Video Abstract

Video Abstract

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BACKGROUND AND OBJECTIVES:

Latino children in immigrant families experience health care disparities. Text messaging interventions for this population may address disparities. The objective of this study was to evaluate the impact of a Spanish-language text messaging intervention on infant emergency department use and well care and vaccine adherence.

METHODS:

The Salud al Día intervention, an educational video and interactive text messages throughout the child’s first year of life, was evaluated via randomized controlled trial conducted in an urban, academic pediatric primary care practice from February 2016 to December 2017. Inclusion criteria were publicly insured singleton infant <2 months of age; parent age >18, with Spanish as the preferred health care language; and at least 1 household cellular phone. Primary outcomes were abstracted from the electronic medical record at age 15 months. Intention-to-treat analyses were used.

RESULTS:

A total of 157 parent-child dyads were randomly assigned to Salud al Día (n = 79) or control groups (n = 78). Among all participants, mean parent age was 29.3 years (SD: 6.2 years), mean years in the United States was 7.3 (SD: 5.3 years), and 87% of parents had limited or marginal health literacy. The incidence rate ratio for emergency department use for the control versus intervention group was 1.48 (95% confidence interval: 1.04–2.12). A greater proportion of intervention infants received 2 flu vaccine doses compared with controls (81% vs 67%; P = .04).

CONCLUSIONS:

This Spanish-language text messaging intervention reduced emergency department use and increased flu vaccine receipt among a population at high risk for health care disparities. Tailored text message interventions are a promising method for addressing disparities.

What’s Known on This Subject:

Compared with nonimmigrants, immigrant patient populations have benefitted less from advances in health care information technology. A comprehensive approach to addressing health care disparities may require specific focus on implementation and use of digital patient engagement tools among at-risk populations.

What This Study Adds:

A Spanish-language text messaging intervention for parents with limited health literacy and limited English proficiency decreased emergency department use and increased flu vaccination. With this study, we contribute to emerging literature on the utility of these interventions to address health care disparities.

Latinos are the largest US minority and comprise the majority of the 25 million people in the United States with limited English proficiency (LEP).1,2  Health care disparities among Latino children are partially attributable to family-level barriers to effective health care access and use, particularly among children with immigrant and/or LEP parents.313  Gaps in health care knowledge and skills that contribute to health care disparities among immigrant Latino populations include the following: (1) enrollment in and use of pediatric primary care and public benefit programs, (2) management of health care interactions and communicating with health care providers, and (3) management of routine childhood illnesses.3,9,1417  Language barriers and limited parent health literacy complicate efforts to close these gaps for Latino immigrant familes.18  Patient engagement interventions are often focused on addressing health care knowledge and skills gaps.1921  Culturally and linguistically appropriate patient engagement interventions tailored for low health literacy populations are needed, but development of sustainable, scalable interventions is a challenge.22 

The ability to reach larger populations at lower cost, with the potential for increased tailoring and interactivity, is an underlying premise of the development of text messaging interventions (TMIs) to support patients in managing their health and health care.23,24  TMIs have demonstrated efficacy in improving appointment adherence, increasing vaccination, and decreasing emergency department (ED) use among primary care populations and are increasing in pediatrics.2531  Immigrant and LEP patient populations have benefitted less from advances in health care information technology, such as TMIs or patient portals, than nonimmigrants because these interventions often target patients with high levels of health literacy and are often not available in non-English languages.32,33 

Salud al Día (Health Up-to-Date) is multimodal intervention including an educational video and interactive text messages. The intervention, developed in partnership with immigrant Latino families, was designed to support health care engagement and navigation by immigrant Latino parents of infants. We hypothesized that the support provided by the intervention would promote family connection with their child’s medical home and result in decreased ED use. The purpose of this study was to compare the effectiveness of Salud al Día with usual care on ED use and well care and vaccination adherence from birth to 15 months.

This 2-arm randomized controlled trial (RCT) was conducted at an urban, academic general pediatrics clinic in the United States that averages ∼13 000 visits annually. The clinic’s majority patient population is publicly insured Latino children with LEP immigrant parents. Parents or legal guardians (referred to as parents) of publicly insured, singleton US-born infants <2 months of age were eligible to participate. Additional inclusion criteria were as follows: minimum parent age of 18 years, self-identification as Latino or Latina, preferred health care language of Spanish, and 1 household cellular phone. Potentially eligible participants were identified via review of the clinic schedule for completed initial newborn visits, and families were sent a letter describing the study. Potential participants were then recruited either by follow-up phone call or during a subsequent newborn visit between February and October 2016 by a bilingual research assistant.

Eligible and interested parents participated in an informed consent process, in which the Spanish-language form was read aloud and understanding was ascertained, and then the participants completed an enrollment survey. Allocation to the intervention or usual care arm of the RCT was then unmasked to participants and research staff. Random assignment was performed by computer random number generation in blocks of 10, with a 1:1 allocation ratio. Clinic staff and providers were not aware of group assignment unless revealed by the participant, excepting a clinic nurse assigned to manage any e-mails to the clinic generated by the text message system. The Institutional Review Board at Johns Hopkins Medicine approved this study. The study is registered at ClinicalTrials.gov (identifier: NCT02647814).

The Salud al Día intervention, consisting of interactive text messages throughout the child’s first year of life and an educational video, was developed with the Latino Family Advisory Board (LFAB), the patient family advisory council for the clinic in which the RCT was conducted. LFAB members assisted with all portions of the intervention design, from grant proposal to implementation during regularly scheduled meetings. LFAB meetings were conducted in Spanish and were attended by a cohort of 12 to 15 members who were immigrant women from across Latin America. LFAB members primarily had US-born children insured through Medicaid and most had less than a high school education; demographics of members reflected that of the larger clinic population. The situated Information, Motivation, Behavioral Skills (sIMB) model, which has been used previously to understand and intervene on patient engagement, was used in the development of intervention content.34  Application of the model resulted in intervention components to increase parent information, motivation, and behaviors that promote health care engagement tailored to the distinct factors among LEP Latino families across personal, cultural, situational, and structural domains. Supplemental Table 4 displays application of the sIMB model. Bright Futures and the accompanying Family Voices guide were used to ensure consistency with anticipatory guidance and education recommended by the American Academy of Pediatrics.35,36 

Salud al Día text message interactive sequences included the following: appointment reminders, support for obtaining medicines, support for completing referrals, and illness care monitoring and education. Text messages used tailored “smart forms” to allow interactivity by delivering messages and automated responses via preprogrammed algorithms. Some response sets generated an e-mail to a clinic nurse to contact the participant to offer additional assistance. The intervention did not include an opportunity for participants to initiate text sequences. Three different types of push messages that did not prompt replies were also sent during the study: flu vaccine reminders, parent support program reminders, and public benefit program reminders. Text messages were personalized to the name and sex of the child, and message delivery was scheduled according to birth date and clinic appointment dates. Intervention participants began receiving text messages after random assignment. A timeline of delivered text messages are displayed in Figure 1, and sample text messages are displayed in Supplemental Figs 3 and 4. Messages were programmed and delivered via emocha, an open-source, secure, Health Insurance Portability and Accountability Act–compliant, and modifiable mHealth application.37 

FIGURE 1

Timeline of delivered text messages. Sample content from text messages is included as Supplemental Information. APT, appointment reminder text message; ICI, illlness care inquiry; ICM, illness care monitoring; MED, prescription medicine support; PUB, public benefit program reminder; REF, specialty care referral support; WCC, well-child care visit.

FIGURE 1

Timeline of delivered text messages. Sample content from text messages is included as Supplemental Information. APT, appointment reminder text message; ICI, illlness care inquiry; ICM, illness care monitoring; MED, prescription medicine support; PUB, public benefit program reminder; REF, specialty care referral support; WCC, well-child care visit.

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Parents viewed the educational video at the 2-month well-child visit, rather than at random assignment, because pairing viewing with the baseline survey and orientation to study text messages would have negatively affected clinic flow. LFAB members recommended that all initial study activities should be completed in clinic because they believed this would increase willingness to participate in the study. During the 2-month visit, interention participants were also enrolled in the health system patient portal. The educational video, a 9-minute Spanish-language animated video, was developed in response to LFAB concerns that immigrant parents did not receive effective orientation to pediatric primary care via written materials or during initial clinic visits. Video content included health care navigation topics prioritized by board members: clinic hours and support services (eg, after-hours telephone triage, social work), the public health insurance enrollment and renewal process, selecting a primary care provider and prioritizing seeing this provider at visits, taking an active role during medical visits, and managing infant illness. Video design and production were completed in partnership with a design fellow from the Maryland Institute College of Art and the LFAB.

In addition to the enrollment survey, participants completed a phone-administered midpoint survey (child age: 7–9 months) and an in-person follow-up survey (child age: 12–15 months). All participants received $30 for the enrollment and final surveys and $10 for the midpoint survey. Intervention participants also received $20 remuneration to provide support for cellular phone charges because participants’ personal phones were used for text messaging. All surveys were orally administered by bilingual research assistants. Survey responses were captured simultaneously with administration using a touchscreen tablet computer and Research Electronic Database Capture software.38,39  Clinical data were abstracted from the electronic medical record (EMR) for each child from birth to 15 months via standardized abstraction form.

Sociodemographic information obtained during baseline surveys included the following: parent age, educational attainment, country of origin, length of stay in the United States, income, birth history, family structure, and parental employment. English proficiency was assessed by using the US Census Bureau question, “How well do you speak English?”40  Parent health literacy was measured by using the Spanish-language version of the Newest Vital Sign.41  Parent health care engagement was evaluated by using the Parent-Patient Activation Measure (P-PAM).42  P-PAM responses generate a score ranging from 0 to 100; higher scores represent higher parent health care engagement. The Patient Health Questionnaire–8 (PHQ-8) was used to assess parent depressive symptoms.43  Infant health knowledge was assessed on the basis of intervention education topics, including (1) fever criteria, (2) public health insurance renewal, (3) right to interpretation during medical encounters, (4) obtaining an outside care report, and (5) availability of after-hours clinic resources. The infant health knowledge assessment consisted of 5 multiple choice or true or false questions, with 1 point awarded for each correct response. Parents were also asked about their cellular phone and plan type and child’s health status. The midpoint and follow-up surveys included questions assessing usability of and satisfaction with the interactive text messages.

ED use, up-to-date (UTD) immunizations, and well visits were assessed as primary outcomes and determined by using individual EMR data. ED encounters were available for any location in the health system, owing to a shared EMR. Children were designated as having UTD immunizations on the basis of the age-specific schedule used in the clinic that is derived from the Centers for Disease Control and Prevention Recommended Immunization Schedule.44  The American Academy of Pediatrics Bright Futures periodicity guidelines were used to determine age-specific criteria for number of well visits to be considered as UTD.35 

Secondary outcomes were parent experience of care rating via the follow-up survey and change in mean parent engagement and infant health knowledge between baseline and follow-up surveys. Parents were asked to report their experience of care by using selected questions from the Consumer Assessment of Healthcare Providers and Systems Clinician and Group 12-Month Survey.45  Parent satisfaction with the clinic and primary provider was assessed by using a scale of 0 (“not satisfied”) to 10 (“extremely satisfied”). Responses were dichotomized by using a top-box system of “10” versus other responses.46 

Process outcomes were as follows: receipt of 2 doses of the influenza vaccine, well visit no-shows, well visit cancellations, clinic visit provider continuity, number of sick care visits, specialty care referral completion, participant-generated telephone encounters, EMR patient portal (MyChart) status, Supplemental Nutrition Assistance Program (SNAP) or food stamp participation, and change in parent depression. Provider continuity was measured by using the Bice-Boxerman Continuity of Care Index based on well-child and sick clinic visits in the 15 months since birth.47,48 

The sample size for this study was estimated by using a nondirectional test to achieve 80% power and significance of α = .05. A sample size of 40 per group was determined sufficient to detect a difference of one ED visit per group. A priori increased enrollment was targeted to increase power to detect differences in secondary outcomes. Demographic and clinical characteristics of parent and child participants randomly assigned to the Salud al Día and usual care groups were summarized and compared by using Student t tests with unequal variances and χ2 or Fisher exact tests for continuous and categorical variables, respectively. In addition, for the count outcome of ED use, the total number of ED visits and infants per group was used to calculate an incidence rate (number of ED visits per infant). To compare the incidence rates between groups, we used an incidence rate ratio and corresponding 95% confidence intervals. Lastly, differences in mean parent engagement, infant health knowledge, and parent depression from baseline to follow-up were assessed within each group by using a paired t test. Analyses of primary outcomes were conducted per the intention-to-treat principle. Analyses of secondary and process outcomes that were not abstracted from the EMR included only those individuals with corresponding follow-up survey data. A 2-sided P value <.05 was considered statistically significant. All analyses were conducted using Stata 15.1 (StataCorp LP, College Station, TX).

A total of 157 parent-infant dyads participated in the study, with 79 randomly assigned to the intervention and 78 randomly assigned to usual care (Fig 2). Overall mean parent age was 29.3 years (SD: 6.2 years), and mean years in the United States was 7.3 years (SD: 5.3 years). Sixty-seven percent of parents had less than a high school education, and 87% of parents had limited or marginal health literacy. Participants were balanced in baseline characteristics (Table 1). Intervention participants received a mean of 45.0 (SD: 8.5) messages and sent a mean of 15.5 (SD: 6.7) messages. Five percent (n = 4) of intervention participants did not send any responses. Ninety-three percent of intervention participants rated text message sequences as very easy or easy to use, 96% strongly agreed or agreed that the messages made them feel more connected to the clinic, and 92% strongly agreed or agreed that the text messages made them feel able to do more for their child’s health. Free text comments on the program included positive comments on helpfulness in remembering appointments and in providing information about clinic and community services.

FIGURE 2

Study consort diagram. aAll participants allocated to the intervention received the intervention. The number of text messages received by each participant varied by the number of scheduled and completed well visits and participant responses to the interactive message sequences.

FIGURE 2

Study consort diagram. aAll participants allocated to the intervention received the intervention. The number of text messages received by each participant varied by the number of scheduled and completed well visits and participant responses to the interactive message sequences.

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TABLE 1

Parent and Child Baseline Characteristics

CharacteristicSalud al DíaUsual Care
n = 79n = 78
Mean maternal age, y (SD) 30.1 (6.1) 28.7 (6.3) 
Maternal education, n (%)   
 Eighth grade or less 27 (34) 37 (47) 
 Some high school 23 (29) 18 (23) 
 High school or greater 29 (37) 23 (29) 
Maternal country of origin, n (%)   
 Mexico 18 (23) 16 (21) 
 El Salvador 22 (28) 24 (31) 
 Honduras 22 (28) 25 (32) 
 Other Latin American countries 17 (22) 13 (17) 
Mean maternal length of stay in the United States, y (SD) 7.5 (5.1) 7.2 (5.5) 
Maternal LEP, n (%) 77 (97) 75 (96) 
Birth history, n (%)   
 Primigravida 19 (24) 25 (32) 
 Multigravida, first US-born child 14 (18) 21 (27) 
 Multigravida, previous US-born child or children 46 (58) 32 (41) 
Annual family income, n (%)   
 <$20 000 26 (33) 41 (53) 
 $20 000–$30 000 22 (28) 16 (21) 
 >$30 000 7 (9) 5 (6) 
 Did not report or unknown 24 (30) 16 (21) 
Family structure, n (%)   
 Single 14 (18) 18 (23) 
 Spouse or partner 65 (82) 60 (77) 
Maternal plans to work in the next 6 mo,an (%)   
 Yes 29 (37) 38 (49) 
 No 34 (43) 29 (37) 
 Unsure 16 (20) 11 (14) 
Spouse or partner employed,bn (%) 65 (100) 59 (98) 
Maternal health literacy, newest vital sign, n (%)   
 Limited health literacy, 0–1 36 (46) 40 (51) 
 Marginal health literacy, 2–3 31 (39) 29 (37) 
 Adequate health literacy, 4–6 12 (15) 9 (12) 
Mean parent health care engagement score,c P-PAM (SD) 69.22 (17.04) 69.20 (14.01) 
Mean infant health knowledge scored (SD) 2.95 (0.93) 2.85 (1.01) 
Maternal depression, PHQ-8, n (%)   
 No significant depressive symptoms, 0–4 49 (63) 57 (73) 
 Mild depressive symptoms, 5–9 22 (28) 17 (22) 
 Moderate or severe depressive symptoms, ≥10 7 (9) 4 (5) 
Parent-reported child health status, n (%)   
 Excellent, very good, or good 77 (97) 78 (100) 
 Fair or poor 2 (3) 0 (0) 
Current smartphone user, n (%) 72 (91) 72 (92) 
Primary user of cell phone, n (%) 75 (95) 77 (99) 
Cell phone plan, n (%)   
 Contract plan 55 (70) 52 (67) 
 Prepaid 24 (30) 26 (33) 
CharacteristicSalud al DíaUsual Care
n = 79n = 78
Mean maternal age, y (SD) 30.1 (6.1) 28.7 (6.3) 
Maternal education, n (%)   
 Eighth grade or less 27 (34) 37 (47) 
 Some high school 23 (29) 18 (23) 
 High school or greater 29 (37) 23 (29) 
Maternal country of origin, n (%)   
 Mexico 18 (23) 16 (21) 
 El Salvador 22 (28) 24 (31) 
 Honduras 22 (28) 25 (32) 
 Other Latin American countries 17 (22) 13 (17) 
Mean maternal length of stay in the United States, y (SD) 7.5 (5.1) 7.2 (5.5) 
Maternal LEP, n (%) 77 (97) 75 (96) 
Birth history, n (%)   
 Primigravida 19 (24) 25 (32) 
 Multigravida, first US-born child 14 (18) 21 (27) 
 Multigravida, previous US-born child or children 46 (58) 32 (41) 
Annual family income, n (%)   
 <$20 000 26 (33) 41 (53) 
 $20 000–$30 000 22 (28) 16 (21) 
 >$30 000 7 (9) 5 (6) 
 Did not report or unknown 24 (30) 16 (21) 
Family structure, n (%)   
 Single 14 (18) 18 (23) 
 Spouse or partner 65 (82) 60 (77) 
Maternal plans to work in the next 6 mo,an (%)   
 Yes 29 (37) 38 (49) 
 No 34 (43) 29 (37) 
 Unsure 16 (20) 11 (14) 
Spouse or partner employed,bn (%) 65 (100) 59 (98) 
Maternal health literacy, newest vital sign, n (%)   
 Limited health literacy, 0–1 36 (46) 40 (51) 
 Marginal health literacy, 2–3 31 (39) 29 (37) 
 Adequate health literacy, 4–6 12 (15) 9 (12) 
Mean parent health care engagement score,c P-PAM (SD) 69.22 (17.04) 69.20 (14.01) 
Mean infant health knowledge scored (SD) 2.95 (0.93) 2.85 (1.01) 
Maternal depression, PHQ-8, n (%)   
 No significant depressive symptoms, 0–4 49 (63) 57 (73) 
 Mild depressive symptoms, 5–9 22 (28) 17 (22) 
 Moderate or severe depressive symptoms, ≥10 7 (9) 4 (5) 
Parent-reported child health status, n (%)   
 Excellent, very good, or good 77 (97) 78 (100) 
 Fair or poor 2 (3) 0 (0) 
Current smartphone user, n (%) 72 (91) 72 (92) 
Primary user of cell phone, n (%) 75 (95) 77 (99) 
Cell phone plan, n (%)   
 Contract plan 55 (70) 52 (67) 
 Prepaid 24 (30) 26 (33) 
a

Current employment measure was not used because of maternal interview timing before 2 mo of age; nearly all mothers remained at home with their infant.

b

Further specification of hours worked per week or full-time versus part-time was not possible because work as a day laborer or short-term construction jobs were primary sources of spouse employment.

c

Parent health care engagement score ranges from 0 to 100; higher scores represent higher parentage of health care engagement.

d

Infant health knowledge score ranges from 0 to 5. Questions on the assessment were based on educational topics included in the intervention.

Among the primary outcomes for this study, there was a statistically significant difference between groups in ED use (Table 2). The mean number of ED visits in the intervention group was 1.23 (SD: 1.66), and mean ED visits for the control group was 1.82 (SD: 1.64) (P = .03). The incidence rate ratio for ED use for the control versus intervention group was 1.48 (95% confidence interval: 1.04–2.12). There were no differences in UTD immunizations or well visits between groups. Among secondary outcomes, both intervention and control participants had a statistically significant increase in parent engagement and infant health knowledge from baseline to follow-up, but the changes in these scores were not significantly different between groups (Table 2).

TABLE 2

Intervention Outcomes and Use

CharacteristicSalud al DíaUsual CareP
n = 79n = 78
Primary outcomes, intention-to-treat analysis    
 ED visits, mean (SD) 1.23 (1.66) 1.82 (1.64) .03a 
 ED use, n (%)    
  0 visits 33 (42) 17 (22) .03a 
  1 visit 19 (24) 23 (29) — 
  ≥2 visits 27 (34) 38 (49) — 
 Immunizations UTD, n (%)b 67 (85) 62 (79) .38 
 Well visits UTD, n (%) 60 (76) 53 (68) .26 
Secondary outcomes, based on follow-up survey n = 72 n = 63  
 Parent experience of care, top-box rating, n (%)    
  Clinic overall 59 (82) 50 (79) .71 
  Primary provider 58 (81) 46 (73) .30 
 Parent health care engagement score change, mean (SD) 10.88 (2.14) 8.53 (2.75) .50a 
 Infant health knowledge score change, mean (SD) 0.67 (0.15) 0.52 (0.15) .52a 
CharacteristicSalud al DíaUsual CareP
n = 79n = 78
Primary outcomes, intention-to-treat analysis    
 ED visits, mean (SD) 1.23 (1.66) 1.82 (1.64) .03a 
 ED use, n (%)    
  0 visits 33 (42) 17 (22) .03a 
  1 visit 19 (24) 23 (29) — 
  ≥2 visits 27 (34) 38 (49) — 
 Immunizations UTD, n (%)b 67 (85) 62 (79) .38 
 Well visits UTD, n (%) 60 (76) 53 (68) .26 
Secondary outcomes, based on follow-up survey n = 72 n = 63  
 Parent experience of care, top-box rating, n (%)    
  Clinic overall 59 (82) 50 (79) .71 
  Primary provider 58 (81) 46 (73) .30 
 Parent health care engagement score change, mean (SD) 10.88 (2.14) 8.53 (2.75) .50a 
 Infant health knowledge score change, mean (SD) 0.67 (0.15) 0.52 (0.15) .52a 

—, not applicable.

a

P value based on χ2 or Fisher exact tests for categorical variables; Student t tests were used to compare continuous outcomes and reflect difference in change in scores from baseline to follow-up between groups.

b

UTD immunizations through 12 mo well visit vaccines were determined on the basis of available data in the EMR and were not restricted to those immunizations administered at the clinic. Receipt of rotavirus vaccination was not used in this determination because of local factors that affected rotavirus vaccine availability during the study period.

Among the process outcomes (Table 3), a greater proportion of infants in the intervention group received 2 flu vaccine doses versus infants in the usual care group (81% vs 67%; P = .04). Well visit no-shows approached significance, with 34% of intervention group participants having 1 or more no-shows compared with 49% of usual care (P = .06). Although a minority of intervention group participants remained in active status for the patient portal, this was significantly greater than control group participants. Only 1 intervention group participant sent a patient portal message to the clinic, and no control participants sent a message.

TABLE 3

Intervention Education and Support Process Outcomes

Health Care TopicIntervention ComponentOutcomeaSalud al DíaUsual CarePb
Clinical care support      
 Flu vaccines Flu vaccine reminder text messages Received 2 flu shots 64 (81%) 52 (67%) .04 
 Promoting attendance at scheduled visits Clinic appointment reminder text messages that included an option to change or cancel well visit Well visit no-shows    
 0 52 (66%) 40 (51%) .06 
 ≥1 27 (34%) 38 (49%) — 
Well visit cancellations    
 0 29 (37%) 24 (31%) .37 
 1–2 37 (47%) 45 (58%) — 
 >2 13 (16%) 9 (12%) — 
 Having a primary care provider Clinic appointment reminder text message supplemental education (age 6 mo); video content on scheduling visits with the same provider Provider continuity of care index, mean (SD)c 0.66 (0.3) 0.66 (0.31) .97 
 Where to seek care for infant illness Text messages inquiring about the need for illness care with education or reinforcement of use of the clinic for sick care rather than the ED (ages 3, 7, and 11 mo); video content on managing infant illness Sick care visits    
 0 29 (37%) 28 (36%) .23 
 1–2 38 (48%) 30 (38%) — 
 >2 12 (15%) 20 (26%) — 
 Specialty care attendance Specialty care referral support text messages after clinical visit attendance Specialty care referral completion    
 Mean (SD) 67.4 (44.2) 72.2 (42.2) .69 
 Obtaining prescribed medicines Medicine referral support text messages after clinical visit attendance No feasible measure    
 Phone triage at clinic Illness care monitoring and education (ages 3, 7, and 11 mo); clinic appointment reminder text message supplemental education (age 9 mo); video content on how to contact clinic or phone triage Participant-generated telephone encounters 21 (27%) 20 (26%) .89 
 EHR patient portal use Clinic appointment reminder text message supplemental education (age 9 mo); video content on patient portal use; assisted enrollment in patient portal Patient portal status    
 Active 6 (8%) 0 (0%) .01 
 Inactive 73 (92%) 77 (100%) — 
Social determinant support      
 Food stamp program SNAP application reminder text message (age 5 mo) Reported current SNAP participation at follow-up    
 Yes 22 (31%) 25 (40%) .52 
 No 46 (64%) 37 (59%) — 
 Do not know 2 (3%) 1 (2%) — 
 Parenting support Text messages for parenting class, mental health support, and healthy lifestyle events (monthly recurring messages) Parent depression, PHQ-8, change, mean (SD) 0.68 (3.82) 0.70 (4.18) .97 
 Health insurance renewal Insurance renewal reminder text message (age 10 mo); video content on public health insurance processes No feasible measure    
Health Care TopicIntervention ComponentOutcomeaSalud al DíaUsual CarePb
Clinical care support      
 Flu vaccines Flu vaccine reminder text messages Received 2 flu shots 64 (81%) 52 (67%) .04 
 Promoting attendance at scheduled visits Clinic appointment reminder text messages that included an option to change or cancel well visit Well visit no-shows    
 0 52 (66%) 40 (51%) .06 
 ≥1 27 (34%) 38 (49%) — 
Well visit cancellations    
 0 29 (37%) 24 (31%) .37 
 1–2 37 (47%) 45 (58%) — 
 >2 13 (16%) 9 (12%) — 
 Having a primary care provider Clinic appointment reminder text message supplemental education (age 6 mo); video content on scheduling visits with the same provider Provider continuity of care index, mean (SD)c 0.66 (0.3) 0.66 (0.31) .97 
 Where to seek care for infant illness Text messages inquiring about the need for illness care with education or reinforcement of use of the clinic for sick care rather than the ED (ages 3, 7, and 11 mo); video content on managing infant illness Sick care visits    
 0 29 (37%) 28 (36%) .23 
 1–2 38 (48%) 30 (38%) — 
 >2 12 (15%) 20 (26%) — 
 Specialty care attendance Specialty care referral support text messages after clinical visit attendance Specialty care referral completion    
 Mean (SD) 67.4 (44.2) 72.2 (42.2) .69 
 Obtaining prescribed medicines Medicine referral support text messages after clinical visit attendance No feasible measure    
 Phone triage at clinic Illness care monitoring and education (ages 3, 7, and 11 mo); clinic appointment reminder text message supplemental education (age 9 mo); video content on how to contact clinic or phone triage Participant-generated telephone encounters 21 (27%) 20 (26%) .89 
 EHR patient portal use Clinic appointment reminder text message supplemental education (age 9 mo); video content on patient portal use; assisted enrollment in patient portal Patient portal status    
 Active 6 (8%) 0 (0%) .01 
 Inactive 73 (92%) 77 (100%) — 
Social determinant support      
 Food stamp program SNAP application reminder text message (age 5 mo) Reported current SNAP participation at follow-up    
 Yes 22 (31%) 25 (40%) .52 
 No 46 (64%) 37 (59%) — 
 Do not know 2 (3%) 1 (2%) — 
 Parenting support Text messages for parenting class, mental health support, and healthy lifestyle events (monthly recurring messages) Parent depression, PHQ-8, change, mean (SD) 0.68 (3.82) 0.70 (4.18) .97 
 Health insurance renewal Insurance renewal reminder text message (age 10 mo); video content on public health insurance processes No feasible measure    

—, not applicable.

a

Outcomes were based on data abstracted from participant EMR review or follow-up survey responses.

b

P values were based on χ2 or Fisher exact tests or Student t test with unequal variances for categorical and continuous outcomes, respectively.

c

Provider continuity measured using Bice-Boxerman Continuity of Care (COC) Index for sick and well visits in the 15 mo since birth. At least 3 visits are required to calculate the COC; children with <3 visits in the past year were excluded from the COC analysis.

In this RCT evaluating the Salud al Día intervention, we found significantly reduced infant ED use compared with control group participants. In addition, a greater proportion of infants in the intervention group received 2 doses of the flu vaccine compared with the control group. We did not, however, find a difference in well care or overall immunization adherence. Our results demonstrate that delivery of interactive text messages with preprogrammed algorithms was feasible and usable by immigrant Latino parents with low educational attainment and/or health literacy. Employing an established health behavior theory and involvement of immigrant Latino parents throughout the design and implementation of the study may have contributed to the intervention’s usability and feasibility. This study adds to the growing literature that TMIs can be used to improve health care outcomes among vulnerable populations.

Our finding of reduced ED use in the intervention arm is notable given the relatively high ED use among Latino parents with LEP.10,49  This intervention was also designed for parents with limited health literacy, which is common among Latino immigrant parents and has been associated with increased ED use.18,50,51  The mechanism by which the intervention decreased ED use is unclear, although it is likely multifactorial. The intervention was designed to provide information and motivation to increase parent health care engagement behaviors. On the basis of adult studies, we hypothesized that increased engagement would lead to improved health care outcomes.19,20,5256  We found, however, that parent engagement, as measured by the P-PAM, increased over the study period among parents in both groups, but there was no significant difference in the magnitude of change by group. We have demonstrated previously that Spanish-dominant immigrant Latino parents have lower engagement scores than English-dominant parents, a finding consistent with adult studies.57,58  Additional studies, however, have raised concerns about P-PAM measurement limitations for parent health care engagement.59,60  Intervention participants endorsed high levels of feeling connected to the clinic through intervention participation, which may indicate parent engagement not captured by the P-PAM.

Our findings of increased receipt of 2 doses of flu vaccine in the Salud al Día group is consistent with other TMIs employing flu vaccine reminders.27,28  In contrast to other studies of text message appointment reminders, we did not find a decreased no-show rate in the intervention group.26  The sample size may have been inadequate to detect a difference because the study was not powered for this outcome, but this measure approached significance. We also cannot exclude contamination of the control group because the health system where the study took place implemented text message appointment reminders during the study period. Enrollment in the health system reminders was elective and not advertised in Spanish. We were unable to link data to determine how many control group participants may have been enrolled, although overall enrollment of patients in the study clinic was low. Many health care systems are now employing some form for text message appointment reminders. In several reviews, authors have found variable effectiveness of these reminders in decreasing no-shows and considerable heterogeneity in text messaging programs.6164  The heterogeneity of TMIs and the common practice of focusing on one theme (eg, appointment or vaccine reminders or singular disease management) creates a fragmented menu of potentially effective TMIs. The current state of narrowly focused TMIs limits potential effectiveness of these interventions to promote improved access to or quality of pediatric primary care.

The impact of the Salud al Día intervention on some outcomes and the positive end-user assessments highlight the potential of more broadly focused TMIs to address the emerging digital divide in health care. Salud al Día allowed for families to request assistance with appointment rescheduling, medications, and referrals in a workflow that routed requests for assistance to clinic nursing staff. This workflow is not unlike a patient portal. Patients portals, however, do not seem to be an effective digital engagement tool for immigrant Latino families. In fact, patient portal use has been comparatively lower among low-income and racial- or ethnic-minority populations.6567  As part of Salud al Día, we promoted patient portal use. Intervention participants received education about the portal in the initial video, were enrolled by the research assistant in the portal, and received reinforcement education about the portal via text message. Only 1 patient portal message was sent by a participant, and few intervention participants remained in active status, despite intervention components and the availability of the patient portal in Spanish. These findings suggest that alternatives to patient portals, such as the interactive text messages we employed, should be considered to promote digital engagement across diverse patient populations.

This study is not without certain limitations. This study was conducted in a single clinic with tailored services to meet the particular sociocultural needs of Latino immigrant families. This may reduce generalizability but also may have biased our results toward the null. Additionally, we did not have access to full usage data that may have been available via claims data to determine ED use. Current trends in use at the clinic demonstrate that ED use outside of the health system for which we had data is low. Urgent care use, however, is common, and we were unable to assess this. Because urgent care use is generally less costly than ED use, the finding of decreased ED use remains notable.68  In the future, it will be critical to capture all usage in determining the impact and cost-effectiveness of TMIs. Next, we are unable to determine the independent effect of the 2 intervention components on outcomes. We believe that the primary impact on health care outcomes stemmed from the text messages, given the difference in exposure between 1 video and the text messages over a year, but cannot be certain. Finally, we cannot exclude selection bias in our sample and in determining outcomes assessed by the follow-up survey. The majority of approached patients did enroll in the study, but the most at-risk patients may be among those who did not. Similarly, our study retention rates were high, especially given the vulnerability of this sample, but it could be that the most vulnerable patients were not retained.

With this study, we contribute to the emerging literature on the utility of TMIs to address health care disparities. The Salud al Día intervention was based on existing health behavior theory and was designed in partnership with patients to ensure that the intervention met user needs and preferences and was applicable across the range of pediatric primary care patients. Whether increasingly available TMIs from commercial vendors will be able to meet the needs of vulnerable populations remains to be seen. Without a specific focus on vulnerable populations in the design and implementation of new health care information technology, the gap in digital health care engagement may widen, potentially increasing health care disparities for these populations.

We thank the members of the LFAB, without whom this project would not have been possible. Additionally, this project was partially supported by the Johns Hopkins School of Medicine Biostatistics, Epidemiology, and Data Management Core.

Dr DeCamp made a substantial contribution to the conceptualization and design of the study, data acquisition, and analysis and interpretation of the data and drafted the initial manuscript; Ms Godage made a substantial contribution to data acquisition and analysis and interpretation of data and drafted the initial manuscript; Ms Valenzuela Araujo made a substantial contribution to the conceptualization and design of the study and acquisition of data; Ms Quintanilla and Ms Rivera Rodriguez made substantial contributions to the acquisition of data; Mr Dominguez Cortez made a substantial contribution to the analysis and interpretation of data; Ms Wu and Dr Psoter made substantial contributions to the analysis and interpretation of data and drafted the initial manuscript; Dr Polk made a substantial contribution to the conceptualization and design of the study and the analysis and interpretation of data; and all authors revised the manuscript critically for important intellectual content, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

This trial has been registered at www.clinicaltrials.gov (identifier NCT02647814).

Data Sharing Statement: Deidentified individual participant data will not be made available.

Dr DeCamp’s current affiliation is the Adult and Child Consortium for Health Outcomes Research and Delivery Science, Department of Pediatrics, School of Medicine, University of Colorado and Children’s Hospital Colorado, Aurora, CO.

FUNDING: Supported by the Gordon and Betty Moore Foundation.

     
  • ED

    emergency department

  •  
  • EMR

    electronic medical record

  •  
  • LEP

    limited English proficiency

  •  
  • LFAB

    Latino Family Advisory Board

  •  
  • PHQ-8

    Patient Health Questionnaire–8

  •  
  • P-PAM

    Parent-Patient Activation Measure

  •  
  • RCT

    randomized controlled trial

  •  
  • sIMB

    situated Information

  •  
  • Motivation

    Behavioral Skills

  •  
  • SNAP

    Supplemental Nutrition Assistance Program

  •  
  • TMI

    text messaging intervention

  •  
  • UTD

    up-to-date

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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