Significant barriers to healthcare access and utilization disproportionately obstruct receipt of appropriate healthcare among disadvantaged minorities and persons of lower socioeconomic status.9–12
Our data suggest that persons in these groups would be highly receptive to text message reminders. Cell phone ownership was found to extend across socioeconomic lines; even among persons surveyed who were homeless or marginally housed, nearly 40% (7 of 18) owned a cell phone. In the case of these individuals, text messages may reach a person when traditional mail delivery services cannot reach them. Further, receiving a text message does not impose the inconvenience of having to answer a telephone call, and the message is saved for later viewing.
Our data suggest that cell phones may be increasingly useful in reaching disadvantaged populations. A recent survey from the Center for Health Statistics reported that 22.9% of all adults surveyed during July–December 2009 resided in households in which the only telephone is a cell phone, a proportion that has been increasing dramatically over the past 5 years.8
Further, adults residing in these “cell phone only” households were more likely to report being uninsured, experiencing financial barriers to healthcare, and participating in deleterious behaviors such as binge drinking and smoking.13,14
The demographics of cell phone use are evolving rapidly; for example, in a 2007 study of 515 individuals with HIV, Whites, those with more education, and those who were employed were more likely to use cell phones.15
However, a 2008 study of primarily African-American women attending an urban sexually transmitted infection clinic reported very high rates of cell phone ownership (93%) and text messaging (79%).4
Our data confirm that the demographic reach of cell phones has expanded, and further we found that minority groups (African-Americans and Hispanics) surveyed were more amenable to receiving information from healthcare providers via text messaging than White patients.
There are some drawbacks to using text messaging for healthcare-related communication. A significant minority of respondents in our survey did not own cell phones. Further, use of text messaging requires adequate literacy, which may be a problem in some populations. For a healthcare provider to utilize this mode of communication, there is the expense of purchasing software and the logistical challenge of automating the reminders. Cost to the receiver is another issue; although each text message may only cost a few cents, many survey respondents listed cost of texting as one of their main reservations about receiving texts from healthcare providers. However, as the cost of text messaging is relatively low, a relatively small increase in appointment attendance due to text messaging would probably be cost-effective even if the provider paid for the cost of the message. We found less enthusiasm for frequent, daily reminders to take medications than for less-frequent appointment reminders. In addition, fewer people were amenable to the idea of receiving text messages for health education purposes than for reminders. This suggests that the frequency and content of text messages from healthcare providers is important; based on this survey, it appears that less-frequent, targeted reminders would be most acceptable. Overutilization of text messaging as a means of communication could lead to loss of effect; text messages could become like “spam” e-mails, deleted without reading. Fatigue with loss of text message efficacy may also occur over time, as demonstrated in a recent randomized trial of text messaging for diabetes management.16
However, persons with more complex medical conditions may accept more intensive texting interventions, as demonstrated by a recent study of a relatively intensive cell phone-based program for patients with cystic fibrosis17
and pilot studies of health-monitoring programs for blood pressure, blood glucose, and TB medication adherence.18,19
Designing systems that are easy to use and educating users as to the importance of the underlying health condition may also improve acceptance of more intensive texting interventions.20
It will be important to find a balance with this technology that provides adequate information without causing information overload.
Another interesting finding was that a number of persons who do not own cell phones had positive attitudes toward healthcare-related text message reminders. Inexpensive, disposable cell phones are now available with the ability to remotely add prepaid minutes. Given the positive attitudes observed here, one could envision programs in which inexpensive cell phones were given to targeted populations specifically for healthcare-related communication. The use of cell phones for medical purposes in vulnerable or hard-to-reach populations was effective in one study of homeless cocaine-addicted adults in a treatment program. Subjects were given cell phones to record information about craving and using cocaine, and 80% completed the full 2-week protocol. The cell phone self-reports in this study were also quite reliable; drug use reported via text messaging was in agreement with urine toxicology results 73% of the time.21
Our study has some important limitations. Individuals in waiting rooms were given the opportunity to complete a survey if they were so inclined; this was not a randomly generated sample. Because the population of survey respondents was self-selected, this may limit the ability to generalize these findings to a larger population. However, the findings of this survey suggest that using text messaging to enhance healthcare utilization and adherence may be an effective tool in traditionally underserved individuals such as those with HIV or TB infection. Further studies are needed to assess the effect of text message reminders and health-related educational texts on health outcomes.