RU Healthy? Public Health Efforts Take on Text Messaging: Campaigns Adapting to New Technology

Kim Krisberg


Nations Health. 2009;39(2) 

With a few quick thumb swipes, San Francisco youth literally have health information at their fingertips. They can receive the information anywhere, anytime without having to log into a computer, make a phone call or pick up a pamphlet. For Bay area youth, getting the "411" on sexual health is as easy as hitting "send" on their cell phones.

Thanks to today's texting trend, the youth are getting answers from SexInfo, a public health text messaging service that was launched in 2006. The service received 4,500 sexual health inquiries in just its first 25 weeks of service, with broken condoms, pregnancy and sexually transmitted diseases topping the subject list. The effort came after local health officials spotted rising rates of gonorrhea and chlamydia among black teens in one of the city's low-income neighborhoods, according to Deb Levine, MA, executive director and founder of Internet Sexuality Information Services Inc., which developed SexInfo in partnership with the San Francisco Department of Public Health. While the initial idea was to create a new Web site, both Levine and colleague Jacqueline McCright, MPH, a community-based STD services manager at the public health department, decided it was time to think outside the box. While visiting high schools for inspiration, the new idea walked right in front of their faces: After the school bell rang, students filed out with cell phones in hand. But they weren't talking -- they were typing.

"That's when we knew we were on to something," Levine told The Nation's Health.

While San Francisco's health workers could be considered pioneers in text messaging, public health has been taking advantage of mobile communication devices to improve surveillance and the delivery of health interventions for some time, said Jay Bernhardt, PhD, MPH, director of the National Center for Health Marketing at the Centers for Disease Control and Prevention. But because text messaging is "multidirectional" -- in other words, because users can send and receive information in real time -- it can be a "real game-changer in public health both domestically and especially globally," said Bernhardt, who added that CDC took a "big step" last year when it co-sponsored the first Texting4Health conference at Stanford University. Mobile communication platforms, he said, are "the next wave of public health communication and surveillance."

While new communication technologies offer great opportunities for public health, Bernhardt noted, lack of access to tools such as the Internet can be a significant barrier, particularly on the global front. Cell phones, however, are the first interactive communication devices cutting across economic, educational and social divides, he said. In turn, text messaging can be used on a number of health fronts, from delivering information to managing chronic diseases to treatment adherence.

"Today, effective public health requires us to provide our information and interventions to our communities where, when and how they need them," Bernhardt told The Nation's Health. "Our communities are using social media and mobile technology as an important part of their lives and if we want to reach them and help them, then we need to communicate with them the way they communicate with each other."

In San Francisco, Levine, McCright and colleagues knew young people were texting each other, but were unsure if youth wanted to receive text messages from their local health department. Fortunately, in focus groups of young black men and women, participants liked the text messaging idea. However, they were insistent that they be the ones initiating the process, Levine said. The resulting SexInfo service allows youth -- or anyone interested -- to text the word "SexInfo" to a five-digit number to receive a message back with codes telling them to text, for example, "B2 if u think ur pregnant," "D4 to find out about HIV" or "F8 if ur not sure u want to have sex." Participants are then texted back basic health information or referrals for in-person visits. According to a SexInfo study published in the March 2008 issue of APHA's American Journal of Public Health, 2,500 of the first 4,500 text inquiries led to access to more information and referrals for testing and screening.

"Things are changing rapidly and we have to do things differently to reach different people," McCright told The Nation's Health. "We can't keep doing the same old things and expecting different results. We have to be creative."

Of course, SexInfo's success depends on smart marketing and continually checking in with young people about cell phone trends, Levine said. To spread the word about SexInfo, health workers passed out cards, put up posters, bought billboards, created public service announcements and ran ads on local television and radio shows, according to McCright. The same aggressive marketing is working for the Kaiser Family Foundation's "KnowIt" text messaging campaign, which allows users to find HIV testing sites in their area. First promoted with the help of an ongoing partnership with MTV in the summer of 2007, the service received 15,000 text requests in its first month alone and more than 200,000 text inquiries in 2008, according to Tina Hoff, vice president and director of the foundation's entertainment-media partnerships. To use the service, cell phone users send a text message with their ZIP codes to KnowIt and within seconds, receive back a text message with information on nearby HIV testing sites. The service relies on a CDC database of HIV testing sites organized by ZIP codes, and in turn, CDC uses the texting service for its own HIV outreach as well, Hoff said.

"Clearly, it's a format for communicating that (young people) are comfortable with," Hoff said. "One of the nice things about new media technologies is that they're really very accessible and not exceedingly costly to implement. But for a campaign like ours to work, it's incumbent to have effective promotion strategies. The resource is only as good as the promotions you can do."

Getting the word out is the focus for Lauren Weber, a community health educator with Arizona's Mohave Department of Public Health, whose insights led to the launch of the department's Stop Smoking Over Mobile Phone, or STOMP, program in fall 2008. The youngest member of the department's Tobacco Use Prevention Program, the 23-year-old joined the team in 2007 and began visiting schools to teach students about tobacco use. Weber said she noticed that there was no educational component for students caught on campus with tobacco. When searching online for a tobacco intervention method that would appeal to students, Weber hit upon the company Healthphone Solutions and its text messaging smoking cessation service. Now, Mohave County is the first to use the Healthphone product in the United States.

Today, Mohave County students caught with tobacco can avoid suspension from school by signing up for the smoking text service. The 26-week program creates a personalized smoking cessation service based on a participant's demographics and quit date. The text messaging service guides users through the preparations for quitting, sends encouraging messages on the quit date, and begins sending multiple texts per day after the quit date. The program is open to anyone interested and about 40 people have taken part so far, said Weber, noting that some participants couple the text messaging program with traditional in-person cessation classes.

"I know I'd rather text than talk," Weber told The Nation's Health. "What better way to reach people than to get them on the phones that they're already using."

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