Why text4baby might work

Dr. Robyn Whittaker

Text4baby is a free program that aims to promote maternal and child health by making prenatal and postnatal health information available to mothers across the U.S. via their mobile phones.(1) Anyone can register by sending a text message (SMS, short message service) providing their ZIP code and estimated due date or baby’s birth date. They then receive three text messages per week with information that is relevant to their stage of pregnancy or age of their baby. The text4baby messages are aimed at: increasing knowledge of relevant health issues; providing emotional support for women; affecting health behaviors such as healthy eating, breastfeeding, the use of substances that may adversely affect the baby, safe sleeping practices, immunizations; and prompting appropriate healthcare utilization in the form of prenatal and well child visits. Can simple SMS messages achieve this?

Well for a start there is some literature to support the use of SMS for healthy behavior change and as reminders for healthcare processes. Fjeldsoe reviewed 14 studies of behavior change interventions delivered by SMS - four focused on preventive health behaviors (smoking cessation, physical activity and weight management) and the remainder on clinical care (diabetes, asthma, hypertension and bulimia nervosa).(2) Significant positive behavioral changes were observed in eight studies, five had positive trends but not enough power to demonstrate significance, and one showed no change in behavior.

Cole-Lewis reviewed 12 studies using SMS as a tool for behavior change in disease prevention and management.(3) Eight of the nine sufficiently powered studies found evidence to support the effectiveness of SMS resulting in greater prevalence of nonsmoking, increase in frequency of blood glucose monitoring, greater weight loss in obese adults, and improved diabetes control. A systematic review of mobile phone use in smoking cessation concluded that there was evidence of short-term benefit but insufficient evidence on the long-term effect of mobile phone-only interventions. Other studies not included in the above reviews have described successful SMS reminders to take medications (5-7), to attend healthcare appointments (8-12), to apply sunscreen (13) and to complete adult vaccinations.(14)

So there is some limited evidence to support the use of SMS for behavior change, but does it make sense theoretically? At least five of these studies either described the use of behavior change theory in their development (social cognitive theory (15-16), behavioral self-regulation theory (17), a combination (18-19)) or the use of behavior change techniques in their messages (such as goal setting, self-monitoring, feedback, intention formation and barrier identification (16,19,20)). A recent taxonomy describes 26 behavior change techniques derived from 6 theoretical frameworks, many of which could fit within the SMS delivery context (21-22).

Mobile phones may actually add value over and above traditional methods of providing information and behavior change support, due to the ability to proactively send frequent tailored messages. Behavior change is a continuous process and so more frequent contacts may well be more effective in supporting behavior change (23-24). Prestwich showed that reminders of intentions by SMS were particularly effective in strengthening the effects on exercise behavior change compared with intentions alone (25). SMS is likely to be a cost-effective way of providing ongoing support and motivation beyond intensive programs, which may help to prevent relapse in the long-term. Possibly the greatest benefit of mobile phones is the ability to send the right messages at the right times. Tailored messages are known to be effective in other delivery modes. (23,26) However the importance of ‘the moment’ in behavior change has been highlighted by two recent models - the PRIME theory of motivation where immediate wants and needs act as stimulus to impulses and inhabitations which cause individuals to behave in a certain way at a particular moment (27); and the Fogg Behavior Model which describes the importance of a trigger (such as a message) arriving at a moment when there is sufficient motivation and ability to act (28).

So what is text4baby doing right? Text4baby is a very simple program that uses a ubiquitous and familiar technology that is well integrated into daily lives. Scalability is obvious and has been demonstrated by over 170,000 enrollments across the country to date. There is very little in the way of barriers to entry and once registered the messages arrive automatically. Messages provide information and reminders/prompts that are relevant to the stage of pregnancy or baby’s development – that is, they are to some degree sent at the right times.

Pregnant women and new mothers are a highly motivated knowledge-seeking population (29), but whether text4baby can impact health outcomes depends to some extent on whether it is taken up by those who need it – particularly those who are not otherwise linked in to sources of health information or care. The potential is there, with over 1.8 trillion text messages sent in the U.S. by all sectors of the population including 63% of uninsured and 79% of Medicaid populations (30), 83% of Hispanic Americans and 79% of African Americans (31). If text4baby can make even a small difference in health behavior amongst a large number of those who otherwise are not receiving good prenatal and postnatal care, then it has the potential to significantly improve health outcomes.

References

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