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CRAMER et al .
1 | INTRODUCTION
medical care adherence. The third aim was to explore the financial implications of the intervention 30‐day postdelivery using return on investment (ROI).
1.1 | Background Premature birth is a critical public health problem that causes a significant social and economic burden in the U.S. (Centers for Disease Control, 2017). Each year, 1 in 10 babies in the U.S. is born prematurely (before 37‐week gestation), leading to serious health problems, lengthy hospitalizations, lifelong disability, and death (American College of Obstetrics and Gynecology, 2016; March of Dimes, 2017). In the first year of life, the average health care expen‐ ditures for preterm infants are more than 10 times as high as those for uncomplicated newborns (March of Dimes, 2015). The financial burden from prematurity stretches into adulthood as babies born prematurely can experience lifelong problems including physical and intellectual disabilities, learning delays, vision or hearing loss, behav‐ ior problems, and neurological disorders (March of Dimes, 2017). Access to adequate prenatal health care is essential for reducing preterm births. However, many rural and underserved communities have limited access to care due to health care provider shortages and limited prenatal and social support services (National Conference of State Legislatures, 2016; Van Vleet & Paradise, 2015). Mobile tech‐ nology and community health workers (CHW) are two resources that can address rural and underserved barriers to health care by enhancing patient communication and extending provider outreach across distances (Abroms, Whittaker, Free, Mendel Van Alstyne, & Schindler‐Ruwisch, 2015; Singh et al., 2016; Thirumurthy & Lester, 2012). More than 65% of rural Americans own smartphones (Pew Research Center, 2018; Sterling, 2016), and 62% use their smart‐ phones to get information about health conditions (Smith, 2015). Another emerging resource for underserved areas are CHWs. CHWs are frontline public health workers, most commonly lay people with‐ out formal health care training, who have a close understanding of the community they serve. CHWs provide local, community‐based, culturally appropriate health counseling and education, and help patients connect with health and social support services (American Public Health Association, 2018; Hostetter & Klein, 2016; Kunz et al., 2017). Combining a smartphone intervention with CHW rein‐ forcement has the potential to increase health self‐care in pregnancy to reduce preterm birth in rural and underserved communities. 1.2 | Objectives The primary aim of this pilot study was to assess the feasibility of a tailored smartphone platform intervention (hereinafter re‐ ferred to as prenatal technology platform [PTP]) combined with CHW reinforcement among rural pregnant women. The HIPPA compliant PTP predeveloped by GoMo Health™ combined “tex‐ ting,” mobile websites, and other technologies to deliver targeted evidence‐based prenatal health information, instructional videos, and general wellness tips for pregnant women. The secondary aim was to obtain preliminary data on the appropriateness and prom‐ ise of the intervention on birth outcomes, patient activation, and
2 | METHODS
2.1 | Community‐based participatory research This research project used a community‐based participatory re‐ search approach that partnered academic researcher investigators from a large University with a 30‐member rural community advi‐ sory board formed for the purposes of this study. The community advisory board, named Central Nebraska Prenatal Advisory Board, included local rural health providers, hospital executives, pregnancy testing site directors, the rural regional public health department di‐ rector, a former state senator for the area, representatives from the state’s department of health, two Hispanic, Spanish‐speaking CHW, several directors of regional rural social service agencies, and two health care consumers who were new mothers (Cramer, Lazoritz, Shaffer, Palm & Ford, 2017). Community‐based participatory re‐ search is an essential tool for public health that utilizes community members to identify and address priority clinical problems and test evidence‐based solutions (Barkin, Schlundt, & Smith, 2013; Lasker & Weiss, 2003). Community‐based participatory research is an ideal method to ensure that priority health problems identified by com‐ munity members are understood by researchers and that health is viewed in a manner that is culturally and contextually relevant to people’s real‐life experiences (Barkin et al., 2013). 2.2 | Design, sample, & procedures This two‐group experimental design was approved by the research team’s University Institutional Review Board (IRB). Pregnant women ( n = 114) were recruited through referral by their health care provid‐ ers from five individual medical clinics in rural Midwestern counties. There was no formal training for providers to refer participants and the providers were not reimbursed or incentivized. After participants were referred to the study, enrollment was conducted at an in‐home visit conducted by the CHW where intervention participants were provided the preloaded smartphone. At 36 weeks, the CHW made a second home visit, collected conclusion data, and the smartphone. Inclusion criteria were rural women who planned to deliver at one of three rural hospitals, pregnancy at less than 24 weeks, and the ability to speak and read either Spanish or English. Exclusion criteria were women who required more than usual medical care (e.g., chronic hypertension, heart disease, uncontrolled diabetes) or those significantly predisposed to preterm birth (e.g., multiple gestation or history of preterm delivery). All ages could enroll, although minors had to obtain parental consent. Of those who met inclusion criteria, 98 enrolled and were assigned to the in‐ tervention or control group. Early recruits were assigned to the intervention group and later recruits to the control group due to
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