Mobile Health (mHealth) is a general term used for the use of mobile phones and other wireless technology in medical care. Common uses are:

• Health promotion and disease management promoting healthy behaviors
• Treatment compliance, such as appointment reminders
• Emergency response and disaster management
• Data collection
• Point-of-care support

The most successful form of mHealth communication is text messaging; however, it’s important to consider the language, age, and literacy of your target population. An ideal mHealth program will incorporate both SMS text and phone messaging seamlessly delivered according to the recipient’s language (calls to languages with a low written literacy) or by device type (calls to landlines, texts to cell phones). 

An in-depth study on mHealth was conducted by King County Public Health in Seattle, WA.
This study identified four different available options:

1. Use a fully hosted vendor solution.
2. Commercial Off-the-Shelf (COTS) solution. Your agency houses the physical infrastructure needed to support the COTS application.
3. Develop an in-house SMS application. You would contract with an aggregator (SMS Gateway) to transport messages to the carriers.
4. Develop your own application and operate as the SMS Gateway.

In summary, the King County study found that options 2 and 3 cost approximately 20% more than the first option and require available IT staff. Option 4 is not feasible, due to excessive cost (in excess of $4 million over five years).

Choosing an mHealth Vendor
Since a fully hosted vendor solution is the recommended option for an affordable mHealth program, you need to be careful when selecting a vendor.

The following is taken from 6 must-read tips on SMS Broadcasts and how to pick the right vendor for your business.

When it comes to choosing your SMS broadcast provider, don’t let the dollars drive the decision-making. Here, we share tips on what to look for to ensure your SMS messages are not only delivered, but deliver the results you want.

Cheaper providers might provide you with the means to deliver budget SMS communications, but unfortunately that’s where the good news ends. When it comes to SMS providers, the less you pay, the more you compromise on reliability, speed of delivery, customer support, and issue resolution times.

1. Reliability

Reliability is a top priority for SMS broadcasts, so the first factor you should consider when weighing providers is how reliable, scalable, and secure the platform is. Look for an uptime guarantee.

2. Message delivery

With any communications, you want your messages to get through with minimal hurdles and delays. So when you pay for an SMS delivery service, at the very least you should expect your messages to be delivered at the right time to the right people. However, the less you pay for your service, the less chance there is of this happening the way you want.

Look for a provider with direct connection to all US carriers, as this will provide faster delivery speeds. The better the provider, the higher the percentage of delivered messages will be.

3. Scalability

While you might start out only sending a couple of thousand messages per month, as you realize the success rate of SMS communications and as your business grows, your messaging needs will increase. Look for a provider whose platform handles large messaging volumes and can support your future requirements.

4. Support

An established provider will give you access to a responsive support team, preferably with round-the-clock support. This means you can expect any issues to be resolved quickly and properly, letting you focus on what you do best.

5. Account management

Going hand-in-hand with customer support is the provision of dedicated account management. When choosing your provider, look at the additional services they offer beyond just a platform, like expert advice and account management.

6. Industry expertise

If the provider ticks all the above boxes for your business, check if they have the industry experience and expertise you need. Some research will quickly tell you how many customers they have, how long they have been delivering Broadcast SMS in the industry, and the status of their reputation. This is just as valuable as the technical capabilities outlined above and will ensure you choose the right mobile messaging provider for your business.

Message Size and Phone Number for Display
Many agencies have a lot of information they wish to deliver to the text recipient, particularly when delivering important “what to bring” information to WIC recipients. The TCPA Declaratory Ruling of July 2015 clearly states the messages must be concise (for calls, generally one minute or less, and for texts, 160 characters or less). This makes it important to select a vendor with a lengthy history of working with WIC to draft text messages which fit the character limitations. Non-English texts, such as Spanish, use more words to deliver the same message and many languages use Non-Western characters, which use two spaces for every character.

Dynamic Caller ID is a desirable feature for your call deliveries but this is not allowed for broadcast SMS. Broadcast SMS from an Applications Provider to a person is called A2P. In the US, A2P messages are required to use a 5- or 6-digit Short Message Code versus the 10-digit Long Code.

Legality of Sending Text Messages
WIC is exempt from HIPAA, which means you are not required to collect written permissions before transferring PHI to a third party according to the HIPAA Omnibus ruling. The TCPA has also determined that calls and texts to cell phones from Public Health are not considered an “annoyance” and are not subject to written authorization. A method to opt-out of messaging is required. For most local and state agencies, this means you are legally allowed to deliver treatment compliance–related messaging, such as appointment reminders and nutritional outreach messaging to promote healthy behavior. As an added security layer, most choose to carefully script messages so they do not contain PHI, as nobody can ensure the security of the SMS message once delivered to the recipient.

State law will supersede the ruling if it is more restrictive. Some WIC agencies are part of entities subject to HIPAA. In these cases, you will need to work with a vendor who is capable of managing your state’s required method of authorization, i.e. written or electronic. If your agency is part of a HIPAA non-exempt entity, a Business Associate Agreement would then be required between your agency and the vendor. Written consent would be required if PHI will be transferred to the vendor. In all cases, the vendor needs to maintain a high level of security to protect the client data.

Security
Beware of vendors who simply state they are HIPAA Compliant. Compliance not only encompasses the physical security of the PHI transmitted to the vendor, but also the PHI included in the messages drafted by you as part of a covered entity. It is your responsibility to be collecting/documenting the proper written authorizations when required and to not send PHI through mHealth channels when not authorized. The vendor’s (Business Associate’s) responsibility involves the physical security of the PHI after transmission and a requirement to properly respond to a breach. “Guidelines for a Compliant Business Associate” states: “Under the regulation, a breach occurs only when PHI is unsecured. For this reason, CEs (Covered Entities) may consider requiring that the BA (Business Associate) employ technologies that render PHI unusable, unreadable, or indecipherable to unauthorized individuals that are consistent with guidance from the National Institute of Standards and Technology (NIST) and OCR.”

NIST Compliance Benefits
The initial benefit of NIST compliance is that it helps to ensure an organization’s infrastructure is secure. NIST also lays the foundational protocol for companies to follow when achieving compliance with specific regulations such as HIPAA or FISMA.

It is very beneficial to ensure your chosen vendor’s security is modeled after NIST standards. For more on what to look for in a vendor’s security, please see Data Security, HIPAA and Cloud-Based Automated Messaging.

One of the biggest challenges facing WIC is how to keep their clients after the child turns one. This year’s National WIC Association Conference in Los Angeles’ theme was Reach Them, Teach Them, Keep Them.

Tuesday’s most-attended session at the conference was the USDA-sponsored “Strategies for Increasing WIC Retention.” With data supporting a 60% decline rate from infants to 4-year-olds, this indeed is a significant topic and worthy of discussion in hopes of bringing fresh and bold ideas to the table.

To have any hope of finding a solution, we need to know why they drop out. Some advocates worry that needy mothers aren’t bothering to enroll in WIC or are dropping out because food stamps are easier to get and easier to use. Food stamps are now provided on an unobtrusive debit-like card, whereas states have until 2020 to provide WIC benefits that manner. In many states, WIC benefits are still given as vouchers.

WIC applicants also have different hurdles to clear before they can get their benefits. For example, they must be seen by a health professional such as a physician, nurse, or nutritionist who determines whether the individual is at nutrition risk. Sometimes the applicant must go to a WIC clinic for a free examination; in other cases, the information is obtained from the family’s own doctor.

The average American on food stamps today gets $134/person a month. The average monthly WIC amount is $47. Benefits for infants under WIC are better: typically $100 for the infant and $50 for the mother.

However, USDA data suggests a different reason for the high drop-out rates after a child turns one. An Investigation of Delayed Entry and Early Exit / ERR-109 Economic Research Service/USDA  reports the following types of households were more likely than others to exit WIC after their child turns one:

• Households with higher income.
• Households in which mothers are more educated and were employed after the child’s birth.
• Mothers who did not breastfeed and those who breastfed for less than 6 months.

Interestingly some of these groups overlap with delayed enrollment into WIC until after their child is born. The same USDA study shows that the following types of households were more likely than others to delay participating in WIC until after their child was born:

• Households with higher income and those with private insurance.
• Households in which the mother has a college degree and was employed the year before giving birth.
• Households in the Northeast and those in urban areas with a population of at least 50,000.

By contrast, Medicaid recipients were much less likely to delay WIC enrollment until after having a child and less likely to exit after their child turned one.

27.8% of moms report that they no longer needed the benefits once their child turned one. Approximately 33% believed they were no longer eligible to receive WIC benefits after their child turned one, even though roughly 90% of postnatal-infant participants retained eligibility after the child turned one. Not breastfeeding and a shorter duration of breastfeeding by the mother were associated with a greater chance that the household would leave WIC because the household no longer needed the benefits. The other two explanations for WIC exits indicated that the household was challenged by the effort required to participate in WIC. Living in the South or the Northeast was associated with a higher likelihood of exiting WIC, due to transportation issues/time to access the clinic. 26.2% report the benefits are not worth the time.

Results suggest that WIC’s provision of infant formula and participants’ breastfeeding decisions played a significant role in the early exit from the program. Households in which the mother breastfed for a longer time were less likely to exit WIC.

Based on the data collected, the primary target groups are:

• Participants with delayed enrollment until after their child is born.
• Non-breastfeeding participants.
• Participants not receiving Medicaid.

What can be done to address these groups so that they see the value in WIC beyond formula benefits?

Before the child turns one, it is important that the mom feels a sense of belonging to her WIC clinic. She needs to enjoy the value provided to her from WIC and to have formed a relationship prior to the child turning one.

Reach Them: First, ensure they make those appointments. There is very strong evidence to support that sending automated appointment reminders increases show rates, particularly if by text and personalized for her language and appointment. Look for a reminder program which can incorporate that important personalization by importing data from your software program. Also, look for one which will deliver messages seamlessly to cell phones by text and land lines by phone, ensuring you reach all active numbers. Remember, a text is opened and read within three minutes.

However, consider this: engaging WIC clients only four times throughout the year is not enough to foster a relationship with WIC. It is only one more to-do in her never-ending task list. When the financial benefit ends, it is all too easy to quit WIC. There needs to be more to help moms connect.

Before the child is one, it is important to create routine touchpoints, to actively and proactively engage moms on a regular basis. Use her favorite media methods to regularly communicate interesting and informative information.

Teach Them: This is a prime time for utilizing electronic technology to promote the benefits of breastfeeding and offer encouragement during tough times, such as back-to-work. Statistics show that moms who breastfeed longer tend to stay on WIC after their child turns one. Consider automated text nutrition education outreach programs, which use the data from your software to specially tailor messages to the child’s age and the current WIC status.

Maintain a good social media presence and let her know it exists. Millennials love opportunities to speak out and share information. It will help them foster a stronger connection towards their WIC clinic. For more information, check out Using Social Media and other Electronic Technologies to Connect with WIC Moms.

Hold special, fun events and be sure she is aware of them. Baby fairs, mommy-and-me lunches on a voucher pick-up day, brown bag recipe sharing in the park, holiday parties, and other fun, low-cost events are each a way for moms to connect further with WIC and have fun, compared to just coming for the appointment to check off another task.

Be sure they know about these events. Read the amazing story from Brenda Foreman, Columbus Co Georgia WIC Director, who promoted the local Farmer’s Market using her One Call Now/US Netcom WIC Communication Service.

“I have a clinic with 8,000 participants. Last week – July 10^th, 2015 – we were having a Farmer’s Market for this clinic. We had done quite a bit of advertising for the event – radio announcements, a newspaper article, and we put a reminder notice in each participant’s WIC folder. We started promptly at 8:00am and had a long line. By 9:00, we had printed checks for 250 clients and we had served everyone. We had allotted 600 checks for this clinic. I was hesitant to send a text message to 8,000 people, but I decided to go ahead and do it. So, I went to my One Call system, typed a short message reminding clients about the Farmer’s Market going on “Right Now,” and said there was NO LINE, NO WAIT. The message went out around 9:30am. In about 15 minutes, the waiting room was full and people were in line outside waiting to come in. They came that quickly. My staff asked me what happened. I whispered, ‘I sent a text message to all of our clients.’ By 3:00, we had issued checks to 685 people.”

Keep Them: Beyond routine engagement, social media, and fun events to help foster relationships before the child turns one, it also needs to be convenient for moms to access their WIC benefits. A couple of great studies from Maricopa County AZ WIC and MN WIC discuss overcoming barriers to WIC participation by offering walk-in clinics and changing clinic hours. State Agency Research for Increasing WIC Participation and Retaining Caseload.

A great study conducted by CT WIC piloted cross-collaboration with Head Start. The program showed increased WIC caseloads and identified lessons learned. A WIC staff quoted, “Regarding HS survey to families: We identified at least 20 families who were either never on WIC or had been terminated from failure to recertify/pick up checks. What a boost in caseload this will be over time!” https://s3.amazonaws.com/aws.upl/nwica.org/wic-hs-cross-collaboration-presentation-5-11-15-final.pdf

In summary, while there is no magic bullet to keep them coming after the child turns one, creative methods will definitely help. Remember to focus on your at-risk groups identified above, be creative, communicate routinely, keep them engaged, and have fun.

Happy New Year! As we enter 2015, many of us make New Year’s Resolutions, and the number one resolution centers around health: lose weight, exercise more, and eat healthier. We’re all feeling a little blah, considering holiday overindulgence. This issue will focus on how to help moms make healthy lifestyle choices – Warm Regards Jan 2015.

As health professionals, you know that fats and sugars make us feel tired, sluggish, and unmotivated. They create a cycle of cravings and often increase depression. When we’re able to break that vicious cycle by adding fruits, vegetables, whole grains, nuts, lean meats, and exercise into our lives, it does wonders for our health. We feel better, have more energy, and think clearer.

A secondary, but equally important, benefit is the impact healthy choices have on our children. Children are going to copy us. If we load up on chips and sodas, so will they. But when we encourage our families to eat healthy and stay active while under our roof, the odds are greatly increased they will continue these lifestyles into adulthood.

The goal of WIC is to improve the health of infants and children. WIC is a tremendous educational resource teaching moms how to properly take care of themselves while pregnant/nursing, and how to manage the health of their children. But as you know, these healthy choices need to become healthy lifestyles to truly affect change. If WIC can effectively create behavioral changes in moms, it will filter down to the children as they grow and continue with their own families.

First, let’s look at trends and habits of the Y Generation (aka Millennials), which comprise the majority of today’s WIC caseload and 1/3 of our nation’s adults.

In the past, the majority of homes planned meals before shopping, shopped for ingredients, and stocked pantries with familiar foods. We were more cooks than eaters. We ate together, and typically had three defined meals with snacks reserved for the afternoon. What we ate and how we ate was very predictable.Shopping trends have evolved where we are becoming a society of eaters versus cooks. Millennials, especially, are eaters. As eaters, we shop more spontaneously, do more fill-in shopping, and shop for new and unique foods. Fewer than half of all trips to the grocery store are pantry-stocking trips. We look at food more as an occasion driven by cravings, cost, and convenience. Millennials are anxious to try new foods and flavors, and are not particularly loyal to any brand. See full story.

Millennials are serial snackers and are said to spend a higher percentage of their total foodservice dollars on snacks than other generations. According to the trend watchers, The Kruse Co, 35% of meals eaten by Millennials aren’t really meals at all; they’re snacks. “Desserts are now eaten at any time, sometimes even before breakfast. Lunch and dinner are increasingly combined into ‘linner,’ and many consumers insist on breakfast for dinner, forcing restaurants to keep the breakfast grills fired all day to serve ‘brinner.’

A study published in the European Journal of Preventive Cardiology found that adults age 30 are so unhealthy, they are like their parents or grandparents were at age 45. They are more likely to suffer from high blood pressure and diabetes. They are 20% more likely to be obese, and women in their 20s are twice as likely to be obese. One-third of those ages 16 to 27 years old are overweight or obese.A highly computer-literate generation, Millennials are spending more time than ever on their laptops, smartphones, and video games. The shopping malls are deserted on the weekends; instead of walking around the shops, Millennials are at home or at Starbucks, glued to the internet.

What can be done to encourage WIC moms to shop smart, eat healthy, and get active? Spontaneous shopping and snacking isn’t likely to change, so the goal would be to encourage moms to think of new fun and flavorful healthy foods. Millennials want good taste and they want something to differentiate their experience from their friends.WIC can also help by providing nutrition education to moms where knowledge gaps exist, such as appropriate serving size and balancing daily caloric intake with physical activity. Show moms ways to incorporate physical activity with their family into their busy schedule. Ideas are to walk the dog with the children and exercise while watching TV. They can develop a set of activities that are always available regardless of the weather, such as stair climbing, rope skipping, dancing, and active games that you can play indoors. WIC can also help teach moms how to understand the “nutrition facts” panel, watch for unhealthy/unnatural ingredients, and deceptive labeling. Since over three quarters of all eating occasions by Millennials involve processed food, the ability to accurately look at a label to ascertain if it’s healthy for her family is vital.

The book Slim by Design by Brian Wansink PhD, Executive Director of the USDA Center for Nutrition Policy and Promotion 2007-2009, promotes the idea that small changes in the food environment will encourage healthier eating.What would Batman eat? When 22 students were given a choice of apples vs fries, all but 2 ordered the fries. However, when asked “What would Batman eat: apples or fries?” 10 children ordered apples. Studies showed it didn’t matter who you said: Batman, Joker, or the kid’s teacher, simply having to answer for anyone makes them think twice and nearly half of the children made the healthier choice.

Dividing the cart. When shoppers had or placed a dividing line in the middle of their cart and asked to put all fruits and vegetables in the front half and everything else in the back, they found shoppers bought 23% more fruits and vegetables than shoppers whose carts were not split in half.

The slim person’s kitchen. After studying slim people’s vs overweight people’s kitchens in Syracuse, NY, it was discovered that the average woman who kept a bag of chips on the counter weighed 8 pounds more, and those who kept one box of breakfast cereal visible weighed 21 pounds more than their neighbors who didn’t. When it’s “in sight, it’s in the stomach.” We eat what we see, not what we don’t. Dr. Wansink’s book suggests rearranging the pantry and refrigerator so that the first visible foods are the best for us.

Experts who study behavior change agree that long-lasting change is most likely achieved when it’s self-motivated and rooted in positive thinking. Studies have also shown that goals are easier to reach if they’re specific (“I’ll walk 20 minutes a day,” rather than “I’ll get more exercise”) and not too numerous (having too many goals limits the amount of attention and willpower you can devote to reaching any single goal).

Here are a few factors perceived as motivational for Millennials:

Effectively addressing the health challenges facing the Millennials will require an integrated approach across multiple sectors. In a generation where 8 out of 10 of its members sleep with their cell phones on or next to their bed, mobilizing social media tools to advance the health of young people (M-Health) will be critical. Increased study of this generation’s health trends and needs, as well as developing effective delivery mechanisms for health information, will be important for this age group.Studies have found that periodic prompts and reminders are an effective method to encourage and reinforce healthy behaviors. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3082846/. Therefore, increased communication, accountability, and reinforcement created by text messaging may increase the likelihood of remembering the changes that one should be making. Other features used to tailor messages to individuals included using a participant’s nickname.

Eight of the nine sufficiently powered studies found evidence to support the effectiveness of text messaging as a tool for behavior change in disease prevention and management.

Significant clinical outcomes observed included greater weight loss in obese adults at 4 and 12 months, and greater decrease in hemoglobin A1C levels in adolescents and obese and non-obese adult diabetics.

This evidence is consistent with existing literature suggesting that mobile phones are a useful tool for interventions seeking improvement in health outcomes. Specifically, it supports recent evidence that text messaging is a useful tool for behavior change interventions.

Dr. Thomas Brennan, who researches mobile health applications at the University of Oxford, believes text messaging is especially useful for chronic diseases. “Conditions like hypertension, diabetes, asthma, obesity, smoking – they all have to do with changing individual behavior over time. SMSes are probably the most useful way of engaging with [patients with these conditions].”From an operational standpoint, there is a very real risk of health text messages eventually being considered spam. Brennan believes this risk is greatest if the messages are not personalized. “If they’re just coming out of the cloud,” Brennan said, “I think they’ll have a limited impact.”

An interesting study was conducted by Seattle’s King County in 2010 at two mass vaccination clinic settings with 1,225 ethnically diverse attendees. This study is posted in the American Journal of Public Health: Text Messaging to Communicate with Public Health Audiences. http://www.medscape.com/viewarticle/781061_5

Researchers looked at PHI, electronic information, the Security/Privacy Rule, and the effectiveness of text messages sent to its participants. This study concluded, “Despite inherent risks, public health departments have a responsibility to use communication channels that will reach their communities effectively, particularly in instances in which there is a benefit to the public’s health. Texting is a powerful communication channel, in part because it can be customized. If all personally identifying information is removed, this may eliminate the greatest strength of text messaging.”

“In summary, we recommend that the federal government take steps now to clarify how health departments can reasonably use text messaging to send protected health information. Text messaging is a technology that reaches the vast majority of US adults and has the potential to be a powerful tool to improve health and wellbeing.”

A study on Marketing to Millennials states, “As consumers, we’re now expecting a more personalized experience. This is a result of our current experience on the web, where we spend the large majority of our time and where we’re seeing more prevalent contextual experiences of content and messages tailored to our behaviors and needs.

In summary, it will be easier for moms to make healthy lifestyle changes if they: 1) are educated in understanding labels and encouraged to think up creative healthy food options for their families; 2) have attainable goals to incorporate physical activity into their daily life; 3) make small changes in their food environment; and 4) receive positive, upbeat, and personalized mobile health text messages made to encourage self-motivation.