The Impact of Short Message Service (SMS) Reminder and Home

Monitoring on Blood Pressure Control in Hypertension Patients:

A Case Study of Two Primary Health Care Facilities

in Banyumas Regency

Laksmi Maharani

, Hening Pratiwi

, and Ika Mustikaningtias

Department of Pharmacy, Faculty of Health Sciences, Jenderal Soedirman University,

Jl. Soeparno, Karangwangkal, Purwokerto, Banyumas Regency, Central Java Province, Indonesia

Keywords: SMS, home monitoring, blood pressure, hypertension.

Abstract: The use of antihypertensive drugs is an effective strategy to reduce blood pressure. Several studies suggest

that an intervention like SMS reminders and home monitoring programs may be effective for improving

patient’s adherence and, as a result, controlling the blood pressure in hypertensive patients. This study aimed

to determine the role of SMS reminders and home monitoring in lowering patient’s blood pressure. A pre-

and post- intervention design were conducted at two primary healthcare facilities in Banyumas Regency

from May to June 2018. Thirty patients were recruited, and they received a one-month intervention of daily

SMS and home visits by a research assistant once in two weeks. The primary measurable outcome was

the improvement of blood pressure control between the control and the intervention groups. The data were

analyzed using a paired T-test at a signicance level of 0.05. The result showed that the systolic blood pressure

in the control group was less improved than the intervention group (-2.4 and -6.43, respectively). The diastolic

blood pressure improved by -3.1 and -0.04, but these results could not be explained. The systolic blood

pressure decreased signicantly in the intervention group (p<0.05). When compared with the absence of

intervention, the combination of SMS reminders and home blood pressure monitoring were more effective in

lowering the systolic blood pressure in hypertension patients.

1 INTRODUCTION

Hypertension is a chronic condition with high

prevalence (30-45%) worldwide (Filipovský et al.,

2014). In Indonesia, hypertension affects 25.8% of

the total population (Ministry of Health of Republic

of Indonesia, 2013). The treatment for hypertension

involves lifestyle change and antihypertensive drug

(Filipovský et al., 2014).The use of antihypertensive

drugs is an effective strategy to reduce blood

pressure and prevent further cardiovascular and

renal complications, but it requires patient adhering

to treatment. Patients’ adherence to antihypertensive

drug therapy is less than 50% in developing countries

(Suffoletto and Muldoon, 2017).

There are many strategies to improve patients’

adherence to antihypertensive therapy, such as

pharmacist interventions, patient educational

programmes, and peer assistance program (Abughosh

et al., 2016; Margolis et al., 2013; Su et al., 2014). Peer

assistance is one of the low-cost programs that gives a

high impact on a patient’s blood pressure control (Haidari

et al., 2016). The peer support includes telemonitoring,

home visits, and group training (Haidari et al., 2016;

Semper, 2015; Su et al., 2014; Yasmin et al., 2016).

Weekly SMS service for 12 months signicantly reduces

the systolic blood pressure baseline by -2.2 mmHg

(Bobrow et al., 2016) and increases adherence to the

prescribed antihypertensive therapy (Yasmin et al.,

2016).

While several previous studies suggest that either

SMS reminder or peer assistance program as a single

intervention may be effective for controlling blood

pressure in hypertensive patients, none of them

combined the two methods.

Maharani, L., Pratiwi, H. and Mustikaningtias, I.

The Impact of Short Message Service (SMS) Reminder and Home Monitoring on Blood Pressure Control in Hypertension Patients: A Case Study of Two Primary Health Care Facilities in

Banyumas Regency.

DOI: 10.5220/0008238400050010

In Proceedings of the 1st Muhammadiyah International Conference on Health and Phar maceutical Development (MICH-PhD 2018), pages 5-10

ISBN: 978-989-758-349-0

2 MATERIALS AND METHOD

2.1 Design, Setting, and Patients

The measurements of the pre- and post-intervention

blood pressure were conducted at two primary

healthcare facilities in Banyumas Regency from

May to June 2018. Thirty patients were recruited,

and they received a one-month intervention of daily

SMS and home visits by the research assistant once

in two weeks. The subjects were selected from 150

hypertensive patients purposively using a set of

inclusion criteria. The inclusion criteria were patients

diagnosed with hypertension and treated with at least

one antihypertensive drug who had the willingness

to participate in the study and the ability to receive

and read SMS, attended primary healthcare facilities

regularly, lived in an accessible home, and consumed

no traditional medicine supplements to control their

hypertension. Out of the 150 patients, only 30 patients

met these inclusion criteria.

The research assistants who delivered the SMS

and monitored the blood pressure during the home

visits were selected from the undergraduate pharmacy

students of Jenderal Soedirman University. They were

trained to use the automatic blood pressure monitor

properly and send SMS in the right time with the right

template.

The trial was approved by the Medical and Health

Research Ethics Committee, Faculty of Medicine,

Gadjah Mada University, Indonesia with the

Approval No. KE/FK/0570/EC/2018. All participants

were provided with written informed consent, and the

trial was conducted according to the Declaration of

Helsinki in 2008.

2.2 Intervention

All eligible subjects (n=30) had their blood pressure

measured using the Omron Automatic Blood Pressure

Monitor HEM 8712 to obtain their blood pressure

baseline. The research assistants recorded the address

and mobile phone number of the subjects, as well

as their antihypertensive drug prescription. After

four weeks of no intervention, their blood pressure

was measured again to examine the effect of self-

treatment. Then, the intervention commenced. The

subjects received daily SMS from the research

assistants ten (10) minutes before and after the time

to take their antihypertensive drugs. The research

assistants also called them weekly to check if they

had any complaints or health issues. A home visit by

the research assistant to measure the blood pressure

of the subject was organized and conducted every

two weeks. After four weeks, the intervention was

concluded, and the subjects had their blood pressure

measured again. The owchart of the study is

illustrated in Figure 1. The primary expected outcome

was the improvement of the systolic and diastolic

blood pressures in the intervention group (after a

four-week intervention) compared with the control

group (four weeks of self-treatment and before the

start of the intervention).

2.3 Data Analysis

The collected data were checked for normality using

the Shapiro-Wilk test. Because all of them were

distributed normally, a parametric test was used in

further analysis. The paired t-test aimed to compare

the changes in the systolic and diastolic blood

pressures of the control group and the intervention

group before and after the intervention. The outcomes

were categorized as statistically signicant if the

resultant alpha was <0.05.

Figure 1: The ow chart of the study.

MICH-PhD 2018 - 1st Muhammadiyah International Conference on Health and Pharmaceutical Development

3 RESULTS AND DISCUSSION

3.1 Patients Demography

From the two primary healthcare facilities with 150

hypertension patients, only 30 patients were eligible

and willing to participate in this study. Most of the

patients were excluded because they had difculty

reading the SMS due to aging. The demographic

characteristics of the subjects are described in Table 1.

Most of the subjects in this study were female

(63%). Women have better control of blood pressure

than men, but they tend to have emotional stress,

which can induce and prolong the case of hypertension

(Silva et al., 2016). Unlike men, women have greater

anti-inammatory immune proles that may act as a

compensatory mechanism to limit increases in blood

pressure (Gillis and Sullivan, 2016). However, in the

Asian population, after the age of 60 years old, women

likely develop hypertension but have less probability

of adhering to long- term hypertension control (Choi et

al., 2017). In this study, most subjects were female, and

some of them were over 60 years old. This demography

might affect the effectiveness of the intervention

because women under 60 years old might naturally be

better in controlling their blood pressure.

The prevalence of hypertension in the elderly is

about 60-70% (Alhawassi et al., 2017). However,

only 47% of geriatric patients participated in this

study because most of them had difculty reading an

SMS. Forty percent of the elderly do not implement

technology in their homes; therefore, providing

SMS reminders for this group of patients would be

unproductive (Fox and Felkey, 2014). Future research

must take into account the eligibility of geriatric

patients for technology-based intervention in the

selection of suitable monitoring services.

Education is one of many factors affecting blood

pressure control. Patients with a higher education

level have better control of their blood pressures

(Sengul et al., 2016). Higher education is associated

with greater health care and awareness (Tedesco et

al., 2001). Most of the patients in this study had a

low education level (elementary and high school;

84%). Low education level is likely behind the

minimum control of blood pressure that requires

antihypertensive medication.

3.2 Blood Pressure Control

The research subjects were initially treated as the

control group for one month. Afterward, they were

parts of the intervention group for another month.

There was a difference in the systolic and diastolic

blood pressures of the former and the latter group. In

the control group (table 2), there was a reduction in

both systolic and diastolic blood pressure. The systolic

blood pressure decreased by 2.4 mmHg, while the

diastolic blood pressure was down by 3.1 mmHg. The

diastolic blood pressure reduction was statistically

signicant (p<0.05). Being a part of a study sometimes

become a burden to the patients. Some of them feel

the pressure to be better in controlling blood pressure

because the study process will show their hypertension

management efforts. Many hypertensive patients

never measure their blood pressure regularly (Sengul

et al., 2016), but when they are included in a study,

a regular measurement is inevitable. This situation

might affect the measurement results of the control

group’s blood pressure and signicantly reduce their

diastolic blood pressure.

Systolic blood pressure is a strong predictor of

cardiovascular disease in hypertensive patients (Nair,

2016), especially in older men (Sesso et al., 2000),

while diastolic blood pressure is a strong predictor

of risk of stroke in young adults. Patients whose

diastolic blood pressures are higher than 71 mmHg

are at high risk of stroke (Vishram et al., 2012).

Furthermore, age determines the effects of different

systolic and diastolic blood pressure controls on

mortality rate. Patients under 50 years old have a

higher mortality rate if their diastolic blood pressure

is uncontrolled, while patients over 50 years old have

a higher mortality rate if their systolic blood pressure

is uncontrolled (Taylor et al., 2011). The elderlies tend

to have a lower diastolic blood pressure, which may

reduce their survival rate (Protogerou et al., 2007).

Table 1: Patients demographic information.

Characteristics

Frequency

(n)

Percentage

(%)

Gender

Male 11 37

Female 19 63

Age

Adult (35-65 y.o.) 16 53

Elderly (≥ 65 y.o.) 14 47

Education Background

Elementary School 4 13

Junior High School 6 20

Senior High School 15 51

Diploma 1 3

Undergraduate 4 13

The Impact of Short Message Service (SMS) Reminder and Home Monitoring on Blood Pressure Control in Hypertension Patients: A Case

Study of Two Primary Health Care Facilities in Banyumas Regency

In the intervention group, the subjects received

daily SMS, weekly phone service, and a home visit

once in two weeks to measure their blood pressure.

After this treatment, there was a reduction in the

systolic and diastolic blood pressure. The systolic blood

pressure decreased by 6.43 mmHg, while the diastolic

blood pressure decreased by 0.04 mmHg. There was

a signicant reduction in systolic blood pressure after

the treatment. These results are inline with Bobrow et

al. (2016) that reveal the effect of SMS reminder on

patients’ adherence to antihypertensive medication,

i.e., patients who receive the SMS have lower systolic

blood pressure than those who obtain no regular

medical intervention. Peer assistance program is also

found to be effective in lowering systolic and diastolic

blood pressure (Haidari et al., 2016). In this study, the

systolic blood pressure of the intervention group was

signicantly lower than the control group. However,

this case did not apply to the diastolic blood pressure.

The reduction of the diastolic blood pressure in the

intervention group was not statistically signicant. It

might be affected by cholesterol level.

3.3 SMS Reminder and Home Blood

Pressure Monitoring Service

Peer support or assistance program is effective and

efcient to achieve better control of blood pressure

in hypertensive patients (Haidari et al., 2016). The

peer assistant can be a researcher or a family member.

However, a peer assistant from family members

shows a positive effect on blood pressure control, but

it is no longer effective after six months (Shen et al.,

2017). Meanwhile, a peer assistant from the researcher

community can give an additional program, like training

and education about the disease and treatment, aside

from supporting the adherence of said patient to the

medication process (Semper, 2015). In this study, peer

assistants were non-family members. This selection

was expected to be benecial for patient monitoring.

They were trained to measure blood pressure and

answer patient’s questions about hypertension.

This study chose the SMS program as an

intervention to hypertensive patients. SMS and voice

calls are proved to be effective to achieve better

control in patients with chronic diseases, particularly

related to their adherence to medication, exercise,

and diet, but these reminders only last for a short

period (Yasmin et al., 2016). SMS is more useful

when preceded with the provision of education about

hypertension to the targeted patients (Suffoletto and

Muldoon, 2017). A longer blood pressure control

with the SMS program can be reached by involving

pharmacists in the service (Margolis et al., 2013).

In the future, SMS service can be an alternative for

the pharmacist community to monitor their patients’

medication when they cannot implement the home

visit program.

4 CONCLUSIONS

The intervention using SMS reminders and home

blood pressure monitoring by research assistants

successfully reduced the baseline of patients’ blood

pressure, as well as the blood pressures after four

weeks of self-treatment and before the intervention.

The reduction in the control group was SBP -2.4,

DBP -3.1, while the reduction in the intervention

group was SBP -6.43, DBP -0.04. The systolic blood

pressure decreased signicantly in the intervention

group (p<0.05), while the diastolic blood pressure

decreased signicantly in the control group. SMS

reminders and home blood pressure monitoring by

research assistants were both effective in lowering the

systolic blood pressure of the samples in this study.

Nevertheless, a study with a larger sample is required

to conrm these results.

The limitation of this study lies in the sample

size, the duration of the treatment in the control and

intervention group, and the program of the home

blood pressure monitoring. The sample size and the

duration need to be expanded to signify the difference

between the blood pressures of the control and

Table 2: Subjects blood pressure before and after treatment.

Groups Mean SBP (mmHg) Mean DBP (mmHg)

Before After ∆ SBP Before After ∆ DBP

Control 138.17 136.3 -2.4 (p 0.451) 83.67 80.57 -3.1 (p 0.039*)

Intervention 136.3 129.87 -6.43 (p

0.003*)

80.57 80.53 -0.04 (0 0.981)

SBP : Systolic Blood Pressure

DBP : Diastolic Blood Pressure

*statistically signicant

MICH-PhD 2018 - 1st Muhammadiyah International Conference on Health and Pharmaceutical Development

intervention group. The home visit in this study was

limited to blood pressure monitoring only. A home

visit may provide more benets when it includes

education of hypertension.

ACKNOWLEDGMENTS

Authors would like to thank the Research and

Community Service Institute of Jenderal Soedirman

University for the research grant and dr. Mulyono

for his help as a referral physician in this research.

Authors would also like to thank Eling Bunga Nurani

and Rahma Ayu Esalia for their willingness to assist

the patients during the research.

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MICH-PhD 2018 - 1st Muhammadiyah International Conference on Health and Pharmaceutical Development