Automated text messaging offers an innovative, cost-effective way to improve self-care and wellbeing. Interventions that consist solely of text messages have been found to effectively promote health self-management (Willcox et al, 2019; Whittaker et al., 2019). In this case, it helps patients feel connected with their healthcare providers (Berrouiguet et al., 2016). It increases patients’ health-related awareness and knowledge for a wide variety of issues (Sahin et al., 2018). Because text messages allow for real-time information exchange, are accessible even in rural locales, and can be sent to many recipients simultaneously, they are suitable tools for public health outreach (Schwebel & Larimer, 2018).
A growing percentage of US veterans also agree that text messaging is a desirable modality for communicating health-related information (Erbes et al., 2014; McInnes et al., 2014; Whealin et al., 2015). Among 600 ethnoculturally diverse Veterans and National Guard members, 32.2% indicated that they would be willing to receive text messages to support their well-being (Whealin et al., 2016). Among 290 Veterans with spinal cord injuries and disorders, only 26.2% reported the use of text messaging (Hogan et al., 2016). A survey of 106 homeless veterans found that most were interested in receiving mobile phone communications from their healthcare providers, with 93% interested in receiving a mobile phone calls or text message appointment reminders (McInnes et al., 2014).
A survey of 77 veterans with a mental health diagnosis found that most reported having a cell phone (97%), but fewer than half reported having a smartphone (35/74, 47%). However, most were interested in using technology for some types of healthcare-related communications. (Miller et al., 2016). Among 149 veterans who attended another VA for mental healthcare, 79.2% used texting technology, and 10.7%used mental health-related app (Erbes et al., 2014). Last, a study of 77 older veterans (mean age = 69 years) found that, when questioned about the mode of delivery, about a quarter (28.6%) preferred receiving messages via mobile apps (28.6%), compared to about a third (35.1%) who preferred mailed paper materials (Gould et al., 2020).
Despite widespread interest and growing use, very little research has examined veterans’ preferences for text message interventions (Iversen et al., 2014). One study that examined 100 veterans who had attended an appointment at a single Veterans Health Administration facility found that veterans expressed interest in mobile support and increased physical activity. It amounted to (79.8%), get better sleep via CBT techniques (73.1%), change negative/self-critical thinking (72.3%), increase activities (72.3%), track mood/stress/anxiety/PTSD symptoms (67.2%), speak to a coach (66.4%), learn more about your mental health condition (psychoeducation (64.7%), improve your social skills (63.0%), medications reminders (61.3%), and connect with others who have similar problems (51.3%) (Lipschitz et al., 2019).
In another study, 28 older patients (mean age = 69.5 and 14 of whom were veterans) receiving antiplatelet medication participated in focus groups. The majority of participants viewed text message reminders favorably (Rubeis, 2022). Most participants preferred that text messages be sent from their healthcare providers and be personalized to their condition or procedure. They chose a two-way texting interface to engage with the text’s information more thoughtfully. Some participants saw the potential of text message fatigue that could result in ignored text reminders (Schwebel & Larimer, 2018). Some also reported negative reactions to messages that would praise them for adhering to their medication regimen, calling them “condescending” (Park et al., 2020).
Every VA patient is eligible to use the Annie platform and at any given time, 5,000-6,000 veterans are actively subscribed to a protocol (such as CPD and Coping). Annie users reside in all 50 states and range from the 18 to over 74 years old, with the most significant percentage (29%) between 65-74 years (compared to the US veteran mean average age of 58 years, with most between 45-64 years (Planning, 2010).
The VA Annie Platform
The VA has developed a variety of eHealth interventions to enable patients to self-manage their health (Iversen et al., 2014). The Coping and CPP subscriptions are part of the VA Office of Connected Care (OCC) automated SMS tool ‘Annie.’ (Rogal et al., 2019). The platform was hosted on Amazon Web Services Veterans Affairs Enterprise Cloud–Mobile Applications Platform. The platform allows the delivery of various protocols comprising short message service text messages to practically all cell phones. The Annie application is accessible to any Veteran enrolled in the VA, although typical texting charges may have applied depending on a veteran’s texting plan (Planning, 2010).
This project was a retrospective analysis of open-ended item survey response data captured as part of a national quality improvement initiative (Schmidt et al., 2020). This project evaluated data collected from veterans enrolled in one or both of two population-scale automated text interventions (Schmidt et al., 2020). The first, called Coronavirus Precautions (CPP), was a 60-day text subscription that delivered educational content on coronavirus precautions, In addition, it guided Veterans in monitoring their clinical symptoms, and, based on their responses, advised them to call their care team or a nurse triage line when appropriate (Saleem et al., 2020). Educational tips (e.g., “Annie again. If you are ill, use a separate bedroom and bathroom if possible.”) were sent Monday, Wednesday, and Friday and wellness questions (“Annie here. Are you feeling well today?”) were sent Monday, Wednesday, Friday, and Sunday. Beginning March 2020, the protocol was available on the VA’s text messaging platform “Annie.” Any Veteran registered as a VA patient could self-enroll free or be assigned by a VA staff member.
The second, called “Coping during COVID” (Coping) was a 60-day subscription that sent one of four rotating message prompts on Tuesdays, Thursdays, and Saturdays (Whealin et al., 2021). In these messages, “Annie” prompts veterans to take steps daily to prevent stress and states that veterans can “type TIP YES to request a coping tip now or whenever you want one.” Veterans could receive one of 60 motivational/educational text messages designed to encourage proactive efforts to manage COVID-19-related stress, such as setting a new goal for something you’d like to accomplish in the month ahead. What would you like to change in your life?” and “Dwelling on negative thoughts is not good for your health. Balance out negative news by focusing on positive thoughts (Rubeis, 2022). The subscription became available in May 2020. Any Veteran registered as a VA patient could self-enroll for free in either/both subscription(s) or be assigned by a VA staff member.
This project was a retrospective analysis of open-ended item survey response data captured as part of a national quality improvement initiative. Approval for the procedure was completed through the Clinical Coordination Cell, a VHA Emergency Management Coordination Cell function. In this project, further research is needed to evaluate ways of combining qualitative comments and statistical data, which could be utilized for public reporting and quality improvement.
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