Problem Addressed

• Increased risk of HIV for minority youth: HIV disproportionately affects African-American and Latino youth. African Americans make up only 14 percent of the U.S. population, but account for 52 percent of new HIV diagnoses and 55 percent of all HIV infections among those aged 13 to 24. Latinos make up 13 percent of the population, yet account for 17 percent of new HIV cases.¹ African-American and Latino youth are more likely to have sex at an earlier age and to have multiple partners, and less likely to use condoms.²
• Often through heterosexual sex: Although minority men are more likely to contract HIV through sex with other men, nearly one-fourth of African-American men and more than 10 percent of Latino men acquire the disease through heterosexual contact. Among minority women, heterosexual contact accounts for the overwhelming majority of cases (84 percent among Latinos and 87 percent among African Americans).¹
• Many obstacles to testing and prevention education: Although education and testing can help stem the spread of the disease and connect youth with effective treatment, the stigma associated with homosexuality and HIV often prevent minorities from seeking information, counseling, and testing. Poverty, immigration status, lack of health insurance, and limited access to health care also make getting accurate information and services more difficult.^3,4 Finally, prevention programs designed for white populations may not be culturally appropriate for—and hence effective in—minority populations.

Description of the Innovative Activity

• Low-cost marketing through community partners, social media: Youth learn about the text messaging service at local health fairs, churches, schools, and other community events sponsored by the program’s 52 community partners, which include testing sites, advocacy and educational groups, and churches. Program and partner staff distribute flyers and postcards describing the service and sponsor contests designed to encourage young people to use it. The program also uses a variety of free and low-cost advertising vehicles, such as the Web sites and social media sites of sponsoring organizations and affiliated programs (see the Context section for more information) and low-cost public service announcements (PSAs) posted on YouTube.
• Referrals to free local clinics: Anyone with a cell phone can get a list of nearby clinics offering free testing by texting "IL" and their zip code to an easy-to-remember number (36363). Those who text the word "CENTRO" and their zip code get the same information in Spanish. Although other services often list clinics based only on location, this service gives priority listing to free testing sites funded by the state of Illinois.
• Various text messaging services: The service offers several distinct activities, as outlined below:
  • Listings of free health events: Anyone with a cell phone can text the word “event” to 36363 to receive a list of health fairs and other free events sponsored by community partners and other health organizations in the area. Added just before the program's launch in 2010, this service has become the most popular feature.
  • Monthly educational tips via text message: Roughly once a month, registered users who have signed up for the text-message service receive a 160-character message with tips, news, or other information related to HIV. For example, on February 7, 2011, program staff sent out a message about Black HIV Awareness Day and urged people to get tested. Registered users also get periodic notifications about upcoming events, with the first 10 who RSVP being given a free gift card when they attend.
  • Interactive quizzes and contests: Youth can text "game" to 36363 to participate in interactive quizzes and games that promote awareness of HIV prevention and testing and invite participants to learn more. For example, a quiz might include the following true-false question—“You can get HIV from oral sex. Press 1 for True, Press 2 for False.” Users immediately find out if they got the answer correct. If they answered incorrectly, they receive feedback with accurate information. Program developers can also customize the quizzes for special events. Flyers encourage attendees to play a game, then they can come to the program booth to claim a prize if they get the answer right.
  • New medication reminder feature: Information provided in May 2012 indicates that the program now includes a new medication reminder feature, which allows individuals to sign up to receive free medication reminders on their cell phones by texting the word MED to 36363. To enable this feature, users provide their phone number, email address, mobile carrier, and select the frequency of reminders. This feature is particularly helpful for patients on HIV medications, as research shows that taking medications regularly not only helps to keep HIV-positive patients healthy, but also helps minimize the spread of the disease.
• Web widget expands access: The program recently released a Web widget (http://idph.riproad.com/widget.php) for local health departments and community-based organizations to place on their Web sites (updated May 2012). The widget provides the same information as the mobile (texting) feature, so visitors to these organizations' Web sites can use the widget to search for the nearest HIV/STD testing center, sign up to receive medication reminders and health alerts, and find free health events around the state.

References/Related Articles

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Results

• Enhanced access to testing: In the first year, 790 individuals used the service to locate nearby testing sites. At present, roughly 50 new users access this service each month. For confidentiality reasons, the program does not track how many of these users actually get tested. However, staff at testing sites report that patients do come in as a result of the service.
• Enhanced access to accurate health information: More than 1,000 individuals have learned about HIV prevention and other educational health events through the service. Many likely would not have known about these events in the absence of the service. In addition, more than 320 individuals have signed up to receive the regular text messages that provide accurate information on HIV prevention and healthy living.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps included the following:

• Investigating new media, mobile technology use among young minorities: Program developers conducted research to identify new outreach methods that would appeal to minority youth. They found that African-American and Latino youth tend to use cell phones—especially texting—more than white youth, thus making texting a logical vehicle to reach them.
• Adapting from other health-related texting services: Additional research revealed other health-related texting services that provide testing locations and educational alerts, including Kaiser Foundation’s Get Text-Ed service. Program developers contacted Rip Road, the company that supplied the platform for Kaiser, to see how it could be adapted to meet Illinois’ needs.
• Reorganizing database to highlight clinics offering free testing: To remove financial barriers to getting tested, program developers reorganized the Centers for Disease Control and Prevention (CDC) database of test sites so that state-funded clinics offering free testing could be listed first in the locator service.
• Initial pilot testing: In June 2009, program leaders conducted an initial pilot test of the system to gauge user interest and identify and address any potential problem areas. (For example, the system initially did not work with all cell phone providers. Rip Road was able to address this issue.) This testing also helped to determine the appropriate radius for the clinic search, as some users in urban areas received too many listings while others in less populated areas received too few. Program leaders announced the pilot test through flyers and a statewide press release that included a contest in which those using the service during the testing period were entered into a drawing for a $50 gift card. During this initial test, users could also forward the text message urging individuals to be tested to friends.
• Refining system, adding Spanish-language service: Although 384 people used the service during the 1-month pilot test, only 75 forwarded the testing message to friends. As a result, program leaders decided to discontinue that feature. After the pilot test, program developers decided to add the capability to provide testing site information in Spanish and also added the event listing service and various features to the text alerts.
• Program launch: Program developers timed the launch to coincide with National Testing and Counseling Day, which helped them take advantage of media attention. They also held a contest for youth to make their own PSA for the program.
• Initial and ongoing partnership building: The Brothers and Sisters United Against HIV/AIDS program has a cadre of peer educators who work in local communities. As part of their awareness building and educational efforts, they recruit and work on an ongoing basis with the various community partners, encouraging them to support and spread the word about the texting service.
  
  
  

Resources Used and Skills Needed

• Staff: The program took about 1 month to set up, with the program director and 2 interns devoting about 120 hours total to the project. The most time-consuming aspect of this process involved revamping the CDC database so that clinics offering free screening got priority placement in the list. Staff members from Rip Road worked with program staff to create the story board and message flow for the pilot program. Since the service became operational, it has not required a significant amount of staff time. Once a week, a staff member updates the events database and uploads it to the service. This person also develops the text alerts and posts them on social media sites (e.g., Facebook, Twitter) as well as the texting service. Currently, the program director devotes 10 to 20 percent of her time to the project. She spends about one-fourth to one-half of that time updating the mobile calendar and social media pages. For the rest of her time on this program, she researches new ways to improve and expand the system.
• Costs: The service costs about $36,000 a year to operate, although costs vary based on the number of features used. Text 2 Survive saves money by using an already existing code rather than one developed just for the program. (Annual costs could reach $100,000 with use of a unique code.) One-time costs included $400 for gift cards during the pilot testing period and $5,000 for custom-printed postcards and flyers handed out during health fairs and other community events.

Funding Sources

Tools and Other Resources

• Government sites, such as http://www.aids.gov/using-new-media/ and http://www.cdc.gov/socialmedia/index.html.
• The Kaiser Family Foundation. Available at http://www.kff.org/entmedia/index.cfm.
• Social media information Web sites such as Mashable available at http://mashable.com/.

Getting Started with This Innovation

• Research best practices in mobile technology, social marketing: As noted, researching mobile technology applications in health care helped program developers design an up-to-date service that accomplishes their health goals and appeals to the target audience. Keeping current with technological developments also helps keep the service fresh and interesting. (See the Other Resources and Tools section for good sources of information in this area.) Mobile health technology plays an increasingly important role in HIV prevention and other health efforts in Africa. Programs implemented there may have application in the U.S. market as well.
• Beware of regulations, problems related to incentives: Program developers originally planned to enter anyone who got tested during the pilot period in a drawing for a $200 gift card. However, they abandoned this plan due to confidentiality concerns and burdensome requirements related to coordination with testing sites. Program developers also decided not to use sweepstakes due to strict regulations related to such promotions offered via mobile technology.
• Choose easy-to-remember code: Although program developers do not recommend spending the extra money required for a unique program code, they do advise use of an easy-to-remember code if at all possible. During the pilot test, the number assigned to the program proved difficult to remember. For the official program, staff chose a much more memorable code.

Sustaining This Innovation

• Track service use and refine accordingly: Ongoing tracking of service usage allowed program staff to discover the popularity of the event listing service. As a result, they are now building up the event database and developing an interface so that community partners can add events on their own. After discovering that not many users sign up for the text alerts, staff began to limit the number of messages so that users do not feel bombarded and hence cancel the service.
• Use events and partners to build interest: Health fairs and other events provide an excellent opportunity to build excitement about the service. As noted, community partners can promote the service effectively to their patients and at local events.
• Take advantage of free advertising: As noted, the program uses many free and low-cost advertising vehicles, including social media and the Web sites of sponsoring organizations and community partners. The program also sponsored a contest that led to the development of low-cost PSAs.
• Consider expansion to other minorities: Based on the program's success in the African-American and Latino communities, the Center for Minority Health Services is now considering expanding it to other minorities, such as Native Americans.

Additional Considerations and Lessons