The influenza pandemic of 1918-1919 killed more than 600,000 people in the United States alone and an estimated 20 million or more victims worldwide. Today, infectious diseases continue to pose a significant health security threat to nations throughout the world. Because of the increasing mobility of the global population, it is likely that newly emerging diseases will spread even faster than the pandemics experienced in the last century. Many smaller communities have difficulty preparing for emergencies. Nonetheless, effective preparedness remains an essential tool for reducing the spread of disease.
In the United States, as federal funding decreases, local health departments are pressed to do more with less. According to a 2011 review of ongoing gaps in preparedness, Trust for America’s Health – a nonprofit, nonpartisan health policy organization – found that local health departments face three principal problems:
- A Funding Gap: From fiscal year 2005 to 2012, federal funds for state and local preparedness declined 38 percent, and additional cutbacks are expected;
- A Workforce Gap: From 2008 to 2011, an estimated 34,400 local health department jobs have been eliminated; moreover, within the next five years, a third of local health department workers will be eligible to retire; and
- A Community Resiliency Support Gap: Large-scale disease outbreaks require public health departments to address the additional concerns posed by at-risk special needs and vulnerable populations, but most local health departments lack the staff required to fully engage those populations.
In large part because of the three gaps, innovative solutions may be needed to overcome these and other challenges facing local health departments. One solution believed to have significant potential is described as “mobile health” (mHealth), which is defined as the use of mobile technologies to not only preserve and improve the health of special populations but also to upgrade the capabilities of healthcare delivery systems. Preliminary research shows that mHealth can specifically be directed to: (a) improve communications with the public; and (b) make the dispensing of medical countermeasures more effective during a large-scale pandemic.
Fortunately, technological advances in mobile devices have coincided with an increase in both the access to and usage of mobile technology. The increased frequency with which Americans now use smartphones, coupled with the advanced capabilities of the phones themselves – for text messaging, web browsing, GPS navigation, geo-location services, e-mail access, and a still growing spectrum of other purposes – provides an opportunity for communicating more, and more effective, preparedness information as well. Moreover, it seems clear that, although some new programs have emerged in recent years at local health departments, additional federal guidance could help significantly in determining how mHealth can and should be incorporated into improved preparedness planning at all levels of government.
Communicating & Dispensing Countermeasures During Emergencies
Local health departments are responsible for the critical function of providing information, warnings, and notifications to the public during pandemics. Although many public communication channels already exist, mHealth technology offers a unique way to provide more effective information as well as more frequent reminders, through text messaging programs and mobile apps – related to vaccines, for example, requiring more than a single dose.
One forward-looking health department, Public Health–Seattle (Washington) & King County (PHSKC), has carried out, and published – in the Washington State Journal of Public Health Practice – preliminary research on communicating with the public during major emergencies. In a recent phone survey of about 400 King County residents: (a) the vast majority (82 percent) of respondents said they wanted to receive text messages from PHSKC during an actual emergency; (b) about 50 percent also wanted to receive text messages about how to prepare for an emergency; and (c) 25 percent wanted to receive text messages on a number of other health topics. Because interventions that use mHealth technology must be not only specialized but also personalized to some extent – to meet the needs of a specific population, for example – understanding such variations in interest levels related to the services offered is a key finding.
Other research – reported in a 2010 issue of Epidemiologic Reviews – found not only that text messaging is in fact an effective tool for behavior change but also that the beneficial effects range across a broad spectrum of age, minority status, and nationality groups. It seems probable, therefore, that reminder-based text messaging programs can promote behavior change by providing cues to action – a text reminder to return for the second dose of a vaccine, for example, or to complete the full course of a particular medication.
Similar results were found when the communications team of PHSKC conducted a two-year pilot study, beginning in 2010, to determine if parents would opt in, during a mass flu vaccination exercise, for a text message program to remind them to return for their children’s second dose of vaccine. In the first year of the pilot, 84 percent of parents did in fact opt into the program, and 95 percent opted in the following year. It should be noted that, although the studies demonstrated the public’s desire to receive information, they did not evaluate the effectiveness of the interventions to improve vaccine uptake.
In addition to helping in the dissemination of information, local health departments also play a critical role in rapidly dispensing medical countermeasures during a pandemic. Denver (Colo.) Public Health (DPH) addressed that task by developing a mobile app with the potential to be replicated by other health departments throughout the country. More specifically, DPH designed and implemented the Hand-held Automated Notification for Drugs and Immunizations (HANDI) application as a tool that could be used to collect the essential data needed during mass prophylaxis and immunization incidents and events.
The app addresses issues that were identified by DPH during the 2009-2010 H1N1 pandemic by capturing patient data, and collecting other standardized information, through the use of scanning technology embedded into a mobile device, thereby eliminating the need for manual data entry. Moreover, HANDI also makes it possible – by scanning drivers’ licenses, monitoring contraindications, and tracking the prophylaxis/immunizations administered – for health workers at different stations to work as a unified team. In addition, eliminating the need both to fill out paper forms and to manually enter the data required helps medical countermeasures be dispensed more quickly and with fewer staff hours required.
New Challenges, Opportunities & Policy Changes
Despite the considerable evidence suggesting that mHealth provides an unprecedented opportunity for local health departments to develop innovative solutions, the technology now available has yet to be widely adopted. The study published in the Washington State Journal of Public Health Practice concluded that, among the main challenges remaining, are the minimal understanding of: (a) how text messages could be used; (b) how to select companies and vendors for the development process; and (c) the cost and effectiveness of the technology.
Another factor that also must be addressed is that, because of the current economic and fiscal state of the nation, many local health departments face increasingly severe budgetary constraints. With limited financial resources, department leadership may be hesitant to invest financial resources in new technologies that may not be well understood among staff and/or by the general public. In recent years, many local health departments also have had to reduce the size of their staffs, another factor that might compromise the breadth and depth of the public health programs offered.
A new and more comprehensive evaluation of the cost-effectiveness of mHealth technologies, particularly in comparison to standard preparedness activities, would help strengthen the case for mHealth programs. However, it is important to note that the mHealth technologies currently in use demonstrate that local health departments already have the ability to broaden their reach while at the same time increasing their operational efficiency.
If nothing else, the following four recommendations might serve as the talking points needed for additional policy discussions on the use of mHealth and/or similar technologies to improve and expand local pandemic preparedness capabilities:
Collaboration – Preparedness programs that use mHealth technology could and should be replicated in communities across the country. Instead of developing such programs in local “silos,” greater collaboration and additional regional partnerships among health departments and other stakeholders would improve and accelerate the development and expansion of the already proven mHealth technologies for pandemic preparedness.
Federal Guidance – More prescriptive federal guidance to spur development and innovation should be provided to allow and encourage the further advancement and identification of ways in which local health departments can use mHealth. The U.S. Department of Health and Human Services (HHS) and its Centers for Disease Control and Prevention (CDC) already offer some preliminary guidance and tools – e.g., the Text Alert Toolkit, a library of developed text messages for emergencies that could be used for local mHealth programs. As immunization health registries and electronic health records continue to become the norm in public health, mHealth programs can increasingly build upon those frameworks.
Training – More, and more effective, training is required at the local level to develop and implement an mHealth programs for pandemic preparedness. Local health department staff could benefit from learning a step-by-step approach to developing, testing, and implementing a mHealth program. In addition, specific training modules could focus greater attention on understanding the different types of mHealth technologies available, the capabilities needed to select a capable and cost-effective vendor or developer, and the signs and symptoms that must be present to evaluate the effectiveness of an intervention.
Public-Private Partnerships – The development of a successful mHealth program requires partnerships across a broad spectrum of organizations – including but not limited to capable private-sector companies and businesses, the multiple levels of government that might be involved, non-profit organizations, researchers, academia, and telephone companies. More work should be done to bring all of these groups together to fully discuss the shift in pandemic preparedness toward implementing mHealth technology.
For additional information on: The CDC’s social media tools, guidelines, and best practices, visit http://www.cdc.gov/SocialMedia/Tools/guidelines/
The Department of Health and Human Services’ mHealth Initiative, visit https://www.hhs.gov/web/building-and-managing-websites/mobile/index.html
Epidemiologic Reviews’ 2010 article, “Text messaging as a tool for behavior change in disease prevention and management,” by H. Cole-Lewis and T. Kershaw, visit http://epirev.oxfordjournals.org/content/32/1/56.abstract
Public Health–Seattle & King County’s information about using text messages as vaccine reminders, visit www.kingcounty.gov/health/texting
The 2011 Trust for America’s Health’s report, “Ready or not? Protecting the public’s health from diseases, disasters, and bioterrorism,” visit http://healthyamericans.org/report/92/
The 2011 Washington State Journal of Public Health Practices article, “What 2 know b4 u text: Short Message Service options for local health departments,” by H. Karasz and S. Bogan, visit https://kingcounty.gov/depts/health/emergency-preparedness/text-messaging/resources.aspx
Sara Rubin is a program analyst at the National Association of County and City Health Officials (NACCHO), where she manages day-to-day tasks for two initiatives, funded by the Centers for Disease Control & Prevention, that are focused on exploring alternative methods for antiviral distribution and dispensing in the event of a pandemic. She served as a 2012 fellow in the Emerging Leaders in Biosecurity Initiative at the Center for Biosecurity of UPMC (University of Pittsburgh Medical Center), and previously worked at: a congressional and a presidential commission; the Federal Emergency Management Agency; and the Bipartisan WMD Terrorism Research Center. In 2011, she received dual degrees, MA/MPH in international affairs and global health, from The George Washington University.