Going Mobile: Integrating Texting and Online Tools into Health Care Delivery
Innovative uses of information technology (IT) in public health campaigns can expand access to preventive and chronic care for underserved populations and may even improve health outcomes while reducing costs. Programs in New Zealand and the Netherlands may offer lessons for the United States, where recent policies are spurring interest in the use of health information technology to improve care.
New Zealand created one of the first free public health campaigns using text messages. Initially tested in a national randomized controlled trial that showed a doubling of quit rates, the smoking cessation program targeted young people (ages 16 to 24) as well as Maori and Pacific Island populations. Subscribers received automated text messages that help them to set goals, provide encouragement, and offer tips to avoid smoking triggers. Those identifying themselves as Maori, the indigenous population of New Zealand, also received Maori-specific text messages. Users could also take quizzes, polls, and be matched with a "quit buddy."
In 2008, this program was implemented as a free national service funded by the New Zealand Ministry of Health called Txt2Quit. The program has since been adapted for the United Kingdom, where a randomized controlled trial of 5,800 people was recently completed. This trial confirmed the doubling of quit rates in the intervention group compared with a control group, and verified that participants were not smoking up to six months later.
Some lessons from New Zealand's research and implementation of Txt2Quit include:
- conduct formative research and testing with target audiences to ensure usability and usefulness;
- work with wireless network providers and other industry partners to ensure there are no costs to end-users;
- keep up with technological advances so that IT tools remain relevant;
- consider implementation from the start and involve the organizations that will ultimately be delivering the program;
- consider intellectual property issues; and
- evaluate the program beyond implementation to capture data on any unintended consequences and to continue to improve the program.
In the Netherlands, a large Web-based depression prevention program launched in 2009 using educational and social media tools to engage those with mild to moderate depression. The initiative includes the Color Your Life program, targeted at adults, which asks users to complete a diagnostic test for depression and take an online course on its symptoms, to be completed at their own pace. Currently, 37 health insurers reimburse the program cost at 90 percent to 100 percent.
In the Master Your Mood program, targeting those ages 16 to 25, users complete a diagnostic test for depression and take part in an educational course in a password-protected chat room of up to six students, with moderation by a mental health expert. The course consists of weekly chat sessions, plus homework assignments and exercises. Participants can also read personal stories about depression submitted by others. The program is integrated into treatment at numerous mental health care institutions and reimbursed by numerous health insurers.
Other Dutch online interventions include "Drinking Less," developed by the Trimbos Institute for problem alcohol drinkers. "Drinking Less" is currently being distributed in collaboration with the World Health Organization (WHO) in four developing countries. And this year the Trimbos Institute is collaborating with the University of California, San Francisco (UCSF) on an eight-week online depression prevention intervention for Latinas. The "Mothers and Babies Course" developed by UCSF as part of this project will be adapted for pregnant Turkish and Moroccan women in the Netherlands. Text messages will be sent to participants' cell phones if the weekly online exercise was not completed and to obtain daily mood ratings.
To maintain and expand upon the success of these programs, it will be important to investigate users' preferences, particularly on how to effectively engage ethnic minorities. It also will be important to ensure quality monitoring and clarify the funding mechanisms for maintaining the Web sites and reimbursing patients.
Health reform in the United States has made programs such as Txt2Quit and Drinking Less more feasible than ever. The HITECH Act of 2009 has helped to fund the development of a health IT infrastructure and the new Center for Medicare and Medicaid Innovation is supporting the testing and dissemination of innovative models of care delivery.
One text message program that has already enjoyed popular success in the United States is text4baby, a service for pregnant women and new mothers launched in 2010. Upon receipt of their estimated due date or baby's birth date and ZIP code, the service sends subscribers three free text messages per week relevant to their stage of pregnancy or their baby's stage of development through age one. The messages, which are available in Spanish, also provide links to access local low-cost or free health services. Supported by a public–private partnership, text4baby is run by a private company and the Healthy Mothers, Health Babies national coalition.
The program is promoted to women through more than 400 local, state, and national partners. According to the program's Web site, as of August 2011, more than 200,000 people have enrolled and satisfaction has been high. The federal government is funding an independent evaluation of the service to assess its effects on behavior and health service utilization. Obvious factors in common with the New Zealand national Txt2Quit service include promotion by credible national organizations and community health workers, a simple registration process, the use of familiar technology, and the fact the service is free to users.
As demonstrated by text4baby and the international examples, public health programs can take advantage of information technologies to communicate and engage with targeted audiences—delivering tools and support when and where people want them.