Using Health Text Messages to Improve Consumer Health Knowledge, Behaviors, and Outcomes An Environmental Scan U.S. Department of Health and Human Services May 2014 This publication was produced for the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) by Mathematica Policy Research and Public Health Institute under contract number: HHSH250200646027I/HHSH25034004T. This publication lists non-federal resources in order to provide additional information to consumers. The views and content in these resources have not been formally approved by HHS or HRSA. Listing these resources is not an endorsement by HHS or HRSA. Using Health Text Messages to Improve Consumer Health Knowledge, Behaviors, and Outcomes: An Environmental Scan is not subject to copyright restrictions. Readers are free to duplicate and use all or part of the information contained in this publication and to use the information contained therein. This publication also contains certain tables that are clearly attributed to non-federal sources, and reproduction and redistribution of these tables outside of this publication may require permission of third-party copyright owner(s). This HHS publication may not be reproduced, reprinted, or redistributed for a fee, under 42 U.S.C. § 1320b-10. Suggested Citation: U.S. Department of Health and Human Services. Health Resources and Services Administration. Using Health Text Messages to Improve Consumer Health Knowledge, Behaviors, and Outcomes: An Environmental Scan. Rockville, Maryland: U.S. Department of Health and Human Services, 2014. CONTENTS Abstract ............................................................................................................ 1 Introduction ....................................................................................................... 2 The Current mHealth Landscape ...................................................................... 4 The mHealth Technology Context: Widespread Use of Cell Phones in the United States .............................................................................................. 5 Evidence on the Effectiveness of Health Text Messaging Programs .............. 10 Evidence from Systematic Reviews ......................................................... 10 Evidence from the Health Care Innovations Exchange ............................ 17 Evidence on the Acceptance of Health Text Messaging Programs ................ 22 Implications for Improving Future Research and Program Implementation .... 24 Concluding Remarks ...................................................................................... 27 References ..................................................................................................... 29 iii This page left blank for double-sided copying. TABLES 1 Selected Federal Text4Health Text Messaging Initiatives ............................... 3 2 Demographics of Cell Phone and Smart Phone Users, 2013 .......................... 6 3 Demographics of Adult Cell Phone Owners Who Send and Receive Text Messages, 2013 ..................................................................................... 7 4 Use of Cell Phones to Look Up Health Information or to Manage Health, 2010 ....................................................................................................... 9 5 Summary of Findings from Systematic Reviews on the Effectiveness of Text Messaging Interventions in Health Care ...................................... 11 6 Evidence of the Effectiveness of Health Text Messaging Programs Profiled on the AHRQ Health Care Innovations Exchange .................. 18 v This page left blank for double-sided copying. Abstract Background and Objectives The rapid expansion of mobile health (mHealth) programs through text messaging provides an opportunity to improve health knowledge, behaviors, and clinical outcomes, particularly among hard-to- reach populations. To support future efforts by the U.S. Department of Health and Human Services (HHS) related to text messaging programs specifically and mHealth initiatives more broadly, this environmental scan reviews the current landscape on the effectiveness and acceptance of health text messaging programs. This environmental scan examines the technology context related to cell phone ownership and text messaging use, current evidence on the effectiveness and acceptance of text messaging interventions, and implications for future research and program implementation. Methods This environmental scan includes studies on the effectiveness and acceptance of health text messaging interventions published between January 2009 and October 2012, including seven systematic reviews and a synthesis of evidence from the Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange. The scan focuses on individual-level interventions in the United States and other high-resource countries. The scan excludes studies of interventions that had been implemented primarily in developing countries or that targeted only system-level interventions (such as those aimed at the physician workforce or hospital administrative systems). Results A substantial body of research has shown that health text messaging programs can bring about behavior change to improve short-term smoking cessation outcomes as well as short-term diabetes management and clinical outcomes (increasing frequency of blood glucose monitoring and reducing HbA1c levels). Research has also shown that text messaging improves treatment compliance, including both medication adherence and appointment attendance. Research suggests that text messaging can improve immunization rates, increase sexual health knowledge, and reduce risky behaviors related to HIV transmission, although the literature is less definitive in these areas. Conclusions With the recent proliferation of health text messaging applications in the United States, emphasis should be placed on addressing gaps in knowledge about the effectiveness and acceptance of health text messaging programs. Future efforts should include (1) conducting an ongoing environmental scan of the field, (2) performing systematic reviews of new research and sharing lessons learned, and (3) determining the reach of text messaging programs, particularly among underserved populations. In addition, future research should focus on assessing long-term outcomes of text messaging interventions. The trends toward wide spread ownership of cell phones and widespread text message use across virtually all segments of the U.S. population will continue to support the spread of health text messaging programs. This scan provides encouraging evidence related to the use of health text messaging to improve health promotion, disease prevention, and disease management. 1 Introduction The rapid expansion of mobile technology infrastructure presents an opportunity to improve health and health care through new forms of interactive mobile health (mHealth) services that promote personal wellness, preventive care, and disease management. Recognizing the potential of text messaging programs to improve health and health care, the U.S. Department of Health and Human Services (HHS) established a Text4Health Task Force in November 2010 to identify existing initiatives and recommend strategies to promote the development, implementation, evaluation, and coordination of health text messaging programs in the United States. Table 1 highlights seven HHS text messaging initiatives that are under way (or under development) to address various health issues. These initiatives represent a mix of approaches: some offer applications that provide text messages directly to consumers who sign up, while others offer libraries containing evidence-based text messages that state or local agencies or health professionals can use in their own text messaging programs. Two common features of current text4health initiatives are cross-agency federal collaboration and public-private partnerships. The Task Force recommended that HHS develop evidence of the effectiveness of health text messaging programs through formal evaluations of current and future initiatives (HHS 2011). The task force recommendations are available at http://www.hhs.gov/open/initiatives/mhealth/recommendations.html. Despite a high level of activity and interest in mHealth applications and programs, documented evidence of their effectiveness remains limited (Boncana 2013; Cole-Lewis and Kershaw 2010; Mehl 2010; Nilsen et al. 2012; Sarasohn-Kahn 2010; Tamrat and Kachnowski 2012). However, recent evaluations of text messaging applications indicate their potential for supporting patient self- management by facilitating patient education, behavior change, and adherence to recommended care practices. For example, a systematic review of the literature on disease management and prevention services delivered through text messages found evidence to support text messaging as a tool for behavior change in eight of nine studies with sufficient sample sizes (Cole-Lewis and Kershaw 2010). To support future HHS efforts related to health text messaging programs specifically and mHealth initiatives more broadly, this environmental scan reviews the current landscape on the effectiveness and acceptance of health text messaging programs. This environmental scan examines the technology context related to cell phone ownership and text messaging use, current evidence on the effectiveness and acceptance of text messaging interventions, and implications for