Underdeveloped or underreported? Coverage of pretesting practices and recommendations for design of text message-based health behavior change interventions

A text messaging intervention to support the mental health of young adults: User engagement and feedback from a field trial of an intervention prototype

Background

Young adults have high rates of mental health conditions, but most do not want or cannot access treatment. By leveraging a medium that young adults routinely use, text messaging programs have potential to keep young adults engaged with content supporting self-management of mental health issues and can be delivered inexpensively at scale. We designed an intervention that imparts strategies for self-managing mental health symptoms through interactive text messaging dialogues and engages users through novelty and variety in strategies (from cognitive behavioral therapy, acceptance and commitment therapy, and positive psychology) and styles of interaction (e.g., prompts, peer stories, writing tasks).

Methods

The aim of this mixed-methods study was to pilot 1- and 2-week versions of an interactive text messaging intervention among young adults (ages 18-25), and to obtain feedback to guide intervention refinements. Young adults were recruited via a mental health advocacy website and snowball sampling at a North American University. We used Wizard-of-Oz methods in which study staff sent messages based on a detailed script. Transcripts of interviews were subject to qualitative analysis to identify aspects of the program that need improvements, and to gather participant perspectives on possible solutions.

Results

Forty-eight individuals ages 18-25 participated in the study (mean age: 22.0). 85 % responded to the program at least once. Among those who ever responded, they replied to messages on 85 % of days, and with engagement sustained over the study period. Participants endorsed the convenience of text messaging, the types of interactive dialogues, and the variety of content. They also identified needed improvements to message volume, scheduling, and content.

Conclusions

Young adults showed high levels of engagement and satisfaction with a texting program supporting mental health self-management. The program may be improved through refining personalization, timing, and message volume, and extending content to support use over a longer timeframe. If shown to be effective in randomized trials, this program has potential to help address a substantial treatment gap in young adults' mental health.

The Development of Text Messages to Support People at Risk of Diabetes in Low-Resourced Communities: The South African Diabetes Prevention Programme

Emerging evidence suggests that the addition of text messages to standard healthy lifestyle interventions may improve the outcomes of diabetes prevention programs (DPP). This paper describes the process of developing text messages targeting behavior change in people at risk of developing diabetes in low-resourced communities as part of the South African DPP (SA-DPP). The development comprised multiple steps led by nutrition and physical activity experts. The steps included the following: (1) text message development based on the existing SA-DPP curriculum and its formative research; (2) text message evaluation for readability/understandability in terms of content, language, and quality, with 75 participants from two low-resourced areas in Cape Town; (3) text message refinement by the expert panel; (4) evaluation of the refined text messages by participants from Step 2; and (5) text bank finalization. Based on the readability survey, 37 of the 67 formulated text messages [24 of the 44 encouraged healthy eating, and 13 of the 23 promoted physical activity] were refined. Based on focused discussions with participants, seven more messages were refined to consider alternative terminology. The final text bank includes a total of 67 messages comprising topics related to fruit and vegetable consumption as well as the importance of having variety in the diet (n = 15), limiting fat intake (n = 10), avoiding sugar (n = 11), avoiding salt (n = 5), promoting fiber-rich foods (n = 1), messages promoting physical activity (n = 21), and general check-in messages (n = 4). Most of the text messages were acceptable, understandable, and largely feasible to all participants, with some of the nutrition-related messages being less feasible for participants due to their socioeconomic position. The next step is to assess the text messages in the SA-DPP intervention trial.

Feasibility, Acceptability, and Initial Efficacy of a Digital Intervention to Improve Consumption of Foods Received within a National Nutrition Assistance Program

Many mothers are vulnerable to poor diet quality, particularly those living in low-income households. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrient-rich foods through its benefits packages, but many WIC participants are not redeeming them. We assessed the feasibility and acceptability of a digital intervention to support redemption and consumption of WIC-approved foods to ultimately improve diet quality. We enrolled 54 maternal-child dyads receiving WIC benefits to receive three to four weekly text messages for 12 weeks focused on behavioral goals to improve consumption of WIC-approved foods. We assessed engagement with weekly tracking messages and satisfaction and collected 24 h dietary recalls to assess preliminary efficacy on dietary intake. Participants were mostly non-Hispanic white (63%) and working (63%), and responded to 7.4 (standard deviation: 4.6) of the 12 weekly messages. Half (n = 27) were high engagers (responded to 80% or more of weekly messages), with 28% (n = 15) responding to all messages. Most felt the feedback (94%) and tips (87%) were helpful and would recommend the program (91%). More were consuming leafy green vegetables compared to baseline (p = 0.01). Mothers of children enrolled in WIC found a text messaging intervention focused on consumption of WIC-approved foods enjoyable and helpful.

Fifteen Years after a 10-year Retrospective: The State of Health Mass Mediated Campaigns

In 2006, a 10-year retrospective of successful mass mediated health communication campaigns reviewed the field and highlighted strategies for successful campaigns. In the 15 years since the retrospective, there have been dramatic changes in the media environment and advances in health communication research. In this article, we describe changes in the health communication media landscape and in our understanding of mass mediated health communication campaigns in the 15 years since the retrospective. Although the media environment has shifted, we argue that effective principles of health communication have remained relatively constant. We note significant advances in technology since the previous retrospective that can further advance health communication campaigns, with new technologies offering promise as channels for health communication campaigns as well as for campaign planning. We also recommend that campaign researchers report in detail on their use of theory, audience segmentation, channel selection, and the role of formative research when describing campaign efforts; that communicators continue to develop frameworks that integrate principles of effective campaign design; and that additional research focus on understanding how technology can be effectively incorporated into campaign planning, distribution, and evaluation.

Digital interventions for promoting sun protection and skin self-examination behaviors: A systematic review

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A considerable number of digital interventions for skin cancer prevention have been evaluated.

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Most skin cancer digital interventions focus on sun protection-related outcomes.

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Most interventions use web-based digital technology (websites, webpages, mobile apps) rather than videos, emails or text messages alone as the delivery platform.

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Multi-component digital interventions are effective in promoting sun protection and skin self-examination.

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Almost all studies found digital interventions to be equally or more effective compared to non-digital interventions.

The skin cancer incidence rate has been rising, and digital health interventions can promote skin cancer prevention and detection behaviors. A systematic review was conducted to investigate the outcomes of digital interventions that promote sun protection and skin self-examination (SSE). This review examined studies that utilized randomized controlled designs or quasi-experiments, included outcomes related to sun safety or SSE, employed at least one digital platform, and were published in English from January 2000 to October 2020. A total of 62 studies were included in the review. Digital modalities included web-based (e.g., websites) alone (n = 29), mobile-based (e.g., mobile apps) alone (n = 12), game-based (n = 1), emails or text messages alone (n = 8), videos alone (n = 6), social media (n = 3), both text messages and mobile apps (n = 2), or both text messages and video (n = 1). Most studies (n = 44) only evaluated sun protection-related outcomes, seven studies assessed SSE outcomes only, nine studies examined both, and two assessed other related outcomes. Digital interventions are effective compared to non-intervention control conditions in promoting sun safety or SSE. Almost all studies found digital interventions to be equally or more effective compared to non-digital interventions. This review suggests that although the digital interventions varied, they showed promising effects on improving sun protection or SSE outcomes. Future research should include more sophisticated phase-based and rigorous longitudinal research designs, additional investigation of social media and other newer technologies, as well as more detailed reporting of methods and results.

mHealth prompts within diabetes prevention programs: a scoping review

BACKGROUND

Mobile health (mHealth) prompts (e.g., text messaging, push notifications) are a commonly used technique within behaviour change interventions to prompt or cue a specific behaviour. Such prompts are being increasingly integrated into diabetes prevention programs (DPPs). While mHealth prompts provide a convenient and cost-effective way to reinforce behaviour change, no reviews to date have examined mHealth prompt use within DPPs. This scoping review aims to: (I) understand how mHealth prompts are being used within behaviour change interventions for individuals at risk for developing type 2 diabetes (T2D); and (II) provide recommendations for future mHealth prompt research, design, and application.

METHODS

The scoping review methodology outlined by Arksey and O'Malley were followed. Medline, CINAHL, PsycInfo, Web of Science, and SportDiscus were searched. The search strategy combined keywords relating to T2D risk and mHealth prompts in conjunction with database-controlled vocabulary when available (e.g., MeSH for Medline).

RESULTS

Of the 4,325 publications screened, 44 publications (based on 33 studies) met the inclusion criteria and were included for data extraction. Text messaging was the most widely used mHealth prompt (73%) followed by push notifications (21%). Only 30% of studies discussed the theoretical basis for prompt content and time of day messages were sent, and only 27% provided justification for prompt timing and frequency. Fourteen studies assessed participant satisfaction with mHealth prompts of which only two reported dissatisfaction due to either prompting frequency (hourly) or message content (solely focused on weight). Nine studies assessed behavioural outcomes including weight loss, physical activity, and diabetes incidence, and found mixed effects overall.

CONCLUSIONS

While mHealth prompts were well-received by participants, there are mixed effects on the influence of mHealth prompts on behavioural outcomes and diabetes incidence. More thorough reporting of prompt content development and delivery is needed, and more experimental research is needed to identify optimal content, delivery characteristics, and impact on behavioural and clinical outcomes.

Six-Month Outcomes from the NEXit Junior Trial of a Text Messaging Smoking Cessation Intervention for High School Students: Randomized Controlled Trial With Bayesian Analysis

Background

The prevalence of daily or occasional smoking among high school students in Sweden was approximately 20% in 2019, which is problematic since lifestyle behaviors are established in adolescence and track into adulthood. The Nicotine Exit (NEXit) Junior trial was conducted in response to a lack of evidence for the effects of text message smoking cessation interventions among high school students in Sweden.

Objective

The aim of this study was to estimate the 3- and 6-month effects of a text messaging intervention among high school students in Sweden on smoking cessation outcomes.

Methods

A 2-arm, single-blind randomized controlled trial was employed to estimate the effects of the intervention on smoking cessation in comparison to treatment as usual. Participants were recruited from high schools in Sweden using advertising and promotion by school staff from January 10, 2018, to January 10, 2019. Weekly or daily smokers who were willing to make a quit attempt were eligible for inclusion. Prolonged abstinence and point prevalence of smoking cessation were measured at 3 and 6 months after randomization.

Results

Complete case analysis was possible on 57.9% (310/535) of the participants at 6 months, with no observed statistically significant effect on 5-month prolonged abstinence (odds ratio [OR] 1.27, 95% CI 0.73-2.20; P=.39) or 4-week smoking cessation (OR 1.42; 95% CI 0.83-2.46; P=.20). Sensitivity analyses using imputation yielded similar findings. Unplanned Bayesian analyses showed that the effects of the intervention were in the anticipated direction. The findings were limited by the risk of bias induced by high attrition (42.1%). The trial recruited high school students in a pragmatic setting and included both weekly and daily smokers; thus, generalization to the target population is more direct compared with findings obtained under more strict study procedures.

Conclusions

Higher than expected attrition rates to follow-up 6 months after randomization led to null hypothesis tests being underpowered; however, unplanned Bayesian analyses found that the effects of the intervention were in the anticipated direction. Future trials of smoking cessation interventions targeting high school students should aim to prepare strategies for increasing retention to mid- and long-term follow-up.

Trial Registration

IRCTN Registry ISRCTN15396225; https://www.isrctn.com/ISRCTN15396225

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-018-3028-2

Adding to the Message Testing Tool Belt: Assessing the Feasibility and Acceptability of an EMA-Style, Mobile Approach to Pretesting mHealth Interventions

Effective health message design requires strong pretesting to ensure that potential audiences see communication efforts as acceptable. Previous research has often used long-form surveys to test messaging, even when the potential communication efforts are going to take place in a non-traditional format, such as on a text message platform. This study asks whether real-time sampling on a mobile phone could serve as a message-testing alternative to traditional surveys. Participants evaluated health messages over a week using mobile phones in a style similar to ecological momentary assessment. More than 90 percent of messages were evaluated, and a majority of participants preferred this methodology to other pretesting methods. This approach, while not without limitations, is a viable tool for diversifying message testing efforts.

Evaluation and Refinement of a Bank of SMS Text Messages to Promote Behavior Change Adherence Following a Diabetes Prevention Program: Survey Study

Background

SMS text messaging is a low-cost and far-reaching modality that can be used to augment existing diabetes prevention programs and improve long-term diet and exercise behavior change adherence. To date, little research has been published regarding the process of SMS text message content development. Understanding how interventions are developed is necessary to evaluate their evidence base and to guide the implementation of effective and scalable mobile health interventions in public health initiatives and in future research.

Objective

This study aims to describe the development and refinement of a bank of SMS text messages targeting diet and exercise behavior change to be implemented following a diabetes prevention program.

Methods

A bank of 124 theory-based SMS text messages was developed using the Behaviour Change Wheel and linked to active intervention components (behavior change techniques [BCTs]). The Behaviour Change Wheel is a theory-based framework that provides structure to intervention development and can guide the use of evidence-based practices in behavior change interventions. Once the messages were written, 18 individuals who either participated in a diabetes prevention program or were a diabetes prevention coach evaluated the messages on their clarity, utility, and relevance via survey using a 5-point Likert scale. Messages were refined according to participant feedback and recoded to obtain an accurate representation of BCTs in the final bank.

Results

76/124 (61.3%) messages were edited, 4/124 (3.2%) were added, and 8/124 (6.5%) were removed based on participant scores and feedback. Of the edited messages, 43/76 (57%) received minor word choice and grammar alterations while retaining their original BCT code; the remaining 43% (33/76, plus the 4 newly written messages) were recoded by a reviewer trained in BCT identification.

Conclusions

This study outlines the process used to develop and refine a bank of SMS text messages to be implemented following a diabetes prevention program. This resulted in a bank of 120 theory-based, user-informed SMS text messages that were overall deemed clear, useful, and relevant by both individuals who will be receiving and delivering them. This formative development process can be used as a blueprint in future SMS text messaging development to ensure that message content is representative of the evidence base and is also grounded in theory and evaluated by key knowledge users.

TEXT4myBACK: A Text Message Intervention to Improve Function in People With Low Back Pain-Protocol of a Randomized Controlled Trial

OBJECTIVE

The authors sought to describe the protocol of a randomized controlled trial that will investigate the effects of the TEXT4myBACK self-management text message intervention compared with control in people with low back pain (LBP).

METHODS

A single-blind (assessor and statistician), randomized controlled trial with economic analysis and process evaluation will be conducted. A total of 304 people with non-specific LBP of less than 12 weeks will be enrolled and randomly allocated either to TEXT4myBACK intervention or control groups. The TEXT4myBACK intervention group will receive 4 semi-personalized text messages per week providing advice, motivation, and information about LBP, physical activity, sleep, mood, use of care, and medication during 12 weeks. The control group will receive 1 text message with a link to a LBP and diet online information package. Outcomes will be assessed at baseline and 3, 6, and 12 months. The primary outcome will be function assessed with the Patient-Specific Functional Scale. Secondary outcomes will include pain intensity, physical activity participation, sedentary behavior, global impression of change, health-related quality of life, and eHealth literacy. Data on demographic characteristics, smallest worthwhile change (ie, smallest function scored needed to be achieved at the end of the intervention to consider it to be worthwhile), health care utilization, and adverse events (ie, any new health issue that occurs during participation in the study) will be collected. An economic and process evaluation will also be conducted.

IMPACT

This study will assess if a self-management text message intervention is effective and cost-effective in improving function of people with LBP. This study can inform clinical practice of a simple, scalable, and affordable intervention for managing LBP.

TEXT4myBACK - The Development Process of a Self-Management Intervention Delivered Via Text Message for Low Back Pain

OBJECTIVE

To develop a bank of text messages for a lifestyle-based self-management intervention for people with low back pain (LBP).

DESIGN

Iterative development process.

SETTING

Community and primary care.

PARTICIPANTS

Fifteen researchers, clinicians, and consumer representatives participated in the concept and initial content development phase. Twelve experts (researchers and clinicians) and 12 consumers participated in the experts and consumers review phase. Full study sample of participants was N=39.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We first conducted two 2-hour workshops to identify important domains for people with LBP, sources of content, appropriate volume, and timing of the messages. The messages were then drafted by a team of writers. Second, we invited expert researchers and clinicians to review and score the messages using a 5-item psychometric scale according to (1) the appropriateness of the content and (2) the likelihood of clinical effectiveness and to provide written feedback. Messages scoring ≤8 out of 10 points would be modified accordingly. Consumers were invited to review the messages and score them using a 5-item psychometric scale according to the utility of the content, the understanding of the content, and language acceptability and to provide feedback. Messages scoring ≤12 out of 15 points would be improved.

RESULTS

Exercise, education, mood, sleep, use of care, and medication domains were identified and 82 domain-specific evidence-based messages were written. Messages received a mean score of 8.3 out of 10 points by experts. Twenty-nine messages were modified accordingly. The mean score of the messages based on consumers feedback was of 12.5 out of 15 points. Thirty-six messages were improved.

CONCLUSIONS

We developed a bank of text messages for an evidence-based self-management intervention using a theory-based, iterative, codesign process with researchers, consumers, and clinicians. This article provides scientific support for future development of text message interventions within the pain field.

Developing Messaging Content for a Physical Activity Smartphone App Tailored to Low-Income Patients: User-Centered Design and Crowdsourcing Approach

Background

Text messaging interventions can be an effective and efficient way to improve health behavioral changes. However, most texting interventions are neither tested nor designed with diverse end users, which could reduce their impact, and there is limited evidence regarding the optimal design methodology of health text messages tailored to low-income, low–health literacy populations and non-English speakers.

Objective

This study aims to combine participant feedback, crowdsourced data, and researcher expertise to develop motivational text messages in English and Spanish that will be used in a smartphone app–based texting intervention that seeks to encourage physical activity in low-income minority patients with diabetes diagnoses and depression symptoms.

Methods

The design process consisted of 5 phases and was iterative in nature, given that the findings from each step informed the subsequent steps. First, we designed messages to increase physical activity based on the behavior change theory and knowledge from the available evidence. Second, using user-centered design methods, we refined these messages after a card sorting task and semistructured interviews (N=10) and evaluated their likeability during a usability testing phase of the app prototype (N=8). Third, the messages were tested by English- and Spanish-speaking participants on the Amazon Mechanical Turk (MTurk) crowdsourcing platform (N=134). Participants on MTurk were asked to categorize the messages into overarching theoretical categories based on the capability, opportunity, motivation, and behavior framework. Finally, each coauthor rated the messages for their overall quality from 1 to 5. All messages were written at a sixth-grade or lower reading level and culturally adapted and translated into neutral Spanish by bilingual research staff.

Results

A total of 200 messages were iteratively refined according to the feedback from target users gathered through user-centered design methods, crowdsourced results of a categorization test, and an expert review. User feedback was leveraged to discard unappealing messages and edit the thematic aspects of messages that did not resonate well with the target users. Overall, 54 messages were sorted into the correct theoretical categories at least 50% of the time in the MTurk categorization tasks and were rated 3.5 or higher by the research team members. These were included in the final text message bank, resulting in 18 messages per motivational category.

Conclusions

By using an iterative process of expert opinion, feedback from participants that were reflective of our target study population, crowdsourcing, and feedback from the research team, we were able to acquire valuable inputs for the design of motivational text messages developed in English and Spanish with a low literacy level to increase physical activity. We describe the design considerations and lessons learned for the text messaging development process and provide a novel, integrative framework for future developers of health text messaging interventions.

Design, development and usability testing of Essential Coaching for Every Mother: A postnatal text message educational intervention

BACKGROUND

The transition to motherhood is an exciting yet challenging period that requires physical, emotional, and social adjustment. During the postpartum period, mothers require support and information to ensure a smooth transition and adjustment to motherhood. One innovative strategy to provide mothers with this information is mobile health (mHealth), and specifically, text messaging.

OBJECTIVE

To describe the design, development and usability testing of a postnatal text message intervention called Essential Coaching for Every Mother.

METHODS

First time mothers (n=11) and postpartum healthcare providers (n=18) were involved in iterative interviewing in Halifax, Canada. Adaption of content occurred through three rounds of user testing using semi-structured interviews. The Information Assessment Method (IAM) Parents survey was also completed by mothers.

RESULTS

Three cycles of iterative testing were conducted with eight participants (3 mothers, 5 healthcare providers), thirteen participants (8 mothers, 5 healthcare providers) and 8 participants (8 healthcare providers), respectively. Messages evolved from risk-focused to prevention and education focused. Mothers felt the messages addressed their needs and healthcare providers ensured the content was consistent with the messaging currently provided to postpartum mothers.

CONCLUSION

Essential Coaching for Every Mother is the first postnatal educational text message intervention developed for mothers in Halifax, Canada. We sought to involve first time mothers (end-users) and postpartum healthcare providers (experts) in the development and usability evaluation to ensure the intervention adequately met needs and was consistent with current practices related to postpartum education.

mHealth smoking cessation intervention among high school students: 3-month primary outcome findings from a randomized controlled trial

Background

Smoking among adolescents remains a global public health issue as youth continue to maintain high prevalence rates. The evidence for the efficacy of text messaging interventions to reduce smoking behavior is well established, yet there is still a need for studies targeting high school students. The aim of the study was to determine the effectiveness of a text-based smoking cessation intervention among high school students in Sweden.

Methods

The study was a two-arm randomized trial conducted from January 10 2018 to January 11 2019, data were analysed from April 12 2019 to May 21 2019. Inclusion criteria were high school students who were daily or weekly smokers willing to attempt to quit smoking and owned a mobile phone. The study invited all students at 630 high schools units throughout Sweden. The intervention group received text messages based on components of effective smoking cessation interventions for 12 weeks. The control group were offered treatment as usual. The primary outcomes were self-reported prolonged abstinence (not having smoked more than 5 cigarettes over the last 8 weeks) and 4-week point prevalence of smoking abstinence.

Findings

A total of 535 participants, with a median age of 17 (IQR 16–18), were randomized into the study; 276 (164 [59.4%] women) were allocated to the intervention and 259 (162 [62.5%] women) to the control group. The outcomes of the trial were analyzed on a total of 212 (76.8%) participants in the intervention group and 201 (77.6%) participants in the control group. Prolonged abstinence at the 3-month follow-up was reported by 49 (23.1%) individuals in the intervention group and 39 (19.4%) individuals in the control group (adjusted OR, 1.21; 95% CI, 0.73–2.01; P value, .46). Four-week point prevalence of complete smoking cessation was reported by 53 (25.0%) individuals in the intervention group and 31 (15.4%) individuals in the control group (adjusted OR, 1.87; 95% CI, 1.12–3.17; P value, .018).

Conclusions

Estimates of 4-week point prevalence of complete cessation was 10 percentage points higher in the group that were given access to the intervention compared to the control. Findings provide confirmation that text messaging-based smoking cessation programs can affect quit rates among adolescents.

Trial registration

ISRCTN15396225; registration date October 13, 2017, https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3028-2.

"The Closer, the Better:" The Role of Telehealth in Increasing Contraceptive Access Among Women in Rural South Carolina

BACKGROUND

Rural populations face unique health disparities that prevent women from accessing reproductive health care services. Telehealth initiatives offer a health care delivery tool to increase access to contraception.

OBJECTIVE

To understand women's contraceptive needs and perceptions of accessing contraception through telehealth services.

METHODS

Researchers conducted 52 in-depth interviews with women ages 18-44 years living in five rural counties in South Carolina from May to July 2015. Researchers employed constant comparative data analysis using HyperRESEARCH 3.7.2.

RESULTS

Most participants identified as Black (62%) or White (28%). Findings suggest successful telehealth interventions should accommodate women's complex and nuanced community views, including benefits and barriers of telehealth, to improve access to contraceptive methods in rural locations. In addition, telehealth initiatives should frame contraception as contributing to women's overall health and well-being.

CONCLUSIONS FOR PRACTICE

Telehealth initiatives may address barriers to contraceptive access in rural locations. Findings from this study offer theoretical and practical opportunities to guide telehealth interventions that support and empower women's access to contraceptive methods in rural areas.

Utilizing Digital Health Technologies for Patient Education in Lifestyle Medicine

Technology has redefined the way patients and providers communicate and obtain health information. The realm of digital health encompasses a diverse set of technologies, including mobile health, health information technology, wearable devices, telehealth and telemedicine, and personalized medicine. These technologies have begun to improve care delivery without the traditional constraints of distance, location, and time. A growing body of evidence supports the use of digital health technology for improving patient education and implementation of skills and behaviors integral to lifestyle medicine. Patient education can now be delivered in standard formats (eg, articles, written messages) as well a wide array of multimedia (video, audio, interactive games, etc), which may be more appropriate for certain topics and learning styles. In addition, patient engagement in their care plays an important role in improving health outcomes. Despite digital health technology development often outpacing its research, there is sufficient evidence to support the use of many current technologies in clinical practice. Digital health tools will continue to grow in their ability to cost-effectively monitor and encourage healthy behaviors at scale, and better methods of evaluation will likely increase clinician confidence in their use.

Feasibility and acceptability of a mobile messaging program within a church-based healthy living intervention for African Americans and Latinos

Church-based programs can act on multiple levels to improve dietary and physical activity behaviors among African Americans and Latinos. However, the effectiveness of these interventions may be limited due to challenges in reaching all congregants or influencing behavior outside of the church setting. To increase intervention impact, we sent mobile messages (text and email) in English or Spanish to congregants (n = 131) from predominantly African American or Latino churches participating in a multi-level, church-based program. To assess feasibility and acceptability, we collected feedback throughout the 4-month messaging intervention and conducted a process evaluation using the messaging platform. We found that the intervention was feasible to implement and acceptable to a racially ethnically diverse study sample with high obesity and overweight rates. While the process evaluation had some limitations (e.g. low response rate), we conclude that mobile messaging is a promising, feasible addition to church-based programs aiming to improve dietary and physical activity behaviors.

Examining Development Processes for Text Messaging Interventions to Prevent Cardiovascular Disease: Systematic Literature Review

Background

Interventions delivered by mobile phones have the potential to prevent cardiovascular disease (CVD) by supporting behavior change toward healthier lifestyles and treatment adherence. To allow replication and adaptation of these interventions across settings, it is important to fully understand how they have been developed. However, the development processes of these interventions have not previously been systematically examined.

Objective

This study aimed to systematically describe and compare the development process of text messaging interventions identified in the Text2PreventCVD systematic review.

Methods

We extracted data about the development process of the 9 interventions identified in the Text2PreventCVD systematic review. Data extraction, which was guided by frameworks for the development of complex interventions, considered the following development stages: intervention planning, design, development, and pretesting. Following data extraction, we invited the developers of the interventions to contribute to our study by reviewing the accuracy of the extracted data and providing additional data not reported in the available publications.

Results

A comprehensive description of the development process was available for 5 interventions. Multiple methodologies were used for the development of each intervention. Intervention planning involved gathering information from stakeholder consultations, literature reviews, examination of relevant theory, and preliminary qualitative research. Intervention design involved the use of behavior change theories and behavior change techniques. Intervention development involved (1) generating message content based on clinical guidelines and expert opinions; (2) conducting literature reviews and primary qualitative research to inform decisions about message frequency, timing, and level of tailoring; and (3) gathering end-user feedback concerning message readability, intervention acceptability, and perceived utility. Intervention pretesting involved pilot studies with samples of 10 to 30 participants receiving messages for a period ranging from 1 to 4 weeks.

Conclusions

The development process of the text messaging interventions examined was complex and comprehensive, involving multiple studies to guide decisions about the scope, content, and structure of the interventions. Additional research is needed to establish whether effective messaging systems can be adapted from work already done or whether this level of development is needed for application in other conditions and settings.

Design and development of a complex narrative intervention delivered by text messages to reduce binge drinking among socially disadvantaged men

Background

Socially disadvantaged men are at high risk of suffering from alcohol-related harm. Disadvantaged groups are less likely to engage with health promotion. There is a need for interventions that reach large numbers at low cost and which promote high levels of engagement with the behaviour change process. The aim of this study was to design a theoretically and empirically based text message intervention to reduce binge drinking by socially disadvantaged men.

Results

Following MRC guidance, the intervention was developed in four stages. Stage 1 developed a detailed behaviour change strategy based on existing literature and theory from several areas. These included the psychological theory that would underpin the intervention, alcohol brief interventions, text message interventions, effective behaviour change techniques, narratives in behaviour change interventions and communication theory. In addition, formative research was carried out. A logic model was developed to depict the pathways between intervention inputs, processes and outcomes for behaviour change. Stage 2 created a narrative which illustrated and modelled key steps in the strategy. Stage 3 rendered the intervention into a series of text messages and ensured that appropriate behavioural change techniques were incorporated. Stage 4 revised the messages to ensure comprehensive coverage of the behaviour change strategy and coherence of the narrative. It also piloted the intervention and made final revisions to it.

Conclusions

The structured, systematic approach to design created a narrative intervention which had a strong theoretical and empirical basis. The use of a narrative helped make the intervention realistic and allowed key behaviour change techniques to be modelled by characters. The narrative was intended to promote engagement with the intervention. The intervention was rendered into a series of short text messages, and subsequent piloting showed they were acceptable in the target group. Delivery of an intervention by text message offers a low-cost, low-demand method that can reach large numbers of people. This approach provides a framework for the design of behaviour change interventions which could be used for interventions to tackle other health behaviours.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0298-0) contains supplementary material, which is available to authorized users.

Photo-sharing social media for eHealth: analysing perceived message effectiveness of sexual health information on Instagram

Health professionals increasingly use social media to communicate health information, but it is unknown how visual message presentation on these platforms affects message reception. This study used an experiment to analyse how young adults (n = 839) perceive sexual health messages on Instagram. Participants were exposed to one of four conditions based on visual message presentation. Messages with embedded health content had the highest perceived message effectiveness ratings. Additionally, message sensation value, attitudes and systematic information processing were significant predictors of perceived message effectiveness. Implications for visual message design for electronic health are discussed.

Beyond Basic Feedback in Mobile Brief Interventions: Designing SMS Message Content for Delivery to Young Adults During Risky Drinking Events

BACKGROUND

Brief interventions can reduce alcohol consumption in young people through screening and delivery of personally relevant feedback. Recently, Web and mobile platforms have been harnessed to increase the reach of brief interventions. Existing literature on mobile-based alcohol brief interventions indicates mixed use of theory in developing interventions. There is no research available to guide the development of SMS text messaging (short message service, SMS) interventions delivered during risky drinking events.

OBJECTIVE

The aim of this study was to develop and pilot an alcohol-related risk-reduction brief intervention delivered by SMS to Australian young adults during drinking events. This paper describes the development of intervention message content, with specific focus on the context of delivery during drinking events.

METHODS

A sample of 42 young adults attended 4 workshops; these comprised focus-group style discussion on drinking habits and motivations, discussion of intervention design, analysis of existing alcohol media campaigns, and participant development of message content. Data were analyzed thematically.

RESULTS

Participants described a focus on having fun and blocking out any incongruent negative influences during drinking episodes. For content to be acceptable, nonjudgmental and non-authoritative language was deemed essential. A preference for short, actionable messages was observed, including suggestions for reminders around drinking water, organizing transport home, checking on friends, and plans the next day. Participants were excited about the potential for messages to be tailored to individuals, as previous alcohol-related campaigns were deemed too generic and often irrelevant. Normative-based messages were also perceived as largely irrelevant as participants felt that they understood the drinking-related norms of their immediate peers already.

CONCLUSIONS

Findings from this study offer insights into young adults' drinking events and practical advice for designing alcohol-related brief interventions. During our formative development process, we demonstrated a neat correspondence between young people's preferences for alcohol harm reduction interventions and the theoretical principles of brief interventions, including acceptable topics and message style.

The Effect of Timing and Frequency of Push Notifications on Usage of a Smartphone-Based Stress Management Intervention: An Exploratory Trial

Push notifications offer a promising strategy for enhancing engagement with smartphone-based health interventions. Intelligent sensor-driven machine learning models may improve the timeliness of notifications by adapting delivery to a user’s current context (e.g. location). This exploratory mixed-methods study examined the potential impact of timing and frequency on notification response and usage of Healthy Mind, a smartphone-based stress management intervention. 77 participants were randomised to use one of three versions of Healthy Mind that provided: intelligent notifications; daily notifications within pre-defined time frames; or occasional notifications within pre-defined time frames. Notification response and Healthy Mind usage were automatically recorded. Telephone interviews explored participants’ experiences of using Healthy Mind. Participants in the intelligent and daily conditions viewed (d = .47, .44 respectively) and actioned (d = .50, .43 respectively) more notifications compared to the occasional group. Notification group had no meaningful effects on percentage of notifications viewed or usage of Healthy Mind. No meaningful differences were indicated between the intelligent and non-intelligent groups. Our findings suggest that frequent notifications may encourage greater exposure to intervention content without deterring engagement, but adaptive tailoring of notification timing does not always enhance their use. Hypotheses generated from this study require testing in future work.

Trial registration number: ISRCTN67177737

Participatory development of MIDY (Mobile Intervention for Drinking in Young people)

Background

There are few effective strategies that respond to the widespread practice of risky single-occasion drinking in young people. Brief interventions, which involve screening of alcohol consumption and personalised feedback, have shown some efficacy in reducing alcohol consumption, but are typically delivered in clinical settings. Mobile phones can be used to reach large populations instantaneously, both for data collection and intervention, but this has not been studied in combination during risky drinking events

Methods

Our study investigated the feasibility and acceptability of a mobile-phone delivered Ecological Momentary Assessment (EMA) and brief intervention for young people during drinking events. Our participatory design involved development workshops, intervention testing and evaluation with 40 young people in Melbourne, Australia. The final intervention included text message prompts to fill in mobile-based questionnaires, which measured drinks consumed, spending, location and mood, with additional questions in the initial and final questionnaire relating to plans, priorities, and adverse events. Participants received a tailored feedback SMS related to their drinking after each hourly questionnaire. The intervention was tested on a single drinking occasion. Prompts were sent between 6 pm and 2 am during a drinking event, with one follow up at 12 pm the following day.

Results

Participants reported being comfortable with hourly mobile data collection and intervention during social occasions, and found the level of intrusion acceptable; we achieved an 89 % response rate on the single occasion of testing. Participants were proactive in suggesting additional questions that would assist in the tailoring of feedback content, despite the added time burden. While we did not test the effectiveness of the intervention, participants reported value in the tracking and feedback process, with many stating that they would normally not be aware of how much alcohol they consumed in a night.

Conclusions

Findings suggest that the intervention was considered acceptable, feasible and novel to our participants; it now requires comprehensive testing and evaluation.

Unpacking the Black Box: A Formative Research Approach to the Development of Theory-Driven, Evidence-Based, and Culturally Safe Text Messages in Mobile Health Interventions

Background

Mobile-cellular subscriptions have increased steadily over the past decade. The accessibility of SMS messages over existing mobile networks is high and has almost universal availability even on older and unsophisticated mobile phones and in geographic settings where wireless coverage is weak. There is intensive exploration of this inexpensive mobile telecommunication technology to improve health services and promote behavior change among vulnerable populations. However, a neglected area of research is the documentation and critical analysis of the formative research process required in the development and refinement of effective SMS messages.

Objective

The objective of this qualitative research study was to identify major factors that may impact on the effectiveness of evidence-based SMS messages designed to reduce health inequities in hypertension management in low resource settings, including Aboriginal populations in high-income countries and rural populations in low-income countries. Specifically, we were interested in uncovering the range of mediators that impact on appropriate message content transmission and, ultimately, on health behavior improvements in a range of these sociocultural settings.

Methods

Collaborative qualitative research with Canadian Aboriginal and Tanzanian participants was conducted to deconstruct the content and transmission of evidence-based health information contained in SMS messages in the context of an international research project designed to address health inequalities in hypertension, and to develop a grounded theory of the major factors that mediate the effectiveness of this communication. We also examined the interrelationship of these mediators with the three essential conditions of the behavior system of the Behavioral Change Wheel model (capability, opportunity, and motivation) and cultural safety.

Results

Four focus groups with a total of 45 participants were conducted. Our grounded theory research revealed how discrepancies develop between the evidence-based text message created by researchers and the message received by the recipient in mobile health interventions. These discrepancies were primarily generated by six mediators of meaning in SMS messages: (1) negative or non-affirming framing of advocacies, (2) fear- or stress-inducing content, (3) oppressive or authoritarian content, (4) incongruity with cultural and traditional practices, (5) disconnect with the reality of the social determinants of health and the diversity of cultures within a population, and (6) lack of clarity and/or practicality of content. These 6 mediators of meaning provide the basis for sound strategies for message development because they impact directly on the target populations’ capability, opportunity, and motivation for behavior change.

Conclusions

The quality of text messages impacts significantly on the effectiveness of a mobile health intervention. Our research underscores the urgent need for interventions to incorporate and evaluate the quality of SMS messages and to examine the mediators of meaning within each targeted cultural and demographic group. Reporting on this aspect of mobile health intervention research will allow researchers to move away from the current black box of SMS text message development, thus improving the transparency of the process as well as the quality of the outcomes.