Pre-notification and reminder SMS text messages with behaviourally informed invitation letters to improve uptake of NHS Health Checks: A factorial randomised controlled trial

Anna Sallis*, Joseph Sherlock, Annabelle Bonus, Ayoub Saei, Natalie Gold, Ivo Vlaev, Tim Chadborn

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

12 Citations (Scopus)


Background: The NHS Health Check (NHS HC) is a cardiovascular risk assessment to prevent cardiovascular disease. Public Health England (PHE) wants to increase uptake. Methods: We explored the impact of behaviourally informed invitation letters and pre-notification and reminder SMS on uptake of NHS HCs. Patients at 28 General Practices in the London Borough of Southwark who were eligible to receive an NHS HC between 1st November 2013 and 31st December 2014 were included. A double-blind randomised controlled trial with a mixed 2 (pre-notification SMS - yes or no) × 4 (letter - national template control, open-ended, time-limited, social norm) × 2 (reminder SMS - yes or no) factorial design was used. The open-ended letter used simplification, behavioural instruction and a personalised planning prompt for patients to record the date and time of their NHS HC. The time-limited letter was similar but stated the NHS HC was due in a named forthcoming month. The social norms letter was similar to the open-ended letter but included a descriptive social norms message and testimonials from local residents and no planning prompt. The outcome measure was attendance at an NHS HC. Results: Data for 12, 244 invites were analysed. Uptake increased in almost all letter and SMS combinations compared to the control letter without SMS (Uptake 18%), with increases of up to 12 percentage points for the time-limited letter with pre-notification and reminder (Uptake 30%; Adjusted Odds Ratio AOR 1.86; 95% CI 1.45-2.83; p < 0.00); 10 percentage points for the open-ended letter with reminder (Uptake 27%; AOR 1.68; 95% CI 1.31-2.17; p < 0.00) and a 9 percentage point increase using the time-limited letter with reminder (Uptake 27%; AOR 1.61; 95% CI 1.25-2.10; p < 0.00). The reminder SMS increased uptake for all intervention letters. The pre-notification did not add to this effect. Conclusions: This large randomised controlled trial adds support to the evidence that small, low cost behaviourally informed changes to letter-based invitations can increase uptake of NHS HCs. It also provides novel evidence on the effect of SMS reminders and pre-notification on NHS HC attendance. Trial registration: Retrospectively Registered (24/01/2014) ISRCTN36027094.

Original languageEnglish
Article number1162
JournalBMC Public Health
Issue number1
Publication statusPublished - 22 Aug 2019

Bibliographical note

Funding Information:
The work was funded by the Department of Health and Social Care (DHSC). DHSC designed the study, PHE analysed and interpreted the data, and wrote the manuscript. DHSC and PHE did not collect the data.

Publisher Copyright:
© 2019 The Author(s).


  • Behavioural insights
  • Cardiovascular disease
  • Invitation letters
  • NHS Health Checks
  • Planning prompts
  • Pre-notifications
  • Reminders
  • SMS
  • Social norms
  • Text messages
  • Uptake


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