A national health and wellness SMS text message program for breast cancer survivors during COVID-19 (EMPOWER-SMS COVID-19): mixed methods evaluation using the RE-AIM framework

Background:

COVID-19 lockdowns caused widespread closures to supportive care services for breast cancer survivors in Australia. Our team’s EMPOWER-SMS lifestyle-focused, evidence-based text message support program was found to be supportive for breast cancer survivors in a randomized controlled trial and was ready for rapid widespread delivery.

Objective:

Evaluate the reach (uptake) of a 3-month pre-post lifestyle-focused text message program (EMPOWER-SMS COVID-19) and barriers and enablers to adoption and implementation using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.

Methods:

Mixed-methods pre-post study evaluated reach and representativeness using the proportion of participant enrolment (number enrolled/number visited study website x 100) and demographics (age, sex, ethnicity, time since completing treatment, Australian Standard Geographical Classification Remoteness Area and Index of Relative Socio-economic Advantage and Disadvantage [IRSAD; quintile 1 most-disadvantaged areas to quintile 5 least-disadvantaged areas]). Adoption barriers and enablers were measured using a user feedback survey (5-point Likert Scale and free-text responses) and text message response data. Implementation was evaluated by the fidelity of the intervention including text message delivery data, opt-outs, and intervention costs.

Results:

844/1340 (63.0%) participants enrolled after visiting the study website and provided e-consent. Participants had a mean age (±standard deviation) of 58.9 (±9.8) years old (range: 30-87 years). Most participants identified as female (841/844, 99.6%), Caucasian/white (737/843, 87.4%) and 50% finished treatment within the past 18-months. Most resided in Major Cities (577/841; 68.6%) and 31.1% resided in Australia’s least disadvantaged areas (ISRAD quintile 5). Of participants who provided feedback (449/844; 53.2%), most ‘agreed’ or ‘strongly agreed’ that the text messages were easy to understand (99%), useful (85%) helped participants feel supported (87%), and motivated participants to be physically active (70%) and eat healthier (70%). Free-text responses revealed five factors influencing engagement: i) feeling supported and less alone, ii) motivation and reassurance for health self-management, iii) the variety of information, iv) weblinks to information and resources and v) the option to save the messages. Messages were delivered as-planned (97.4% ‘successfully delivered) with minimal dropouts (92.7% retention rate) and low-cost ($AUD11.88/participant for three months). A total of 852 replies were received from 511 unique participants (median: 1; range 1-26). The most common replies were participants stating how they heard about the program (467/852; 54.8%) or ‘thank you’ (131/852; 15.4%). No replies contained urgent safety or health-related issues requiring a reply from the health counsellor.

Conclusions:

EMPOWER-SMS COVID-19 was implemented quickly, had a broad reach, with high retention and acceptability among socioeconomically diverse participants. The program was low-cost and required minimal staff oversight, which may facilitate future implementation. Further research is needed to evaluate the effectiveness for improving health outcomes, adoption and implementation enablers and barriers for health professional and strategies for long-term program maintenance. Clinical Trial: N/A