Mobile health technology, or mHealth, is a new and emerging innovative approach to address health disparities for all populations.1 mHealth supports using mobile devices in medical and public health for the delivery of healthcare services.2 Text messaging interventions, an mHealth method, has demonstrated effectiveness in improving health outcomes among a variety of healthcare-related activities including promotion of behavioral changes and management of chronic diseases.3-7 A majority of the population including 78% of low socioeconomic groups use text messaging as a means of communication on a daily basis.1 This article presents a case study discussing the development, implementation, and impact of a text-based mHealth intervention, TXT2DASH, in three free healthcare clinics. Challenges and strategies will be discussed.

BACKGROUND

Hypertension is a global public health issue affecting approximately 1 billion people worldwide; it accounts for 45% of deaths annually around the globe.2 The prevalence of hypertension is thought to be due to unhealthy lifestyles and aging. If left uncontrolled, hypertension can lead to complications including blindness, myocardial infarction, and cerebrovascular accidents.1,8,9 If the prevalence of hypertension and its sequelae continues to increase globally, the World Health Organization projects healthcare expenditures will continue to increase out of control.8

Patients living in poverty are at higher risk of developing hypertension and the resulting complications that can lead to premature death.9,10 Thus, there is a need to address this disparity, related in part to stressors that are more prevalent in low socioeconomic groups such as poor nutritional habits, obesity, and persistent worry and anxiety of daily living.8-10 This population also faces other challenges that create barriers in healthcare, such as a lack of access to healthcare education, lower educational levels, or transportation issues. A person who lacks education about his/her specific disease and how to self-manage can have more complications compared

KEY POINTS:

* Mobile Health technology can play a key role in preventing and controlling chronic diseases for medically underserved populations.

* Low socioeconomic groups are at higher risk of having complications from chronic diseases.

* TXT2DASH provided behavioral dietary changes and increased self-efficacy in patients who used free healthcare clinics.

with those who are more knowledgeable. This project was undertaken to see if use of a text-based intervention to deliver health education messages increased knowledge and self-management in patients with hypertension.

TEXT-BASED INTERVENTION DEVELOPMENT

TXT2DASH is an mHealth program designed to improve self-management and increase nutritional self-efficacy in patients with hypertension. One objective of its approach is to negate the need for patients to attend an onsite educational program. The program sent patients weekly educational text messages on the Dietary Approaches to Stop Hypertension (DASH) diet. The DASH diet has been demonstrated to reduce and control blood pressure. The DASH dietary guidelines were used to develop the text messages.11-13

The messages were based on food categories from the DASH diet including meats, fruits, and vegetables. Examples of messages that were sent every Monday and Tuesday include the following: "DASH 2 eat fruits and vegetables. Race 2 fill 1/2 ur plate with fruits," and "vegetables and TXT2DASH: Did u know lean meats include poultry such as chicken and fish? A serving size is 3 ounces or the size of a deck of cards. U should eat 4-5 servings every day. Keep up the good work!!" To address the higher costs associated with eating a nutritionally sound diet, the text message that was delivered every Friday focused on how to eat healthy on a budget and was labeled "DASHing to the grocery store." One example is: "DASHing 2 the grocery store? Make sure u add fruits and vegetables 2 ur list. Check out the frozen foods aisle; fruits and vegetables are cheaper."

Prior to program implementation, approvals were received from two institutional review boards. Messages were sent 3 days a week for a total of 4 weeks. Initially, the program was to be completed over a 6-week period and discuss one food category each week. After amendment, food categories were combined limiting the amount of information that could be delivered. What made this issue more complex was the limited number of characters that could be used in formatting each message.

Cost containment was an issue for implementation and sustainability. Because of limited resources and funding, an online text messaging company was chosen to deliver messages to the participants. EZ Texting (Santa Monica, CA) allows for a limited number of messages each month with no cost to the subscriber. The subscriber may opt to pay to expand the service for a monthly fee. It is hoped that future implementations will take place over 6 weeks as originally planned.

PROJECT OUTCOMES

Three healthcare clinics providing free care participated in the project. They provided access to low-income patients and convenient locations and were eager to be part of the project. A total of 23 participants enrolled in the program. The majority were men (57%) with an average age of 46 years. Mobile devices included mobile phones (69%; n = 16) and three smart phones (30%; n = 7).

To assess change in nutritional behavior and nutritional self-efficacy, an evaluation using two surveys, Rapid Eating Assessment for Patients (REAP) and Nutritional Self-efficacy (NSE), was done as a pretest and posttest. Approvals to use both instruments were obtained from the authors. Both assessments are well validated and reliable.14-16 The REAP demonstrated statistically significant test-retest reliability (r = 0.86, P < .0001). The NSE demonstrated excellent reliability with a Cronbach's [alpha] of .93.14

Forty-three percent of participants completed the final data collection (n = 13) and demonstrated improvements in dietary behaviors and in NSE. Participants demonstrated a statistically significant decrease after the intervention in both consumption of soda (P <= .05) and in use of fats and oils (.005) Participants demonstrated clinically significant changes from preintervention to postintervention by consuming more fruits and vegetables, whole grains, and dairy products. Although participants demonstrated a higher level of confidence in their ability to make dietary changes during baseline assessment, NSE showed a clinically significant increase after the intervention.

CHALLENGES AND OPPORTUNITIES

There were several challenges in successfully implementing the program, including transportation and overall timing of the project. Participants were asked to attend a pre- and post-on-site appointment to complete the REAP and NSE, but this turned out to be an issue for many. To address this problem, surveys were mailed, but three surveys were not returned in time to be included in the final analysis. In the future, we might consider having surveys sent via text message or be available online, which would possibly require participants to have access to e-mail or a computer, and could be a different type of barrier.

The project was implemented in the winter, which also posed challenges. Several participants were unable to get to the clinic to complete the survey because of a major snowstorm. Many participants stayed indoors and had limited food choices. A strategy for improving implementation is to revise the text messages to include information on making healthier food choices when options are limited.

Although text messaging is relatively inexpensive, limited cellular plans can lead to an additional cost for overage or loss of the ability to text message. During the implementation phase of the project, it was learned that a federally funded program, The Lifeline Assistance Program, provides an opportunity for qualifying residents to have a mobile phone free of charge with limited by-the-minute plans. This program increases accessibility for patients to both a mobile device and mHealth technology. This program would assist in recruitment and provide benefit for future implementation of the TXT2DASH program.

IMPACT ON PRACTICE

Two key concepts considered to be important were readability and user-friendliness of the program. Overall, the participants were highly satisfied with the program. Ninety-two percent of the participants felt the messages were easy to understand. A majority of the participants (69%) were satisfied with the frequency of the messages, and 61.5% reported the program helped them to make healthier food choices. Ninety-two percent of the participants would recommend the TXT2DASH program to their family. Increased accessibility to health education was a reported benefit from the participants. Participants commented that saving messages allowed them to refer to them again later.

At the touch of a button or screen, health education can be made readily available and easily accessible. The TXT2DASH program demonstrated that mHealth is a viable option for delivery of health education to low socioeconomic groups who face barriers to attending an on-site educational program. With the Lifeline Assistance Program and the free monthly programs offered by online text messaging companies, mHealth can be relatively inexpensive. Ultimately, an mHealth educational program has the potential for patients to have better control of their hypertension, which will create better long-term health outcomes, decrease complications, and ultimately decrease healthcare costs.

Acknowledgements

The author thanks Dr Maryjane Miskovsky as chair and advisor for project development and completion (current affiliation: Wilkes University, Wilkes Barre, PA).

The author was a participant in the National League for Nursing Scholarly Writing Retreat, sponsored by the NLN Foundation for Nursing Education.

REFERENCES