Journal of Health Communication
International Perspectives
ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: https://www.tandfonline.com/loi/uhcm20
Perceptions, Attitudes, and Experience Regarding
mHealth Among Homeless Persons in New York
City Shelters
Ramin Asgary, Blanca Sckell, Analena Alcabes, Ramesh Naderi, Philip
Adongo & Gbenga Ogedegbe
To cite this article: Ramin Asgary, Blanca Sckell, Analena Alcabes, Ramesh Naderi, Philip
Adongo & Gbenga Ogedegbe (2015) Perceptions, Attitudes, and Experience Regarding mHealth
Among Homeless Persons in New York City Shelters, Journal of Health Communication, 20:12,
1473-1480, DOI: 10.1080/10810730.2015.1033117
To link to this article:  https://doi.org/10.1080/10810730.2015.1033117
Published online: 27 Aug 2015.
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Journal of Health Communication, 20:1473–1480, 2015
Copyright # Taylor & Francis Group, LLC
ISSN: 1081-0730 print/1087-0415 online
DOI: 10.1080/10810730.2015.1033117
Perceptions, Attitudes, and Experience Regarding mHealth
Among Homeless Persons in New York City Shelters
RAMIN ASGARY1,2, BLANCA SCKELL3, ANALENA ALCABES3, RAMESH NADERI2,
PHILIP ADONGO4, and GBENGA OGEDEGBE1,2
1Department of Population Health, New York University School of Medicine, New York, New York, USA
2Department of Medicine, New York University School of Medicine, New York, New York, USA
3Community Medicine Program, Lutheran Family Health Centers, New York, New York, USA
4School of Public Health, University of Ghana, Accra, Ghana
Mobile health may be an effective means of providing access and education to the millions of homeless Americans. We conducted
semi-structured interviews with 50 homeless people from different shelters in New York City to evaluate their perceptions, atti-
tudes, and experiences regarding mobile health. Participants’ average age was 51.66 (SD¼ 11.34) years; duration of homelessness
was 2.0 (SD¼ 3.10) years. The majority had a mobile phone with the ability to receive and send text messages. Most participants
attempted to maintain the same phone number over time. The homeless were welcoming and supportive of text messaging regard-
ing health care issues, including appointment reminders, health education, or management of diseases considering their barriers and
mobility, and believed it would help them access necessary health care. Overwhelmingly they preferred text reminders that were
short, positively framed, and directive in nature compared to lengthy or motivational texts. The majority believed that free cell
phone plans would improve their engagement with, help them navigate, and ultimately improve their access to care. These positive
attitudes and experience could be effectively used to improve health care for the homeless. Policies to improve access to mobile
health and adapted text messaging strategies regarding the health care needs of this mobile population should be considered.
The homeless population of the United States is estimated to population, the homeless die from cancer twice as often,
be approximately 3.5 million annually (Link et al., 1994; but their rate of cancer screening is lower (Asgary, Garland,
National Coalition for the Homeless, 2013). The homeless Jakubowski, et al., 2014; Asgary, Garland, & Sckell, 2014;
are more likely to be of a racial and ethnic minority back- New York City Departments of Health and Mental Hygiene
ground, and men in early to middle age are at greater risk and Homeless Services, 2005). In general, chronic diseases
for being homeless (Culhane, Metraux, Byrne, Stino, & among the homeless are often not well controlled (Lee
Bainbridge, 2013; Fargo et al., 2012). Close to a quarter of et al., 2005; Szerlip & Szerlip, 2002), and the homeless face
the homeless population are chronically homeless, and a sig- barriers to therapeutic lifestyle changes (Moczygemba et al.,
nificant number stay in the shelter system for more than 1 2013). They suffer disproportionately from mental illness,
year or are frequently homeless. which complicates the management of their medical
Most homeless individuals in the United States were born conditions.
during the latter part of the baby boom era and are in their The homeless encounter multilevel barriers to accessing
early 50 s; thus, they are more at risk for developing chronic health care, including lack of a primary care physician or
diseases and need more preventive care (Culhane et al., 2013; consistent primary health care, inadequate preventive
Kushel, Vittinghoff, & Haas, 2001). Hypertension is one of counseling, lack of insurance, fatalistic views regarding
the most common conditions among the homeless (Gelberg health issues, and a history of discrimination in the health
& Linn, 1989; Kim et al., 2008; Kleinman, Freeman, system (Asgary, Garland, Jakubowski, et al., 2014; Asgary,
Perlman, & Gelberg, 1996; Moczygemba, Kennedy, Marks, Garland, & Sckell, 2014; Chau et al., 2002; Khandor et al.,
Goode, & Matzke, 2013; Savage et al., 2006; Szerlip & 2011; Lebrun-Harris et al., 2013; Wen, Hudak, & Hwang,
Szerlip, 2002), and rates of smoking and substance abuse 2007; Zlotnick & Zerger, 2008). There are biases against
are high among the homeless (Kim et al., 2008; Lee et al., the health needs and priorities of the homeless among provi-
2005; Szerlip & Szerlip, 2002). Compared to the general ders who often lack training to address social issues that
affect the health care of these individuals (Wen et al.,
2007). The current health system at best focuses on address-
Address correspondence to Ramin Asgary, Department of
ing acute health issues of the homeless and neglects their
Population Health, New York University School of Medicine,
227 East 30th Street, Room 639, New York, NY 10016, USA. chronic disease management, health education, or preventive
E-mail: ramin.asgary@caa.columbia.edu care. Homeless populations are mobile, often lack an
1474 R. Asgary et al.
established relationship with health care providers, and are and translated into English if needed. We then coded
more likely to miss their medical appointments and transcripts and analyzed them for major themes.
follow-ups because of multiple social conditions, including A qualitative descriptive approach was used for analysis
unemployment, a lower level of education, lack of social by two authors (Ramin Asgary and Analena Alcabes).
support, and substance abuse (Khandor et al., 2011; Content analysis was performed to identify core themes
Zlotnick & Zerger, 2008). regarding knowledge, understanding, and perceptions of
Little information exists regarding strategies that use mobile technology and health care. We developed the
mHealth (i.e., mobile technology for providing health infor- preliminary coding based on priority codes derived from
mation or services) to mitigate barriers to health care access the theoretical framework and conceptual model guiding
among the homeless. Exploring perceptions, attitudes, and the study. Our theoretical framework was built around the
experiences of the homeless regarding potential mHealth following concepts: (a) There are misconceptions and
methods may help to design programs to mitigate some of negative experiences regarding the health care system among
these barriers and address health disparities among homeless the homeless, largely due to barriers to accessing health care
individuals. Qualitative research is useful in eliciting the per- and lack of health education and proper counseling for
spective of recipients of health care (Marshall & Rossman, preventive care by providers; (b) the homeless are mobile
1989), and semi-structured interviews provide the opport- and are often hard to reach; and (c) the homeless have good
unity to explore factors that affect health-seeking behavior experiences with mobile phones and technology and have
(Krueger, 1994; Sim, 1998). We explored these perspectives positive attitudes toward using mobile technology to
and attitudes among homeless persons in New York City improve their health care access. We performed critical
shelters. deliberation about initial coding and reviewed the coding
for similarities and variations to achieve a high level of
agreement. Two authors reviewed all codes independently,
Methods reviewed and discussed all codes, discussed the specific
categories, and characterized and agreed on major impor-
This study was performed at six shelters and=or tant themes. Coding was open and selective. Codes fell into
shelter-based clinics supported by the Community Medicine distinct but overarching categories. Codes were referenced
Program of Lutheran Family Health Centers, New York, back to the subject characterizations to evaluate responses
during 2014. We used both random and criteria sampling based on age and gender. Emerging themes were compared
to enroll 50 non-domicile adult participants. We used criteria across cases to explain commonality and variability of
sampling to include women, age ranges below and above 50 themes.
years, and both chronic and recently homeless individuals.
One research assistant approached patients in waiting rooms
Results
of the shelters or shelter-based clinics, discussed the study,
assessed eligibility, obtained consents, and performed inter- Fifty homeless men and women participated in the study.
views. Days of enrollment were selected randomly for each Demographic data on the participants are presented in
site. Criteria sampling was applied on an ongoing basis. Table 1.
Semi-structured interviews in English or Spanish (if needed)
were performed in a private room in the shelters or
Ownership of Cell Phones and Use of Text Messaging
shelter-based clinics. We also held formal discussions with
key informants who possessed knowledge of particular rel- The majority of women (F; n¼ 25) and men (M; n¼ 14) had
evance to the research themes, including staff and case man- a working cell phone with the ability to send and receive text
agers at shelters, allied health workers, and medical messages: ‘‘I can get text messages? And voice messages?’’
providers at shelter-based clinics. These discussions [M53]. Most participants had had their phones for at least
informed our interview tool and areas to explore further some years: ‘‘[I have had it] for 4–5 years’’ [M52], ‘‘Two
but were not included in the analysis. This study received years’’ [F52], ‘‘Two or 3 years, I have other backup
institutional review board approval from Lutheran Family
Health Centers, New York.
Semi-structured individual interviews were performed Table 1. Demographic data on the participants
rather than focus group discussions to ensure a private
and candid environment in which participants could freely Indicator Value
discuss their experience. We asked a series of open-ended Average age (SD), range 51.66 (11.34), 25–79
questions, with directing probes or follow-up clarifications Female, n (%) 29 (58)
if needed. Questions regarded possession of cell phones, atti- Age above 50, n (%) 33 (66)
tudes toward and acceptance of mHealth strategies such as Average years of homelessness (SD), max 2.03 (3.10), 14
text messaging on access to health care, and ideas on the History of chronic diseases, n (%)a 30 (60)
content of text messages and the perceived effect of free-of- Active mental illness, n (%) 10 (20)
charge mobile services to improve preventive care and aHistory of chronic diseases included hypercholesterolemia, hypertension,
chronic disease management. We obtained oral consent. diabetes, asthma=chronic obstructive pulmonary disease, or seizure
The interviews were recorded and documented verbatim disorder.
Attitudes Toward mHealth Among Homeless People 1475
phones . . . ’’ [F25], ‘‘This has been my number for 4 or 5 Experience Using Mobile Technology
years’’ [F54], ‘‘One year’’ [F52], ‘‘Since 2009 I have not,
Participants usually kept the same phone numbers; however,
but [then] I just got a new phone’’ [F53]. Others indicated
men were more likely than women to change phone numbers
a relatively shorter time period of ownership, including
over time. Older women changed their phone numbers less
within months: ‘‘Not long’’ [F49], ‘‘Four months’’ [F27].
often than younger women: ‘‘Try not to, [I] used to change
Most participants knew how to send or receive text mes-
it often’’ [F53], ‘‘Every 3 years [I] change it’’ [F42], ‘‘I change
sages. However, some older men had difficulty sending text
it once a year. Change it frequently’’ [F43], ‘‘[I have had] it
messages because the phones were so small: ‘‘But I am not
for long time, got it from Google software, had smartphone
using text much, can’t see well’’ [M79].
and there were problem with them but I kept this Internet
Most of the participants who did not have cell phones had
Google phone’’ [M53], ‘‘Two years same number, different
had them before: ‘‘No [I don’t have now], it was stolen’’
phone. Don’t change the number’’ [F52], ‘‘[I have it for] 3
[M52], ‘‘No I don’t have cell phone, [I] use landline’’
years’’ [M61], ‘‘[I have it for] almost 4 years’’ [M62], ‘‘[I have
[M58], ‘‘Not now but I had until weeks ago’’ [M60].
it for] 3 months’’ [F42], ‘‘I’ve had it for about 10 months . . . I
Additional quotes are presented in Table 2.
keep them all the time so family members can contact me’’
Table 2. Mobile phone ownership and experience among the homeless, New York City, 2014
Question Sample quotes
How long have you had a cell ‘‘I’ve had it for about 10 months,’’ ‘‘I keep them all the time so
phone? family members can contact me’’ [M59]
‘‘Four years’’ [M55]
‘‘Three years, not often I have the same one for a while’’ [M53]
‘‘Don’t know number, my wife uses it, I don’t like cell phones.
I prefer landlines’’ [M55]
‘‘One month, first number’’ [F59]
‘‘One year’’ [F43]
How often do you change ‘‘I don’t’’ [M53]
your phone=number? ‘‘Same number it was given to me from Safe Link, I could text
as well, they pay 250 minutes a month and rest is on you if
you go over, if you forget to recertify (based on low income)
then you will get new number, I had same number for some
years’’ [M60]
‘‘Three times in 2 years’’ [F57]
‘‘I change it once a year. Change it frequently’’ [F43]
‘‘I try not to [change it]’’ [F27]
‘‘Three times in 2 years [I have changed it]’’ [F57]
‘‘I have it for several years, it’s a 212 number I will never
change it’’ [F42] ‘‘One year’’ [F33]
How much credit=many ‘‘It’s a free phone, they call it an Obamaphone,’’ ‘‘I only make
minutes do you have? Do calls when I need to more than when I want to’’ [M59]
you have enough? ‘‘Usually yeah’’ [M52]
‘‘Yeah, but I turned it off this time because I didn’t’’ [M58]
‘‘I make sure my phone gets paid’’ [M53]
‘‘No’’ [M75]
‘‘Have free Obamaphone, but I add minutes’’ [F46]
‘‘Always, that was a part of a deal’’ [F59]
‘‘I keep the bill paid, that’s important for me to keep in touch
with my family. Health care appointments’’ [F52]
‘‘Obamaphone is basic phone you can get if you’re on public
assistance. Sixty minutes a month, rolls over. Don’t check
e-mail, it’s hard to text. Have to be conservative with it’’
[F42]
‘‘Yeah I’ve never struggled on that’’ [F54]
‘‘Yeah’’ [F42]
‘‘We’ll see,’’ ‘‘It’s very important’’ [F59]
‘‘Sometime’’ [F28]
‘‘Yeah unlimited plan’’ [F33]
Note. M¼male; F¼ female.
1476 R. Asgary et al.
[M59]. A minority stated that their current phone was their [M53], ‘‘Yeah, usually’’ [F67], ‘‘Well, I have to save it,
first mobile number=phone: ‘‘Four months, I never had many pennies’’ [F57]. And a minority got help from family
before in my life, this is the first time, Medicaid sent it in’’ for their plan: ‘‘No, I get 250 minutes, sometimes my friend
[M55], ‘‘First time I did get a cell’’ [F49]. will help me get the $30 unlimited, most of my calls are to
Around a third of both men and women had an ‘‘Obama- my doctors’’ [F53], ‘‘No, my daughters are the ones helping
phone’’ (provided and paid for by insurance) and elaborated me to pay’’ [F47], ‘‘I never pay the bill for the phone, my
on being able to manage to keep enough phone plan min- family helps with that. They have to, it’s a must if they
utes: ‘‘It’s a free phone, they call it an Obamaphone. I only want to keep in touch’’ [F25]. Please see Table 2 for
make calls when I need to more than when I want to’’ [M59], additional quotes.
‘‘Mine was paid, yes I could afford pay extra minutes’’
[M60], ‘‘I do [afford it]’’ [F27], ‘‘I try to keep at least 5 minutes Perceptions of and Attitudes Toward Text Messaging to
on the phone’’ [F43], ‘‘Yes, it’s only $50 a month’’ [F45], Improve Medical Care
‘‘This is from insurance’’ [F56]. Very few had unlimited
minutes. Close to half stated they usually had money to The majority of women, across age groups and more than
pay for their phone and minutes: ‘‘Yes, I can pay the bill’’ men, welcomed and preferred receiving texts regarding
health messages and navigating health system: ‘‘Hell yeah,
Table 3. Attitudes toward the use of text messaging and mobile technologies in regard to health care among the homeless in New
York City, 2014
Question Sample quotes
How do you feel if someone sends you text ‘‘They could call me for appointment reminders and I’ll answer and
messages regarding your health care? tell them to call her [my wife] and she’ll tell me’’ [M55]
‘‘It’s a free phone, they call it an Obamaphone,’’ ‘‘I only make calls
when I need to more than when I want to’’ [M59]
‘‘That’s no problem, that’s great’’ [M52]
‘‘Yes, that is good idea, I am not annoyed at all’’ [M60]
‘‘That’s good, that would be a nice thing’’ [F57]
‘‘That would be okay with me. Rather they call me into the office
and give me information’’ (in person) [F52]
‘‘Uh, yeah, as long as it wasn’t monotonous,’’ ‘‘Wouldn’t want to
get three texts’’ [F42]
‘‘It would be helpful. It might slip my mind, might be going through
something that day, might need a reminder’’ [F49]
‘‘Yeah that would be very helpful’’ [F66]
‘‘Yeah I think so, it’s always good to get a reminder’’ [F59]
What=how do you suggest=prefer text ‘‘Reminder’’ [M75],
messages be like, the content of texts? ‘‘A reminder, I would like the text message the day before’’ [M59]
‘‘Time for your test . . .whatever’’ [M62]
‘‘Just reminders’’ [M58]
‘‘Tell me what needs to be done, information’’ [M53]
‘‘Information or asking about my health’’ [M53]
‘‘Whatever works for you=doctor, as far as I get info it is all right’’
[M60]
‘‘The information’’ [F46]
‘‘A reminder of the appointment and what it is for’’ [F52]
‘‘Reminders when to get screenings,’’ ‘‘My memory isn’t all that, the
seizures make me forget sometimes’’ [F66]
‘‘Time for a checkup! And just say the appointment, GYN appt on
this date. Very straightforward’’ [F59]
What could be the advantages of free phones ‘‘Yeah, I guess so, how free is it if you run out of minutes . . . so no,
or plans for health-related issues? the plan I have now I pay $40 a month’’ [M62]
‘‘I have one that is free, if they take it back then sure, it would help a
lot’’ [M55]
‘‘Yeah, definitely, that’s one of the calls I don’t ignore’’ [M55]
‘‘Yeah’’ [F27]
‘‘Oh yeah, definitely, I would love to have a free phone’’ [F57]
‘‘Yes,’’ ‘‘Could call that cell to remind about appointments’’ [F40]
‘‘It probably would. Extra incentive for others.’’ [F49]
Note. M¼male; F¼ female.
Attitudes Toward mHealth Among Homeless People 1477
yes I always like to be reminded. I’d like them to do it a week maintaining their phone plans consistently, others either got
in advance as well as the night before’’ [F59], ‘‘Yeah, that free limited insurance phone plans or were supported by
would be cool, that’s fine’’ [F53], ‘‘That helps a lot because family or friends. Most homeless are familiar with and know
that’s something I can save or store’’ [F43], ‘‘I think it is a how to use text messaging; however, older men may have
good idea depending who sends it, if my doctor or for my more difficulty using text messaging because of lack of
health it is great, I love it’’ [M53], ‘‘If it is my doctor it is practice or poor eyesight. The homeless usually make every
okay and if it is for health, texting is good for health related’’ attempt to keep the same phone number over time to main-
[M58]. Very few preferred solely phone calls or in-person tain connections and communication, as they are mobile and
encounters because they were not familiar with texting: lack access to landlines. Limited previous research indicates
‘‘Even to call. Calling is better. Sometimes I don’t remember that 70% of the homeless owned cell phones and had no
to check the phone . . . ’’ [F56], ‘‘Not really, I don’t know significant differences in new media use, modality, or fre-
how to use it yet, calling is better’’ [F59]. Additional quotes quency compared to domicile populations (Post et al.,
are presented in Table 3. 2013). The homeless, however, have significantly lower rates
Overwhelmingly both men and women preferred a simple of contract plans with unlimited minutes (Post et al., 2013).
text message reminder that provides necessary information The homeless appreciate receiving text messages from provi-
rather than lengthier texts and motivational messages: ‘‘To ders or clinics regarding their health care and better manage-
remind me and also to inform me if there’s been something ment of their medical concerns. Many believe that free cell
wrong I can come in and take care of it immediately’’ [M52], phone plans will give them better control over managing
‘‘Reminder with information of my appointment and their health problems and navigating the convoluted health
location and time’’ [F49], ‘‘I think it would be just a general care system. Prior studies have shown that patients experi-
reminder . . . [because] with questions I may not have enough encing homelessness welcome health information regarding
minutes left’’ [F53], ‘‘Little reminder not that much info’’ substance abuse, smoking cessation, pregnancy, domestic
[F49], ‘‘Don’t forget, a reminder’’ [M61], ‘‘Just say you have violence, and mental health (Eyrich-Garg, 2010; Post et al.,
an appointment, date, time, address, and a number to call 2013).
back to confirm. Something simple, nothing too elaborate. There are millions of homeless Americans who need and
Less information, all the extra shit distracts me. Text mess- want to have better access to care but face multilevel barriers
age is easier for me because it’s something visual’’ [F43]. that are not addressed systematically (Asgary, Garland,
Very few participants requested other health tips=recom- Jakubowski, et al., 2014; Asgary, Garland, & Sckell, 2014;
mendations, and others suggested more interesting messages: Chau et al., 2002; Khandor et al., 2011; Lebrun-Harris
‘‘Pink [colored message]’’ [F43], ‘‘Not repeating the same et al., 2013; Wen et al., 2007; Zlotnick & Zerger, 2008).
information verbatim. If there is new information, new The current complex health system poses difficulties to the
machine . . . little tips. Things that would take the stress off homeless in terms of navigating it effectively for preventive
of it. Not the same stuff you could get from a book’’ care and chronic disease management. The homeless also
[F42], ‘‘Information, good news, what I need to do’’ [M55]. face discrimination in the health care system, which dis-
The majority of women and men stated that they would suades them from seeking care (Cooper et al., 2012; Haus-
be more open to text messaging, more empowered to keep mann et al., 2011; Wen et al., 2007). Providers may have
medical appointments, and better able to follow health prejudice and biases against the medical needs and priorities
recommendations if they were given free phones or phone of minorities and may focus largely on addressing their acute
plans: ‘‘I never thought of that, I think everyone would want care needs rather than chronic disease management, risk
that, if that’s possible I’d be 100% behind it’’ [F53], ‘‘I would reduction and risky behaviors, and preventive care (Haus-
imagine it helps a lot for people who can’t afford it’’ [M53], mann et al., 2011; Teal et al., 2010). Strategies to address
‘‘That would be great!’’ [M53], ‘‘That would help a lot of biases among providers have been proposed (Devine, For-
people. Communication means everything. In the shelter scher, Austin, & Cox, 2012; Peek et al., 2012), and mHealth
you should be able to contact your counselor and they give strategies may help reduce missed opportunities for health
you the message. But it doesn’t happen’’ [F43], ‘‘Yeah education and counseling by providing a more consistent
because I need to call my psychiatrist and I didn’t call’’ approach and improved connectivity (Post et al., 2013).
[F56], ‘‘Hell yeah, who doesn’t want that?’’ [F59]. A few The homeless in our sample acknowledged their barriers
men did not think free phones and plans would help them and social conditions and recommended and welcomed
much regarding access to health information as they faced using mHealth technology to get reminders for their preven-
other difficulties or distrusted the government and system: tive care and medical appointments to improve adherence
‘‘I wouldn’t take one of those, I’d rather buy myself a plan. and receive health education.
The government never did anything for me before, why do Mobile technologies are ubiquitous and provide a poten-
they wanna give me a free phone?’’ [M55]. tially excellent platform for providing targeted health ser-
vices especially for mobile populations or those who are
Discussion out of reach and socially marginalized without direct access
to usual health care facilities or health education. The home-
The majority of homeless in New York City own mobile less have poor access to primary care and use emergency
phones. Although some homeless in this study had difficulty departments largely because of their difficulty effectively
1478 R. Asgary et al.
communicating and connecting with health providers or the semi-structured interviews to focus group discussions. Focus
health system and maintaining follow-up visits (Post et al., groups may have allowed for more synergy and potentially
2013). mHealth strategies have been used for the manage- improved sharing of experience and perception. We did
ment of chronic diseases such as hypertension and diabetes not collect data on history of substance abuse, educational
with excellent results in terms of improving uptake, adher- background, or race=ethnicity and were unable to compare
ence, and clinical outcomes of treatment modalities (Car, responses across those spectra. However, previous data from
Gurol-Urganci, de Jongh, Vodopivec-Jamsek, & Atun, our population indicate that the majority of our population
2012; Chen, Fang, Chen, & Dai, 2008; Dick et al., 2011; were Black and Hispanic, and more than half had a high
Guy et al., 2012; Leong et al., 2006; Márquez Contreras school education or less (Asgary, Garland, Jakubowski,
et al., 2004; McGillicuddy et al., 2013) and could be adapted et al., 2014; Asgary, Garland, & Sckell, 2014). We have col-
to address the medical needs of the homeless (Eyrich-Garg, lected data on mental health problems, which did not differ
2010). in regard to response themes among the homeless.
The homeless in this sample overwhelmingly preferred Despite adequate attitudes and perceptions regarding
simple reminders or short, straightforward text messages mobile technologies and text messaging for health care
regarding health issues and disliked long or motivational issues, these strategies have not been generally evaluated or
texts. Contrary to general assumptions, they are enthusiastic used with the homeless. Because of multiple system-level
about getting health education that targets their specifics risks barriers, the current health system fails to provide effective
and conditions and improves their preventive care, which has support for the homeless to have access to the same stan-
been largely ignored. Studies have shown that the content and dards of care that average Americans have. mHealth plat-
format of text messages are important and need to be adjusted forms could be very effective in improving knowledge and
specifically to populations and their needs (Car et al., 2012; access to care for largely mobile populations of homeless
Dick et al., 2011; Márquez Contreras et al., 2004). The type who face discrimination and prejudice within the health sys-
and content of such mHealth communications and their fre- tem; generally avoid the health care system (Wen et al.,
quency could be tailored to recipients’ age range, gender, 2007); and therefore miss common opportunities for health
and cultural background. The homeless in our study were lar- education, regular care, or checkups. Health education and
gely open to receiving straightforward health messages from strategies to improve and promote healthy behaviors are
their providers or people they recognize. particularly important among this unusually marginalized
Existing opportunities in the shelter system with case population. The attitude of the health system needs to
workers and social services could be coupled with mHealth change significantly from providing only basic care to more
text messaging to more effectively help the homeless connect equal opportunities for accessing preventive care and man-
with the health system, reinforce peer education, facilitate agement of chronic diseases, which may be achieved through
the making of medical services referrals, and bring the home- the effective use of mobile technology in the health system.
less and medical providers together and improve communi- Aside from health system changes, there need to be societal
cation. They can provide an opportunity for reciprocal strategies to address and prevent homelessness.
communication as messages and recommendations are
recorded and stored for follow-up and support during coun- Conclusions
seling for changing unhealthy behaviors and addressing mis-
conceptions. mHealth modalities could serve as patient The homeless regularly use mobile technologies and wel-
navigators to counterbalance multilevel barriers to accessing come text messaging modalities to improve their health care.
health care, as they have shown sustained improvement in This significant positive attitude toward and experience with
chronic disease management in the general population. mobile technologies could be effectively used to improve
Our study is among the very few qualitative studies of homeless people’s connection with the health care system
mHealth strategies among the homeless with direct input from and providers, health education, and preventive care and
patients and without preconceived notions from providers or chronic disease management. Policies and plans to improve
health systems, and it helps better explain the priorities and availability of and access to mobile technologies along
underpinning of homeless people’s decision making regarding with targeted and adapted mHealth strategies should be
health care. We collected data from multiple shelters in differ- considered for highly vulnerable and mobile homeless
ent neighborhoods and boroughs of New York City, a city populations.
with one of the largest homeless populations in the country,
and we included a good-size sample of different age ranges Acknowledgment
and genders, which makes our data more generalizable.
Our study is not without limitations. We primarily We thank staff and leadership at the Community Medicine
enrolled participants from shelters and may have missed Program, Lutheran Family Health Centers, New York, for
homeless individuals living exclusively on the street. These their invaluable support of this project.
individuals, however, constitute less than 10% of the total
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