TXT 4 Health: Results from CDC’s Text Message Evaluations<br />Ann Aikin<br />Electronic Media Branch<br />Division of New...
Overview Text Messaging Pilot<br /><ul><li>Launched September 2009
Subscribers receive 2-3  msgs/week
Everyday health tips
Health message testing and user evaluation</li></li></ul><li>Portable Devices <br />Average number of hours per day mobile...
Mobile Engagement & Information Access<br />“Mobile technology is associated with deeper engagement in social media and an...
Available & Efficient<br /><ul><li> In some crises, text messages have been used when landline, mobile calls, radio, and o...
 Text messages can go through faster in an emergency because they sit on servers until there is an opening to send unlike ...
Reaching the Hard to Reach<br /><ul><li> There are more than 285 million U.S. mobile subscribers, accounting for 91% of th...
 According to Pew, while almost three quarters of white Americans have cell phones, 84% of English-speaking Hispanics and ...
Popular Channel<br />Text messaging is available on 98% of all cell phones.  <br />Source:  CTIA – The Wireless Associatio...
Mobile-Only Households<br /><ul><li>Nearly 23% of U.S. households are now wireless-only households 1</li></ul>CTIA Wireles...
Behavior Change Outcomes<br />Review of current research for delivering health behavior change interventions via text mess...
Mobile Texting Pilot<br />Overall Satisfaction  (N=2,435)<br /><ul><li>How would you rate UR overall satisfaction with the...
How can we improve?</li></ul>Help us improve our text messages! Please answer one question about UR satisfaction so we can...
Mobile Texting Pilot<br />To make messages more actionable & relevant: <br /><ul><li>Created subgroup of users who want to...
Began targeting messages by age (including vaccine recommendations), by gender (including messages on cervical cancer) and...
Text Messaging Survey<br />Evaluation Dates:  <br />March 30, 2010 – March 31, 2010<br />N=237<br />We need UR help! Pls t...
Mobile Texting Pilot<br />Overall Satisfaction  (N=2,435)<br /><ul><li>How would you rate UR overall satisfaction with the...
How can we improve?</li></ul>Help us improve our text messages! Please answer one question about UR satisfaction so we can...
Overall Satisfaction<br />In your opinion, how effective are CDC's text messages in meeting your needs?<br />How would you...
Health Behavior Change<br />How likely are you to use any of the information in text messages to improve your health?<br /...
91%<br />said the messages were easy to understand<br />
91%<br />said the messages were easy to understand<br />90%<br />said the messages were credible<br />
91%<br />said the messages were easy to understand<br />90%<br />said the messages were credible<br />89%<br />said the me...
91%<br />said the messages were easy to understand<br />90%<br />said the messages were credible<br />89%<br />said the me...
87%<br />of respondents would like the opportunity to tailor the messages <br />by signing up for topics they are interest...
91% said the messages were easy to understand, 90% said they were credible, 89% said they were friendly, and 70% said they...
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TXT 4 Health: Results from CDCs Text Message Evaluations

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  • In September, 2009, CDC launched a text messaging pilot to reach users with important health messages when and where they need them. Users receive three health messages a week with links to CDC’s mobile Web site, http://m.cdc.gov and a click-to-call phone number for CDC national call center.Although the pilot began as a way to communicate critical information about H1N1 flu, it quickly evolved to address important health issues such as smoking cessation, nutrition &amp; physical activity awareness, STD information, and food outbreaks. To date, we have more than 16,000 subscribers in the text messaging pilot.
  • With text messaging available on 98% of all cell phones and more than 1.5 trillion text messages sent last year, Americans send/receive twice as many text messages than phone calls, making text messaging a potentially effective way to provide health information to users when and when they need it.
  • In addition, text messaging also affords an opportunity to communicate with underserved audiences and those with lower levels of health. With more than 285 million Americans (or 91% of U.S. population) owning mobile devices, mobile is helping to close the digital divide. Not only are text messages an excellent way to reach users in times of emergencies, but the technology also affords an opportunity to communicate with underserved audiences in the U.S. who may not have access to the Internet. In fact, A study published by the Pew Internet and American Life project last week found that lower income teens (ages 12-17) were higher users of text messaging and the mobile internet. In fact, the study showed that 1/5 of teens without internet access at home, use their mobile device to access the internet, thus beginning to close the digital divide with mobile web. In addition, more and more households are getting rid of their landlines and becoming ‘mobile-only’ households. This is significant because research shows that persons in cell-phone-only households have higher rates of binge drinking or excess alcohol consumption, are more likely to smoke, less likely to have had a flu shot in the last year, less likely to be tested for HIV, and less likely to have a usual place to go for medical care, etc.
  • In fact, there have been several attempts to try to measure the effectiveness of text messaging for delivering health behavior change interventions. In fact, the American Journal of Preventive Medicine publish an article in late 2009 comparing 14 SMS program for impacts on healthy behaviors. Four of the 14 studies reviewed targeted preventive health behaviors (e.g., smoking cessation), and ten focused on clinical care (e.g., diabetes self-management). The study found that 13 of the 14 studies resulted in positive behavior change outcomes. The study found that key elements of a successful health intervention included a two-way dialogue with individuals, tailored content, and interactivity of the interventions. This service allows for instantaneousdelivery of short messages (maximum 160characters) directly to individuals at any time, place, orsetting. These messages are asynchronous, meaningthey can be accessed at a time that suits an individual. reviewed Customized SMS messages can be tailored to individuals,which is important given that personally tailoredmessages are more effective for health behavior changethan untailored messages.20–24 This medium also allowsfor seamless (and quantifiable) interaction between theparticipant and the interventionist, so that participantengagement with the intervention can be monitoredand compared to exposure. Communication with SMSmay also be more cost effective than other telephone orprint-based interventions.19,25There were no clear differences in interventionoutcomes based on SMS dialogue initiation. However,all the preventive health behavior studies usedresearcher-initiated techniques, and most of the tertiarylevelinterventions used participant-initiated techniques.The frequency of SMS transmission reflected theexpected frequency of the targeted behavior (e.g.,smoking [5/day], physical activity [5/week]) for all butthree studies.66,72,74 Most of the interventions providedpersonally tailored SMS, except two studies66,74 thatused bulk, untailored SMS. Tailoring variables includedparticipant’s name or nickname, nominated supportperson’s name, age, gender, behavioral history, behavioralpreferences, behavioral goals, behavioral barriers,previous SMS responses, and medical status. The twostudies66,74 that used untailored SMS were in the topthree for highest participant attrition.It is well established that tailored health messages aremore engaging and effective at changing behavior thanuntailored, bulk messages.21–24 All but two studies inthis review used tailored SMS. The two studies66,74using untailored SMS targeted a wide range of behavioralchanges (e.g., physical activity, nutrition, medicationcompliance, smoking, alcohol consumption) andwere among the studies with the highest participantattrition. This finding may support the notion thatuntailored health messages are less engaging for participants.Because participant engagement and retentionare critical factors in successful behavior changeresearch, it is important to further investigate theimpact of tailoring content in SMS research.Interactivity and responsiveness to participants’
  • Therefore, in January, we sent out our first interactive feedback survey, asking users to rate their level of satisfaction with the text messaging pilot. 87% of users were satisfied with the messages. Three days later, we sent another message asking users how we could improve, and the two most popular responses were to make the messages more actionable and more relevant.
  • Therefore, we began targeting messages by age, gender, and creating “subgroups” for smaller more targeted topics, including creating a NEWYEAR list to allow users to sign up for messages about nutrition and physical activity. This list was very popular as we timed it to be sent out on New Year’s Day, when many make resolutions to become healthier.
  • In March, we conducted a much larger evaluation, by sending a message to users asking them to participate in a web survey. Not surprisingly, the number of users who participated in the study decreased significantly, as users had to take their phone to their computer and type in a web address.
  • Therefore, in January, we sent out our first interactive feedback survey, asking users to rate their level of satisfaction with the text messaging pilot. 87% of users were satisfied with the messages. Three days later, we sent another message asking users how we could improve, and the two most popular responses were to make the messages more actionable and more relevant.
  • 71% of the respondents report that they were satisfied or very satisfied with the text messages. What is somewhat surprising is that 87% of respondents to the text message survey were satisfied. This is a marked decrease that we are not able to explain. One hypothesis is that the difficulty involved in taking a web survey prevented a great deal of people from taking the survey, meaning that those who did take the survey were likely either very satisfied or very dissatisfied. This is a question that requires further research, showcasing the fact that additional research needs to be conducted to determine the best ways to evaluate the effectiveness of text messaging programs.
  • One of the most interesting facts we found in the study was that 62% of respondents said that they had used the messages to improve their health and the 60% were very likely to recommend CDC’s text messages to a friend.
  • When asing about user perceptions of the text messages, we found that….
  • In order to better target the messages, we began targeting by events, by age and by creating new lists targeting to smaller subgroups of people.
  • One other surprising finding was that users did mind abbreviations in text messages from friends and family members, but that they thought the abbreviations from the CDC reduced the credibility of our messages.
  • We also began tailoring messages by providing more interactivity…
  • TXT 4 Health: Results from CDCs Text Message Evaluations

    1. 1. TXT 4 Health: Results from CDC’s Text Message Evaluations<br />Ann Aikin<br />Electronic Media Branch<br />Division of News and Electronic Media<br />Office of the Associate Director for Communication<br /> Office of the Associate Director for Communication<br />
    2. 2. Overview Text Messaging Pilot<br /><ul><li>Launched September 2009
    3. 3. Subscribers receive 2-3 msgs/week
    4. 4. Everyday health tips
    5. 5. Health message testing and user evaluation</li></li></ul><li>Portable Devices <br />Average number of hours per day mobile phones are within arm’s reach: 19 hours(From: Pew Internet & American Life Project, The Social Life of Health Information, Accesed September 10, 2009ttp://www.pewinternet.org/Reports/2009/8-The-Social-Life-of-Health-Information.aspx)<br />
    6. 6. Mobile Engagement & Information Access<br />“Mobile technology is associated with deeper engagement in social media and an accelerated pace of information exchange.”<br />Mobile provides us with the ability to engage immediately, in real time, in this case in Bangladesh after flooding and cyclones. <br />http://www.pewinternet.org/Reports/2009/8-The-Social-Life-of-Health-Information.aspx<br />
    7. 7. Available & Efficient<br /><ul><li> In some crises, text messages have been used when landline, mobile calls, radio, and other communications have not worked.
    8. 8. Text messages can go through faster in an emergency because they sit on servers until there is an opening to send unlike mobile calls.</li></ul>R U ready for an emergency? Make a disaster supply kit with food, water, first aid items & other essentials. CDC: m.cdc.gov/kit or 800-232-4636. <br />
    9. 9. Reaching the Hard to Reach<br /><ul><li> There are more than 285 million U.S. mobile subscribers, accounting for 91% of the total U.S. population.
    10. 10. According to Pew, while almost three quarters of white Americans have cell phones, 84% of English-speaking Hispanics and 71% of black Americans have them.</li></ul>Responding to Haiti quake? Learn about travel warnings & health recs for relief workers responding to disasters. CDC: m.cdc.gov/travel or 800-232-4636 <br />
    11. 11. Popular Channel<br />Text messaging is available on 98% of all cell phones. <br />Source: CTIA – The Wireless Association<br />Number of text messages sent per user increased by nearly 50% in the U.S. last year<br />Source: CTIA – The Wireless Association<br />
    12. 12. Mobile-Only Households<br /><ul><li>Nearly 23% of U.S. households are now wireless-only households 1</li></ul>CTIA Wireless Association. Wireless Quick Facts. CTIA. [Online] January 2010. [Cited: February 27, 2010.] http://www.ctia.org/media/industry_info/index.cfm/AID/10323.<br />
    13. 13. Behavior Change Outcomes<br />Review of current research for delivering health behavior change interventions via text message <br />Of 33 studies identified, 14 met the inclusion criteria: <br />Evaluated an intervention delivered primarily via SMS<br />Used pre–post to measure behavior change<br />Published in a peer-reviewed scientific journal<br />Positive behavior change outcomes were observed in 13 of the 14 reviewed studies!!<br />Keys to Success: <br />Tailoring of SMS content<br />Interactivity<br />American Journal of Preventive Medicine 2009 <br />Behavior change interventions delivered by mobile telephone short-message service. Fjeldsoe, Brianna, Marshall, Alison and Miller, Yvette: American Journal of Preventative Medicine, 2009, Vol. 36.<br />
    14. 14. Mobile Texting Pilot<br />Overall Satisfaction (N=2,435)<br /><ul><li>How would you rate UR overall satisfaction with the text messages:  A) Very Satisfied, B) Satisfied, C) Dissatisfied, D) Very Dissatisfied
    15. 15. How can we improve?</li></ul>Help us improve our text messages! Please answer one question about UR satisfaction so we can improve our msgs & better meet UR needs. Reply FEEDBACK to begin.<br />87% Satisfied<br />Relevant<br />Actionable<br />
    16. 16. Mobile Texting Pilot<br />To make messages more actionable & relevant: <br /><ul><li>Created subgroup of users who want to receive weekly tips for health & nutrition (NEWYEAR)
    17. 17. Began targeting messages by age (including vaccine recommendations), by gender (including messages on cervical cancer) and by location (including messages on winter weather for subscribers in NE)</li></ul> Traveling 4 the holidays? Wash hands often & postpone travel if ill. Wait 24 hrs after fever is gone (w/o fever-reducing meds) to travel. <br />
    18. 18. Text Messaging Survey<br />Evaluation Dates: <br />March 30, 2010 – March 31, 2010<br />N=237<br />We need UR help! Pls take 5 mins to tell us what U think of our txt msgs & how 2 improve. To start, go to computer & type in: http://www.cdc.gov/mobilefeedback<br />
    19. 19. Mobile Texting Pilot<br />Overall Satisfaction (N=2,435)<br /><ul><li>How would you rate UR overall satisfaction with the text messages:  A) Very Satisfied, B) Satisfied, C) Dissatisfied, D) Very Dissatisfied
    20. 20. How can we improve?</li></ul>Help us improve our text messages! Please answer one question about UR satisfaction so we can improve our msgs & better meet UR needs. Reply FEEDBACK to begin.<br />87% Satisfied<br />Relevant<br />Actionable<br />
    21. 21. Overall Satisfaction<br />In your opinion, how effective are CDC's text messages in meeting your needs?<br />How would you rate your overall satisfaction with CDC's text messaging pilot? <br />There was a statistically significant difference in satisfaction by role. <br />
    22. 22. Health Behavior Change<br />How likely are you to use any of the information in text messages to improve your health?<br />How likely are you to recommend CDC's text messaging pilot to a friend?<br />
    23. 23. 91%<br />said the messages were easy to understand<br />
    24. 24. 91%<br />said the messages were easy to understand<br />90%<br />said the messages were credible<br />
    25. 25. 91%<br />said the messages were easy to understand<br />90%<br />said the messages were credible<br />89%<br />said the messages were friendly<br />
    26. 26. 91%<br />said the messages were easy to understand<br />90%<br />said the messages were credible<br />89%<br />said the messages were friendly<br />70%<br />said the messages provided helpful information to improve my health<br />
    27. 27. 87%<br />of respondents would like the opportunity to tailor the messages <br />by signing up for topics they are interested in<br />Key Findings<br /><ul><li>71% of respondents are satisfied or very satisfied with the text messages
    28. 28. 91% said the messages were easy to understand, 90% said they were credible, 89% said they were friendly, and 70% said they provided helpful information to improve my health
    29. 29. 62% of respondents said that they had used the information in the text messages to improve their health</li></li></ul><li>Improvements<br />Target/Tailor Messages<br />Stop Abbreviations<br />Key Findings<br /><ul><li>71% of respondents are satisfied or very satisfied with the text messages
    30. 30. 91% said the messages were easy to understand, 90% said they were credible, 89% said they were friendly, and 70% said they provided helpful information to improve my health
    31. 31. 62% of respondents said that they had used the information in the text messages to improve their health</li></li></ul><li> Targeting Messages<br />Example Message for 50+<br />CDC: Achy joints? Arthritis affects 1 in 5 adults. Decrease pain by staying active, 30 min-5 days/wk. See your doctor if you have symptoms. CDC 800-232-4636  <br />Example Topic Lists for Women 18-45<br />CDC: Are you pregnant? Have a new baby? Reply PREGNANT for tips on staying healthy while pregnant. Reply BABY for tips on keeping UR baby safe. CDC 800-232-4636<br />
    32. 32. Stopping Abbreviations<br />What do you think about getting information to improve your health through text messages?<br />“Stop using the number 2 instead of the word to.”<br />“I know that it is 'text speak' to abbreviate messages like your to UR, but since I am older than some texters (27) - text abbreviated words look ridiculous and teenager-like to me which makes me less inclined to pay attention.”<br />“I hate the usage of texting shortcuts like "UR" for your, etc. I know UR trying to appeal to a young, hip audience, but to me it's a real turnoff.”<br />“I was put off by the fact that the messages were written in txt: "We need UR help! Pls take 5 mins to tell us what U think of our txt msgs & how 2 improve." I get that you're speaking to a specific audience, but coming across like a 14-year-old does a lot to undermine your authority.”<br />
    33. 33. Adding Interactivity<br />Interactivity<br />When was UR last pap test? Most cervical cancer can be prevented w/ regular pap tests & follow-up. Need free/low-cost tests? Reply PAP <br />Response: <br />If you are low income or without health insurance, you may be able to get a free or low-cost Pap test. To find out if you qualify, call 800-232-4636. <br />
    34. 34. Frequency of Messages<br />How often would you like to receive messages?<br />67% have no preference for when the messages arrive!<br />
    35. 35. CDC Mobile Resources<br />Mobile Activities at CDC http://www.cdc.gov/mobile/<br />Mobile Health Coalitionhttp://www.cdc.gov/mobilehealth/<br />eHealth Data Briefshttp://www.cdc.gov/HealthMarketing/ehm/databriefs/<br />Mobile Metricshttp://www.cdc.gov/metrics/socialmedia/mobile.html<br />
    36. 36. Social Media Resources<br />Social Media at CDC: http://www.cdc.gov/SocialMedia/<br />
    37. 37. Thank You!<br />Ann Aikin<br />Social Media Strategist<br />aaikin@cdc.gov<br />@bujulicious<br />Connect with CDC!<br />@CDCgov, CDC_eHealth, @CDCemergency…<br />www.facebook.com/CDCwww.youtube.com/CDCstreaminghealth...<br />

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