Evaluation of a Pilot mHealth Intervention to Engage Primary Care Clients at an Urban Clinic Serving Marginalized Populations: Mixed-Methods Cohort Study.

BACKGROUND: Many individuals in urban low-income settings face barriers to engaging in primary care and experience systemic challenges such as homelessness and discrimination in the health care system. This study was conducted in the Downtown Eastside of Vancouver, Canada, a low-income neighborhood with intersecting structural vulnerabilities and disproportionate rates of substance use disorders. Advancements in mobile health expand options for facilitating communication between primary care providers and clients.

OBJECTIVE: We conducted a pilot project that provided primary care clients a mobile phone and access to WelTel, a mobile health tool that uses a 2-way texting approach and sends weekly automated check-in messages. Our study measured phone retention, defined as retaining a study-supplied device and being reachable on the study-supplied device over a 6-month period and explored the acceptability and feasibility of WelTel among a cohort of clients with complex health challenges.

METHODS: Stratified random sampling was used to recruit participants from a larger cohort study of primary care clinic clients in the Downtown Eastside. The sample was stratified to ensure equal participation based on gender and Indigenous and non-Indigenous participants. In this mixed methods research, participants completed 3 surveys over a 6-month period from November 2022 to May 2023. The surveys assessed phone retention and functionality as well as phone use, including use of the WelTel platform. Clients who had access to a functional mobile phone after the follow-up period were invited to complete an in-person interview. The semistructured interviews explored clients' experiences with WelTel, primary care, and engagement with technology.

RESULTS: We enrolled 49 participants (median age 48 y; 53% women and 49% Indigenous) and interviewed 16 participants. A total of 44 clients completed the 6-month survey, and of those clients, 26 (59%) had a functional phone. However, only 14 (29%) clients retained the mobile device supplied during the study and completed the 6-month survey. Phone retention or access to a nonstudy phone was lower among those who had used opioids (18% for both) in the past 3 months (P<.01), as well as those who reported not having access to a cellphone at enrollment (25% and 15%, respectively) compared to those who did have phone access at enrollment (P=.05). Both the surveys and semistructured interviews indicated that WelTel was generally well received; 25 (96%) of those with a functional phone reported that they liked receiving the weekly messages. During qualitative interviews, the WelTel intervention was reported to strengthen client-provider relationships and create pathways for receiving care.

CONCLUSIONS: Overall, the pilot study found this intervention feasible and acceptable to clients; however, barriers to phone retention were an ongoing challenge. Expanded enrollment in the WelTel service will allow us to examine whether it also facilitates engagement in primary care among marginalized urban populations.