The Text4baby

Program: Evaluation of

a Mobile Health

Initiative:

World Social Marketing Conference

Dublin, 11 April 2011

W. Douglas Evans, Ph.D.

The George Washington University

2

text BABY to 511 411

What is text4baby?

Text4baby is a free mobile information service designed to promote

maternal and child health. An educational program of the National

Healthy Mothers, Healthy Babies Coalition (HMHB), text4baby provides

pregnant women and new moms with information to help them care for

their health and give their babies the best possible start in life.

Women who sign up for the service by texting BABY (or BEBE for Spanish)

to 511411 receive free SMS text messages each week, timed to their due

date or baby’s date of birth.

These messages focus on a variety of topics critical to maternal and child

health, including birth defects prevention, immunization, nutrition,

seasonal flu, mental health, oral health and safe sleep. Text4baby

messages also connect women to prenatal and infant care services and

other resources.

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Sample Messages

Every state has a program to help you have a healthy baby.

Call 1-800-311-BABY to find out about services in your area.

Reply Back

Don’t forget your multivitamin! Baby’s spine and brain are developing now.

Getting 400 micrograms of folic acid daily is key to help prevent birth defects.

Reply Back

Consult with your doctor before taking any medication, including over-the-counter items you find at the drug

store.

Reply Back

Have you seen your dentist lately? You may notice

changes in your gums because of extra blood flow during pregnancy. Floss and brush your teeth to protect your baby’s health!

Reply Back

Be a flu-free mom-to-be! Flu shots are safe during every trimester. You’re at high risk

for complications from flu, so protect yourself from getting the flu in the first place.

Reply Back

Don’t eat any raw or undercooked meat, poultry, fish or shellfish (sushi or sashimi) while pregnant.

Reply Back

Text4baby Program Goals

§ Demonstrate the potential of mobile health

technology to address a critical national health

priority: maternal and child health.

§ Demonstrate the potential of mobile health

technology to reach underserved populations

with critical health information.

§ Develop a base of evidence on the efficacy of

mobile health interventions.

§ Catalyze new models for public-private

partnerships in the area of mobile health.

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Infant mortality rates by race & ethnicity

Infant mortality rates by education level

Infant Mortality by age of mother

Infant mortality and income levels

Infant Mortality and Socioeconomic Status: New Bottle, Same Old Wine Edward G. Stockwell, Franklin W. Goza and Kelly S. BalistreriBowling Green State Universityhttp://www.bgsu.edu/organizations/cfdr/main.html

Nearly 95% of Americans have mobile phones

300+ million untapped behavior change devices just in the US

2 trillion text messages sent in 2010

Hours/day mobile phones are within arm’s reach: 19~ 5 billion mobile phones globally

Why go mobile?

Why go mobile?

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§ Mobile phones are especially important in

reaching the main target audience for text4baby:

§ Younger women

§ Lower-income women

§ Women of color

§ Many more of these women have phones than

Internet access and an overwhelming percentage

use SMS.

Sources: Pew Internet & American Life Project, “Degrees of Access” (May 2008); Nielsen, “Record High TV Use, Despite Online/Mobile Video Gains”(November 2008); Harris Interactive, “Cell Phone Usage Continues to Increase” (April 2008); US Centers for Disease Control, “Wireless-Only Phone Use Varies Widely Across United States” (March 2009); CTIA, “Wireless Quick Facts” (March 2009).

Cell Phone v. Internet Access by income, education,

race/ethnicity

82%

31%

0

29%

39%

78%

0

41%

56% 55%

95%

53%

0

44%

63%

91%

0

59%

75%

80%

32%

92%

63%

0

59%

73%

89%

0

73%

79% 80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

>75K Income <$30K Income No High School

Degree

High Schoo l

Degree

College Degree Blacks Whites English-Speaking

Hispanics

Spanish-

Dominant

Hispanics

Broadband Internet Cell PhoneSource: Pew Internet & American Life Project Survey, May 2008

African-Americans

Mobile Technology Use by Race/Ethnicity

Source: Pew Internet & American Life Project Survey, December 2007, n=1,704 for those with cell phones or

PDAs. Margin of error is +/- 3 points. Survey conducted in English.

African-American

Text4baby National Launch – February 4, 2010

U.S. Chief Technology Officer

Aneesh Chopra

“Text4baby is the first free mobile health service

to be taken to scale in the United States… We

know that mobile phones hold tremendous

potential to inform and empower individuals.

Text4baby represents an extraordinary opportunity

to expand the way we use our phones, to

demonstrate the potential of mobile health

technology, and make a real difference for moms

and babies across the country.”

Text4baby Message Development

§ Literature review

§ Special focus on guidelines: ACOG, USPSTF, AAP

§ Sought input across CDC and HHS regarding priorities and

program-specific messages

§ Developed list of important topics and HHS-cleared messages as

template

§ Negotiated across HHS to determine priority topics

§ Contributors

§ Medical epidemiologists (OB, Peds, FP)

§ Epidemiologists

§ Program managers

§ Health communication specialists

Priority Topics

Pregnancy Infant

Tobacco Tobacco

Alcohol and drugs Infant feeding/oral health

Nutrition Developmental milestones

Safety Safety

Services: referral, encourage use Services

Infection prevention/screening Immunizations

Medications Postpartum depression

Breastfeeding Infection prevention

Support/bonding/”feel good” Support/crying

Influenza

Input to HMHB

§ Shared background work so that HMHB could

develop 160-character messages (content does not

belong to HHS)

§ Participate in ongoing process of revising messages

when there are:

§ Issues with understanding

§ Issues with content

§ e.g., August 12-13, 2010, meeting of experts in

influenza, pregnancy, and newborn care

Content Development & Review Process

CDC (priority topics/

researchbase)

Topical insight

Audience Insight

(discussion groups)

MessageDevelopment

(HMHB)

Medical/Nat’lAssociations

Content Review

Health Care Providers

FederalGovernment

MessageRevision (HMHB)

Content Review

CDC/HHS

Messages “Finalized”(HMHB)

MessageTesting (Emory)

MessageRevision

(HMHB & CDC)

Delivery of Time-sensitive Messages

§ Pertussis messages: July 8, 2010

§ “Whooping cough is spreading in CA: To protect baby, you

and everyone near your baby need a whooping cough

booster shot. More from CDC: 1-800-232-4636."

§ "You and everyone near your baby need a whooping cough

booster shot. Don’t risk spreading serious disease to your

baby. More from CDC: 1-800-232-4636.“

Health Literacy Testing

§ Worked with the Emory at Grady Health Literacy Team to test

pregnancy and infant text messages with the target audience

§ Team highlighted suggested edits to text messages with the

application of health literacy principles.

§ Team conducted 1:1 cognitive patient testing to assess:

§ What do the messages mean to patients?

§ What do patients find useful, not useful?

§ What are the patients’ suggestions for improving how

they obtain this essential information?

Health Literacy Testing

§ Requirements for participation included English-speaking women who

were either currently pregnant or had been pregnant in the last 18

months.

§ 100 lower-income pregnant and recently pregnant women recruited at a

large city hospital in Atlanta, Georgia

§ Pregnant- 74%

§ Mean Age - 23.5 years

§ African-American- 96%

§ Single- 66%

§ High school graduate or GED – 48%

§ Income $35,000 – 100%

§ Unemployed – 38%

Findings

§ Overall, women rated messages well, with most responses

being “excellent.”

§Percentage of women able to understand and articulate the

main idea of each message varied from 40%-100%, depending

on the message.

§Messages with highest percentage of understanding gave a

specific action, followed by additional information, a phone

number for resources, or both.

§Messages that were not understood told facts with no

accompanying action or contained technical jargon.

Example: Medicine safety

§ Original message:

§ “Be careful when giving baby medicine. Only use what the

doctor says, with the medicine dropper or spoon that tells

you the right dose for an infant.”

§ Feedback: Well understood

§ Final:

§ “Be careful when giving baby medicine. Only use what the

doctor says. Use the medicine dropper or spoon that tells

you the right dose for an infant.”

Example: Access to care

§Original message:

§ “Do you need help paying for your visits to the doctor or

midwife? Now that you’re pregnant, you may qualify for

Medicaid. Call 1-877-543-7669.”

§Feedback: Confusion about what Medicaid could help with.

§Final:

§ “Medicaid can help you pay for your visits to the doctor or

midwife. If you need help, call Medicaid to see if you

qualify: 1-877-543-7669.”

Findings: Texting Behavior & Preferences

● Frequency of texting: 70% text “all the time.”

● Best time of the day for participants to receive

messages: 12-4pm

● Equal preferences for text lingo versus regular

words: Keep text lingo to only very commonly used

words like “u” and “Dr.”

● Direct dial from text: over 2/3 can direct dial from

text message

Promotional Strategy

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Partnership Engagement

§ Partner Portal at http://text4baby.ning.com with flyer

art, web banners and buttons, boilerplate language,

press release template, and more.

§ Text4baby Tuesday weekly e-mail alert providing

program updates.

§ Technical assistance through HMHB/Voxiva.

§ Access to text4baby logo and Adobe InDesign art files

for customization.

§ Free pre-printed promotional materials while supplies

last.

Promotional Materials

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Outreach Partners At-a-Glance

Total Signed Partners: 352

…plus hundreds more without

MOU

Watch the clip here:

http://www.mtv.com/videos/misc/496217/text4baby.jhtml#id=163455

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Evaluation Overview

Text4baby is a brand:

Stands for health & wellbeing

Based on behavior change theory

Evaluation built on theory of change

Short-term effects on brand equity, KAB

Intermediate effects on behavior

Long-term impact on maternal and newborn health

Theory of Behavior Change

T4B messages are a cue to action for low-income

mothers (Glanz, Lewis and Rimer, 2002)

Role of social influence and diffusion of information

in text messages within population

Social Cognitive Theory: Psychosocial factors (self-

efficacy, social modeling) mediate effects of

messaging on behavior (Bandura, 2004)

Mhealth is a new level of social ecology, interacts

with existing levels such as family, community

33Source: Institute of Medicine, 2000

Theory-based mHealth Behavior Change

Process

• Selected theory of behavior change drives mHealth service and evaluation processes

Evaluation conceptual model

Evaluation at Altitude

What is the level of exposure to the text4babybrand among the target audience?

What is exposure among selected population groups?

Does it work to change health behaviors?

How does it work (what processes)?

Process Evaluation Questions

Who subscribes?

What are their demographic & health profiles?

What are mothers reactions/receptivity to messages?

Are they perceived useful, credible?

Are there differences in perceptions between messages

or categories?

What are health care provider (HCP) reactions?

Are text4baby messages consistent with HCP provided

information?

Process Evaluation Methods

Mobile surveys

Interviewer administered by mobile phone

IVR (automated)

In-depth interviews

Focus groups

Qualitatively assess how messages received, used, intended/unintended effects

Outcome Evaluation Issues

Obtain statistical equivalence between exposed

& not exposed to text4baby

Eliminate the potential for selective exposure

bias (i.e., those most inclined to subscribe are

exposed to messages)

Minimize ambiguity in relationship between

messages and key outcomes

Outcome Evaluation Questions

Do text4baby subscribers also use the www.text4baby.org

website?

Are subscribers more likely than non-subscribers to use

other health information sources (helplines, etc.)?

Are subscribers more likely to form positive pre-natal care

and health promoting attitudes/beliefs?

Are subscribers more likely to engage in behaviors targeted

by messages?

Campaign has behavioral objectives embodied in the

messages – are they achieved?

Outcome Evaluation Methods

Randomized experiments

Comparison of sites (hospitals, clinics) promoting

text4baby v. those not

Control for mothers who visit non-promoting sites but

still subscribe

Mobile surveys, typically interviewer administered

Electronic Health Record abstraction

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Self-efficacy - Individual measures of self-

efficacy to engage in each

text4baby promoted behavior

Investigator

developed

Outcome

expectations

- Measures for each promoted

behavior

Investigator

developed

Social norms - Descriptive and subjective norms

for each promoted behavior

Investigator

developed

Intentions - Measures for each promoted

behavior

Investigator

developed

Self-reported

recall of text

messages

- Measures for each message to be

delivered during pregnancy

Investigator

developed

Behavioral Mediators (Change Mechanisms)

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Health care utilization - Intention to keep pre-natal

appointment

- Pre-natal appointments kept

PRAMS phase 6 survey

APNCU

Immunization - Most recent seasonal flu shot

- Most recent H1N1 shot

PRAMS

Investigator developed

Pre-natal vitamins - Taking vitamin with folic acid? PRAMS

Smoking - Smoking frequency

- Cessation attempts/success

- Secondhand smoke exposure

PRAMS

NYTS

Alcohol use - Alcohol consumption past 30 days

- Frequency of consumption

PRAMS

Nutrition - Dietary intake

- Food preferences

BRFSS

Health information

seeking

- Use of health information Websites

- Use of FQHC Web resources

Investigator developed

Referral to other health

services

- Referral to 311 Babyline

- Utilization of referred health services

Investigator developed

Behavioral Outcomes

Evaluation Methods

Mobile surveys

Interviewer administered by mobile phone

Integrated Voice Response (automated)

Web-based surveys

Direct respondents to a survey Website using mobile messages

Randomized Controlled Trials in central locations (health clinic, hospital) to control message exposure

Review of medical records (pre-natal care adherence, birth outcomes)

Two Ongoing Evaluation Studies

US Army Telemedicine and Advanced Technology Research Center (TATRC)

Conducting RCT in Army hospital facilities to compare enrolled and not-enrolled mothers

HMHB-sponsored study with Inova Health System

Pilot study in Inova Health System in Fairfax County, Virginia to evaluate message receptivity and identify

opportunities for new/improved messages

Stratum 1: First pregnancy Stratum 2: At least 1 previous

live birth

Text4baby +

usual care

Usual care Text4baby +

usual care

Usual care

Baseline 249 249 249 249

4 week post-

baseline follow up

245 245 245 245

28 weeks gestation

follow up

235 235 235 235

Post-partum

follow up

224 224 224 224

Army RCT Design (sample size)

Conclusions & Next Steps

● Multiple existing, empirically tested theories support mHealth programs like text4baby

● Need to develop & validate theory-based metrics

§ Imagine in 5 years someone wanted to do a meta-analysis of mHealth

§ What would need to be in place to do that analysis coherently?

● Build evidence base!

Thank you!

Doug Evans: wdevans@gwu.edu

About text4baby:

• www.text4baby.org

• http://text4baby.ning.com