Text message reminders for improving sun protection habits: A systematic review

Background Excessive exposure to ultraviolet radiation increases the risk of skin cancer and other conditions. SMS text reminders may be a useful tool to improve sun protection habits due to its massive reach, low cost, and accessibility. Objective To perform a systematic review of randomized controlled trials (RCTs) that evaluated the effects of SMS text reminders in promoting sun protection habits. Methods We performed a systematic search in PubMed, Central Cochrane Library, and Scopus; following the PRISMA recommendations to perform systematic reviews. We included RCTs published up to December 2018, which evaluated the benefits and harms of SMS text reminders to improve sun protection habits. Random-effects meta-analyses were performed whenever possible. The certainty of the evidence was assessed for RCTs estimates using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The study protocol was registered in PROSPERO (CRD42018091661). Results Five RCTs were included in this review. When pooled, the studies found no effect of SMS text reminders in "sunburn anytime during follow-up" (two studies, risk ratio: 0.93; 95% confidence interval: 0.83-1.05). Contradictory results were obtained for sunscreen use (three RCTs) and sun protection habits (two RCTs), however, they could not be meta-analyzed because outcomes were measured differently across studies. The certainty of the evidence was very low for these three outcomes according to GRADE methodology. Conclusions RCTs that assessed effects of SMS text reminders did not find a significant benefit on objective outcomes, such as having a sunburn, sunscreen use and composite score of sun protection habits. Since certainty of the evidence was very low, future high-quality studies are needed to reach a conclusion regarding the balance of desirable and undesirable outcomes.