SMS campaign - Can it facilitate prevention of cardiovascular diseases in India?

To the Editor

We have read with great interest the recently published article by Bishav Mohan et al. Cardiovascular disease (CVD) is the leading cause of death in India and worldwide. Lack of knowledge and motivation regarding risk factor prevention is one of the major factors responsible for its poor control. We need pragmatic, affordable, and evidence-based solutions to control this massive problem. Mobile phone based technologies offer a potentially scalable, convenient and cost-effective solution, considering the fact that mobile penetration has reached 90% in developing countries. Furthermore, India has the second largest mobile subscriber base globally, with 877 million mobile phone users across all age, income, and ethnic groups, combined with one of the world’s lowest tariff rates. In a resource-constrained country like India, healthcare professionals have limited opportunity to have direct one-to-one interaction with people. The effective use of mobile phone-based technology like short-text message service (SMS) thus represents a promising approach to extend the reach of health systems to provide preventive cardiac rehabilitation. Most of the trials addressing the usefulness of SMS based intervention in the primordial, primary and secondary prevention of CAD have been done in high-income countries. Data from India are limited.[1], [4] Bishan Mohan et al. have done a remarkable job to send health information related SMS to 40,000 people in Punjab and then assessing the knowledge about prevention of heart disease in 800 participants. However, we have few concerns:

Based on their results, the authors have concluded that SMS campaign led to an increase in the health-related knowledge among the participants. However, the results and methodology need to be interpreted cautiously. The cross-sectional design of the study renders it extremely unreliable to draw any temporal causal association between the intervention (SMS) and the outcome (increase in health-related knowledge). It would have been more appropriate if the participants were made to answer the questionnaires both before and after the SMS campaign. A randomized controlled trial or a pre-post interventional study design would have been better suited to draw temporality.

Secondly, the study also showed that people with higher level of education were more likely to recall the health-related knowledge imparted through SMS. Similarly, in a previous Indian study assessing the impact of mobile-based technology on the prevention of CVD by Leo Feinberg et al4, it was shown that SMS is not favoured by individuals of older age, lower educational status or lacking employment. Since these groups have a higher prevalence of CVD risk factors, there is potential for SMS based interventions to widen the existing health disparities in CVD.

To conclude, SMS based intervention appears a promising, pragmatic and affordable tool for cardiovascular health education in India. However, the evidence base is lacking. Well designed randomized controlled trials evaluating its impact on ‘hard end-points’ are needed to make any conclusions.

Funding

None.

Conflicts of interest

None.