-Provera."

Methods

The researchers conducted the study "in a large urban academic General Pediatric and Adolescent Medicine Practice in Baltimore ... between October 2011 and February 2012." The program "provides confidential, adolescent-centered sexual and reproductive health services to young persons who are uninsured, underinsured, and seeking confidential services and is easily accessible by public transportation."

Trent and colleagues recruited individuals ages 13 to 21 who were enrolled in the practice's Depo-Provera MARC program and who had cell phones with text messaging capacity. During the study, all enrollees "received standard of care according to the existing clinical protocol for management of Depo-Provera," including "a nursing assessment, medical assessment if indicated, counseling, their next injection (if no contraindications), and an appointment card with the date of the next injection." Program participants also were reminded about their next appointments via their home phones.

Once program participants enrolled in the study, they "completed a baseline Web-based survey to provide demographic, reproductive health history, sexual behavior and technology use data and were followed for up to three injection cycles." Study participants assigned to the DepoText group "received a welcome text message" and "daily text appointment reminders ... starting 72 hours before the clinical visit with the option to cease messages by responding (yes or no) with their plans to attend the visit." If the participants replied "no," a program nurse was automatically notified via email and "contacted the patient to reschedule." Participants "also received scheduled health messages regarding condom use for [sexually transmitted infection] prevention, healthy weight management, encouragement to call the nurse for problems, and an STI screening reminder."

Results

The majority of study participants were African-American (96%) and lived in low-income (75%), single-parent, mother-led homes (66%). According to Trent and colleagues, "Participants had high rates of parental knowledge and support for contraceptive use as 92% of parents knew that they were using Depo-Provera and 87% of parents had spoken to them about sex." Overall, 18% of study participants had an STI history.

Program Feasibility

The study found that 100% of welcome text messages, appointment reminders and support messages were successfully delivered to active participants. Overall, 76% of participants responded to appointment-related messages and 68% responded to informational messages. In addition, the program resulted in "no adverse events such as confidentiality breeches or conflict with parents/sexual partners reported by participants related to receipt of text messages and/or study participation."

Preliminary Program Efficacy

Of the 100 total study participants:

~ 87% received a Depo-Provera shot during the first injection cycle;

~ 77% received the injection during the second cycle; and

~ 69% received the injection during the third cycle.

Meanwhile, the study found that "[c]omplete on-time visit adherence declined over time with 51% for the first visit, 47% for the second visit, and 43% for the third visit." In addition, the "proportion of intervention adolescents compared with control peers who returned on time for their appointment was higher for the first (68% vs. 56%) and second (68% vs. 62%) cycles but not the third (73% vs. 72%)." The authors noted that intervention adolescents "returned sooner after [their] scheduled appointment than their control peers for the first ... but not the second and third cycles."

Overall, they found no "difference in those who received injections within the on-time [60]- to 90-day Depo-Provera injection window because the nurse case manager provided additional telephone outreach to all patients who missed their Depo-Provera appointment visits per the existing Depo-Provera quality assurance protocol as a standard-of-care practice."

Discussion

According to Trent and colleagues, the "study demonstrates that the DepoText intervention is both a feasible and an acceptable clinical support tool for adolescents and young adult women choosing MARCs for family planning." In addition, the study "supports the preliminary efficacy of DepoText for improving clinic attendance at family planning visits for the first two visits." They noted that while "there was some waning efficacy by visit 3, there was no overall difference in the number of adolescents who received Depo-Provera during the optimal injection window."

Overall, they note that using cell phone technology "for person-based communication may further improve the effectiveness of MARCs," which are a major contributor to "reducing unplanned pregnancy among adolescent and young adult women." Trent and colleagues urge further research to "explor[e] the cost-effectiveness and longitudinal prevention effectiveness for DepoText as an adjunctive family planning tool in the prevention of unplanned pregnancy and strategies for integration into the existing electronic medical record systems and/or institutional communication platforms for medical providers."