Delivering Laboratory Results by Text Message and E-Mail: A Survey of Factors Associated with Conceptual Acceptability Among STD Clinic Attendees

Introduction

Cell phones and the Internet are becoming indispensable means of obtaining information and communication in the United States. In 2010, an estimated 83% of adults had a cell phone, and about 42% of them were smartphones capable of Internet connectivity. ¹ According to the 2009 U.S. Census Bureau survey, 77% of American households had some Internet access, which is up from 62% in 2007, 55% in 2003, and 18% in 1997. ² Text messaging on cell phones is also rapidly increasing. In a May 2010 Pew survey, 72% of U.S. adults reported regular use of text messaging compared with 65% in a similar survey in September 2009. ¹ Similarly, e-mail remains the most popular online activity and is rapidly gaining ground among Internet users of all age groups. ^2,3 However, a significant digital divide still remains in the United States because of socioeconomic disparities such as education, income, and urban–rural residence. ^4,5

Because of limited healthcare resources, text messaging and e-mail could potentially be a cost-effective means of improving patient care in sexually transmitted disease (STD) clinics by facilitating rapid communication and information sharing between providers and their patients. Previous studies have suggested that many STD clinic attendees own a cell phone and that text messaging could improve appointment adherence and dissemination of information about sexual health. ^{6 –9} However, similar studies exploring the use of Internet and e-mail for streamlining healthcare utilization in STD clinics is largely lacking. ¹⁰ In addition, there is a paucity of literature on the potential use of text messaging and e-mail to deliver STD laboratory results. ^7,11 This is important because substantial resources in STD clinics are directed at the personnel who report screening laboratory results, which in the majority of cases are negative. ^7,12 A software system for automated provision of screening laboratory results via text message and/or e-mail may help to reduce cost as well as ensure rapid and complete test result reporting. This consequently may reduce time to treatment of STD and onward transmission.

The objectives of this survey study were to assess the use of cell phone and the Internet among individuals visiting STD clinics in the southern United States and to explore the factors of personal preferences and characteristics associated with the acceptability of receiving the screening STD laboratory results by text message and/or e-mail.

Subjects and Methods

We conducted an anonymous prepiloted survey of attendees at 33 STD clinics across South Carolina and a large urban STD clinic in Jackson, MS in 2009–2010. The South Carolina Department of Health and Environmental Control and the University of Mississippi Medical Center institutional review boards both approved the study. Persons visiting STD clinics were presented with the survey along with a brief written explanation about the study and assurance that the participants' information would be kept confidential. Personal information such as name and social security number was not recorded; each survey was given a unique identification number. Participation was voluntary with no financial incentives, and completion of the survey implied participants' consent to use the information for research purposes only. Participants were instructed to approach designated clinic personnel if they had any questions or required assistance to complete the survey. No specific effort was made to approach individuals who declined to participate. The survey included questions about gender, age, highest education level attained, access to the Internet, frequency of the Internet use and most common activities online, access to text messaging and the frequency of its use, and participants' preference for regular communication with the clinic such as appointment scheduling and reminder notifications with choices including cell phone, landline, e-mail, text message, and regular mail. Finally, the survey included four separate questions about participants' acceptability (“agree” or “disagree”) of receiving STD laboratory results in the future via text message and e-mail for two separate scenarios: (1) for negative results only and (2) for both negative or positive results. It is noted that by answering separately for each question, a participant could demonstrate acceptability simultaneously for both e-mail and text messaging or any combination of the two means of communication.

Results

The survey was completed by 2,719 individuals: 1,698 (62.5%) in South Carolina and 1,021 (37.5%) in Mississippi. The median age of participants was 26 years (interquartile range, 21–32 years), and 59.1% were females. Descriptive results by state are presented in Table 1. A majority had high school or higher education (82.2%). More than two-thirds of respondents (68.4%) reported being very comfortable with using the Internet, and 70.4% had access to the Internet at home and/or on personal smartphones. A majority went online at least once weekly (73.6%) and usually reported accessing the Internet for work, school, and online shopping. About 80% of respondents reported using text messaging daily. It is notable that most of the respondents preferred cell phone calls (67.3%) as the preferred means of regular communication and notification with STD clinic compared with text messaging (8.0%), e-mail (8.4%), and landline calls or regular mail (15%). A majority (62.9%) showed acceptability of receiving laboratory test results electronically, with 29.2% for both e-mail and text message, 12.7% for e-mail only, and 21.0% for text message only. More than a third (37.1%) of participants disagreed to receiving test results by both text message and e-mail. Overall, a higher proportion of respondents agreed to receiving laboratory results (positive or negative) by text message compared with e-mail (50.2% versus 41.9%; p<0.0001). Furthermore, it was noted that of those who disagreed to receiving test results electronically by text message or e-mail, a majority indicated daily use of text messaging (72.2%) and daily or weekly use of Internet (66.6%).

Discussion

This survey of STD clinic attendees explores the feasibility and acceptability of using text message and e-mail for reporting laboratory results. The results suggested that most of the individuals visiting STD clinics use cell phones and text messaging, and a majority have regular access to the Internet. However, respondents' most preferable modality of regular contact by STD clinics was calls on their cell phone compared with text message and e-mail. Most of the respondents reported being very comfortable with the Internet use and regularly going online for activities such as checking e-mail accounts, for work and school-related activities, and for shopping. Previous studies have suggested increasing cell phone ownership among STD clinic attendees, even in groups worst affected by socioeconomic deprivation. ^5,6,8,14 For example, Person et al. ⁸ suggested that nearly 40% of the homeless or marginally housed individuals attending an STD clinic owned a cell phone. Another study reported 93% of African American women attending an urban STD clinic owned a cell phone. ⁵ Although limited published data are available on the Internet access among the STD clinic attendees in the United States, the proportion of respondents in our survey who reported having Internet access at home or on smartphones was substantially higher compared with previous studies. ^10,15 Higher use of the Internet among our patients could be explained by a continuing trend of increasing the Internet access nationally. ³ Overall, these data support the plausibility of using both text messaging and the Internet/e-mail as a means of communication with STD clinic clientele. Reporting laboratory results electronically may be a cost-effective strategy of achieving higher rates of result reporting and timely follow-up appointments if needed. ⁷ This is especially important for regions such as the southern United States, which remains disproportionately affected by socioeconomic deprivation and accounts for one of the highest incidence of STD in the nation. ^16,17

Results suggested that respondents were more supportive of receiving both negative or positive results rather than negative-only results. This is an important consideration because it is customary in medical practice to report positive results in-person or over the phone by the provider, followed by an explanation of the various options of management and support available to the patient. Therefore, despite acceptability of receiving both positive and negative results among the patients, the providers and policymakers will need to address pertinent issues such as promptly setting up follow-up appointments and providing some basic information along with the delivery of result. ^6,12 In general, males and those of younger age had higher acceptability of receiving laboratory results by text message and/or e-mail. In addition, those with a lower level of education were more receptive of receiving results by text message compared with e-mail. Previous studies that have examined the difference in access to modern modalities such as cell phones and the Internet in the United States due to socioeconomic factors have reported lower access among females, individuals of older age, lower education, and lower annual income. ^4,5 Results of this study also suggested that personal preference plays an important role. For example, those who reported their preferred means of contact as e-mail were also more willing to receive laboratory results via e-mail. Given that nearly half of our respondents reported willingness to receive laboratory results by text message and/or e-mail, these data suggest that delivering laboratory results by these modalities is an acceptable strategy. However, it is important to do a prior ascertainment of patients' personal preference for receiving laboratory results and to have a basic understanding of patients' comfort of use and access to these modern modalities of communication.

Although literature on this topic remains scarce, the few previous studies have suggested that this strategy of delivering laboratory results to STD clinic attendees could be cost-effective. ^7,11 However, several issues need to be considered before implementing automated electronic STD test reporting. The expense of purchasing software and logistical challenges of automated reporting and also the patients' cost of receiving text messages would need to be evaluated for cost-effectiveness at the regional level. Moreover, policies and logistics of protecting confidentiality of patients' laboratory results will need to be addressed. ⁸

Several study limitations need to be acknowledged. The possibility of respondent bias remains because the characteristics of individuals who declined to participate in the survey were not explored. It may be assumed that those with access to the Internet and cell phones were more likely to participate in the survey. The majority of STD clinic attendees, especially in the southern United Sttes, are disproportionately affected by socioeconomic deprivation and tend to be of minority race/ethnicity. ^18,19 Therefore, we did not enquire about race/ethnicity to minimize prejudice and also because our primary objective was to assess acceptability of receiving laboratory results via text message and/or e-mail based on participants' access to these modalities, personal preference, and education level. The survey was provided only in English, which excluded individuals who only speak Spanish. This investigation pertains to the southern United States, and therefore the results may not be generalizable to other populations and geographical areas.

The major strength of this survey was that unlike previous studies, which were mostly based on data from urban STD clinics and/or had smaller study cohorts, ^{7,8,10 –12} our data included a large group of STD clinic attendees spanning across two states. This diverse population also helps to mitigate the effect of respondent and selection bias. Furthermore, we used multiple imputation methodology to control for nonrespondent bias. In conclusion, our survey suggested that the majority of STD clinic attendees have access to cell phones and the Internet and showed conceptual acceptability for receiving STD screening laboratory results by text message and e-mail. Future research is needed in different populations and geographical areas to better understand the practical aspects, especially those concerning the protection of patient confidentiality and the cost-effectiveness of electronic dissemination of STD screening laboratory results compared with traditional methods.