The Text4baby Program: Evaluation of a Mobile Health Initiative

Mobile Health 2011 @ StanfordW. Douglas Evans, Ph.D.wdevans@gwu.edu The George Washington University

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text BABY to 511411

What is text4baby?

…a free mobile information service of Healthy Mothers Healthy Babies Coalition (HMHB)

…in English and Spanish to promote maternal and child health especially among low-income moms

…provides pregnant women and new moms with motivation and information to help them care for their health and their baby’s

…sign up by texting BABY (or BEBE) to 511411 to receive 3 free SMS text messages each week, timed to their due date/date of birth

…messages 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

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

Promotional Materials

Watch the clip here: http://www.mtv.com/videos/misc/496217/text4baby.jhtml#id=1634555

Theory-based Evaluation

Text4baby is a health brand Based on behavior change theory, so is evaluation Health Belief Model: Texts are a cue to action Social influence and diffusion stems from texts Social Cognitive Theory: Self-efficacy, outcome

expectations, social modeling behavior change mHealth is a new level of social ecology, interacts

with existing ecologies like family, community

9Source: Institute of Medicine, 2000

Evaluation conceptual model

Evaluation Questions

Who subscribes and what are they like (demographics, psychographics, health profiles)?

What dose is delivered and what are dose-response effects? Do subscribers also use www.text4baby.org? For what? Are subscribers more likely to use promoted 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?

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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

APNCUImmunization - Most recent seasonal flu shot

- Most recent H1N1 shotPRAMS

Investigator developedPre-natal vitamins - Taking vitamin with folic acid? PRAMSSmoking - 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

Strategy is place-based evaluation:2 Current Evaluation Studies

US Army Telemedicine and Advanced Technology Research Center (TATRC) Conducting RCT in Army hospital facility to

compare subscribers/non-subscribers Launches May 2011

HMHB-sponsored study with Inova Health System Pilot in community clinics in Fairfax County,

Virginia to evaluate message receptivity and short-term outcomes

Launched April 2011

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)

Powered to detect 12% increase in pre-natal care utilization

Text4baby + usual care Usual care

Baseline 130 130

28 weeks gestation follow up 117 117

Fairfax County RCT Design (sample size)

Powered to detect 15% increase in intentions to utilize pre-natal care

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Fairfax Data – Type of Health Care Provider Visit Since Pregnancy

65%

35%

DoctorCommunity-based clinicOther No

*73% of community-based clinic visitors went in the past month

n = 30

Fairfax Data – Participation in WIC Program

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37%

21%

37%

5%

Yes, currentlyIn the pastNeverDon't Know

Fairfax Data – Search Online for Pre-natal Care Information

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n = 30

Yes, in the past month 1-2 months ago More than 3 months ago Never0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fairfax Data - Smoking and Alcohol Beliefs

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Smoking will harm health of baby

Second hand smoke will harm my baby

Drinking alcohol will harm my baby

0.00

20.00

40.00

60.00

80.00

100.00

Per

cen

t A

gre

emen

t

n = 30

Fairfax Data – F&V Servings per Day

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1 - 2 3 - 4 5 or more Don't Know0%

10%

20%

30%

40%

50%

60%

70%

80%

n = 30

Conclusions & Next Steps

● Empirically-tested behavioral theory supports mHealth programs like text4baby

● New programs need to be grounded in theory

● Need to develop & validate theory-based metrics Imagine in 10 years someone tried to do a meta-

analysis of mHealth What’s needed now?

● Build evidence base!

Thank you!

Doug Evans: wdevans@gwu.edu

About text4baby: • www.text4baby.org • http://text4baby.ning.com