NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

“People need to be reminded more often than they need to be instructed.”

These are the wise words of Samuel Johnson, an English author, critic and lexicographer. Even though he lived more than 200 years ago, international development interventions are proving him correct today.

Reminders for Malaria

It’s widely known that failure to adhere to a full course of antibiotic treatment results in treatment failure, and can also encourage bacterial resistance to antibiotics, threatening the sustainability of current medications. This is extremely important for malaria, which, according to the World Health Organization, results in 198 million cases each year and around 584,000 deaths. The burden is particularly heavy in Africa, where around 90 percent of all malaria deaths occur, and in children under 5 years old, who account for 78 percent of all deaths. Low rates of adherence to artemisinin-based combination therapy (ACT) treatments have led to the prevalence of antibiotic-resistant malaria in many parts of the world, particularly Africa. And one of the biggest and simplest reasons why people fail to complete the full treatment for malaria is that they forget.

In an effort to solve the issue of forgetful patients, researchers at Innovations for Poverty Action (IPA), a nonprofit that designs and evaluates solutions to global poverty using randomized evaluations, teamed up with Harvard University to test the impact of text message reminders on adherence to ACT regimens. The researchers worked with IPA staff in Ghana to recruit 1,140 people outside pharmacies and health care facilities. Half of the participants were randomly assigned to an intervention group or a control group. Those in the intervention group were randomly divided into a group that received a simple text message reminder to take their malaria medication, and another group which received the simple text message as well as an additional statement about adhering to the medication’s recommended 12-hour intervals. The control group did not receive any text message reminders. Local staff followed up several days later at the participants’ homes to see how many pills they had taken.

Those who received the text messages were significantly more likely to finish their full regimen of pills. Among those in the control group, 61.5 percent reported treatment completion, while 66.4 percent in the intervention group reported treatment completion. The researchers also found that short text messages were very effective, while longer texts were less so. A simple message saying, “Please take your malaria drugs!” was more effective in encouraging patients to adhere to the medication regimen than the additional message saying, “Even if you feel better, you must take all the tablets to kill all the malaria.”

Reminders to Save

The effective use of reminders is not limited, however, to medical treatment. Similar findings were found in the Philippines when the First Valley Bank, also working with researchers at IPA, designed a bank savings program. In the program, clients who opened a “Dream” savings account were given a small box into which they could deposit coins. Only bank staff could open the boxes to take the coins out and transfer them to the client’s savings account. A subset of the Dream savings account holders was texted periodically. Half of those receiving texts received positively framed messages that stressed their dreams would come true if they continued to save, while the other half received negative framed messages that stressed that their dreams would not come true if they failed to save. Randomly selected individuals from both of these groups also received text message reminders if they failed to make their monthly deposit. A control group did not receive any reminder text messages.

The results were clear: Receiving a reminder increased the total amount saved by 6.3 percent, and increased the likelihood that participants would reach their savings goal by their goal date. There was no significant difference in the savings rates between those who received positively framed reminder messages or negatively framed reminders. There was also no significant difference for late reminders versus regular reminders.

The Science Behind Reminders

Reminders help overcome prospective memory failures – failures that occur when people forget to perform an action or intention they planned. There are two types of prospective memory: time-based and event-based prospective memory. Time-based prospective memory occurs when a certain time of day reminds an individual to do something. For example, seeing the sun set could remind a patient to take their medication. Event-based prospective memory occurs when a circumstantial cue reminds an individual to do something. For example, walking past their bank reminds a group of workers to make a deposit. Problems occur when the event-based or time-based cues are not present, or when the explicit intention to do something is not linked to these cues. In a review of the science on prospective memory, R. Key Dismukes reveals that in order for reminders to be effective, they must prompt the correct action, be specific and be timed right.

Reminders must emphasize the desired action clearly and simply. People encounter a lot of information each day, and they may not be able to adequately process long or confusing messages. The savings program in the Philippines demonstrates this well, as the positive messages, which were clearer, were more effective. They effectively said, “Do this to achieve your goal.” The negative messages, in contrast, discussed a hypothetical scenario, saying, “If you don’t do this, your goal will not be achieved.” The positive messages prompted the desired action (save!) while the negative messages prompted an undesired action (not saving).

Similarly, reminders must be specific. This is one reason why, in the malaria study, longer messages did not prove to be more effective. While they provided more information, they were less specific. The clearer the message, the better the reception.

Finally, reminders must also be timed correctly for maximum results. This is demonstrated in an AIDS treatment study in which weekly text message reminders were shown to be more effective than daily ones. The researchers theorize that daily texts diluted the impact of each reminder.

So, in developing a program, it is important to (ahem) remember that monitoring and evaluation is not enough. Reminding participants to follow through with the desired actions of any intervention is an essential step to helping people achieve their goals.

Editor’s note: This post was originally published on the World Bank’s blog. It is cross-posted with permission.

Roxanne Bauer is a consultant to the World Bank’s External and Corporate Relations, Operational Communications department.