title: Is health literacy related to health behaviors and cell phone usage patterns among the text4baby target population?
abstract: BACKGROUND
  Text4baby provides educational text messages to pregnant and postpartum women and targets underserved women. The primary purpose of this study is to examine the health behaviors and cell phone usage patterns of a text4baby target population and the associations with health literacy.
  
  
  METHODS
  Pregnant and postpartum women were recruited from two Women, Infant and Children clinics in Atlanta. Women were asked about their demographics, selected pregnancy or postpartum health behaviors, and cell phone usage patterns. Health literacy skills were measured with the English version of the Newest Vital Sign. Multivariable logistic regression was used to examine health behaviors and cell usage patterns by health literacy classification, controlling for commonly accepted confounders.
  
  
  RESULTS
  Four hundred sixty-eight women were recruited, and 445 completed the Newest Vital Sign. Of these, 22% had inadequate health literacy, 50% had intermediate health literacy, and 28% had adequate health literacy skills. Compared to adequate health literacy, limited literacy was independently associated with not taking a daily vitamin during pregnancy (OR 3.6, 95% CI: 1.6, 8.5) and never breastfeeding their infant (OR 1.4, 95% CI: 1.1, 1.8). The majority (69.4%) of respondents received nine or more text messages a day prior to enrollment, one in four participants (24.6%) had changed their number within the last six months, and 7.0% of study participants shared a cell phone. Controlling for potentially confounding factors, those with limited health literacy were more likely to share a cell phone than those with adequate health literacy (OR 2.57, 95% CI: 1.79, 3.69).
  
  
  CONCLUSIONS
  Text4baby messages should be appropriate for low health literacy levels, especially as this population may have higher prevalence of targeted unhealthy behaviors. Text4baby and other mhealth programs targetting low health literacy populations should also be aware of the different ways that these populations use their cell phones, including: sharing cell phones, which may mean participants will not receive messages or have special privacy concerns; frequently changing cell phone numbers which could lead to higher drop-off rates; and the penetrance of text messages in a population that receives many messages daily.
authors.affiliation: Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA, USA.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Poorman
authors.affiliation: Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton RdNE, Atlanta, Georgia.
authors.forename: Julie
authors.initials: J
authors.lastname: Gazmararian
authors.affiliation: Department of Biostatistics, Rollins School of Public Health, Emory University, 1518 Clifton RdNE, Atlanta, Georgia.
authors.forename: Lisa
authors.initials: L
authors.lastname: Elon
authors.affiliation: School of Medicine, Emory University, 1648 Pierce DrNE, Atlanta, Georgia.
authors.forename: Ruth
authors.initials: R
authors.lastname: Parker
keywords: Health literacy; Health promotion; Maternal and child health; Postnatal; Prenatal; Text messaging; Underserved populations; mHealth