Abstract
Objectives
The objectives of this study were to (1) describe homeless persons’ access and use of cell phones and their perceptions about using cell phone alerts to help manage medications and attend health care appointments and (2) identify demographic characteristics, medication use and appointment history and perceptions associated with interest in receiving cell phone alerts to manage medications and appointments.
Methods
A cross-sectional survey was conducted in 2013 at a homeless clinic in Virginia. The questionnaire comprised items about cell phone usage, ownership and functions such as text messaging. Participants reported medication use and appointment history, perceptions about cell phone alerts and interest in receiving alerts to manage medications and appointments. Descriptive statistics for all variables are reported. Logistic regression was used to examine predictors of interest in using a cell phone to manage medications and appointments.
Key findings
A total of 290 participants completed the survey; 89% had a cell phone. Seventy-seven percent were interested in appointment reminders, whereas 66%, 60% and 54% were interested in refill reminders, medication taking reminders and medication information messages respectively. Those who believed reminders were helpful were more likely to be interested in medication taking, refill and appointment reminder messages compared to those who did not believe reminders were helpful. A history of running out of medicine and forgetting appointments were predictors of interest in refill and appointment reminders.
Conclusions
Mobile technology is a feasible method for communicating medication and appointment information to those experiencing or at risk for homelessness.
Keywords: appointment reminders, cell phone, homeless, medication adherence, mobile health
Introduction
In the United States, approximately 90% of adults own a cellular phone and 81% use text messaging.[1] Given the widespread use of mobile technology, studies have explored the emerging utility of cellular phones, text messages and mobile applications (apps) to improve medication adherence and personal medication management.[2–10] Studies have found that cellular phones may be a useful tool in improving medication use in urban[4,11,12] and resource-limited settings.[3,5] Mobile phone adherence reminders have demonstrated improved adherence to several chronic disease medications,[6] including HIV,[2–4] diabetes,[13] asthma[7] and schizophrenia.[14] Furthermore, patient attitudes towards receiving medical information or adherence reminders via cell phones have generally been positive.[15–17]
Patients who are homeless experience disproportionately high rates of chronic disease, mental health conditions and substance abuse disorders.[18–23] Many of these conditions require consistent adherence to pharmacotherapy and extensive self-management, which is often difficult for patients in unstable living situations or with severe mental illness.[24–27] Medication non-adherence is one of the most common types of problems that homeless patients experience with taking medications.[28,29] Patient-level factors such as adjusting medications without consulting a prescriber, being out of medication and forgetfulness have been identified as reasons for medication non-adherence among patients served by a federally qualified health care for the homeless (HCH) behavioural health clinic in Virginia.[30] Cell phones have also been shown to be a reliable method for contacting chronically homeless patients who may otherwise lose contact with providers between appointments.[31]
Prior studies indicate that cell phone access among homeless individuals is growing. A 2010 study conducted in Philadelphia, Pennsylvania found that 44% of non-sheltered homeless persons possessed cell phones,[32] and more recent studies conducted in Providence, Rhode Island and Boston, Massachusetts reported that 89–90% of homeless veterans had a cell phone.[33,34] Furthermore, among sheltered homeless individuals in New York City, 78% had a cell phone.[35] One study found homeless persons’ perceptions of cell phones to be mostly favourable, citing them as a preferred way to stay connected to friends and family and a social symbol of well-being and safety.[23,32] Homeless persons who lacked cell phones reported insufficient funds, expressed concern over loss or theft of the phone, did not believe that a cell phone was a priority and disliked cell phones as reasons for not having a cell phone.[32,33] A study of 20 homeless veterans in a Veterans Affairs setting examined the feasibility of using text messages for appointment reminders. Participants favourably viewed the appointment reminders and results indicated a trend in reducing the number of no shows and visits that were cancelled.[36]
The purpose of this study was to describe homeless persons’ access and use of cell phones and their perceptions about using cell phone alerts to help manage medications and attend appointments in a federally qualified HCH clinic setting. Demographic characteristics, medication use and appointment history and perceptions associated with interest in receiving cell phone alerts to manage medications and appointments were also examined.
Methods
Design and sample
A cross-sectional survey was employed as the study design. The study site was a federally qualified HCH centre in central Virginia. The HCH provides medical and behavioural health care to the homeless and those at risk for homelessness regardless of their ability to pay. The HCH centre serves nearly 6000 patients annually. The majority (<60%) of the population is African American. Patients served by the clinic have an income ≤200% of the poverty level and a number of census tracts within the service area are designated as medically underserved areas. Individuals ≥18 years old who used HCH services were eligible to participate in the study. The Virginia Commonwealth University Institutional Review Board approved this study as being in compliance with all ethical and regulatory standards.
Survey questionnaire
The survey questionnaire was developed using surveys from existing studies that have examined cell phone use.[32,37–40] The questionnaire consisted of 22 questions (see Data S1). The initial question asked if participants had a cell phone. Individuals who answered yes to having a cell phone proceeded to answer questions about cell phone use including the duration of owning a cell phone, type of cell phone plan, ability to charge the phone, affordability of the cell phone, history of lost and stolen cell phone(s), history of sharing a cell phone with another person, type of functions available on the cell phone and frequency of using the cell phone to make phone calls, send text and picture messages, use of mobile apps and use of alarm on the cell phone. All participants indicated their level of agreement using a Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree) with statements about their medication use, appointment history and perceptions about using a cell phone to manage medications and appointments. Participants also indicated their interest (yes, no or maybe) in receiving alert reminders sent to a cell phone to take medications, refill medications, attend appointments and interest in receiving information about medications sent to a cell phone. Those who answered yes or maybe to being interested in using a cell phone to help manage medications or appointments were asked to indicate their preference for the mode of delivery. Those who were not interested were asked to check reasons for the lack of interest. Demographic information, including age, gender, race, current housing status and education level, was also collected. Participants self-selected their housing status based on their housing status at the time of the study.
Data collection
A self-administered paper questionnaire was used for data collection on five weekdays over a 3-week period in May–June 2013. All individuals who were ≥18 years old and used HCH services on the days of survey administration were invited to participate when they arrived at the clinic. Study staff reviewed the purpose and goals of the study with interested individuals. Those who were interested in participating proceeded to complete the questionnaire in a semi-private room and returned the questionnaire to one of the study staff members upon completion. On average, it took 5–10 min to complete the survey. Each participant received $5.00 upon completion of the survey.
Data analysis
Frequency and mean summary statistics were calculated for all study variables. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were estimated for demographic factors, medication use history and perceptions about using a cell phone to manage medications related to interest in using a cell phone to receive reminder alerts to take medications, medication refill reminder alerts and medication information messages using three separate logistic regression models. Those who indicated yes to being interested in using a cell phone to receive reminder alerts to take or refill medications or receive information about medications via cell phone were considered interested in using a cell phone to help with these tasks (i.e. yes). Individuals indicating no or maybe to any of these questions were considered not interested in using a cell phone to help with that task (i.e. no). AOR and 95% CI were also estimated for demographic factors and perceptions about using a cell phone for appointment reminders related to interest in receiving appointment reminders via cell phone using a logistic regression model. Individuals who indicated yes to the question about interest in receiving appointment reminder alerts were considered interested in receiving appointment reminder alerts via cell phone (i.e. yes). Individuals indicating no or maybe to the question about interest in receiving appointment reminder alerts were considered not interested in receiving appointment reminders (i.e. no). The study data were stored on a secure server only accessible to study personnel. Data entry was performed by research assistants using a codebook that corresponded to responses for study variables. The data entry was checked for accuracy by examining frequencies and ranges for each variable. Any discrepancies identified were manually checked and updated as appropriate. Microsoft Excel and SAS/PC version 9.4 was used for data management and analysis respectively.
Results
A total of 300 individuals agreed to complete questionnaires. Ten questionnaires were excluded due to missing responses for one or more pages (9) or the participant did not understand questions (1) for a total of 290 usable responses.
Demographics
Table 1 summarizes participant demographics. The mean age of participants was 47.2 ± 10.7 years old and 65% were men. The majority (73%) was African American and 22% were White. Housing status varied with 28% reporting no housing or living on the street, 57% indicated unstable housing which included living with family or friends, living in a shelter, transitional or supportive housing or being in a treatment programme and 15% were housed. Those who were housed most commonly reported that they were renting an apartment or a room in a house. Forty-two percent of participants were a high school graduate or had completed the GED exam, 31% completed less than high school and 27% greater than high school.
Table 1.
Demographics and ownership of cell phone (n = 290*)
| N (%) | Mean (SD) | |
|---|---|---|
| Age | – | 47.2 (10.7) |
| Gender | ||
| Men | 185 (64.7) | – |
| Women | 101 (35.3) | – |
| Race/ethnicity† | ||
| African American | 207 (72.9) | – |
| Caucasian/White | 61 (21.5) | – |
| Other | 16 (5.6) | – |
| Housing status | ||
| No housing or street | 81 (28.2) | – |
| Unstable housing | 163 (56.8) | – |
| Housed | 43 (15.0) | – |
| Education | ||
| High school graduate or GED | 120 (42.0) | – |
| Less than high school | 88 (30.8) | – |
| Greater than high school | 78 (27.3) | – |
| Own a cell phone | ||
| Yes | 258 (89.0) | – |
| No | 32 (11.0) | – |
For each variable, there were less than five missing responses.
Other included Hispanic (6), Native American (4), Asian Pacific Islander (2).
Cell phone use and activities
Eighty-nine percent of participants (258/290) reported owning a cell phone. Of those owning a cell phone, half had owned a cell phone for 5 or more years. Half of participants who had a cell phone enrolled in the government sponsored Safelink or Assurance Wireless program plans, 23% reported using prepaid plans, 23% monthly contracts and 14% pay-as-you-go contracts with 19% sharing their cell phone with another person. The majority (65%) were able to charge their cell phones all of the time. About one-third indicated having a cell phone stolen in the past and 54% had left or lost a cell phone in the past. Nearly all of the participants reported having text messaging capability, whereas only 51% and 41% reported having picture messaging and mobile app support respectively. About half of participants used their cell phone to send or receive text messages multiple times a day and 76% made multiple phone calls a day. The majority reported never sending or receiving picture messages (59%) or using mobile apps (68%). Of those that use a cell phone alarm (168/290), there was variability in the reasons for using an alarm. A majority used the cell phone alarm to wake up (86%) or for appointment reminders (58%). Table 2 summarizes cell phone use and activities of participants.
Table 2.
Summary of cell phone use and activities
| N (%) | |
|---|---|
| I have used a cell phone for: (N = 257) | |
| >1 year | 27 (10.5) |
| 1–2 years | 27 (10.5) |
| 2–3 years | 48 (18.7) |
| 4–5 years | 26 (10.1) |
| <5 years | 129 (50.2) |
| What kind of cell phone plan do you currently use? (N = 258) | |
| Pay-as-you-go | 37 (14.3) |
| Prepaid | 60 (23.3) |
| Monthly contract | 60 (23.3) |
| Free minutes provided by Safelink or Assurance wireless | 130 (50.4) |
| Other | 6 (2.3) |
| I am able to charge my phone: (N = 257) | |
| None of the time | 9 (3.5) |
| Less than half of the time | 11 (4.3) |
| Half of the time | 32 (12.5) |
| More than half of the time | 39 (15.2) |
| Always | 166 (64.6) |
| I am able to afford my cell phone: (N = 253) | |
| None of the time | 41 (16.2) |
| Less than half of the time | 25 (9.9) |
| Half of the time | 40 (15.8) |
| More than half of the time | 36 (14.2) |
| Always | 111 (43.9) |
| I have left my cell phone somewhere or lost my cell phone before: (N = 258) | |
| No | 119 (46.1) |
| Yes | 139 (53.9) |
| I have had my cell phone stolen before: (N = 257) | |
| No | 168 (65.4) |
| Yes | 89 (34.6) |
| Do you share your cell phone with another person? (N = 257) | |
| No | 209 (81.3) |
| Yes | 48 (18.7) |
| My cell phone is capable of text messaging: (N = 255) | |
| No | 23 (9.0) |
| Yes | 232 (91.0) |
| My cell phone is capable of picture messaging: (N = 247) | |
| No | 122 (49.4) |
| Yes | 125 (50.6) |
| My cell phone supports mobile apps: (N = 247) | |
| Yes | 146 (59.1) |
| No | 101 (40.9) |
| I use my cell phone to make calls: (N = 251) | |
| Never | 0 (0.0) |
| Less than once a week | 8 (3.2) |
| At least once a week | 26 (10.4) |
| Once daily | 26 (10.4) |
| Multiple times a day | 191 (76.1) |
| I send/receive text messages: (N = 250) | |
| Never | 68 (27.2) |
| Less than once a week | 13 (5.2) |
| At least once a week | 24 (9.6) |
| Once daily | 24 (9.6) |
| Multiple times a day | 121 (48.4) |
| I send/receive picture messages: (N = 244) | |
| Never | 143 (58.6) |
| Less than once a week | 29 (11.9) |
| At least once a week | 21 (8.6) |
| Once daily | 14 (5.7) |
| Multiple times a day | 37 (15.2) |
| I use mobile apps: (N = 240) | |
| Never | 162 (67.5) |
| Less than once a week | 7 (2.9) |
| At least once a week | 8 (3.3) |
| Once daily | 18 (7.5) |
| Multiple times a day | 45 (18.8) |
| I use the alarm on my cell phone: (N = 251) | |
| Never | 82 (32.7) |
| Less than once a week | 21 (8.4) |
| At least once a week | 25 (10.0) |
| Once daily | 61 (24.3) |
| Multiple times a day | 62 (24.7) |
| I use the alarm on my cell phone: (N = 168)* | |
| To wake up | 144 (85.7) |
| To remind me of errands | 44 (26.2) |
| To remind me of appointments | 98 (58.3) |
| To remind me to take my medications | 33 (19.6) |
| Other | 11 (6.6) |
Participants who did not use cell phone alarms (N = 82) or did not report their alarm use (N = 8) are not included.
Table 3 reports respondents’ level of agreement with statements about medication use, appointments and perceptions about cell phone alerts being helpful in remembering to take and refill medications and attend appointments. The mean scores on a Likert scale from 1 = strongly disagree to 5 = strongly agree indicated that respondents neither disagreed nor agreed with statements about forgetting to take medications (2.9 ± 1.5), getting refills on time (2.7 ± .5) and forgetting health care appointments (2.7 ± 1.4). The mean scores on a Likert scale from 1 = strongly disagree to 5 = strongly agree indicated agreement with believing cell phone alerts would be helpful as a reminder to take (3.7 ± 1.4) and refill medications (3.7 ± 1.4) and attend appointments (3.8 ± 1.3).
Table 3.
Characteristics of medication use and appointments and perceptions about using cell phone for medication management and appointment reminders
| Mean (SD)* | |
|---|---|
| I forget to take my medication(s) some of the time. (N = 289) | 2.9 (1.5) |
| I run out of my medicine because I don't get refills on time. (N = 285) | 2.7 (1.5) |
| I forget about my health care appointments some of the time. (N = 286) | 2.7 (1.4) |
| I would like more information about my medication(s). (N = 278) | 3.1 (1.4) |
| I believe that alerts sent to my cell phone would help me remember to take my medication. (N = 287) | 3.7 (1.4) |
| I believe that alerts sent to a cell phone would help me to remember to refill my medications. (N = 286) | 3.7 (1.4) |
| I believe that alerts sent to a cell phone would help me to remember to attend my appointments. (N = 284) | 3.8 (1.3) |
| I believe that using a cell phone to manage my medications would improve my health. (N = 286) | 3.7 (1.3) |
| I believe that my medication information would be protected on a cell phone. (N = 286) | 3.4 (1.4) |
1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.
Seventy-seven percent of participants were interested in receiving reminder alerts for appointments, and 66% and 60% were interested in receiving refill reminders and reminders to take medications respectively. Just over half of participants (52%) were interested in receiving medication information via a cell phone. Of the participants who indicated yes or maybe to any of the statements about using a cell phone to manage medications or appointments (n = 250), 56% found automated telephone calls or voice messages to be an acceptable method of receiving alerts and 65% reported text messaging to be acceptable. Only 12% indicated interest in using a mobile app for these functions. Of the participants who indicated no to any of the statements about using a cell phone to manage medications or appointments (n = 108), the most common reason checked for not being interested was not having trouble remembering (47%). Other reasons included not needing medication information (32%), not perceiving alerts to be helpful (20%), alerts would be bothersome (17%) and privacy concerns (27%).
Tables 4–7 display the results for each logistic regression model. Those who believed reminders were helpful (AOR: 1.59; 95% CI: 1.19–2.13) and using a cell phone to manage medications would improve health (AOR: 1.62; 95% CI: 1.20–2.18) were more likely to want to receive cell phone reminders to take medications. Participants who ran out of medicine due to not getting medication refills on time (AOR: 1.51; 95% CI: 1.16–1.98) and who believed reminders were helpful (AOR: 1.55; 95% CI: 1.14–2.11) were more likely to be interested in receiving medication refill alerts. Those who were interested in more information about medications (AOR: 1.49; 95% CI: 1.19–1.86) and who believed medication information would be protected (AOR: 1.62; 95% CI: 1.24–2.13) were more likely to be interested in receiving medication information via cell phone. Finally, forgetting appointments (AOR: 1.84; 95% CI: 1.38–2.46) and believing appointment reminders were helpful (AOR: 1.77; 95% CI: 1.38–2.28) predicted interest in receiving appointment reminders via cell phone messaging.
Table 4.
Relationship between demographics, medication use history and perceptions about cell phone alerts and interest in using cell phone to receive reminders to take medication
| Would like to receive cell phone alerts to remind to take medications | Adjusted odds ratio (95% CI) | ||||
|---|---|---|---|---|---|
| Yes (N = 157) | No (N = 100) | ||||
| N (%) | Mean (SD) | N (%) | Mean (SD) | ||
| Age (years) | – | 47.5 (10.1) | – | 47.3 (10.6) | 1.02 (0.99–1.06) |
| Gender | |||||
| Women | 57 (36.3) | – | 37 (37.0) | – | Reference |
| Men | 100 (63.7) | – | 63 (63.0) | – | 0.63 (0.33–1.21) |
| Race | |||||
| Black | 124 (79.0) | 66 (66.0) | – | Reference | |
| White | 24 (15.3) | 28 (28.0) | – | 0.60 (0.29–1.23) | |
| Other | 9 (5.7) | 6 (6.0) | – | 0.93 (0.24–3.60) | |
| Education | |||||
| High school graduate or GED | 66 (42.0) | – | 42 (42.0) | – | Reference |
| Less than high school graduate | 52 (33.1) | – | 26 (26.0) | – | 1.63 (0.78–3.40) |
| Some college or college degree | 39 (24.8) | – | 32 (32.0) | – | 0.84 (0.42–1.69) |
| Housing status | |||||
| Housed | 25 (15.9) | – | 17 (17.0) | – | Reference |
| Unstable housing | 87 (55.4) | – | 57 (57.0) | – | 0.94 (0.40–2.19) |
| No housing or street | 45 (28.7) | – | 26 (26.0) | – | 1.10 (0.42–2.87) |
| I forget to take my medication(s) some of the time | – | 3.1 (1.4) | – | 2.4 (1.3) | 1.15 (0.92–1.44) |
| I believe that alerts sent to my cell phone would help me remember to take my medications | – | 4.0 (1.2) | – | 2.8 (1.3) | 1.59 (1.19–2.13) |
| I believe that using my cell phone to manage my medications would improve my health | – | 4.0 (1.1) | – | 2.9 (1.3) | 1.62 (1.20–2.18) |
Table 7.
Relationship between demographics, appointment history and perceptions about cell phone alerts and interest in using cell phone for appointment reminder alerts
| Would like to receive appointment reminders via cell phone | Adjusted odds ratio (95% CI) | ||||
|---|---|---|---|---|---|
| Yes (N = 197) | No (N = 61) | ||||
| N (%) | Mean (SD) | N (%) | Mean (SD) | ||
| Age (years) | – | 46.9 (10.4) | – | 48.8 (10.2) | 1.01 (0.98–1.04) |
| Gender | |||||
| Women | 73 (37.1) | – | 22 (36.1) | – | Reference |
| Men | 124 (62.9) | – | 39 (63.9) | – | 0.72 (0.34–1.52) |
| Race | |||||
| Black | 140 (71.1) | 48 (78.7) | – | Reference | |
| White | 46 (23.4) | 9 (14.8) | – | 1.81 (0.76–4.35) | |
| Other | 11 (5.6) | 4 (6.6) | – | 0.69 (0.15–3.29) | |
| Education | |||||
| High school graduate or GED | 82 (41.6) | – | 28 (45.9) | – | Reference |
| Less than high school graduate | 57 (28.9) | – | 20 (32.8) | – | 1.34 (0.61–2.94) |
| Some college or college degree | 58 (29.4) | – | 13 (21.3) | – | 1.62 (0.69–3.79) |
| Housing status | |||||
| Housed | 30 (15.2) | – | 11 (18.0) | – | Reference |
| Unstable housing | 111 (56.4) | – | 32 (52.5) | – | 0.89 (0.34–2.27) |
| No housing or street | 56 (28.4) | – | 18 (29.5) | – | 0.79 (0.28–2.24) |
| I forget about my appointments some of the time | – | 2.9 (1.3) | – | 1.7 (1.1) | 1.84 (1.38–2.46) |
| I believe that alerts sent to my cell phone would help me remember to attend my appointments | – | 4.0 (1.1) | – | 2.8 (1.5) | 1.77 (1.38–2.28) |
Table 5.
Relationship between demographics, medication use history and perceptions about cell phone alerts and interest in using cell phone for medication refill alerts
| Would like to receive medication refill alerts via cell phone | Adjusted odds ratio (95% CI) | ||||
|---|---|---|---|---|---|
| Yes (N = 172) | No (N = 82) | ||||
| N (%) | Mean (SD) | N (%) | Mean (SD) | ||
| Age (years) | – | 46.7 (10.3) | – | 48.8 (10.2) | 1.00 (0.97–1.03) |
| Gender | |||||
| Women | 64 (37.2) | – | 31 (37.8) | – | Reference |
| Men | 108 (62.8) | – | 51 (62.2) | – | 0.76 (0.38–1.49) |
| Race | |||||
| Black | 129 (75.0) | 57 (69.5) | – | Reference | |
| White | 33 (19.2) | 20 (24.4) | – | 0.80 (0.38–1.68) | |
| Other | 10 (5.8) | 5 (6.1) | – | 0.85 (0.19–3.85) | |
| Education | |||||
| High school graduate or GED | 67 (39.0) | – | 39 (47.6) | – | Reference |
| Less than high school graduate | 56 (32.6) | – | 22 (26.8) | – | 2.01 (0.93–4.38) |
| Some college or college degree | 49 (28.5) | – | 21 (25.6) | – | 1.47 (0.70–3.12) |
| Housing status | |||||
| Housed | 28 (16.3) | – | 13 (15.9) | – | Reference |
| Unstable housing | 97 (56.4) | – | 45 (54.9) | – | 0.70 (0.28–1.76) |
| No housing or street | 47 (27.3) | – | 24 (29.3) | – | 0.69 (0.25–1.89) |
| I run out of my medicine because I don't get refills on time | – | 2.9 (1.4) | – | 1.9 (1.1) | 1.51 (1.16–1.98) |
| I believe that alerts sent to my cell phone would help me remember to refill my medications | – | 4.0 (1.1) | – | 2.7 (1.4) | 1.55 (1.14–2.11) |
| I believe that using my cell phone to manage my medications would improve my health | – | 4.0 (1.1) | – | 2.9 (1.4) | 1.36 (0.99–1.85) |
Table 6.
Relationship between demographics, medication use history and perceptions about cell phone alerts and interest in using cell phone to receive medication information
| Would like to receive medication information via cell phone alerts | Adjusted odds ratio (95% CI) | ||||
|---|---|---|---|---|---|
| Yes (N = 129) | No (N = 120) | ||||
| N (%) | Mean (SD) | N (%) | Mean (SD) | ||
| Age (years) | – | 48.0 (10.1) | – | 46.7 (10.6) | 1.02 (0.99–1.05) |
| Gender | |||||
| Women | 41 (31.8) | – | 51 (42.5) | – | Reference |
| Men | 88 (68.2) | – | 69 (57.5) | – | 1.12 (0.61–2.06) |
| Race | |||||
| Black | 106 (82.2) | 75 (62.5) | – | Reference | |
| White | 16 (12.4) | 37 (30.8) | – | 0.34 (0.17–0.70) | |
| Other | 7 (5.4) | 8 (6.7) | – | 0.59 (0.18–1.94) | |
| Education | |||||
| High school graduate or GED | 57 (44.2) | – | 49 (40.8) | – | Reference |
| Less than high school graduate | 40 (31.0) | – | 33 (27.5) | – | 1.02 (0.51–2.05) |
| Some college or college degree | 32 (24.8) | – | 38 (31.7) | – | 0.79 (0.40–1.57) |
| Housing status | |||||
| Housed | 23 (19.2) | – | 17 (13.2) | – | Reference |
| Unstable housing | 66 (55.0) | – | 76 (58.9) | – | 1.39 (0.62–3.10) |
| No housing or street | 31 (25.8) | – | 36 (27.9) | – | 1.52 (0.62–3.78) |
| I would like more information about my medication(s) | – | 3.4 (1.4) | – | 2.5 (1.3) | 1.49 (1.19–1.86) |
| I believe that using my cell phone to manage my medications would improve my health | – | 3.9 (1.2) | – | 3.3 (1.4) | 0.99 (0.75–1.30) |
| I believe that my medication information would be protected on a cell phone | 3.7 (1.2) | 2.9 (1.3) | 1.62 (1.24–2.13) | ||
Discussion
In this study, 89% of participants reported owning a cell phone. Out of all participants, there was interest in using a cell phone to manage appointments and medications, with 77% being interested in appointment reminders and 66%, 60% and 54% were interested in refill reminders, medication taking reminders and medication information messages. Participants’ perception of the helpfulness of reminders predicted interest in medication taking, refill and appointment reminders. Those who reported running out of medication and forgetting appointments were more likely to be interested in refill and appointment reminders.
A convenience sample was used in this study which could impact generalizability of study findings since individuals who use clinic services may be more engaged in their health than those who do not use the clinic. However, the clinic in this study is a federally qualified HCH clinic, so results may be interpreted more broadly since similar clinics exist across the United States. The survey used as the data collection instrument was not formally validated for this study. However, it was modified from existing studies that examined homeless individuals in urban settings and it was reviewed for content by experts in homeless care which mitigates this limitation.
Nearly all participants reported owning a cell phone in this study, which aligns with recent studies about cell phone ownership among homeless individuals.[33–35] These results suggest that the use of cell phones among homeless or those at risk of homelessness is similar to non-homeless individuals.[1] Thus, mobile technology is a viable option for communicating with the health care system across all groups, including those with limited incomes and hard to reach, transient groups. Despite the high uptake, there are unique circumstances for homeless individuals that should be considered. First, although homeless individuals may have a cell phone, access to minutes may be limited. In this study, half of the participants’ access was limited to the free minutes provided by the Safelink Wireless or Assurance federal government benefit programmes which provide free cell phones to those who qualify based on participation in public assistance programmes such as Medicaid or household income levels. Although the programme structure may vary, currently it includes 500 free minutes monthly for the first 4 months and 350 min thereafter with unlimited text messaging. Additional minutes may be purchased for a monthly fee.[41,42] These findings align with the qualitative study by Asgary et al. which reported that few had unlimited minutes and another study which found that 16% of 106 homeless veterans had run out of minutes in the past 30 days.[33] Another study found that patients were unsatisfied when receiving automated appointment reminder calls because of the use of free minutes.[34] Taken together, these results suggest that medication or appointment-related messages via text versus automated phone calls may be more reliable in consistently reaching those enrolled in the federal programmes that provide free cell phones. However, it has also been reported that up to 45% of homeless veterans changed their mobile number during a 1-year period,[33] which may result in inaccurate phone numbers in the electronic medical record. In the current study, only 65% reported being able to charge their cell phone all of the time, 35% had a cell phone stolen and 54% left or lost a cell phone in the past. The study by McInnes et al. reported similar rates of being able to charge a phone, but lower rates of having a phone stolen (17%) or lost (20%). These are all issues that can impact being able to consistently reach homeless patients via cell phone. Regularly updating cell phone information during the intake period at each clinic encounter may be one strategy that can help keep up with changes to cell phone numbers.
Participants in this study were most interested in using a cell phone to manage appointments with 77% indicating they would like to receive appointment reminders. This is somewhat lower than a previous report which indicated 93% of homeless veterans were interested in receiving appointment reminders.[33] Forgetting appointments and believing reminders were helpful were predictors of being interested in receiving appointment reminders. This aligns with a previous report which identified poor memory as one reason homeless individuals were interested in appointment reminders.[34,36] Homeless patients have also expressed that it is convenient to be able to store messages in a cell phone, which eliminates the need to carry papers with appointment information.[34–36] To determine if cell phone appointment alerts would be useful for a particular patient, clinicians can review patient records to assess whether or not the patient has a history of poor attendance and talk to the patient to see if forgetfulness is contributing to missed appointments. Also, directly asking patients whether or not they think reminders would help increase attendance at appointments is another approach that can be used to engage patients in their care.
With regard to medication management, 66% and 60% of respondents were interested in receiving refill reminder alerts and reminders to take medications respectively. These results align with a qualitative study that reported homeless patients were interested in receiving refill reminders via phone calls or text messages and there was somewhat less interest in receiving medication adherence alerts as reminders to take medication.[34] Although only half of participants in this study were interested in receiving messages with medication information, this may be an area that can benefit from tailored messaging.[43] Asgary et al. found that homeless individuals were receptive to messages about health that were perceived to be relevant to their needs. Being able to recognize the sender was also important to the patients.[35] In this study, patients who believed their medication information was protected were more likely to be interested in receiving medication information via a cell phone. Health professionals should keep this in mind and provide education about how privacy is protected when introducing mobile health interventions to patients. Similar to appointment reminders, health professionals should also talk to patients about their perceptions of using cell phone alerts for refill and medication taking reminders to ascertain which patients find them to be helpful.
In this study and others,[33,34] patients’ preferences were mixed for how they wanted to receive messages, with some wanting to receive automated phone calls, others text messages and some none at all due to the cost (if paying out of pocket) or impact on minutes (if enrolled in government program). Patients seem to be most comfortable with appointment reminders, which may be because they are more familiar with these.[34] Out of 94 homeless veterans who had a cell phone, 71% had previously used the phone to make a health-related call, whereas only 21% used texting for health-related purposes. Given that 65% of participants in this study were interested in receiving and deemed text messages to be an acceptable method of communication with health care providers about medications and appointments, more emphasis should be placed on developing communication strategies using this approach. This would allow health professionals to reach patients in an efficient and meaningful way despite the sometimes transient nature of homeless patients.[44]
These findings suggest that as mobile health interventions evolve, there will not be a one size fits all approach to mode and frequency of interventions for homeless individuals. It is important for patients to be able to choose if they want to participate and to select the frequency and type of alerts. Patients should also be engaged in the development of messages to ensure the messages are patient-centred and appeal to this group.[35] Some patients may already be using cell phone alarms to help keep appointments as found in this study, and some patients reported using their cell phone alarms to set reminders to take medications. There have been a number of reports describing pharmacists’ roles in medication management at federally qualified health centres, including those that serve homeless individuals.[28,29,45,46] Since mobile health interventions are not widespread, pharmacists can use cell phones as a tool to engage homeless patients in managing their appointments and improve medication adherence, when applicable.
Conclusion
This study will add to the emerging literature about using cell phone alerts to enhance care for homeless individuals. The results show that homeless individuals have access to cell phones and were interested in using their cell phones to manage medications and appointments via automated telephone calls, voice messages and/or text messages. Recognizing a need for a particular cell phone intervention and believing that the intervention would be helpful were predictors of interest in using cell phones to receive medication and appointment reminders and medication information. Providing detailed privacy protection practices and tailoring mobile health information to meet individual needs may increase homeless individuals’ participation in mobile health interventions. Clinicians can use this information to tailor strategies for improving medication use and appointment adherence in a patient-centred manner.
Declarations
Conflict of interest
The authors declare that they have no conflicts of interest to disclose.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Authors’ contributions
Dr. Moczygemba was the principal investigator for the study and was responsible for study design, survey development, data collection, data analysis and interpretation and manuscript preparation. Dr. Moczygemba is also the corresponding author for the manuscript. Dr. Cox was responsible for assisting with study design, survey development and data collection. Dr. Marks was responsible for assisting with data analysis and interpretation and manuscript preparation. Dr. Robinson was responsible for assisting with survey development and data collection. Dr. Goode was responsible for assisting with survey development and data collection. Dr. Jafari was responsible for assisting with data collection. All authors have read, provided feedback and approved the manuscript. At the time of the study, Dr. Moczygemba was an Associate Professor and Drs. Robinson and Jafari were Doctor of Pharmacy students at Virginia Commonwealth University.
Supplementary Material
Data S1. Cell phone use and perceptions about using a cell phone to help manage your medications.
Acknowledgements
This work was supported in part by award number KL2TR000057 from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1. Cell phone use and perceptions about using a cell phone to help manage your medications.