Reaching Mothers via Text

June 11, 2018

Text4baby is a free text messaging service with national coverage that delivers timely health information messages to mothers to improve the health of their babies both before and after they are born. Message topics include nutrition, seasonal flu prevention and treatment, mental treatment, risks of tobacco use, oral health, immunization schedules, breastfeeding, and safe infant feeding practices. In six years, over a million texts have been sent out to women through Text4baby. As of December 2016, over 350,000 women registered for Text4baby and positive knowledge and behavior change has been reported on a large scale among those in the program. The medium of the message – via phone – has proven effective in a country the majority of women have a mobile phone.


Description & Context

The infant mortality rate in the United States is higher than most developed countries at 6.59 per 1,000 live births in 2012, with even higher rates for African American and American Indian mothers (1). More than 1 out of 10 babies were born premature in 2012, which has an annual societal cost (including medical, educational, lost productivity costs) of more than $26 billion dollars in the United States (2,3). Research indicates that health behaviors in the prenatal and postnatal periods, such as smoking, nutrition, breastfeeding, safe sleep practices, and vaccination, greatly affect birth and survival outcomes (1).  Access to information regarding healthy prenatal and postnatal health practices is a barrier for many women in the United States and contributing to poor infant health outcomes, especially for families with lower socio-economic status and level of education.

Text4baby was developed in 2010as a free text messaging service that delivers timely health information messages to mothers nationally to improve the health of their babies both before and after they are born (1,3). Message
topics include nutrition, seasonal flu prevention and treatment, mental treatment, risks of tobacco use, oral health, immunization schedules, breastfeeding, and safe infant feeding practices (3).


Main Components

Text4baby is a private-public partnership between agencies such as the Center for Disease Control (CDC), the Johnson & Johnson Company, Wellpass, Pfizer, and the National Healthy Mothers, Healthy Babies Coalition–a group of 100 non-profit local, state, and national organizations (1). The partnership convinced 18 wireless carriers to absorb messaging costs, providing a completely free service to women (1). Message development was led by the National Healthy Mothers, Healthy Babies Coalition in collaboration with the CDC, which ensured the messages were evidence-based and in harmony with national guidelines (1,3). The messages were reviewed by an interdisciplinary panel of experts including nurses, obstetricians, nurse-midwives, pediatricians, medical epidemiologists, mental health professionals, nutritionists, lactation consultants and a clinical geneticist and then tested with the target audience and revised according to feedback (1). Each text message delivers just one action point and participants receive no more than three messages per week (1).

Text4baby supports data-driven decision-making to guide its outreach and ensure its efficiency and effectiveness (6). To this end, it has developed a Data Analysis Toolkit for its partners designed as a resource to utilize and analyze data garnered from sign-up/texted questionnaires to the Text4baby population on their basic demographics and geographics. It is organized by questions that outreach partners may have, for example, “how can I decide which zip codes or counties I should target for outreach?” which can be answered using the data available in the portal (6). In each section there is a brief overview of how to answer each question using Text4baby data and also link to additional resources, including webinars and step-by-step guides located in the appendix. (6) The toolkit also includes a section on additional ideas for evaluating Text4baby in individual communities (6).

 App Features (7):

  • A weekly planning list of medical, developmental and lifestyle calendar items.
  • Polls that allow participants to see how other moms respond to topics like pregnancy symptoms, infant development and emotional experiences.
  • Appointment reminders scheduled via the app that will be sent through the text message service.
  • Helpful health hotlines and community resources.

Evidence of Implementation Strategy

Recent evidence concludes that the use of text messaging for health behavior change is effective; of 9 studies focusing on the efficacy of text messages to change health behaviors, 8 reported significant behavioral outcomes (8). Text4baby reports similar outcomes. Positive knowledge and behavior change has been reported on a large
scale among those in the Text4baby program through questionnaires: Text4baby participants were more knowledgeable about safe sleep and infant feeding among other topics than non-participants; participants were more likely to obtain flu vaccines and remember appointments because of the message reminders; participants were also more likely to access health services (5).

Other improvements include increased preparedness, improved health beliefs, utilization of health hotlines and websites, and even reported lowering of postpartum alcohol consumption (5).

The program also reports reaching its target population: over 38% of participants enrolled in their first trimester and over half of participants reported their household income less than $16,000 (5). As of December 2016, over 350,000 women have registered for Text4baby (3,4). 


Cost and Cost-Effectiveness

Text messaging is widespread, easily available, and associated with a relatively low cost (8). A study on Text4baby states that while it is hard to estimate costs from the numerous and variable types of contributions from organizations and partners in the United States, the fact that the wireless networks assumed the costs made the program successful at no cost to the user (1). However, without this wireless network subsidy, the cost to the user, particularly a low-income mother, could be significant from text messages that may cost 20 cents each (1). Nonetheless, if the extremely high costs (over $26 billion dollars) associated with pre-term births in the United States are reduced slightly by the program it is clearly quite cost-effective (3). Text4baby attempts to prevent pre-term births, and therefore the costs associated, by sending mothers key prenatal health messages.


Perceptions and Experiences of Interested People

Text4baby has strong support both from outside actors and participants (5):

  • 99% of Text4baby participants in a Health Services and Resources Administration (HSRA) funded evaluation said they would recommend the service to a friend or family member
  • 90% of Text4baby participants read the messages and found them easy to understand
  • 64% of Text4baby participants thought the messages were useful
  • 95% of Text4baby participants reported the enrollment process was easy

In addition, the Text4baby website contains dozens of testimonials from mothers, experts–including government senators, health directors, and doctors–as well as the community (9). The National Institute of Health praised Text4baby for its 3rd year of excellent health outreach (10).


Benefits and Potential Damages and Risks

  • It is important that the texting costs be subsidized by a health entity or wireless network as there a risk that the costs associated with text messages could deter low-income mothers from using the program. However, there is a risk of conflict of interest between the health stakeholders and the wireless carrier: the wireless carrier may have a different perspective and want to expand their consumer population in lieu of health education outreach.
  • There is a risk of conflicts of interest within the partnership. In addition, the outside actors that reviewed the messages, such as experts including nurses, obstetricians, nurse-midwives, pediatricians, medical epidemiologists, mental health professionals, nutritionists, lactation consultants and a clinical geneticist, may also bring different interests and opinions to the table from their specific roles in the health industry.
  • It is crucial that the messages are evidenced-based and in line with international standards on prenatal and postnatal healthcare. Having the messages reviewed by a panel of experts, as in the United States case, is a method to prevent inappropriate or incorrect messages from being disseminated. The messages should be culturally, literacy and socially sensitive as well.

Scaling Up Considerations

  • Data-driven decision-making is a critical component of this intervention; by collecting data from texted questionnaires to participants that ask demographics, geographics, behaviors, and perceptions of the Text4baby service, and constantly evaluating the program with this data, the program is efficient and effective at reaching target populations. The program must have a system of feedback and partners must have trained and hired staff to analyze the data and make important changes based on the results.
  • It is important that the texting costs be subsidized by a health entity or wireless network as there a risk that the costs associated with text messages could deter low-income mothers from using the program.

Barriers to Implement

  • One report cites that there was a high amount of cancelled enrollees who did not update the service from prenatal to postnatal phase (1). This extra step to update the service is being removed to reduce this participation barrier (1) which demonstrates the importance of simplicity and ease within the program.
  • Challenges with partnerships were reported, including information sharing, efforts to estimate the actual costs of the initiative, confusion in defined roles and responsibilities, and differing perspectives and priorities in evolving to the next stage of the partnership (1).

Equity Considerations

It is important that the texting costs be subsidized by a health entity or wireless network as there a risk that the costs associated with text messages could deter low-income mothers from using the program. This could cause inequities in program take-up and further exacerbate the lack of health education among low-income mothers.


References:

1.       Whittaker, R., Matoff-Stepp, S., Meehan, J., Kendrick, J., Jordan, E., Stange, P., . . . Johnson, P. (2012). Text4baby: Development and Implementation of a National Text Messaging Health Information Service. American Journal of Public Health, 102(12), 2207-2213. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3519339/pdf/AJPH.2012.300736.pdf

2.       March of Dimes. (2013). 2013 Premature Birth Report Card. Retrieved from http://health.usf.edu/publichealth/chiles/fpqc/~/media/DCBEF44C3ACA479C91498E0C56D6CE43.ashx

3.       Jordan, E. T., Ray, E. M., Johnson, P., & Evans, W. D. (2011). Text4Baby. Nursing for Women's Health, 15(3), 206-212. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1751-486X.2011.01635.x/full

4.       Text4Baby, Wellpass. (2017). Text4baby Enrollment Data. Retrieved from https://partners.text4baby.org/index.php/partner-resources/105-text4baby-enrollment-data

5.       Text4Baby, Wellpass. (2017). Text4baby Research and Evaluation. Retrieved from https://www.text4baby.org/about/data-and-evaluation

6.       Text4Baby, Wellpass. (2017). Text4baby Data Analysis Toolkit for Partners. Retrived from https://partners.text4baby.org/templates/beez_20/images/HMHB/text4baby_data_analysis_toolkit_final.pdf

7.       Text4Baby, Wellpass. (2017). Free “Text4baby App!” Retrieved from https://partners.text4baby.org/index.php/get-involved-pg/partners/54-get-involved/partners/468-text4baby-launches-app

8.       Cole-Lewis, H., & Kershaw, T. (2010). Text Messaging as a Tool for Behavior Change in Disease Prevention and Management. Epidemiologic Reviews, 32(1), 56–69. DOI: 10.1093/epirev/mxq004.

9.       Text4Baby, Wellpass. (2017). Text4baby Testimonials. Retrieved from https://www.text4baby.org/?name=testimonials 

10. National Institute of Health. (2013). “XLNT! The Text4baby Program Celebrates 3 Years.” Retrieved from https://www.nichd.nih.gov/news/resources/spotlight/032713-text4baby

Submitted by Katie Doucet on June 11, 2018