New research from Johns Hopkins University may help health systems determine which sort of communications technologies will be most effective at reaching some of their high-risk patients.

The study, published in the Journal of Internet Medical Research, examined whether low-income women who were either pregnant or in the post-partum period used Internet-based technologies, smartphones, or basic cell phones to communicate with their providers.

Cell phones stood out by far as the preferred technology that these women, regardless of race or ethnic background, use. The survey results also revealed important differences in the women’s Internet use — differences likely tied to their proficiency in English.

Also See: Texting Valuable for Engaging Low-Income Urban Patients

According to senior author Wendy Bennett, M.D., the study answered some questions about how this demographic used communications technology, and provided a launching pad for examining other issues such as what entities may benefit most from investing in such interventions.

"If you are going to a broad population-based health promotion effort or intervention to help behavior change, and if we deliver it with a one-size fits all approach, like everybody needs to go online or even use an app, then you're not going to be able to reach the most disadvantaged populations," said Bennett. "So we wanted to understand if we're going to pick and choose which digital technologies are most useful for this population, we wanted to understand the access issues they face."

The research team surveyed a cross section of women attending one of four obstetric or pediatric clinics at Johns Hopkins Medicine’s two Baltimore hospitals. Forty percent were African-American, 28 percent were Latina and 23 percent were white. Fewer than 10 percent were of other racial or ethnic groups.

Smartphone use was roughly one-third more common for African-American women than Latinas, the study showed. In general, Internet use by any means to find health information was lowest for Latinas, at 51 percent, with African-Americans at 79 percent and whites at 87 percent. Bennett said that limited English proficiency, highest in Latinas, is a likely barrier to wider use of the Internet by this group.

Texting was high across the board – 85 percent or higher in all groups – though slightly lower for African-Americans. One surprising drawback, Bennett said, was how frequently the study group changed cell phone numbers. More than one-quarter got a new number at least twice in the previous year; with so much churn of cell phones and numbers, even maintaining stable contact with that group could pose concerns unless phones are subsidized to some extent.

Bennett suggested return on investment of such programs could be calculated on both short-term bases, such as those surrounding pregnancy and post-partum care, and longer-term outcomes such as diabetes care and prevention. And, obviously, designing a business and cultural infrastructure around such engagement technologies must consider a wide range of community partners, including insurers and social service agencies.

"Community-based partnerships are very important," Bennett said. "For example, some of these interventions could be delivered through low-income day care centers, which could also provide in-person counseling that help with health behaviors – and in between they may get a text message from a supportive friend or coach that could help them stay motivated or adherent to a program. We need more research, really. I know nobody wants to hear that, but I think that's truly where we are.

"It gets back to the question of showing that you really are moving outcomes along. It is challenging because some of the outcomes we looked at are longer term. If you give somebody a cell phone today, will you prevent diabetes in 10 years?"

The wide variety of possible research vectors and outcomes metrics underscore Bennett's assertion more such research needs to be done prior to wide scale rollout, but she certainly sees potential for health systems and their partners to commit to creating such communications infrastructures.

"If it can be convincingly shown that the cost of a cell phone is so incredibly low compared to the number of hospitalizations such a program prevents, or that if you give them a cell phone you can prevent half of their ER visits, then you can make the case the cell phone is really worth it," she said.

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