664721

research-article2016

CPJXXX10.1177/0009922816664721Clinical PediatricsOlson et al

Article

Texts for Talking: Evaluation of a

Mobile Health Program Addressing
Speech and Language Delay

Clinical Pediatrics
2016, Vol. 55(11) 10441049
The Author(s) 2016
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DOI: 10.1177/0009922816664721
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Kaitlyn B. Olson, MD1,2, Carol L. Wilkinson, MD, PhD1,3,

M. Jackson Wilkinson, AB4, Jamal Harris, MD, MPH1, and Amy Whittle, MD1

Abstract
Speech and language delays are common developmental disorders that can lead to long-term academic and
psychosocial impairments. Affected families often benefit from instruction in cultivating a language-rich home
environment. This study investigated the feasibility of utilizing text messaging to deliver developmental education
to families. Parents of children aged 11 to 36 months with concerning language development were enrolled in a
3-month text messaging program. Preprogram and postprogram telephone surveys were completed. All enrolled
parents were of low socioeconomic status, and 48% were monolingual Spanish speakers. A total of 27 parents (87%)
completed the program and follow-up survey. After program completion, parents reported increased awareness
of language-promoting activities and local child development resources (P = .002; P = .005). Parents also reported
increased engagement in language-promoting activities (P = .004). The marginal program cost was 37 cents per
participant. Findings from this pilot study indicate that text messaging is a feasible, engaging, and inexpensive platform
for delivering developmental education to families.
Keywords
child development, text messages, early childhood, parent education, SMS, low income

Introduction
Pediatric speech and language delays are common developmental disorders that are associated with chronic
impairments in social functioning, emotional health, and
scholastic achievement.1-7 These delays affect up to 15%
of children.8,9 Higher incidences are observed in children
of low socioeconomic status (SES).8,10 In fact, significant
disparities in language proficiency between children from
low- and high-SES families are seen as early as 18 months
of age.11 Speech therapy is often recommended and is
supported by both the US Preventive Services Task Force
and a 2010 Cochrane review article.12,13 However,
because of insufficient funding, a paucity of certified
speech pathologists, and multiple logistical barriers, lowSES families frequently have difficulty accessing these
services.14-16 Parent education can enable low-SES families to improve a childs home linguistic environment17;
this familial modification has also been shown to have a
positive impact on the language development of children
with primary speech and language delay.18,19
Digital health, specifically mobile health (mHealth)
programming, is a potential platform for providing

developmental education to families of children with

speech and language delay outside of the clinic. Within
the field of pediatrics, mHealth programs have demonstrated success in improving medication adherence,
facilitating timely vaccination, and providing health
education.20-25 The uTALK (Texts Advancing Language
in Kids) pilot program was designed to use text messaging to provide parents with regular instruction on simple, actionable, language-promoting activities. This
study evaluates the feasibility of the uTALK program in
delivering developmental education to an urban population of low SES and analyzes the impact of the program
on the home linguistic environment.
1

University of California San Francisco Benioff Childrens Hospital,

CA, USA
2
University of Chicago, IL, USA
3
Boston Childrens Hospital, MA, USA
4
Kinsights, San Francisco, CA, USA
Corresponding Author:
Carol L. Wilkinson, Division of Developmental Medicine, Boston
Childrens Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
Email: [email protected]

1045

Olson et al

Methods

Table 1. Sample Text Messages.

Participants

Language enrichment activities

Even when children cant talk, they learn words by hearing
you speak. The more words he hears, the sooner he will
say new things!
At dinner talk about the food you are eating. Talk about
the color and the shape. Ask your child how it tastes
sweet? salty?
When you talk to your child, try to make eye contact.
Watching you move your mouth can help her learn to
make sounds
Community resources
The public library has free books that you can borrow!
Call XXX to learn how to get a library card
Survey questions
Have you done any of the activities we texted you this
week? Reply to this message with yes or no

Study participants were recruited from the outpatient

pediatric clinic at San Francisco General Hospital
between July 2013 and February 2014. Parents were eligible to participate if the primary care provider identified the child as having concerning speech and/or
language development. Enrollment was limited to families of children between 11 and 36 months old, given
that the studys developmental interventions targeted
this age group. Additional enrollment criteria included
parental literacy in either English or Spanish and possession of a mobile telephone with text message capability.
Families were not excluded from participation on the
basis of medical comorbidities or involvement in other
developmental services. Children enrolled continued to
receive all recommended care from providers, such as
further evaluations for hearing, referral to early intervention, and speech and language services.

University of CaliforniaSan Francisco Institutional

Review Board.

Study Design and Procedures

Text Messaging Platform

This was a pilot intervention study. Parents meeting the

inclusion criteria consented in their preferred language
via telephone. On enrollment, participants completed a
telephone survey consisting of basic demographic information, self-reported knowledge of language-promoting
activities, current engagement in language-promoting
activities, and awareness of community resources for
early child development. Item response formats for survey questions included the 5-item Likert scale, yes-no
questions, and open-ended questions. After survey completion, participants were sent 3 text messages per week
for 12 weeks. Three types of text messages were included
in the program: messages describing activities that promote child language development; messages providing
information on local, low-cost community organizations
specializing in early child development; and messages
containing survey questions. Samples of text messages
are shown in Table 1. Participants were informed that
responding to text message survey questions was
optional. These questions were designed as a tool to
gauge participant engagement in the program; they were
not intended to evaluate program effectiveness.
On completion of the uTALK program, parents participated in a follow-up telephone survey assessing the
same measures of knowledge and engagement as the
baseline survey. The postprogram survey also contained questions designed to assess participant opinion
of the structure of the text message format and participant opinion of the value of the uTALK program. The
study and consent process were approved by the

The text messaging program was built in Python, using

the Django application framework and a Postgresql
database. It was hosted on the Amazons Web Services
platform via Heroku. This framework leveraged the
Twilio application programming interface (API) to automatically send SMS messages at a customizable date
and time. Text messages were disseminated in a preconfigured order, and were personalized based on language
(English or Spanish) of the parent and gender of the
child. Text responses from participants were directly
transferred to and stored in the database. Participants
were able to text STOP at any time to remove themselves from the program.

Data Analysis
To assess the feasibility of using text messages to deliver
developmental education to the target population, the
program completion rate and the response rate to intraprogram text messages were calculated. To evaluate the
programs impact on the home linguistic environment,
parental survey responses were compared before and
after program participation. For survey questions utilizing the Likert scale, statistical analysis was conducted
using a paired t-test. For survey questions involving
dichotomous answers, a 2-tailed sign test was used. A
McNemar test could not be used because of the small
sample size.
To calculate the marginal cost of the text message program, the average cost of the Twilio API per text message

1046
was multiplied by the number of text messages sent per
participant. Twilio also charges a $1 monthly fee for an
account regardless of the number of text messages sent.
We distributed the $1 monthly fee evenly across the 31
participants to calculate the program cost per participant.
The calculated marginal cost of the program does not
include variable text messaging costs charged directly to
participants by their mobile provider.

Results
A total of 31 parents were enrolled in the study. Post
program survey data were collected from 27 participants
(87%). Two parents elected to stop receiving messages
during the program, 1 parent did not remember receiving any messages, and 1 parent could not be contacted
after completion of the program. Demographic information is provided in Table 2. All parents either received or
were eligible for the Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC) at the
time of study participation. Nearly half (48%) of parents
were monolingual Spanish speakers, with 67% of participants identifying as Hispanic or Latino. The majority
of parents had finished high school or some college
(81%); only 1 participant had graduated from college.
Children ranged in age from 11 to 36 months at the time
of enrollment, and 63% of children were older than 24
months.

Program Impact
Results of the programs impact on the language environment are detailed in Table 3. After completing the uTALK
program, more parents reported being knowledgeable of
pediatric language-promoting activities (56% vs 96%, P
= .002) and being aware of community resources for
child development (41% vs 82%, P = .005). Parental
self-report of engagement in language enrichment activities with their child increased from 89% to 100% (P =
.004). After participating in the uTALK program, more
parents reported visiting the library (48% vs 70%, P =
.03). Parental report of the number of times they read to
their child increased (5.2 vs 6.7); however, this was not
statistically significant (P = .15).

Program Format and Participant Engagement

Parents were asked several questions regarding the program length and frequency of text messages. Seven parents (26%) felt that the program was too short, and 20
parents (74%) felt that it was just right. Five parents
(19%) reported that the number of texts were too few,
whereas the remainder reported that the number of texts

Clinical Pediatrics 55(11)

Table 2. Participant Characteristics (n = 27).
Number (%)
Relation to child
Father
Mother
Othera
Age (years)
<21
21-29
30-39
>40
Unknown
Education
Primary school
Finished high school
Some college
Finished college
Primary household language
English
Spanish
Both
Race/Ethnicity
Asian/Pacific Islander
Black
Hispanic/Latino
White
Other/Unknown
Marital status
Single
Married
Divorced
Childs gender
Male
Female
Childs age (months)
11-17
18-23
24-29
30-36
Eligible for WIC benefits
Yes
No

2 (7.4)
24 (88.9)
1 (3.7)

2 (7.4)
12 (44.4)
10 (37.0)
2 (7.4)
1 (3.7)

4 (14.8)
13 (48.1)
9 (33.3)
1 (3.7)

10 (37.0)
13 (48.1)
4 (14.8)

1 (3.7)
5 (18.5)
18 (66.7)
0 (0)
3 (11.1)

14 (51.9)
11 (40.7)
2 (7.4)

17 (63.0)
10 (37.0)

4 (14.8)
6 (22.2)
11 (40.7)
6 (22.2)

27 (100)
0 (0)

Abbreviation: WIC, Special Supplemental Nutrition Program for

Women, Infants, and Children.
a
Foster parent.

received was just right. Two parents specifically commented that they would like daily messages.
During the program, participants received 4 text messages containing optional survey questions. A total of 15
parents (56%) responded by text message to at least 1 of
the optional intraprogram text message survey questions. Although 3 of the 4 questions were designed to be

1047

Olson et al
Table 3. Sample Questions From the Survey of Participants (n = 27).
Pre-uTALK

Post-uTALK

3.44 (1.10)
2.96 (1.23)

4.19 (0.61)
3.89 (1.03)

.002b
.005b

4.03 (0.74)

4.41 (0.49)

.004b

13 (48.1)

19 (70.4)

.03c

5.2 (3.7)

6.7 (5.4)

.15b

Self-reported knowledge, mean score (SD)

I know about activities that help my child learn to talk
I know places in the community where I can go to help my child
learn to talk
I do activities to help my child learn to talk
Languagepromoting activities
Have you been to the public library in the past 3 months?
# yes (%)
How many times have you read to your child in the past week?
Mean (SD)
a

Responses are on a scale of 1 to 5 with 2 anchors: 1 = strongly disagree and 5 = strongly agree.
Statistical analysis by paired t test.
c
Statistical analysis by 2-tailed sign test.
b

answered with a simple yes or no or a numerical answer,

participants often responded with icons or prose.

Value to Parents and Program Cost

In all, 100% of parents reported that they enjoyed the
uTALK program and that they would recommend this
program to other families; 26 participants (96%) considered the program valuable to their family, and 24 participants (89%) reported that the program helped their child.
Parents were also asked to comment about the program.
Several comments were specific to the text messaging
aspect of the program: It was easier to get information
via text message than on the Internet; I was able to
save the text messages and look for them later to remember; and I liked the text message because you didnt
have to talk to anyone. The information was easy and
accessible.
The Twilio service fee was $0.0075 per text message.
When multiplied by the 36 text messages sent per participant during the program, the cost was $0.27 per participant. The $1 monthly fee for a Twilio account was
multiplied by 3 months and divided by the 31 enrolled
participants, totaling $0.10 per participant. The total
marginal cost of the program was calculated to be $0.37
per participant.

Discussion
The objective of this study was to determine whether text
messaging is a feasible platform for delivering developmental education to low-income parents of children with
speech and language delay. The uTALK program was
able to effectively reach the target population of underserved families as evidenced by an 87% program completion rate. Given that almost half of the participants

were nonEnglish speaking, this study supports the idea

that text messaging is a potential modality for providing
education to populations marginalized by language barriers. Furthermore, the participants 56% response rate to
optional intraprogram text message survey questions
suggests that parents were not only receiving the text
messages, but that they were also actively reading the
messages and engaging with the program. In fact, several
participants regularly responded to nonsurvey messages
with thanks or a thumbs-up icon.
This studys results also support the hypothesis that a
text messaging intervention can enable parents to positively change their childs linguistic environment. After
participating in the 3-month program, parents reported
greater knowledge of and participation in language-promoting activities, including visiting the library. Although
there was no statistically significant difference in the
number of times parents reported reading to their child,
this is possibly a result of the studys small sample size
or the variability in parent recall and interpretation of
the question.
Based on prior research, improvements in the home
linguistic environment, such as those produced through
this text messaging program, have direct impacts on the
language development of children,18,19,26 Teaching parents how to create enriching environments early in a
childs life is important. Unfortunately, it is often difficult in a clinic setting because of time constraints and
language barriers. Furthermore, tips given in the clinic
setting are often not translated into actions at home.
Comments from participants in uTALK highlighted the
effectiveness and convenience of text messages. Text
messages can be received on a more frequent basis than
primary care visits. Because they are delivered outside of
the clinic, the suggestions can be acted on immediately
and even saved for future reference. Importantly, the

1048
uTALK program was both lowcost and required minimal time for parents and providers.
This study does have several limitations. It is a small
study with 31 participants and, thus, definitive conclusions regarding the effectiveness of this program in educating parents cannot yet be made. However, given the
high rate of positive responses from parents, as well as a
high engagement rate with the text messages, this study
provides strong support for further developing text messaging platforms in this context. In addition, this study
did not independently assess whether parents participated in suggested activities or whether children
improved their language abilities after parent participation in the program. Future research should examine
whether participation in the uTALK program affects
objective measures of a childs language development.
Given that etiologies of speech and language delay
include a heterogeneous group of primary and secondary disturbances, additional research could also clarify
which subgroups would most benefit from a text message language intervention.

Conclusions
The uTALK program is a low-cost text message intervention that provides developmental education to parents of children with speech and language delays. The
program was able to reach a highly underserved population and was accessible for Spanish speakers. Results of
the pilot study suggest that parents both learned and
implemented developmental interventions to help their
children after participating in this program. Given the
positive results of this study, text message programs
may be a low-cost, logistically simple method for providing timely developmental education to societys most
vulnerable children. More research is indicated to assess
the direct impact of this program on pediatric language
development and to identify the pediatric subgroups that
would most benefit from this intervention.
Author Contributions
All authors contributed to the concept and design of this project. In addition, KBO collected, analyzed, and interpreted
data, and co-drafted the manuscript. CLW helped build the
text message platform, collected, analyized, and interpreted
data, and co-drafted the manuscript. MJW designed and
helped build the text message platform, and critical revised
the manuscript. JH and AW both critically revised the
manuscript.

Authors Note
Kaitlyn B. Olson and Carol L. Wilkinson contributed equally
to this project and article.

Clinical Pediatrics 55(11)

Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of
interest with respect to the research, authorship, and/or publication of this article: Dr Carol Wilkinson, Mr Jackson
Wilkinson, and Dr Kaitlyn Olson have a potential conflict of
interest. Mr Wilkinson was the founder and Dr Wilkinson was
the medical director of Kinsights. Kinsights is a company that
facilitates and provides a platform for parenting communities
and was recently acquired by Care.com; Mr Wilkinson continues to work at Care.com. After completion of the study,
including collection of all data, an updated version of the text
messaging program was made available online for free by
Kinsights. The text messaging program is located on a separate
website (kinsteps.com) and does not require sign-up for
Kinsights or Care.com, nor does it require any payment by participants. It is currently offered as a public service at Care.
coms expense. Dr. Wilkinson and Dr. Olson continue to serve
as volunteer consultants to the Kinsteps program.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this
article: This study was supported by the American Academy
of Pediatrics Resident CATCH (Community Access to Child
Health) grant.

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