Amy Chesser

Text messaging immunization reminders: Feasibility of implementation with low-income parents

Text messaging reminder systems are a cost-effective way of improving attendance in a variety of healthcare settings (Downer et al., 2006; Geraghty et al., 2008; Koshy et al., 2008; Leong et al., 2006). Due to the complicated nature of the child immunization schedule (Massoudi, 2003), and the penetration of mobile phones among hard-to-reach populations (Blumberg and Luke, 2008), text messaging may be a successful strategy to increase immunizations (Vilella et al., 2004). The only identified study regarding text message immunization reminders suggests parents of adolescents are open to receiving such text reminders (Kharbanda et al., 2009). However, this study involved focus groups of only 28 parents. A major public health goal is to increase immunization rates among children to 90% to prevent the circulation of vaccinepreventable diseases (Massoudi, 2003). In particular, programs that promote the 4-3-1-3-3 series among children 2 years of age and younger have been found to dramatically reduce the incidence of these diseases (Nelson et al., 2007). The purpose of this formative study was to determine the feasibility of developing text immunization reminders for parents of young children. A brief survey was administered to 200 consecutive parents of children under six years of age at a Midwestern Pediatric Residency clinic. The survey was approved by two local Institutional Review Boards. All questions were fixed response, and included current use of a cell phone, type of text messaging service, and interest in receiving text messages from health care providers. Finally, respondents provided demographic information. Surveys were completed by 190 parents (95%). The majority were female (165; 87%), had a high school diploma or less (114; 60%), had a household income less than

Navigating the digital divide: A systematic review of eHealth literacy in underserved populations in the United States

20,000 a year (117; 62%), and received public insurance (153; 81%). Nearly all participants owned a cellular phone (174; 92%) and of those, 96% (167) could receive text messages. In addition, 81% (141) had an unlimited text messaging plan. Ninety percent (156) of cell phone owners would be open to receiving text messages from their doctor or nurse. Parents with unlimited text capabilities were more likely (97%) to be open to receiving text messages from health care providers than those with limited text plans (64%) (χ(1)=32.98, pb .001). Of those respondents who own a cell phone andwere interested in receiving text messages from their health care provider (156), 99% (155) would be open to receiving appointment reminders, 87% (135) immunization reminders, 76% (119) test results, and 46% (72) general health tips. Most respondents (136; 87%) would prefer to receive immunization reminders one week or less before the shots are due. Of those parents who would enroll in a text immunization reminder service, 19% (29) would pay up to

Parent Opinions About Use of Text Messaging for Immunization Reminders

9.99 a year for the program, but the majority (97; 62%) would only enroll if the program was free or covered by insurance.

Content of text messaging immunization reminders: What low-income parents want to know

eHealth provides an important mechanism to connect medically underserved populations with health information, but little is known about gaps in eHealth literacy research in underserved adult populations within the U.S. Between June and July 2013, three systematic literature reviews of five databases were conducted and a subsequent hand search was completed. Identified literature was screened and studies meeting exclusion and inclusion criteria were synthesized and analyzed for common themes. Of the 221 articles critically appraised, 15 met these criteria. Thirty-five of these studies were excluded due to international origin. Of the articles meeting the inclusion criteria, underserved populations assessed included immigrant women, the elderly, low-income, the un- and underemployed, and African-American and Hispanic populations. eHealth literacy assessments utilized included one or two item screeners, the eHEALS scale, health information competence and cognitive task analysis. Factors examined in relation to eHealth literacy included age, experience, overall health literacy, education, income and culture. The majority did not assess the impact of locality and those that did were predominately urban. These data suggest that there is a gap in the literature regarding eHealth literacy knowledge for underserved populations, and specifically those in rural locations, within the U.S.

Using Human Factors Techniques to Design Text Message Reminders for Childhood Immunization

Background Adherence to childhood immunization schedules is a function of various factors. Given the increased use of technology as a strategy to increase immunization coverage, it is important to investigate how parents perceive different forms of communication, including traditional means and text-message reminders. Objective To examine current forms of communication about immunization information, parents’ satisfaction levels with these communication modes, perceived barriers and benefits to using text messaging, and the ideal content of text messages for immunization reminders. Methods Structured interviews were developed and approved by two Institutional Review Boards. A convenience sample of 50 parents was recruited from two local pediatric clinics. The study included a demographics questionnaire, the shortened form of the Test of Functional Health Literacy for Adults (S-TOFHLA), questions regarding benefits and barriers of text communication from immunization providers, and preferred content for immunization reminders. Content analyses were performed on responses to barriers, benefits, and preferred content (all Cohen’s kappas > 0.70). Results Respondents were mostly female (45/50, 90%), white non-Hispanic (31/50, 62%), between 20–41 years (mean = 29, SD 5), with one or two children (range 1–9). Nearly all (48/50, 96%) had an S-TOFHLA score in the “adequate” range. All parents (50/50, 100%) engaged in face-to-face contact with their child’s physician at appointments, 74% (37/50) had contact via telephone, and none of the parents (0/50, 0%) used email or text messages. Most parents were satisfied with the face-to-face (48/50, 96%) and telephone (28/50, 75%) communication. Forty-nine of the 50 participants (98%) were interested in receiving immunization reminders by text message, and all parents (50/50, 100%) were willing to receive general appointment reminders by text message. Parents made 200 comments regarding text-message reminders. Benefits accounted for 63.5% of comments (127/200). The remaining 37.5% (73/200) regarded barriers; however, no barriers could be identified by 26% of participants (13/50). Parents made 172 comments regarding preferred content of text-message immunization reminders. The most frequently discussed topics were date due (50/172, 29%), general reminder (26/172, 26%), and child’s name (21/172, 12%). Conclusions Most parents were satisfied with traditional communication; however, few had experienced any alternative forms of communication regarding immunizations. Benefits of receiving text messages for immunization reminders far outweighed the barriers identified by parents. Few barriers identified were text specific. Those that were, centered on cost if parents did not have unlimited texting plans.

Health Literacy and Older Adults A Systematic Review

OBJECTIVE The purpose of this project was to gather preliminary data on preferred content for text reminders sent to low-income parents. METHODS A brief, IRB-approved survey was administered to 200 consecutive English-speaking parents of children under 6 years old at a Pediatric Residency clinic. Because text messages can hold only limited content, parents were given three example texts ranging from very basic to very specific information and asked to select the information they would wish to receive. RESULTS Of the 190 parents (95%) who responded, 22.1% (42) were Hispanic and 76.3% (145) were non-Hispanic. Over 80% (153) received Medicaid. Of the 79.5% (151) of respondents interested in receiving text messages who responded to the question regarding content, nearly 50% (74) preferred Option 2, with the remaining respondents divided between Option 1 (43) and Option 3 (35). Results differed significantly between Hispanic and non-Hispanic respondents (χ(2)(2)=6.36, p=0.042). CONCLUSION The majority of parents preferred a message containing the childs name, specific immunization information and physician information. However, Hispanic respondents were significantly more likely to endorse an option that included additional information. PRACTICE IMPLICATIONS Text messaging may be an optimal vehicle for provider-patient communication, however cultural differences should be considered when developing messages.

Health Literacy Assessment of the STOFHLA: Paper Versus Electronic Administration Continuation Study

This study engaged parents to develop concise, informative, and comprehensible text messages for an immunization reminder system using Human Factors techniques. Fifty parents completed a structured interview including demographics, technology questions, willingness to receive texts from their child’s doctor, and health literacy. Each participant was assigned to one user-centered design test: card sort, needs analysis, or comprehension. The majority of respondents were female (90%), White non-Hispanic (62%), and averaged 29 years (SD = 5). Nearly all (96%) had “adequate” health literacy. The card sort, an activity in which end users organize information into categories, identified six pieces of critical information. These were compiled into eight example texts, which were ranked in the needs assessment. The top two were assessed for comprehension, with 100% of participants able to understand the content and describe intention to act. Using user-centered design methods, the authors developed concise, informative text messages that parents indicated would prompt them to schedule their child’s immunization appointment.

Preliminary benefits of information therapy.

Objective: The objective of this review was to assess published literature relating to health literacy and older adults. Method: The current review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Results: Eight articles met inclusion criteria. All studies were conducted in urban settings in the United States. Study sample size ranged from 33 to 3,000 participants. Two studies evaluated health-related outcomes and reported significant associations between low health literacy and poorer health outcomes. Two other studies investigated the impact of health literacy on medication management, reporting mixed findings. Discussion: The findings of this review highlight the importance of working to improve health care strategies for older adults with low health literacy and highlight the need for a standardized and validated clinical health literacy screening tool for older adults.

Describing Adolescent Breastfeeding Environments Through Focus Groups in an Urban Community

Low health literacy is associated with poor health outcomes. Research is needed to understand the mechanisms and pathways of its effects. Computer-based assessment tools may improve efficiency and cost-effectiveness of health literacy research. The objective of this preliminary study was to assess if administration of the Short Test of Functional Health Literacy in Adults (STOFHLA) through a computer-based medium was comparable to the paper-based test in terms of accuracy and time to completion. A randomized, crossover design was used to compare computer versus paper format of the STOFHLA at a Midwestern family medicine residency program. Eighty participants were initially randomized to either computer (n = 42) or paper (n = 38) format of the STOFHLA. After a 30-day washout period, participants returned to complete the other version of the STOFHLA. Data analysis revealed no significant difference between paper- and computer-based surveys (p = .9401; N = 57). The majority of participants showed “adequate” health literacy via paper- and computer-based surveys (100% and 97% of participants, respectively). Electronic administration of STOFHLA results were equivalent to the paper administration results for evaluation of adult health literacy. Future investigations should focus on expanded populations in multiple health care settings and validation of other health literacy screening tools in a clinical setting.

Necesita Una Vacuna: What Spanish-Speakers Want in Text-message Immunization Reminders

Information therapy (ie, information prescriptions) is a potential new tool for primary care physicians that could improve patient knowledge, decision making, and communication between physicians and patients. Although patients have access to numerous health-related articles online, the availability of this health information does not ensure improved knowledge or better health decisions by patients. Communication between patients and physicians is often limited and messages are commonly misunderstood. Information therapy offers a potential solution for the primary care environment. Method: Two employers, in different geographical locations of the Midwest, offered the MedEncentive program to employees and their dependents as a part of their health plans. This program also offers primary care physicians the opportunity to prescribe information to patients during office visits. Patients were then eligible to participate in this information therapy (Ix) through a Web-based platform. Both primary care physicians and patients were financially incentivized for participation. Physicians received a monetary stipend for prescribing evidence-based information therapy and patients were refunded part or all of their copayment for reading their condition-specific Ix and answering questions about knowledge, compliance, health status, and satisfaction with the care they received compared to the evidence from the Ix. Results: Patients received information therapy from their primary care physicians and reported a high level of satisfaction with care, improved health status, and compliance with pharmaceutical prescriptions. Discussion: This case study had a number of limitations and as such the results should be interpreted with caution. However, there is a need for an immediate solution as patient satisfaction with their care and compliance with pharmaceutical prescriptions continue to decrease, despite the amounts of widely available health information. These preliminary findings suggest that information therapy through a Web-based platform, augmented by doctor-patient mutual accountability, could be part of the solution for the current ambulatory health care environment.