Text Education

March 30, 2011
MDNG Primary Care, March 2011, Volume 13, Issue 2

We ask Katie Malbon, MD, about her program involving women texting questions about their birth control.

One physician took sex education into her own hands by launching a service that sends birth control reminders to teens and lets them text questions directly to physicians.

In January 2009, during her fellowship training at Mt. Sinai Medical Center in New York, Katie Malbon, MD, launched Text in the City (http://hcp.lv/ffNt0X), a pilot project in which teenagers attending Mount Sinai Adolescent Health Center (MSAHC), a free clinic serving the South Bronx and East Harlem areas, received birth control reminders and health education via text messages. Malbon teamed up with Rip Road—a mobile marketing agency—to create the service, which also allows teens to use text messaging to ask physicians confidential questions. The pilot was extended beyond its original six-month time frame and is still in use at MSAHC, where it has been well-received by patients. MDNG spoke with Malbon, now an assistant professor in adolescent medicine at Mt. Sinai, about what it took to launch the service, what she has learned so far, and her plans to expand it.

Tell us about how you developed the idea for Text in the City, and how the project came together.

I had been working at the clinic for about two weeks, and it was very obvious that teenagers were using their cell phones to text their friends. In the waiting room, when they’re in your office and you’re asking them questions, and even during a pelvic exam—they’re always texting.

But also, as we’ve seen at the clinic, teenagers are typically a very hard-to-reach population, so we try to do as much as we can in one visit. They might be coming in because they want to be screened for a sexually transmitted disease, but we’ll notice that their BMI is over 30, or they’ll tell us that they’re using drugs. We try to cover so much during a visit, and given that we have probably 40 walk-ins every day in addition to the scheduled patients, we don’t have a whole lot of time to get all the information across to them. I felt that I wasn’t getting through to the patients I was seeing. And just in terms of their development, we know that they don’t absorb things the same way as adults do.

I needed a research project as part of my fellowship, and I decided that I wanted to do something with text messaging and health education, so I reached out to some of the more vulnerable, high-risk patients and enabled them to send me questions via text messaging. The idea is that it would give them a closer connection to their health home. It wasn’t going to be a replacement for the clinic; it was going to be an adjunct to their care. I really felt strongly that this is what the kids needed.

Those who enrolled would receive birth control reminders and be able to text questions to a physician?

Right, and because the platform was there, it was a great opportunity to be able to push out health education as well—to send out once-a-week text messages [called healthbytes] with a bit of health education in them.

What type of response rate did you get?

Participation was high, pretty much from the beginning. Every month we were getting the same number of patients signing up.

Because this was initially set up as a research project, an evaluation was necessary. So at six months, I looked at the number of patients signed up, the number of questions being sent in, and the types of questions being sent in, and I sent out a patient satisfaction survey.

Although the response rate from the survey was low, which was as expected, the feedback was incredibly positive. Most of the patients had used the service more than six times; they were very satisfied with it, and they thought it was very easy to use. After six months, we had almost 300 unique users—either they signed up for birth control reminders, they signed up for reminders and sent in questions, or they might have just opted in to the healthbytes.

About 500 questions were sent in at six months, and after a year, it was about 1,000.

How is the content for the healthbytes generated?

I sat down with health educators and thought of topics that should be covered. I wanted it to be about not just sexual health, but also topics like obesity, substance use, relationship/dating violence, and bullying—a whole range of adolescent issues. We have a peer educator program at the center, so when they have a teaching session on a topic, they come up with healthbytes at the end of it that we send to the patients.

And the messages have to be customized to fit a 160-character limit because they are text messages.

What about the birth control reminders? How are they set up?

Patients have to sign up and indicate whether they want daily reminders for the pill, or weekly reminders for the patch. That’s the extent of it at the moment. I really want to be able to expand that so that they can include reminders for the NuvaRing, which is administered monthly, and the Depo-Provera shot, which is given once every three months.

And it’s all automated so the messages go out at 8:00 am.

It’s probably difficult to determine whether the program has been successful in help­ing teens to more effectively utilize birth control. But from what you have seen, is it working?

One of the real downsides is that evaluation is just so difficult. But I can tell you, anecdotally, that the kids in the clinic who are using it say that they really like it and that they find it useful. It’s quite telling, because the majority of the questions are about birth control use and initiation of a birth control method. To me, it seems that these kids have birth control, but they’re just not totally confident that they’re going to use it effectively. So they want some clarification. They might have questions like, “Will my birth control be effective immediately?” or “Will my birth control still be effective when I have my period?”

They’re actually quite simple questions, but clearly there’s a gap in the patient’s knowledge, which is actually quite frightening on our end. We think that we give them so much education and we hope that they come away with some understanding of how to use birth control, but clearly, they don’t.

Have you made changes to the program or modified the way you treat patients in the clinical setting based on questions and concerns that patients have voiced?

Yes, definitely. At our weekly provider meetings, I take examples of questions that are sent in and we discuss the questions and talk about ways in which we are counseling these kids and how we can do it better.

What we’re trying to do now is get patients started on birth control the day they come to the clinic. Previously, we would send them home with birth control and tell them to wait until their next period to start on it, but now, we really try not to do that.

It’s definitely improving the quality of our care.

What is the biggest challenge you’ve faced so far?

For me, the challenge is that it’s 24-7. So even if I’m on vacation, I’ll see that I have five questions to answer and I have to address them. And I’ve found that you can get into quite long exchanges. So if I can see that the patient is confused or constantly needs reassurance, I’ll suggest that they come back to the office and see a provider.

Are you planning to expand or improve the service?

My vision is to have it really incorporated into the system of the clinic. For example, quite often, kids will call the main number and ask to speak to a provider, but that’s very difficult because we’re all tied up with patients. I’d like to set it up so that when they call, they have the option of texting the question to the clinic.

I’d also like to make it so that when patients register, they receive information about the service. I would like to see it heavily advertised in the clinic and to have it be part of our clinical service—much more than it is now, and to have more human resources behind it.

I want to incorporate it into the training program of the fellows here so that part of their responsibility when they’re learning about adolescent medicine is to answer the questions. And I would also like to expand it and set up reminders for immunizations and appointments.