1. Laryessa Worthington, MS RD
Lessons Learned from Incorporating a Text Message Based Program into Elementary Schools
Laryessa Worthington, MS RD
Nicole Finkbeiner, PhD
SNEB Webinar – January 2016
Good afternoon, thank you Lauren, and I appreciate the opportunity to share our work today. Today Nicole and I are excited to share with you information on the Text2BHealthy program including the Background and some of the research related to mobile technology,
Our example Text2BHealthy program and evaluation design with most recent data and then finally
Share a few best practices for outreach and delivery along with some brief evaluation findings

2. Promising Findings Increase in health knowledge
Sexual health (Lim et al, 2011)
Cervical cancer screening (Lee et al., 2014)
Increase in positive health behaviors
Child immunization (Stockwell et al., 2012; Brown et al., 2014)
Smoking cessation rates (Free et al., 2011; Rodgers et al., 2005; Whittaker et al., 2012)
Physical activity (Lau et al., 2011)
Adherence to appointment schedules (Koshy et al., 2008; da Costa, 2010)
Some program results have produced negative or inconclusive findings (Cocosila et al., 2009; Schwerdtfeger et al., 2012) `
Unfortunately there is not a large body of research around using text messaging for community nutrition education programs, however, there are numerous studies that show the positive impacts mobile technology programs can have in increasing knowledge for certain health screenings, immunizations, smoking cessation, and appointment adherence.
Few studies show negative or inconclusive findings.

3. Who Texts? U.S. adults Lower income audiences (Pew, 2015)
90% own a cell phone (Pew, 2015)
64% have a smartphone
81% send/receive text messages
Lower income audiences (Pew, 2015)
13% of those who make <$30,000 are smartphone-dependent
Racial and ethnic minorities (Pew, 2014)
90% of Black and 92% of Latino persons use cell phones
Text messaging is the most widely-used smartphone feature among users
If we look at the US population as a whole, it is estimated that about 90% of Americans own a cell phone, and almost 2/3 own a smart phone up from 35% in 2011.
Texting is a particularly common form of communication for low-income individuals, and it is more widely used among these populations than apps.
Pew research data indicates that lower income audience are most smart-phone dependent than higher income audiences. 13% of those who make <$30,000 are smart-phone dependent compared to just 1% of Americans from households earning more than $75,000 per year.
Compared with smartphone owners who are less reliant on their mobile devices, these smartphone-dependent users are less likely to own some other type of computing device.
97% of smartphone users involved in the Pew study used text messaging at least once during the study time frame and reported having used text messaging in the past hour in an average of seven survey out of a maximum total of 14 across a one week period.
So you can see, mobile phones are a viable way to reach racial and ethnic minorities, as well as parents.

4. Benefits of Text Messages
Access to a diverse audience (DHHS, 2013)
Hard-to-reach populations
Relatively low cost to researchers and participants (Fjeldsoe et al., 2009)
Easily and quickly sent to a large audience
Perceived as personal and informal (Gold et al., 2010)
Easy to incorporate into everyday life
Remote (for researchers)
Instant & in context (for participants)
Reduce participant burden (Marshall et al., 2013)
Real-time, interactive evaluation
Mobile technology offers some unique advantages. Some of the benefits of text messages include:
-Ability to reach broad audience, including hard-to-reach populations
-It is a relatively low cost burden to both researchers and participants
Costs are largely associated with payment for the web-based texting platform, which is generally a flat fee for a given number of messages/month and participants either receive messages for free through cell phone plans or they can pay up to $0.20 / text if they do not have a text message plan
Text messages are perceived as personal and informal and therefore less intrusive
Text messages are easy to incorporate into everyday life – to reach people where they are – and reduce the burden on the participant accessing programs in structured face-to-face settings
Lastly, these programs offer the benefit of real-time, interactive evaluation
Programs can be structured with one-way messaging, sending information, or two way messaging, sending information to and receiving information from participants

5. How Has Texting Been Used in Health Promotion?
Improve attendance in health care settings (Downer et al., 2006; Geraghty et al., 2008; Koshy et al., 2008; Leong et al., 2008)
Educational/informational- targeted or general
Reminders
Develop and track goals (Ahlers-Schmidt, 2010)
Measure real-time behavior, check-ins
Feedback/advice
Text messaging has been used in a variety of ways in health promotion. For example,
Many MD and dental offices are using text messages as appointment reminders increases the likelihood people will attend appointments
Many low-income individuals have cell phones and utilized text messages. This demographic is also typically ‘hard-to-reach’ to disseminate health information to, enroll in programming.
Remind participants about an upcoming lesson in a series, deliver them information about the time/location
Can use to obtain evaluation data that’s in ‘real-time’. For example, send a text on Tuesday reminding them about the local farmers market on Saturday morning. Then, Saturday morning, text and ask “Did you make it to the farmers’ market”?

6. I apologize for the blurriness of this photo
I apologize for the blurriness of this photo. Many of you will recognize this image from the SNAP-Ed guidance as the Social Ecological Framework and encompassing nutrition and physical activity into multiple layers of programming to reach a wider audience.

7. In Maryland, we have take the SEM model and incorporated our programming to determine what additional ways that we can reach a larger audience. For example, a large amount of the time our educators are working with youth in schools, headstart/preschool centers, and after school programs. By incorporating parent nights, texting, sending newsletters home, we can also add additional “layers” to our SEM model. We can further expand our reach by offering parent classes, cooking matters in the store tours, and training teachers on integrating nutrition into their classroom to reach even more students.
Additionally, Text2BHealthy provides an additional layer to reach parents in the programming that is already taking place in the schools. We have found that nutrition education in the classroom as been very effective with increasing preferences of fruits and vegetables among the students, but how could we extend that reach into the home? This is the premise behind the Text2BHealthy program – by extending that reach and keeping them informed of what is going on in the classroom and encouraging these behaviors at home.

8. Targeted Messages Elementary schools can help us to know about….
Retail
Recreation
Libraries
Weather
School schedules, testing, events
Lunch menus
Local events
…..without even knowing your name!
Text2BHealthy is a school-based text message program. Text2BHealthy was developed with the intent to provide timely, relevant and actionable messages. Messages are targeted based on each individual school location.
So, instead of getting individual parent information to use for the foundation of the targeted messages, by knowing where a child goes to school, remarkably, we know quite a bit of information about that families’ environment:
-local grocery stores or farmers markets
-places for recreation or physical activity (ie parks)
-What the weather is like
-School events, lunch menus
All of which contribute to making messages targeted and relevant to the participant

9. These are some examples of text messages that we have sent previously to parents. Our text messages include:
-- at the top left -- providing parents with physical activity ideas relevant to the time of year
-- Letting parents know about the local farmers market, what is in season
-- community events that are free or low in cost to take their children too
-- letting parents know what is going on in the school – like school lunch week and providing specific examples of what is on the school lunch menu

10. Program Recruitment Backpack flyers Posters Incentives
Events (paper, tablet enrollment)
Pre/Post Survey-Recruitment Link
Text2BHealthy Website
School channels to promote
Newsletters, robocalls, parent nights, etc.
When we first began, we did not anticipate enrollment to be an issue. Our plans consisted of utilizing a self-enrollment method where parents would “Text [keyword] to 30644”. Posters, flyers, and small incentives all used this self-enrollment method.
We also tried a few in-person events (PTA meetings, Family Fun Nights) where we were able to tell parents about the program and asked for their phone number to manually enroll them into the program. We had a Text2BHealthy enrollment app donated, as you see circled in purple. This helped us to minimize errors in transcribing phone numbers for sign ups. You can imagine what it is like attending a Back to School night with hundreds of people and how organization and penmanship could be an issue! We also collected phone numbers on our pre-test surveys, and through a Text2BHealthy website. Both also examples of manual enrollment, where we collected phone numbers to opt people into the program on our end.
Other indirect methods used to promote the program include school newsletters, robocalls, and other in person forums for announcements.
Green – self-enrollment method
Purple – manual enrollment method

11. Enrollment Barriers
26% of non-participants reported not knowing how to enroll or unsuccessful attempts to enroll
Concern about cost of texting
Apprehensive about program content
Disabled short codes
Knowledge of how to send a message to someone not in address book
Enrollment of non-targeted individuals
*Consider Drop-Outs
-There are a few considerations when thinking about enrollment. Program awareness was a huge barrier. We tried many methods to get the word out about the program and encourage parents to enroll. Again, this is a hard to reach population, as indicated by a substantial % of parents who at the end of the school year had never heard of Text2BHealthy. Year after year we had to focus on exploring new ways to reach parents for enrollment.
-There was some concern of the charges associated with the program. Honestly, most parents had an unlimited plan, and those that did not, we were able to offer an option where folks receive the same messages on the same day as the text.
-We found that there was some apprehension with the content. This was of particular concern for parents being notified through an indirect method such as a poster or flyer. They really seem to enjoy the opportunity to ask questions for clarification on what would be texted.
-Some parents had phone with disabled short codes – so they couldn’t text the 5-digit – it needed to be a 10 digit number.
-A portion struggled with sending an opt-in message to a number that is not in their contacts.
-Something not directly related to the act of enrolling, something to consider, people enrolled who were outside of our target population. For example, community partners, teachers, and other staff members all enrolled. Something to think about when designing your evaluation.
-Also, it is important to consider your dropouts. For our program, we were required to remind participants about how to opt out of the program. There was major concern that participants who did not have an unlimited text message plan (though we marketed specifically to this group) would opt into the program and end up receiving charges. So, once a month we sent a message reminding how to opt out if they needed to. We found that a wave of individuals would opt out every time we sent these messages. So, we developed a system to follow up with each dropout to ensure that they truly wanted to drop from the program, and we found that many were confused or accidentally dropped out and chose to re-enroll.

12. Text2BHealthy Program and Participants
Reaches parents of elementary school children
2 community-specific text messages per week
Participants
Retained
Schools
Counties Y1
203
14%
91% 8
4+Baltimore City Y2
1149
25%
90% 15
6+Baltimore City Y3
2473
33% 21
8+Baltimore City Y4
2341
35%
92% 17
5+Baltimore City
Ok, let’s shift right into our example Text2BHealthy program. Text2BHealthy was developed as an effort to reach “hard to reach” parent population at schools where children are receiving FSNE’s nutrition education programs. The idea is to keep parents engaged with what their child is learning while also providing the resources to reinforce the positive behaviors children are learning about in school in the home.
The program is available as a state-wide effort, however, school selection is based on the breadth of FSNE programming and collaborator interest/quality of collaboration
One interesting piece you’ll notice is the drastic increase in program participants from Y1 to Y4, which is partially due to the increase in participating schools, but also due to our adjustments for lessons learned with recruitment and retention.
Now, I’m going to turn the presentation over to Nicole and she is going to discuss our evaluation and the most recent findings from our school year data.

13. Text2BHealthy Evaluation
Years 1-3:
School-wide pre then post survey
Texted questions
Focus groups
Non-intervention/control schools
Year 4:
Participant self-selected and incentivized pre then post surveys and texted questions
Maximum of $75 gift card to local grocery store
I’d like to take a few minutes to give a brief overview of our evaluation strategy. In the first 3 years, we conducted
-Pre then post surveys sent home in the backpacks of every child
-evaluation messages via text specifically regarding behaviors we encouraged in recent previous text messages
-conducted focus groups before during and after program implementation
-Just to recap Text2BHealthy is a program that complements youth programming at schools. So, we actually ended up collecting data from 3 pools of individuals: Participants enrolled in Text2Bhealthy, parents who chose not to enroll in Text2Bhealthy but whose children could be receiving in school nutrition education, and “control” schools who offer youth education but no Text2Bhealthy.
Last year, we tried something new, and we gave all Text2Bhealthy participants the option to also enroll in the evaluation portion of the program. We incentivized parents who chose to enroll to complete pre, post, and texted evaluation questions. We did not survey the entire school, and we did not survey non-participants at the school. We did mimic the evaluation set up with a “control” population of schools who offered youth nutrition education only (with no Text2BHealthy).
This year, we’ve expanded the evaluation strategy beyond just Text2BHealthy program evaluation to a larger parent evaluation to more effectively assess PSE programming and impacts.

14. Healthy Families Survey
Pre-then-post tool (September and May)
Mailed/online surveys
Eating behaviors, physical activity behaviors, food availability/ accessibility, role modeling
Goal was to assess or evaluate the things we were actually texting about (farmers’ market visits, screen time, etc.)

15. Text2BHealthy Evaluation Group
N=364 intervention parents randomly selected into evaluation group
171 returned pre-tests (49.7%)
142 returned post-tests (83.4%)
142 total matched pairs
N=10 parents enrolled from control schools
9 matched pairs
* Data insufficient for inclusion in data analysis

16. Text2BHealthy Outcomes: Program Feedback
69% of participants felt the information in texts applied to their lives most or all of the time.

17. Text2BHealthy Outcomes: Children’s Eating Behaviors
37% of children increased frequency of eating more than one type of vegetable a day.
30% of children decreased frequency of soda/sugar-sweetened beverage consumption.

20. Text2BHealthy Outcomes: Parental Role Modeling

21. Text2BHealthy Outcomes: Children’s Physical Activity

22. Text2BHealthy Outcomes: Children’s Sedentary Behavior
35% of children decreased the number of hours of TV watched per day.

23. Text2BHealthy Outcomes: Food Accessibility/Availability
Availability of fruits and vegetables
87% of parents reported keeping fruit ready for their children to eat most or every day.
79% of parents reported keeping vegetables ready for their children to eat most or every day.
Parents’ shopping practices
33% of parents decreased frequency of buying chips, candy, or cookies.
20% of parents increased frequency of buying fruits.

24. Evaluation Texts

25. Contingency Question – With Reminder
Reminder text:
Evaluation question:
Sent to 326
163 responses; 50% response rate
Follow-up question:
Sent to 160 “Yes” responses
152 responses; 95.0% response rate
Text2BHealthy checking in again! We will be texting you a question in about 10 minutes. We want to hear from you!
Last week, we texted about sharing family meals, even during the holiday season. Did you sit down & eat a meal with your child this past week? Reply YES or NO.
That's great! How many days did your family eat a meal together? A. 1-2 days, B.3-4 days, C. 5-6 days, D. Everyday 

26. No incentives, no reminders Incentives without reminders
Incentives and
reminders

27. Recommendations for Implementation
Seek substantial buy-in from partners
Can help reach audience, promote and incentivize enrollment, and connect program to other activities
In-person enrollment is critical!
Offer to collect mobile phone numbers and manage enrollment for parents; have alternatives
Focus group test materials, messages
Widespread use of cell phones (smart phones, in particular) and text messaging
Suggestions for appropriate messages (no textisms, personalized)
Preferences for timing of messages
We faced challenges with recruitment, conducting the evaluation, were challenged by the limited existing research there is about implementing a text-message based program
In light of these challenges, we can provide many tips for implementation for anyone interested in pursuing a text-message based education, intervention, or retention program
Key Recommendations:
Seek substantial buy in from partners – these are your champions and they can help you
Help reach audience
Promote enrollment
Connect program to other activities happening at the location, community
Promote in person enrollment opportunities
Attend face-to-face events, talk directly with potential participants to inform them about the program, encourage them to enroll on the spot with your assistance
Offer to collect phone numbers and process enrollment instead of asking people to text into program
We learned a wealth of information through focus groups. Consider testing your materials and messages through focus groups to gauge if the target audience thinks it is relevant, worthwhile. You can also be informed of audience preferences in text message content, delivery, and timing (one piece of information that we learned through focus grouping is that by and large our parents did not like the use of textisms – which is using abbreviations like the letter u for the word y-o-u or the number 4 instead of the word for)

28. Final Notes Targeted and incentivized evaluation strategies work!
Think about sending “prompt” texts if wanting responses back
Be flexible – be open to modifying your processes and ALWAYS learn from previous experiences!
-- We have found that parents are more willing complete surveys and respond to evaluation text when there is an incentive attached.
-- Consider providing a prompt prior to a message going out if you are wanting a response back to ensure parents will be ready when the message comes through.
-- Lastly, be flexible and alter your strategies based on lessons learned each year. With Text2BHealthy we have learned so much and have continued to improve the program to best serve our participants.

29. Acknowledgements
Maryland FSNE: Erin Braunscheidel Duru, Sally Ann Kamen, Lisa Lachenmayr, Amy Bortnick, Ying Yip, Michelle Wilson
UMD SPH: Stephanie Grutzmacher, BreAnna Davis, Kat Downes, Greg Loeb, Andrea Lystrup, Lauren Messina, Kaitlyn Moberly, Ash Munger, Deirdre Quinn, Kate Richard, Kate Speirs, Yassaman Vafai, Lindsey Zemeir
Participating FSNE educators, schools, and families
This project could not have been done without the tremendous efforts of our FSNE and School of Public Health Team along with Local FSNE Nutrition Educators, School Collaborators and of course our participating families.
This project was funded by USDA's Supplemental Nutrition Assistance Program in cooperation with the Maryland Department of Human Resources and the University of Maryland.