Jeremy Snider

Pilot evaluation of the text4baby mobile health program

BackgroundMobile phone technologies for health promotion and disease prevention have evolved rapidly, but few studies have tested the efficacy of mobile health in full-fledged programs. Text4baby is an example of mobile health based on behavioral theory, and it delivers text messages to traditionally underserved pregnant women and new mothers to change their health, health care beliefs, practices, and behaviors in order to improve clinical outcomes. The purpose of this pilot evaluation study is to assess the efficacy of this text messaging campaign.MethodsWe conducted a randomized pilot evaluation study. All participants were pregnant women first presenting for care at the Fairfax County, Virginia Health Department. We randomized participants to enroll in text4baby and receive usual health care (intervention), or continue simply to receive usual care (control). We then conducted a 24-item survey by telephone of attitudes and behaviors related to text4baby. We surveyed participants at baseline, before text4baby was delivered to the intervention group, and at follow-up at approximately 28 weeks of baby’s gestational age.ResultsWe completed 123 baseline interviews in English and in Spanish. Overall, the sample was predominantly of Hispanic origin (79.7%) with an average age of 27.6 years. We completed 90 follow-up interviews, and achieved a 73% retention rate. We used a logistic generalized estimating equation model to evaluate intervention effects on measured outcomes. We found a significant effect of text4baby intervention exposure on increased agreement with the attitude statement “I am prepared to be a new mother” (OR = 2.73, CI = 1.04, 7.18, p = 0.042) between baseline and follow-up. For those who had attained a high school education or greater, we observed a significantly higher overall agreement to attitudes against alcohol consumption during pregnancy (OR = 2.80, CI = 1.13, 6.90, p = 0.026). We also observed a significant improvement of attitudes toward alcohol consumption from baseline to follow-up (OR = 3.57, CI = 1.13 – 11.24, p = 0.029).ConclusionsThis pilot study is the first randomized evaluation of text4baby. It is a promising program in that exposure to the text messages was associated with changes in specific beliefs targeted by the messages.

Perceptions of the food shopping environment are associated with greater consumption of fruits and vegetables.

OBJECTIVE The present study examined whether characteristics such as quality, selection and convenience are associated with dietary intake of fruits and vegetables independent of perceived costs in an inner-city, low-income population. DESIGN Secondary analysis of baseline data from a social marketing intervention designed to change household dietary practices among parents of 3- to 7-year-old children. SETTING A community sample drawn from six low-income, primarily minority neighbourhoods in Chicago, IL, USA. SUBJECTS From the parent study, 526 respondents completed the baseline survey and were eligible for inclusion. Of this number, 495 provided complete data on sociodemographic characteristics, fruit and vegetable consumption, perceptions of the shopping environment, perceived costs of fruits and vegetables, and food shopping habits. RESULTS Logistic regression analysis showed that more positive perceptions of the food shopping environment were associated with greater consumption of fruits and vegetables. There was an increase of approximately twofold in the likelihood of consuming three or more fruits and vegetables daily per level of satisfaction ascribed to the shopping environment. This association was independent of perceived cost, store type and sociodemographic characteristics. CONCLUSIONS Our data show that among a generally minority and low-income population, quality, selection and convenience are important determinants of fruit and vegetable consumption. Nutrition promotion campaigns that aim to alter the built environment by increasing access to fruits and vegetables should recognize that simply increasing availability may not yield beneficial change when characteristics of the shopping context are ignored.

Initial Outcomes From a 4-Week Follow-Up Study of the Text4baby Program in the Military Women’s Population: Randomized Controlled Trial

Background The use of mobile phone technologies for health promotion and disease prevention has advanced rapidly in recent years. Text4baby is a theory-based mobile health (mHealth) program in which text messages are delivered to pregnant women and new mothers to improve their health care beliefs and behaviors and improve health status and clinical outcomes. Recent evaluations of Text4baby have found that it improves targeted health attitudes and beliefs, but effects on behavior have not yet been determined. Objective In this study, investigators aimed to evaluate Text4baby in the military women’s population. Methods Investigators conducted a randomized controlled trial at Madigan Army Medical Center in Tacoma, Washington, from December 2011 through September 2013. All participants were pregnant women first presenting for care at Madigan. Investigators conducted a baseline assessment using a 24-item, self-administered online survey of attitudes and behaviors related to Text4baby message content. Participants were randomized to Text4baby plus usual care (intervention) or usual care alone (control). Investigators analyzed treatment effects of Text4baby on short-term targeted outcomes 4 weeks post enrollment. Results For this study, 943 patients were randomized and completed a baseline assessment. The average patient age was 28 years and nearly 70% self-identified as Caucasian. 48.7% of enrollees (459/943) completed the first follow-up assessment. Higher rates of single and working/in-school patients dropped out of the intervention arm of the study, and we adjusted for this finding in subsequent models. However, while investigators were unable to re-survey these participants, only 1.9% of Text4baby enrollees (18/943) dropped the service during the study period. Adjusted and unadjusted logistic generalized estimating equation models were developed to assess intervention effects on measured outcomes. In the model adjusting for age, marital status, having had a previous baby, and race/ethnicity, there was a significant effect of Text4baby intervention exposure on increased agreement with belief in the importance of taking prenatal vitamins (OR 1.91, 95% CI 1.08-3.34, P=.024). All of these attitudes had been targeted by at least one text message during the 4-week evaluation period examined in this study. In unadjusted models, there was a significant effect of intervention exposure on belief in the importance of visiting a health care provider to be a healthy new mother (OR 1.52, 95% CI 1.01-2.31, P=.046) and in the health risks of alcohol during pregnancy (OR 2.06, 95% CI 1.00-4.31, P=.05). No behavioral effects of the intervention were observed in this analysis. Conclusions Text4baby is a promising program that offers lessons for future mHealth activities. This large-scale study demonstrated initial effects of the program on attitudes and beliefs targeted by the messages received by women during the study period. Results confirm previous findings from Text4baby studies and other mHealth research. Future analyses will examine dosage effects of the intervention on behaviors and clinical outcomes.

Dose-Response Effects of the Text4baby Mobile Health Program: Randomized Controlled Trial

Background Mobile health (mHealth) is growing rapidly, but more studies are needed on how to optimize programs, including optimal timing of messaging, dose of exposure, and value of interactive features. This study evaluates final outcomes of text4baby (a text message service for pregnant and postpartum women) from a randomized trial performed in a population of pregnant female soldiers and family members. Objective The study aims were to evaluate (1) treatment effects and (2) dose-response effects of text4baby on behavioral outcomes compared to control (no text4baby) condition. Methods The study was a randomized trial of text4baby at Madigan Army Medical Center. Female military health beneficiaries who met inclusion criteria were eligible for the study. Participants provided consent, completed a baseline questionnaire, and then were randomized to enroll in text4baby or not. They were followed up at 3 time points thereafter through delivery of their baby. Generalized estimating equation models were used to evaluate outcomes. We examined treatment effects and the effects of higher doses of text4baby messages on outcomes. Results We report descriptive statistics including dosage of text messages delivered. The main finding was a significant effect of high exposure to text4baby on self-reported alcohol consumption postpartum (OR 0.212, 95% CI 0.046-0.973, P=.046), as measured by the question “Since you found out about your pregnancy, have you consumed alcoholic beverages?” The text4baby participants also reported lower quantities of alcohol consumed postpartum. Conclusions Studies of text4baby have helped to build the mHealth evidence base. The effects of text4baby offer lessons for future scalable mHealth programs and suggest the need to study dose-response effects of these interventions.

Outcomes of the 5-4-3-2-1 Go! Childhood obesity community trial.

OBJECTIVES To determine effects of the 5-4-3-2-1 Go! community social marketing campaign on obesity risk factors. METHODS We randomly assigned 524 parents of 3- to 7-year-old children to receive 5-4-3-2-1 Go! counseling or not. We surveyed parents about 5-4-3-2-1 Go! behaviors and perceptions of childrens behaviors at baseline and one year later. We conducted multivariable logistic regression for each outcome. RESULTS Parents who received counseling consumed more fruits and vegetables at follow-up (OR 1.749, [95% CI: 1.01-3.059]). Parental exposure to messaging at childrens school events was associated with higher water consumption (6.879, [1.954-24.212]). CONCLUSIONS 5-4-3-2-1 Go! is a promising intervention.

Brand equity and willingness to pay for condoms in zimbabwe

BackgroundZimbabwe suffers from one of the greatest burdens of HIV/AIDS in the world that has been compounded by social and economic instability in the past decade. However, from 2001 to 2009 HIV prevalence among 15-49 year olds declined from 26% to approximately 14%. Behavior change and condom use may in part explain this decline.PSI-Zimbabwe socially markets the Protector Plus (P+) branded line of condoms. When Zimbabwe converted to a dollar-based economy in 2009, the price of condoms was greatly increased and new marketing efforts were undertaken. This paper evaluates the role of condom marketing, a multi-dimensional scale of brand peceptions (brand equity), and price in condom use behavior.MethodsWe randomly sampled sexually active men age 15-49 from 3 groups - current P+ users, former users, and free condom users. We compared their brand equity and willingness to pay based on survey results. We estimated multivariable logistic regression models to compare the 3 groups.ResultsWe found that the brand equity scale was positive correlated with willingness to pay and with condom use. Former users also indicated a high willingness to pay for condoms. We found differences in brand equity between the 3 groups, with current P+ users having the highest P+ brand equity. As observed in previous studies, higher brand equity was associated with more of the targeted health behavior, in this case and more consistent condom use.ConclusionsZimbabwe men have highly positive brand perceptions of P+. There is an opportunity to grow the total condom market in Zimbabwe by increasing brand equity across user groups. Some former users may resume using condoms through more effective marketing. Some free users may be willing to pay for condoms. Achieving these objectives will expand the total condom market and reduce HIV risk behaviors.

Effects of the above the influence brand on adolescent drug use prevention normative beliefs.

Health brands are based on the relations between individuals and health behaviors and lifestyles. Brands can be measured by the brand equity construct validated in previous studies. The National Youth Anti-Drug Media Campaign brands alternative, non–drug use behaviors as a behavior change strategy. This study goes beyond previous campaign evaluations, which did not include specific brand equity measurements. Using data from a nationally representative media tracking, this study examined the relation between antidrug campaign brand equity and adoption of targeted attitudes, beliefs, and behaviors. Data were gathered before the relaunch of the campaign, and follow-up data collected 3 months later. On the basis of factor analysis, the authors developed a higher order antidrug brand equity factor and regressed campaign outcomes on that factor in multivariable models. The authors observed significant effects of higher brand equity on higher levels of targeted antidrug attitudes and normative beliefs at follow-up. The authors also observed some counterintuitive relations (i.e., less positive attitudes at follow-up). They interpreted these results in light of the changing messages and campaign strategy. The authors conclude that antidrug brand equity is an important construct for understanding campaign effectiveness. The present campaign shows signs of changing targeted antidrug attitudes and beliefs among youth with brand equity.

Design and Feasibility Testing of the truth FinishIt Tobacco Countermarketing Brand Equity Scale.

The original truth campaign was a branded, national smoking prevention mass media effort focused on at-risk youth ages 12–17. Today the truth brand focuses on the goal of finishing tobacco (truth FinishIt). There have been significant changes in the tobacco control landscape, leading FinishIt to focus on 15- to 21-year-olds. The present article reports on formative research and media monitoring data collected to pilot test a new truth FinishIt brand equity scale. The goals of this study were to (a) content analyze truth FinishIt mass media ads, (b) assess truth’s social media and followers’ perceptions of truth’s digital brand identity, and (c) develop and feasibility test a new version of the truth FinishIt brand equity scale using data from an existing Truth Initiative media monitoring study. Through factor analysis, we identified a brand equity scale, as in previous research, consisting of 4 main constructs: brand loyalty, leadership/satisfaction, personality, and awareness. Targeted truth attitudes and beliefs about social perceptions, acceptability, and industry-related beliefs were regressed on the higher order factor and each of the 4 individual brand equity factors. Ordinary least squares regression models generally showed associations in the expected directions (positive for anti-tobacco and negative for pro-tobacco) between targeted attitudes/beliefs and truth FinishIt brand equity. This study succeeded in developing and validating a new truth FinishIt brand equity scale. The scale may be a valuable metric for future campaign evaluation. Future studies should examine the effects of truth FinishIt brand equity on tobacco use behavioral outcomes over time.

Adherence to clinical preventive services guidelines: Population-based online randomized trial

The Patient Protection and Affordable Care Act (ACA) addresses use of clinical preventive services relative to evidence-based guidelines by mandating that most health insurance plans provide coverage without cost-sharing for services that receive an A or B rating. However, knowledge about and positive attitudes towards guidelines are extremely low. This study was a population-based randomized experiment to examine beliefs about and intentions to adhere to screening guidelines for the Prostate Specific Antigen (PSA) and Pap tests. The study had two objectives: (1) test reactions to and understanding of guidelines, and (2) experimentally compare receptivity to messages to promote PSA and Pap test recommendations. We first surveyed a population-based sample of (1) US adults age 18 and over, (2) subsample of women aged 65 or younger, (3) subsample of men aged 40 or older. A sample of 2923 completed an initial questionnaire. Next a subset of participants meeting eligibility criteria were recruited from the population-based sample into a message testing experiment: (1) women aged 65 or younger, (2) and men aged 40 or older. Participants meeting these eligibility requirements were randomized to gain, loss, or balanced PSA (men) or Pap test (women) message stimulus conditions and followed for 8 weeks. Data were collected through the GfK Custom Research panel. A total of 2401 were eligible, 2321 completed the baseline, and 1730 completed follow up. Mixed effect regression models revealed that higher receptivity to messages was associated with greater intentions to seek cancer information and to speak to a Doctor about PSA and Pap tests. The loss frame was associated with higher intentions to speak to friends and family about PSA and Pap tests. Finally, perceived importance and personal understanding of guidelines predicted intentions to seek more information about them. This study contributes to evidence on how best to inform and engage consumers regarding preventive services.

The Living the Example Social Media Substance Use Prevention Program: A Pilot Evaluation

Background Adolescent substance use rates in rural areas of the United States, such as upstate New York, have risen substantially in recent years, calling for new intervention approaches in response to this trend. The Mentor Foundation USA conducts the Living the Example (LTE) campaign to engage youth in prevention using an experiential approach. As part of LTE, youth create their own prevention messages following a training curriculum in techniques for effective messaging and then share them via social media. This paper reports on a pilot evaluation of the LTE program. Objective To conduct a pilot test of LTE in two rural high schools in upstate New York. We hypothesized that positive antidrug brand representations could be promoted using social media strategies to complement the Shattering the Myths (STM) in-person, event-based approach (hypothesis 1, H1), and that youth would respond positively and engage with prevention messages disseminated by their peers. We also hypothesized that exposure to the social media prevention messages would be associated with more positive substance use avoidance attitudes and beliefs, reductions in future use intentions, and decreased substance use at posttest (hypothesis 2, H2). Methods We adapted a previously published curriculum created by the authors that focuses on branding, messaging, and social media for prevention. The curriculum consisted of five, one-hour sessions. It was delivered to participating youth in five sequential weeks after school at the two high schools in late October and early November 2016. We designed a pre- and posttest pilot implementation study to evaluate the effects of LTE on student uptake of the intervention and short-term substance use and related outcomes. Working at two high schools in upstate New York, we conducted a pilot feasibility evaluation of LTE with 9th-grade students (ie, freshmen) at these high schools. We administered a 125-item questionnaire online to capture data on media use; attitudes toward social media; next 30-day personal drug use intentions; personal reasons to use drugs; reasons participants believe their peers would use drugs; self-reported exposure to the LTE program; and receptivity to the LTE program, among those reporting exposure. We constructed multivariable logistic regression models to analyze the relationship between program receptivity and outcomes. First, in a cross-sectional logistic regression model, we regressed self-reported LTE message receipt on drug use intent and actions related to LTE messaging. Then, for analysis of participants with matched pre- and posttest responses, we used multilevel generalized estimating equation (GEE) techniques to model changes in behavior from baseline to follow-up. Results Youth reported increased intentions to use marijuana (odds ratio [OR] 2.134, P=.02) between pre- and posttest. However, youth who reported exposure and receptivity to LTE reported a significant decrease in intentions (OR 0.239, P=.008). We observed a similar pattern for sedatives/sleeping pills—an increase in intentions overall (OR 1.886, P=.07), but a decrease among youth who reported exposure and receptivity to LTE (OR 0.210, P=.02). We saw the same pattern for use of any drug—an increase in reported intentions overall (OR 2.141, P=.02), but a decrease among youth who reported exposure and receptivity to LTE (OR 0.111, P=.004). Conclusions We observed some evidence of significant LTE program effects. Social media may be an effective strategy for peer-to-peer substance use prevention in the future. These findings point both to the potential of LTE and the social media diffusion model and to the need for more research on a larger scale with an expanded youth population in the future.