Texting our way to health equity

How SMS can be used to bridge the digital divide in healthcare.

photo credit: clevelandclinic.org

The Covid-19 pandemic made us all take a closer look at digital health communications, and what we found were blaring inequalities. During the heart of the pandemic, and still today, the economic and educational elite tend to have computers, smart-phones, broadband, and internet, with access to vital mobile health services. While millions of disadvantaged, yet deserving humans couldn’t book appointments or access even the most basic health communications, the more affluent among us took advantage of subscription apps that granted those with the resources to pay, access to telehealth appointments and Covid-19 testing.

What we are talking about here is a major digital divide in America. It is between the “haves” when it comes to hardware, broadband, and digital literacy; and the “have nots.” While the consequences of this divide permeate throughout society, creating inequity in educational and civic arenas, the Covid-19 pandemic did an excellent job of highlighting how the divide is widening on digitized healthcare systems and creating barriers to health services for entire communities. In fact, according to a 2021 report by the FCC, 19 million Americans are still without broadband. That’s millions of Americans who may find it difficult, or nearly impossible to schedule broadband dependent vaccine and telehealth appointments. For 19 million people, this is both detrimental and demoralizing, especially in a crisis situation such as a global pandemic.

While we await the results of President Biden’s plan to deliver a $65 billion (down from $100 billion due to GOP opposition) to get broadband and high-speed internet access to more Americans, it is pragmatic to look for technologies that can bridge the widening digital health divide right now. The great news is that such technology is already literally in the hands of the people.

Short Messaging Services (SMS), better known as text messaging, is widely adopted and even preferred by underserved populations such as minority youth. This is because texting is accessible via cell phone, is typically free or very low cost based on service plans, and it doesn’t require broadband, a computer, or an expensive smartphone.

While smartphone adoption is on the rise in the U.S., with 85% of adults owning one, there are still 11% of U.S. adults relying solely on non-broadband devices that can’t run advanced mobile apps. In 2019, according to Pew Research, 76% of adults in advanced economies owned a smartphone, while only 45% of adults in emerging economies owned one. Thankfully, with SMS, living without a smartphone doesn’t have to mean living without vital digital health communications and services. What we need is health communicators to consider using SMS. Here are a few proven reasons why SMS health communications work:

1. SMS appointment reminders are highly effective: When SMS reminders for colonoscopy appointments were sent to an at-risk, minority population, a majority (72.7%) got a colonoscopy within three months.

2. SMS communications increase vaccination rates: At-risk pregnant mothers in New York City were 30% more likely to be vaccinated for influenza after receiving text message influenza awareness communications, as well as appointment reminders via SMS.

3. SMS platforms as health education tools are well received by marginalized populations: With input from at-risk youth in Peru, a research team developed a successful SMS platform that taught sex education to rural and hard-to-reach youth. Crafted in plain, adolescent friendly, language, the kids loved it.

It is important to note that SMS communications aren’t perfect, for example, there are some security concerns that need to be addressed, and it can be glitchy. However, this seems to be the case with many digital and telecommunications. The truth is, we’re still generally figuring privacy and security out. In the meantime, I do believe that the benefits currently outweigh the risk.

During the pandemic, Covid-19 vaccination appointments, meant for the Latinx community of Washington Heights, totally missed the mark, and went to more affluent, more digitally savvy, White New Yorkers who had traveled from outside of the community. In this case, obtaining vaccination eligibility required that one spoke English, was digitally savvy, and had access to a computer. If this effort had utilized SMS, in addition to other communication methods recommended for targeting Latinx communities, the efforts may have been more successful in reaching actual residents of Washington Heights, who had been disparately hit by the pandemic.

Even if you are otherwise connected, SMS just makes so much sense. For one, everyone is already using it, and so SMS interventions have high compatibility and ease of usage. For example, if you are a multi-tasking mom, like myself, than you know that there is something to be said about receiving a conveinient text about an appointment reminder or health update, without having to log into a website, or download and open an app.

I am looking forward to exciting developments in SMS that will make this old technology cutting edge. We can expect to see more intelligent SMS chatbots, and platforms that incorporate more personalizations, automations, and enhanced conversational capabilities. Leading to more effective and affordable health communications for everyone, whether they are broadband connected or not.

Imani Razat is on the health communications team at Roqo, a personal health and wellness chatbot. She’s a Master’s candidate of Communication at Johns Hopkins University.