The Promise of Mobile: Connecting to Underserved Populations

April 6, 2014
For a growing number of healthcare organizations, mHealth is being used to engage, serve, educate, and improve the health of socioeconomically disadvantaged patients. Whether it’s simply by texting people tidbits of information or monitoring how much medication a patient is taking, providers are finding meaningful ways to connect to the underserved.

If it hasn’t arrived already, the era of mobile health (mHealth) is certainly on the way.

Like a garden in the early days of spring, the market for mHealth apps, devices, and platforms is ripe with potential and possibilities. In many cases, patients are monitoring their health through smartphone apps and wearable health monitoring devices. In other instances, providers are using mobile technology to better connect with various populations of patients (see related story on page 8).

The possibilities seem limitless, and the market research backs the idea of this promise. The global market for mHealth is valued at $2 billion, according to data from the London-based research firm, Vision Gain. By 2017, the market will balloon to $27 billion, predicts Research2Guidance, another research firm. Other estimates, such as the one from Transparency Market Research, have their predictions set at a more modest $10.2 billion by the year 2018.

For a growing number of healthcare organizations, mHealth is being used to engage, serve, educate, and improve the health of socioeconomically disadvantaged patients. Whether it’s simply by texting people tidbits of information or monitoring how much medication a patient is taking, providers are finding meaningful ways to connect to the underserved.


The Center for Connected Health, a non-profit division of the Boston-based Partners Healthcare health system, is driving non-traditional medical interventions, in many cases specifically aimed at changing behaviors in underserved populations. The way the Center for Connected Health’s founder and director, Joseph C. Kvedar, M.D., explains it, mobile is the perfect tool for changing behavior, because it’s there when you need it.

“Mobile can be a gatherer of information, it can be a display tool for information, and it can be a messaging tool. It’s even more dynamic in the underserved population because they have leapfrogged desktop technology and have essentially gone to mobile Internet as their primary source of engagement,” Dr. Kvedar says.

The Center, until recently, has primarily connected with underserved populations through text messaging. Kvedar says texting is a simpler, more ubiquitous form of communication than smartphone applications, especially for underserved populations, so while the organization is in the process of building an app for pain management, the method of engagement it employs is primarily text messaging.

The Center created text-messaging interventions for prenatal and addiction patients. Prenatal care, Kvedar says, provides an ideal opportunity for a text message intervention, because of the start and end date factor. Seventy-two percent of the women involved felt more connected with the obstetrics and gynecology (OB/GYN) doctor. The OB/GYN practice also documented better show rates to appointments. The data was similarly positive for the addiction patients, who felt more connected to their practice.


Similar to the Center’s texting intervention programs is a nationwide initiative piloted by three different Beacon communities called Txt4Health. The three communities, Crescent City (New Orleans), Southeast Michigan, and Greater Cincinnati, all have populations with a high tendency for diabetes and thus were specific targets, reveals Mike Samet, public information officer of Hamilton County Public Health and the man who operated the Greater Cincinnati’s version of Txt4Health.

Within the course of a 14-week program, Greater Cincinnati Beacon relayed targeted, detailed information on diabetes prevention to underserved communities. “It was a wide-open program in that anyone could participate, but we tried to concentrate on underserved communities because their propensity for diabetes is higher,” Samet explains. “Also, that population often finds itself outside of traditional healthcare opportunities. Plus, because it was free, it seemed ideal for that group.”

Participants fell into three buckets based on high, medium, and low risk factors. While the messages weren’t on a personal level, there were specific programs with a lot of positive reinforcements, follow-ups, and links to local resources. Greater Cincinnati Beacon sold the initiative as a “personal health coach in your pocket.”

Both the Center for Connected Health and Greater Cincinnati Beacon faced separate challenges in their texting campaigns. At the Center, getting clinicians to adopt and buy in was a barrier, according to Kvedar, who said they didn’t want to be held liable in case someone texted them in the middle of the night. At Greater Cincinnati Beacon, it was about getting the word out. Along with various marketing campaigns, the organization reached out to local healthcare stakeholders.

“We worked literally a ‘Who’s Who’ of the healthcare community in Cincinnati. That included some of the hospitals, the United Way, the YMCA has a deep diabetes intervention program, and we worked with the mental health board in the county. We threw the doors open,” Samet says.


From area to area, the health challenges of underserved populations differ. While communities in the Midwest and South may have a higher propensity for diabetes, as Samet says, the folks in Sacramento, Calif. are dealing with asthma, thanks to various environmental problems. In addition, the city’s burgeoning Latino population faces language barriers.

Dignity Health, a 42-hospital, multi-state health system based in the city of Sacramento, decided to team up with the California Healthcare Foundation and tackle this problem by monitoring asthmatic patients on a daily basis through the use of a sensor on an inhaler and mobile app from startup app developer, Asthmapolis, Madison, Wis. Through it, physicians are able to determine how much medication patients are using, when they’re using it, and when they might be having an asthma attack.

For the region’s Latino population, the app was made available in Spanish as well, says Rich Roth, vice president of innovation at Dignity. More than being available in multiple languages though, Roth says it worked for them because it was simple.

“There are a lot of things out there that require you to do a lot of stuff, which you not might be able to do because you are trying to live a normal life. You don’t go online and do banking 50 hours a week. You do it on a transactional basis. That is the lesson for mobile health. With Asthmapolis, you use the inhaler as you normally would,” says Roth. “The direction we’re going to see over time is that if you make it simple, mobility has such tremendous opportunity to improve care.”

In terms of connecting with a population that doesn’t speak English, a comparable solution was cooked up by the Columbia Valley Community Health (CVCH). Dealing with a monolingual, Spanish-speaking patient population that primarily lives below the poverty line, CVCH’s leaders invested in a smartphone app from WellFX, a Petaluma, Calif.-based developer. The app provides diabetes patients with interactive resources such as educational videos, digitized support groups where they can communicate with others that share the same disease, and text message-based reminders.


If there is a recurring lesson in the way providers are attempting to connect with underserved patients through mobile devices, it’s essentially the question CVCH’s medical director, Malcolm Butler, M.D., asked when he first came up with the idea that would lead to his organization’s own intervention efforts.

“There’s no way I can communicate everything that needs to be said on the management of diabetes in the course of 15 to 20 minutes a year. But what if every morning, while they’re waiting for the bus, they get on their phone, go to [an app], and see a post from Dr. Butler on how their diabetes works?” Butler recalls asking before the app was created.

Fitting mHealth interventions into the everyday lives of patients is the unique opportunity and challenge inherent in engaging underserved populations. In the Txt4Health program, Hamilton County Public Health’s Mike Samet says the organization had to figure out the right amount of text messages to send before it became a nuisance for people. “One of the drawbacks to the program was that there was a high dropout rate,” he notes.

As providers, advocacy groups, and other stakeholders look to empower socioeconomically disadvantaged patients through the use of mHealth, while improving the quality of care in those areas, healthcare leaders are finding that they must first work to understand the population. Only then, they say, can they begin to change behaviors.

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