title: Exploring bi-directional and SMS messaging for communications between Public Health Agencies and their stakeholders: a qualitative study.
abstract: BACKGROUND
  Communication technologies that enable bi-directional/two-way communications and cell phone texting (SMS) between public health agencies and their stakeholders may improve public health surveillance, ensure targeted distribution of alerts to hard-to-reach populations, reduce mortality and morbidity in an emergency, and enable a crucial feedback loop between public health agencies and the communities they serve. Building on prior work regarding health care provider preferences for receiving one-way public health communications by email, fax or SMS, we conducted a formative, exploratory study to understand how a bi-directional system and the incorporation of SMS in that system might be used as a strategy to send and receive messages between public health agencies and community-based organizations which serve vulnerable populations, health care providers, and public health workers. Our research question: Under what conditions and/or situations might public health agencies utilize bi-directional and/or SMS messaging for disseminating time-sensitive public health information (alerts, advisories, updates, etc.) to their stakeholders?
  
  
  METHODS
  A mixed methods (qualitative and quantitative) study was conducted between April and July 2014. Data collection included a survey distributed to health care providers and semi-structured interviews with providers, community- and government-based organization leaders and directors, and public health agency internal workforce staff. Survey respondents and interviewees were asked about their exposure to public health messages, how these messages are received and how the information in these messages are handled, and in what situations (for example, a local vs. a national event, a pandemic or emergency vs. a health update) a bi-directional and/or SMS messaging system might improve communications between public health agencies and their stakeholder group. Interview and survey data were qualitatively analyzed. Thematic codes were quantitized into dichotomous variables of 0 or 1 on a per respondent basis to enumerate the presence or absence of each thematic code, enable quantitative analysis, and inform interpretation of findings.
  
  
  RESULTS
  Five major themes emerged from synthesizing survey and interview results: 1) Regardless of situational context (emergency vs. non-urgent) and message recipient (stakeholder group), e-mail is a favored modality for receiving public health messages; 2) The decision to use bi-directional, SMS or multiple communication strategies is complex and public health agencies' need to manage messaging concerns/barriers and benefits for all parties; 3) Both public health agencies and their stakeholders share similar values/uses and concerns regarding two-way public health messaging and SMS; 4) Public health is highly trusted, thus thoughtful, effective messaging will ensure continuation of this goodwill; and 5) Information reciprocity between public health agencies and stakeholders who share their information is essential.
  
  
  CONCLUSIONS
  Multiple communication strategies might be utilized but the choice of a specific strategy needs to balance message content (emergency vs. routine communications), delivery (one- vs. two-way), channel (SMS, email, etc.), and public health agency burden with stakeholder preferences and technical capabilities, all while mitigating the risk of message overload and disregard of important communications by recipients.
authors.affiliation: Northwest Center for Public Health Practice, School of Public Health, University of Washington, 1107 NE 45th St, Suite 400, Seattle, WA, 98105, USA. drevere@uw.edu.
authors.forename: Debra
authors.initials: D
authors.lastname: Revere
authors.affiliation: Northwest Center for Public Health Practice, School of Public Health, University of Washington, 1107 NE 45th St, Suite 400, Seattle, WA, 98105, USA. calhounb@uw.edu.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Calhoun
authors.affiliation: Northwest Center for Public Health Practice, School of Public Health, University of Washington, 1107 NE 45th St, Suite 400, Seattle, WA, 98105, USA. jbaseman@uw.edu.|Department of Epidemiology, School of Public Health, University of Washington, Box 357236, Seattle, WA, 98195-7236, USA. jbaseman@uw.edu.
authors.forename: Janet
authors.initials: J
authors.lastname: Baseman
authors.affiliation: Northwest Center for Public Health Practice, School of Public Health, University of Washington, 1107 NE 45th St, Suite 400, Seattle, WA, 98105, USA. moberle@uw.edu.|Department of Epidemiology, School of Public Health, University of Washington, Box 357236, Seattle, WA, 98195-7236, USA. moberle@uw.edu.
authors.forename: Mark
authors.initials: M
authors.lastname: Oberle
mesh_terms: D003142:Communication; D034742:Electronic Mail; D004630:Emergencies; D006282:Health Personnel; D006801:Humans; D011635:Public Health Administration / Q000379:methods*; D036301:Qualitative Research; D060145:Text Messaging