Mobile health (mHealth) is gaining widespread attention for its potential to engage patients in their health and health care in their daily lives. Emerging evidence suggests that mHealth interventions can be used effectively to support behavior change, but numerous challenges remain when implementing these programs at the community level. This paper provides an overview of considerations when implementing community-based mHealth initiatives, based on the experiences of three Beacon Communities across the United States that have launched text messaging (short message service, SMS) pilot programs aimed at diabetes risk reduction and disease management. The paper addresses lessons learned and suggests strategies to overcome challenges related to developing text message content, conducting marketing and outreach, enrolling participants, engaging providers, evaluating program effectiveness, and sustaining and scaling the programs.

BackgroundThere are an estimated 25.8 million American children and adults, equivalent to 8.3% of the US population, living with diabetes. Diabetes is particularly burdensome on minority populations. The use of mobile technologies for reaching broad populations is a promising approach, given its wide footprint and ability to deliver inexpensive personalized messages, to increase awareness of type 2 diabetes and promote behavior changes targeting risk factors associated with type 2 diabetes. As a part of the Beacon Community Cooperative Agreement Program, txt4health, a public-facing mobile health information service, was launched in 3 Beacon Communities: the Southeast Michigan Beacon Community in Detroit, MI, the Greater Cincinnati Beacon Community in Cincinnati, OH, and the Crescent City Beacon Community in New Orleans, LA. Txt4health is a mobile health information service designed to help people understand their risk for type 2 diabetes and become more informed about the steps they can take to lead healthy lives.ObjectiveThe purpose of this investigation was to use the RE-AIM framework to document txt4health reach and adoption by focusing on enrollment and participant engagement in program pilots in Southeast Michigan and Greater Cincinnati.MethodsWe conducted a retrospective records analysis of individual-level txt4health system data from participants in Southeast Michigan and Greater Cincinnati to determine participant usage of txt4health and engagement with the program.ResultsResults from the retrospective records analysis revealed that 5570 participants initiated the 2-step enrollment process via 1 of 3 enrollment strategies: text message, website, or directly with Beacon staff who signed participants up via the website. In total, 33.00% (1838/5570) of participants completed the 2-step enrollment process and were fully enrolled in the program. All participants (100.00%, 1620/1620) who enrolled via text message completed the entire 2-step enrollment process versus 5.52% (218/3950) of participants who enrolled via website or a Beacon staff member. Of those who fully enrolled, 71.00% (1305/1838) completed the diabetes risk assessment and 74.27% (1365/1838) set an initial weight loss goal. Overall, 39.06% (718/1838) of participants completed all 14 weeks of the program and 56.26% (1034/1838) dropped out before completing all 14 weeks, with the bulk of dropouts occurring in the first 4 weeks. Length of participation varied greatly, ranging from 0-48.7 weeks (median 8.6, mean 15.8, SD 15.8). Wide variability of participant engagement in regards to weekly weight and physical activity was documented.ConclusionsAlthough broadly focused public health text message interventions may have the potential to reach large populations and show high levels of engagement among some users, the level of individual engagement among participants varies widely, suggesting that this type of approach may not be appropriate for all.

BackgroundAlthough there is great enthusiasm in both the public and private sector for the further development and use of large-scale consumer-facing public health applications for mobile platforms, little is known about user experience and satisfaction with this type of approach. As a part of the Beacon Community Cooperative Agreement Program, txt4health, a public-facing, mobile phone-based health information service targeting type 2 diabetes, was launched in 3 Beacon Communities: the Southeast Michigan Beacon Community in Detroit, MI, the Greater Cincinnati Beacon Community in Cincinnati, OH, and the Crescent City Beacon Community in New Orleans, LA. This program was marketed via large public health campaigns and drew many users within the respective communities.ObjectiveThe purpose of this investigation was to use the RE-AIM framework to document txt4health efficacy by focusing on perceptions of satisfaction, usage, and behavior change among individuals who used txt4health in pilot studies in Southeast Michigan and Greater Cincinnati.MethodsWe conducted a multimodal user survey with txt4health users recruited via text message through the program to understand participant perceptions of program use and satisfaction, as well as self-reported perceptions of behavior change as a result of using txt4health.ResultsTxt4health users reported very high levels of program satisfaction, with 67.1% (108/161) reporting satisfaction scores of ≥8 on a 10-point scale, with 10 equivalent to most satisfied (mean 8.2, SD 1.6). All survey participants agreed/strongly agreed that the messages included in txt4health were clear and easy to understand (100.0%, 160/160), and most found txt4health made them knowledgeable about their risk for type 2 diabetes (88.1%, 140/159) and made them conscious of their diet and physical activity (88.8%, 142/160). Most participants reported that txt4health helped them to make behavior changes related to diet; after having completed txt4health, most agreed/strongly agreed that they are more likely to replace sugary drinks, such as juice or soda, with water (78.0%, 124/159), have a piece of fresh fruit instead of dessert (74.2%, 118/159), substitute a small salad for chips or fries when dining out (76.1%, 121/159), buy healthier foods when grocery shopping (79.7%, 126/158), and eat more grilled, baked, or broiled foods instead of fried (75.5%, 120/159).ConclusionsResults from this study suggest that participants in txt4health, a large-scale, public health–focused text message program targeting type 2 diabetes, have positive perceptions of the program and that participation has led to positive behavior change.

Purpose:Unprecedented efforts are underway across the United States to electronically capture and exchange health information to improve health care and population health, and reduce costs. This increased collection and sharing of electronic patient data raises several governance issues, including privacy, security, liability, and market competition. Those engaged in such efforts have had to develop data sharing agreements (DSAs) among entities involved in information exchange, many of whom are “nontraditional” health care entities and/or new partners. This paper shares lessons learned based on the experiences of six federally funded communities participating in the Beacon Community Cooperative Agreement Program, and offers guidance for navigating data governance issues and developing DSAs to facilitate community-wide health information exchange.Innovation:While all entities involved in electronic data sharing must address governance issues and create DSAs accordingly, until recently little formal guidance existed for doing so – particularly for community-based initiatives. Despite this lack of guidance, together the Beacon Communities’ experiences highlight promising strategies for navigating complex governance issues, which may be useful to other entities or communities initiating information exchange efforts to support delivery system transformation.Credibility:For the past three years, AcademyHealth has provided technical assistance to most of the 17 Beacon Communities, 6 of whom contributed to this collaborative writing effort. Though these communities varied widely in terms of their demographics, resources, and Beacon-driven priorities, common themes emerged as they described their approaches to data governance and DSA development.Conclusions:The 6 Beacon Communities confirmed that DSAs are necessary to satisfy legal and market-based concerns, and they identified several specific issues, many of which have been noted by others involved in network data sharing initiatives. More importantly, these communities identified several promising approaches to timely and effective DSA development, including: stakeholder engagement; identification and effective communication of value; adoption of a parsimonious approach; attention to market-based concerns; flexibility in adapting and expanding existing agreements and partnerships; and anticipation of required time and investment.

Whether the setting is urban, rural, or somewhere in between, engagement strategies for the underserved require a great deal of flexibility and sensitivity to the socioeconomic, cultural, and geographic conditions of the patient population. The following report details how three unique communities designed specific strategies to engage underserved populations in the management of their chronic conditions.