Design considerations in developing a text messaging program aimed at smoking cessation

Development and Evaluation of Messages to Facilitate Secure Storage and Disposal of Prescribed Opioid Medication

BACKGROUND

Secure storage and disposal is a critical strategy to reduce prescription opioid misuse. We sought to develop effective messages to promote secure storage and disposal of unused opioid medications that can be used in interventions designed to reduce diversion of opioid medications for nonmedical use.

METHODS

We used a mixed-method design to develop and evaluate messages. First, we pretested 34 messages in focus group discussions (FGDs; n = 12 FGDs, n = 2-5 participants per FGD; 37 total participants). Then, we tested the 12 most salient messages in an online survey with a nationally representative Qualtrics® panel (n = 1520 participants). A pretest-posttest design was conducted to assess change in beliefs about storage and disposal of opioid medication following message exposure.

RESULTS

All 12 messages favorably influenced participants' perceptions related to concerns and risks of retaining unused opioid medications and the importance of and self-efficacy in securely storing and disposing of unused opioid medications. Storage and disposal messages that included the sentence-"Your prescription can become someone else's addiction."-outperformed other messages in encouraging people to safely store or dispose of opioid medication.

CONCLUSIONS

This study informs the development of a universal text message intervention using multimodal feedback from the target population that the intervention seeks to serve. The next step is to conduct a randomized controlled trial to assess efficacy of the intervention.

Development of a customized m-Health-based intervention to reduce loss to follow-up among patients undergoing treatment for cervical lesions at a rural referral Hospital, South Western Uganda

Background

Loss to follow-up (LTFU) in individuals undergoing cervical cancer treatment is a major challenge in many low resource settings. We describe development of a customized and tailored mHealth intervention for reducing LTFU among patients undergoing cervical cancer treatment at Mbarara Regional Referral Hospital (MRRH).

Methods

We interviewed all health care providers (HCPs) at the cervical cancer clinic of MRRH, between April and May 2023. Transcripts were subsequently derived, reviewed and coded to generate themes and categories using inductive content analytic approach. Four medical experts used this data to develop relevant SMS content, which was incorporated into an app.

Results

HCPs had owned a phone for 13.8 ≤ years, had worked at the clinic for 5 ≤ years, and used text messages regularly. Qualitative data revealed that the main challenge to re-engagement was absence of a reminder mechanism between HCPs and patients. HCPs preferred text and or audio mode of messaging to improve health care responsiveness to LTFUs, awareness, continuity of care, and health service uptake among the majority illiterate population; though with potential constraints of costs and workload. Identified key messaging content included; the importance of attending scheduled follow-ups, follow up visit date and clinic customization and tailoring the message to the intended recipient. SMS content was uploaded onto the cc-follow-up app platform and customized according to preferred language, day, frequency and time of delivery.

Conclusion

Tailoring an mHealth messaging intervention could help re-engage and reduce LTFU through improved information sharing, awareness, responsiveness, care engagement and medical compliance. A pilot study is required for our intervention in South Western Uganda.

Evaluating the Feasibility, Acceptability, and Preliminary Efficacy of SupportMoms-Uganda, an mHealth-Based Patient-Centered Social Support Intervention to Improve the Use of Maternity Services Among Pregnant Women in Rural Southwestern Uganda: Randomized Controlled Trial

BACKGROUND

SMS text messaging and other mobile health (mHealth) interventions may improve knowledge transfer, strengthen access to social support (SS), and promote positive health behaviors among women in the perinatal period. However, few mHealth apps have been taken to scale in sub-Saharan Africa.

OBJECTIVE

We evaluated the feasibility, acceptability, and preliminary efficacy of a novel, mHealth-based, and patient-centered messaging app designed using behavioral science frameworks to promote maternity service use among pregnant women in Uganda.

METHODS

We performed a pilot randomized controlled trial between August 2020 and May 2021 at a referral hospital in Southwestern Uganda. We included 120 adult pregnant women enrolled in a 1:1:1 ratio to receive routine antenatal care (ANC; control), scheduled SMS text or audio messages from a novel messaging prototype (scheduled messaging [SM]), and SM plus SMS text messaging reminders to 2 participant-identified social supporters (SS). Participants completed face-to-face surveys at enrollment and in the postpartum period. The primary outcomes were feasibility and acceptability of the messaging prototype. Other outcomes included ANC attendance, skilled delivery, and SS. We conducted qualitative exit interviews with 15 women from each intervention arm to explore the intervention mechanisms. Quantitative and qualitative data were analyzed using STATA and NVivo, respectively.

RESULTS

More than 85% and 75% of participants received ≥85% of the intended SMS text messages or voice calls, respectively. More than 85% of the intended messages were received within 1 hour of the expected time; 18% (7/40) of women experienced network issues for both intervention groups. Over 90% (36/40) of the intervention participants found this app useful, easy to use, engaging, and compatible and strongly recommended it to others; 70% (28/40), 78% (31/40), and 98% (39/40; P=.04) of women in the control, SM, and SS arms, respectively, had a skilled delivery. Half (20/40), 83% (33/40), and all (40/40; P=.001) of the women in the control, SM, and SS arms attended ≥4 ANC visits, respectively. Women in the SS arm reported the highest support (median 3.4, IQR 2.8-3.6; P=.02); <20% (8/40; P=.002) missed any scheduled ANC visit owing to lack of transportation. Qualitative data showed that women liked the app; they were able to comprehend ANC and skilled delivery benefits and easily share and discuss tailored information with their significant others, who in turn committed to providing them the needed support to prepare and seek help.

CONCLUSIONS

We demonstrated that developing a novel patient-centered and tailored messaging app that leverages SS networks and relationships is a feasible, acceptable, and useful approach to communicate important targeted health-related information and support pregnant women in rural Southwestern Uganda to use available maternity care services. Further evaluation of maternal-fetal outcomes and integration of this intervention into routine care is needed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04313348; https://clinicaltrials.gov/ct2/show/NCT04313348.

Implementation of a text messaging intervention to patients on warfarin therapy in Brazilian primary care units: a quasi-experimental study

Background

Warfarin remains the most affordable oral anticoagulant in many countries. However, it may have serious side effects, and the success of the therapy depends on the patient’s understanding of the medication and their adherence to treatment. The use of short messages services (SMS) is a strategy that can be used to educate patients, but there are no studies evaluating this intervention in patients taking warfarin. Therefore, we aimed to develop, implement, and assess the feasibility of an intervention using SMS to primary care patients taking warfarin in a medium-sized Brazilian city.

Methods

A bank of 79 SMS was drafted and validated by an expert panel. During 6 months, three times a week, patients received messages about anticoagulation with warfarin. At baseline and after 3 months, we assessed their knowledge and adherence with validated instruments. At the end of the follow-up, participants answered a satisfaction questionnaire. Subsequently, a scale-up phase was conducted, with another round of the intervention including 82 participants (29 from the first phase and 53 newly recruited). Seven months after the end of the scale-up, we asked the patients for their insights about the long-term effects of this program. All patients signed informed consent. The study was approved by the Research and Ethics committee of the Universidade Federal de Minas Gerais.

Results

In the pilot, 33 (89.2%) patients completed the follow-up. Among the participants who answered the satisfaction questionnaire (n = 29), 86.2% considered that the intervention motivated a healthy lifestyle and improved their understanding of warfarin therapy. All patients were willing to continue receiving the messages. Adherence measured by the Measure of Adherence to Treatment (MAT) test was high in the pre-intervention assessment and remained high (96.7% vs. 93.3%; p = 1.0000). The proportion of patients who achieved > 75% correct answers on the Oral Anticoagulation Knowledge (OAK) test increased from 6.5% to 25.6, p = 0.0703. In the scale-up, 23 patients answered the long-term assessment questionnaire. The main long-term knowledge reported was dietary information. Nine patients received the messages but did not remember their content.

Conclusion

The intervention was well-accepted and had a positive impact on patient’s knowledge about oral anticoagulation therapy. The scale-up assessment reinforced the need to constantly monitor digital interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01647-5.

Practice, barriers, and facilitators of healthcare providers in smoking cessation in Mexico

OBJECTIVE

To assess the clinical practice, barriers, and facilitators in promoting smoking cessation in primary healthcare clinics in Mexico City.

MATERIALS AND METHODS

A mixed method design was used. Surveys (n = 70) and semi-structured interviews (n = 9) were conducted with health personnel involved in smoking cessation clinics.

RESULTS

Quantitative data revealed that physicians were more likely than nurses to 1) ask patients if they smoke (57.9% vs 34.5%, p = .057), 2) ask patients if they are interested in quitting smoking (65.7% vs 26.9%, p = .003), 3) provide advice to quit smoking (54.3% vs 29.2%, p = .056), and 4) assess whether pharmacotherapy is needed (21.9% vs 10%, p = .285). Qualitative data showed that nurses were more likely than physicians to report lack of resources to refer patients to smoking cessation services, lack of pharmacotherapy availability, and lack of provider training in smoking cessation. Reported barriers include lack of motivation among patients, lack of time for assessment, long appointment wait times, and lack of training. Reported facilitators include existence of smoking cessation programmes and pharmacotherapy at no cost to the patient, and having a multidisciplinary team.

CONCLUSIONS

Due to numerous barriers, smoking cessation interventions are partially implemented in primary care clinics in Mexico City. A restructuring of services is necessary, and nurses should be given a more prominent role.

mHealth-Based Health Promotion Intervention to Improve Use of Maternity Care Services Among Women in Rural Southwestern Uganda: Iterative Development Study

BACKGROUND

Antenatal care (ANC) prevents perinatal morbidity and mortality, but use of these services in Uganda remains low and maternal mortality rates are among the highest in the world. There is growing evidence that mobile health (mHealth) approaches improve timely communication of health-related information and produce positive health behavior change as well as health outcomes. However, there are limited data to guide development of such interventions in settings where ANC attendance and uptake of skilled maternity care are low.

OBJECTIVE

The aim of this study is to develop a novel patient-centered mHealth intervention to encourage and support women to use maternity care services in Mbarara district, southwestern Uganda.

METHODS

Using an iterative development approach, we conducted formative stakeholder interviews with 30 women and 5 health care providers (HCPs) to identify preferred key ANC topics and characterize the preferred messaging intervention; developed content for SMS text messaging and audio messaging with the help of 4 medical experts based on the identified topics; designed an app prototype through partnership with an mHealth development company; and pilot-tested the prototype and sought user experiences and feedback to refine the intervention through 3 sets of iterative interviews, a focus group discussion, and 5 cognitive interviews. Qualitative data were coded and analyzed using NVivo (version 12.0; QSR International).

RESULTS

Of the 75 women who completed interviews during the development of the prototype, 39 (52%) had at least a primary education and 75 (100%) had access to a mobile phone. The formative interviews identified 20 preferred perinatal health topics, ranging from native medicine use to comorbid disorders and danger signs during pregnancy. In all, 6 additional topics were identified by the interviewed HCPs, including birth preparedness, skilled delivery, male partner's involvement, HCP interaction, immunization, and caring for the baby. Positive audio messaging and SMS text messaging content without authoritative tones was developed as characterized by the interviewed women. The postpilot iterative interviews and focus group discussion revealed a preference for customized messaging, reflecting an individual need to be included and connected. The women preferred short, concise, clear actionable messages that guided, supported, and motivated them to keep alert and seek professional help. Complementary weekly reminders to the women's significant others were also preferred to encourage continuity or prompt the needed social support for care seeking.

CONCLUSIONS

We used an iterative approach with diffuse stakeholders to develop a patient-centered audio messaging and SMS text messaging app designed to communicate important targeted health-related information and support rural pregnant women in southwestern Uganda. Involving both HCPs and end users in developing and formulating the mHealth intervention allowed us to tailor the intervention characteristics to the women's preferences. Future work will address the feasibility, acceptability, and effectiveness of this design approach.

Adaptation and Assessment of a Text Messaging Smoking Cessation Intervention in Vietnam: Pilot Randomized Controlled Trial

Background

Text message (ie, short message service, SMS) smoking cessation interventions have demonstrated efficacy in high-income countries but are less well studied in low- and middle-income countries, including Vietnam.

Objective

The goal of the research is to assess the feasibility, acceptability, and preliminary efficacy of a fully automated bidirectional SMS cessation intervention adapted for Vietnamese smokers.

Methods

The study was conducted in 3 phases. In phase 1, we adapted the SMS library from US-based SMS cessation programs (ie, SmokefreeTXT and Text2Quit). The adaptation process consisted of 7 focus groups with 58 smokers to provide data on culturally relevant patterns of tobacco use and assess message preferences. In phase 2, we conducted a single-arm pilot test of the SMS intervention with 40 smokers followed by in-depth interviews with 10 participants to inform additional changes to the SMS library. In phase 3, we conducted a 2-arm pilot randomized controlled trial (RCT) with 100 smokers. Participants received either the SMS program (intervention; n=50) or weekly text assessment on smoking status (control; n=50). The 6-week SMS program consisted of a 2-week prequit period and a 4-week postquit period. Participants received 2 to 4 automated messages per day. The main outcomes were engagement and acceptability which were assessed at 6 weeks (end of intervention). We assessed biochemically confirmed smoking abstinence at 6 weeks and 12 weeks. Postintervention in-depth interviews explored user experiences among a random sample of 16 participants in the intervention arm.

Results

Participants in both arms reported high levels of engagement and acceptability. Participants reported using the program for an average of 36.4 (SD 3.4) days for the intervention arm and 36.0 (SD 3.9) days for the control arm. Four of the 50 participants in the intervention arm (8%) reset the quit date and 19 (38%) texted the keyword TIPS. The majority of participants in both arms reported that they always or usually read the text messages. Compared to the control arm, a higher proportion of participants in the intervention arm reported being satisfied with the program (98% [49/50] vs 82% [41/50]). Biochemically verified abstinence was higher in the intervention arm at 6 weeks (20% [10/50] vs 2% [1/50]; P=.01), but the effect was not significant at 12 weeks (12% [6/50] vs 6% [3/50]; P=.49). In-depth interviews conducted after the RCT suggested additional modifications to enhance the program including tailoring the timing of messages, adding more opportunities to interact with the program, and placing a greater emphasis on messages that described the harms of smoking.

Conclusions

The study supported the feasibility and acceptability of an SMS program adapted for Vietnamese smokers. Future studies need to assess whether, with additional modifications, the program is associated with prolonged abstinence.

Trial Registration

ClinicalTrials.gov NCT03219541; https://clinicaltrials.gov/ct2/show/NCT03219541

Smoking Cessation Programs for Pregnant Women: Utilizing WhatsApp Text Messaging

OBJECTIVE

This study aimed to develop a Transtheoretical-Model-based and WhatsApp-text-message-supported smoking cessation program for pregnant women and to evaluate its effectiveness.

METHODS

This study is a pretest-posttest designed, randomized controlled and quasi-experimental intervention research. The study was conducted on 50 pregnant women, 25 of them in the intervention group and 25 of them in the control group. A theory-based motivational individual counseling initiative has been applied to the intervention group, and WhatsApp text messages have been sent 3 days a week, in accordance with the stages of change to support the interviews.

RESULTS

In the final follow-up, 60% of pregnant women in the intervention group and 36% of pregnant women in the control group quit smoking. All participants indicated they would recommend the WhatsApp-text-message-supported smoking cessation program. Transtheoretical-Model-based and WhatsApp-text-message-supported smoking cessation programs were found to be effective in reducing nicotine dependency scores and carbon monoxide levels of pregnant women and quitting smoking.

PRACTICE IMPLICATIONS

The smoking cessation program used in the research may be applied by midwives or nurses trained on the subject to help pregnant women quit smoking.

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.

Identifying Mobile Health Engagement Stages: Interviews and Observations for Developing Brief Message Content

BACKGROUND

Interest in mobile health (mHealth) has increased recently, and research suggests that mHealth devices can enhance end-user engagement, especially when used in conjunction with brief message content.

OBJECTIVE

This research aims to explore the stages of engagement framework for mHealth devices and develop a method to generate brief message content to promote sustained user engagement. This study uses the framework by O'Brien and Toms as a point of departure, where engagement is defined as the uptake or the use of an mHealth device. The framework is a linear repeatable process, including point of engagement, period of engagement, disengagement, and re-engagement. Each stage is characterized by attributes related to a person's technology experience. Although the literature has identified stages of engagement for health-related technology, few studies explore mHealth engagement. Furthermore, little research has determined a method for creating brief message content at each stage in this engagement journey.

METHODS

Interviews and observations from 19 participants who used mHealth technologies (apps, devices, or wellness websites) in a solo capacity were recruited for sample group 1. In sample group 2, interviews, and observations from 25 participants using mHealth technologies in a group capacity through the Global Corporate Challenge were used. These samples were investigated at 3 time points in both research contexts. The results underwent deductive-inductive thematic analysis for the engagement stages' framework and attributes.

RESULTS

In addition to the 4 stages identified by O'Brien and Toms, 2 additional stages, self-management and limited engagement, were identified. Self-management captures where users had disengaged from their technology but were still engaged with their health activity. Limited engagement captures where group mHealth users had minimal interaction with their mHealth technology but continued to engage in a group fitness activity. The results revealed that mHealth engagement stages were nonlinear and embedded in a wider engagement context and that each stage was characterized by a combination of 49 attributes that could be organized into 8 themes. Themes documented the total user experience and included technology usability, technology features, technology aesthetics, use motivations, health awareness, goal setting, social support, and interruptions. Different themes were found to have more relevance at different engagement stages. Knowing themes and attributes at all engagement stages allows technology developers and health care professionals to generate relevant brief message content informed by a person-centered approach.

CONCLUSIONS

This research extends an existing engagement stages framework and identifies attributes and themes relevant to mHealth technology users' total user experience and incorporates concepts derived from health, business studies, and information systems literature. In addition, we offer a practical 5-step process based on a person-centered approach to develop mHealth technology brief message content for sustained engagement.

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.

Use of Brief Messages Based on Behavior Change Techniques to Encourage Medication Adherence in People With Type 2 Diabetes: Developmental Studies

BACKGROUND

Brief messages are a promising way to improve adherence to medication for people with type 2 diabetes. However, it is often unclear how messages have been developed and their precise content, making it difficult to ascertain why certain messages are successful and some are not.

OBJECTIVE

The goal of the research was to develop messages that have proven fidelity to specified evidence-derived behavior change techniques (BCTs) and are acceptable to people with type 2 diabetes.

METHODS

Four studies were conducted: (1) a workshop (n=21) where behavioral change researchers and health care professionals developed messages based on specific BCTs or beliefs or concerns related to taking medication, (2) a focus group study with people with type 2 diabetes (n=23) to assess acceptability of the approach, (3) a survey to ascertain the acceptability of a subset of messages to people with type 2 diabetes (n=61) and, (4) a survey with behavior change researchers to assess the fidelity of a subset of messages to their intended BCT (n=18).

RESULTS

In study 1, 371 messages based on 38 BCTs and beliefs/concerns were developed. Workshop participants rated BCTs to be relevant to medication adherence (mean 7.12/10 [SD 1.55]) and messages to have good fidelity (mean 7.42/10 [SD 1.19]). In study 2, the approach of providing medication adherence support through text messages was found to be acceptable. In study 3, mean acceptability of all BCTs was found to be above the midpoint (mean 3.49/5 [SD 0.26]). In study 4, mean fidelity for all BCTs was found to be above the midpoint (mean 7.61/10 [SD 1.38]).

CONCLUSIONS

A library of brief messages acceptable to people with type 2 diabetes and representative of specific evidence-derived BCTs was developed. This approach allowed brief messages to be developed with known content that can be used to test theory.

Using Text Messaging to Improve Access to Prenatal Health Information in Urban African American and Afro-Caribbean Immigrant Pregnant Women: Mixed Methods Analysis of Text4baby Usage

Background

The Text4baby (T4B) mobile health (mHealth) program is acclaimed to provide pregnant women with greater access to prenatal health care, resources, and information. However, little is known about whether urban African American and Afro-Caribbean immigrant pregnant women in the United States are receptive users of innovative health communication methods or of the cultural and systematic barriers that inhibit their behavioral intent to use T4B.

Objective

This study aimed to understand the lived experiences of urban African American and Afro-Caribbean immigrant pregnant women with accessing quality prenatal health care and health information; to assess usage of mHealth for seeking prenatal health information; and to measure changes in participants’ knowledge, perceptions, and behavioral intent to use the T4B mHealth educational intervention.

Methods

An exploratory sequential mixed methods study was conducted among pregnant women and clinical professionals for a phenomenological exploration with focus groups, key informants, interviews, and observations. Qualitative themes were aligned with behavioral and information technology communications theoretical constructs to develop a survey instrument used. repeated-measures pre- and post-test design to evaluate changes in participants’ knowledge, attitudes, and beliefs, of mHealth and T4B after a minimum of 4 weeks’ exposure to the text message–based intervention. Triangulation and mixing of both qualitative and quantitative data occurred primarily during the survey development and also during final analysis.

Results

A total of 9 women participated in phase 1, and 49 patients signed up for T4B and completed a 31-item survey at baseline and again during follow-up. Three themes were identified: (1) patient-provider engagement, (2) social support, and (3) acculturation. With time as a barrier to quality care, inadequate patient-provider engagement left participants feeling indifferent about the prenatal care and information they received in the clinical setting. Of 49 survey participants, 63% (31/49) strongly agreed that T4B would provide them with extra support during their pregnancy. On a Likert scale of 1 to 5, participants’ perception of the usefulness of T4B ranked at 4.26, and their perception of the compatibility and relative advantage of using T4B ranked at 4.41 and 4.15, respectively. At follow-up, there was a 14% increase in participants reporting their intent to use T4B and a 28% increase from pretest and posttest in pregnant women strongly agreeing to speak more with their doctor about the information learned through T4B.

Conclusions

Urban African American and Afro-Caribbean immigrant pregnant women in Brooklyn endure a number of social and ecological determinants like low health literacy, income, and language that serve as barriers to accessing quality prenatal health care and information, which negatively impacts prenatal health behaviors and outcomes. Our study indicates a number of systematic, political, and other microsystem-level factors that perpetuate health inequities in our study population.

Mobile phone text messaging and app-based interventions for smoking cessation

BACKGROUND

Mobile phone-based smoking cessation support (mCessation) offers the opportunity to provide behavioural support to those who cannot or do not want face-to-face support. In addition, mCessation can be automated and therefore provided affordably even in resource-poor settings. This is an update of a Cochrane Review first published in 2006, and previously updated in 2009 and 2012.

OBJECTIVES

To determine whether mobile phone-based smoking cessation interventions increase smoking cessation rates in people who smoke.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group's Specialised Register, along with clinicaltrials.gov and the ICTRP. The date of the most recent searches was 29 October 2018.

SELECTION CRITERIA

Participants were smokers of any age. Eligible interventions were those testing any type of predominantly mobile phone-based programme (such as text messages (or smartphone app) for smoking cessation. We included randomised controlled trials with smoking cessation outcomes reported at at least six-month follow-up.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures described in the Cochrane Handbook for Systematic Reviews of Interventions. We performed both study eligibility checks and data extraction in duplicate. We performed meta-analyses of the most stringent measures of abstinence at six months' follow-up or longer, using a Mantel-Haenszel random-effects method, pooling studies with similar interventions and similar comparators to calculate risk ratios (RR) and their corresponding 95% confidence intervals (CI). We conducted analyses including all randomised (with dropouts counted as still smoking) and complete cases only.

MAIN RESULTS

This review includes 26 studies (33,849 participants). Overall, we judged 13 studies to be at low risk of bias, three at high risk, and the remainder at unclear risk. Settings and recruitment procedures varied across studies, but most studies were conducted in high-income countries. There was moderate-certainty evidence, limited by inconsistency, that automated text messaging interventions were more effective than minimal smoking cessation support (RR 1.54, 95% CI 1.19 to 2.00; I² = 71%; 13 studies, 14,133 participants). There was also moderate-certainty evidence, limited by imprecision, that text messaging added to other smoking cessation interventions was more effective than the other smoking cessation interventions alone (RR 1.59, 95% CI 1.09 to 2.33; I² = 0%, 4 studies, 997 participants). Two studies comparing text messaging with other smoking cessation interventions, and three studies comparing high- and low-intensity messaging, did not show significant differences between groups (RR 0.92 95% CI 0.61 to 1.40; I² = 27%; 2 studies, 2238 participants; and RR 1.00, 95% CI 0.95 to 1.06; I² = 0%, 3 studies, 12,985 participants, respectively) but confidence intervals were wide in the former comparison. Five studies compared a smoking cessation smartphone app with lower-intensity smoking cessation support (either a lower-intensity app or non-app minimal support). We pooled the evidence and deemed it to be of very low certainty due to inconsistency and serious imprecision. It provided no evidence that smartphone apps improved the likelihood of smoking cessation (RR 1.00, 95% CI 0.66 to 1.52; I² = 59%; 5 studies, 3079 participants). Other smartphone apps tested differed from the apps included in the analysis, as two used contingency management and one combined text messaging with an app, and so we did not pool them. Using complete case data as opposed to using data from all participants randomised did not substantially alter the findings.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that automated text message-based smoking cessation interventions result in greater quit rates than minimal smoking cessation support. There is moderate-certainty evidence of the benefit of text messaging interventions in addition to other smoking cessation support in comparison with that smoking cessation support alone. The evidence comparing smartphone apps with less intensive support was of very low certainty, and more randomised controlled trials are needed to test these interventions.

Tobacco control in Europe: A review of campaign strategies for teenagers and adults

BACKGROUND

In Europe the prevalence of tobacco use in adults and adolescents is among the highest within the WHO regions. Many resources have been allocated toward the prevention and support for smoking cessation. However, the implemented strategies in Europe have not been systematically evaluated.

METHODS

A systematic literature review was carried out to identify studies that analyzed the efficacy of the main smoking-prevention campaigns conducted in Europe. PRISMA guidelines were used to systematically review and extract data.

RESULTS

A total of 24 studies meeting inclusion criteria were identified. Each article was thoroughly reviewed and evaluated for quality, design, and methodology, with reference to the main areas of intervention: school (8); mass media (4) and technological tools (4); smoke-free environments (3); packaging (2) and taxes (3). The school programmes focusing on building skills to recognize and resist negative influences, the intensive use of media and technological equipments, health warnings and excise taxes have showed to be effective tools in reducing the tobacco use.

CONCLUSIONS

Intervention programmes to implement tobacco control policies and smoking cessation are active in many European countries. However, these programmes need to be constantly sustained to achieve a long term efficacy.

A Mobile Smoking Cessation Intervention for Mexico (Vive sin Tabaco... ¡Decídete!): Single-Arm Pilot Study

Background

Of the 14.3 million Mexicans who smoke, only a minority take advantage of evidence-based approaches to smoking cessation. Mobile health interventions have the potential to increase the reach of effective cessation interventions in Mexico.

Objective

This study aimed to assess the feasibility and acceptability of an innovative, personalized, and interactive smoking cessation mobile intervention developed for Mexican smokers.

Methods

We recruited 40 Mexican smokers to participate in Vive sin Tabaco... ¡Decídete!, a smoking cessation program that uses a tablet-based decision support software to drive a 12-week text messaging smoking cessation program and pharmacotherapy support. Outcome measures included participant text messaging interactivity with the program, participant satisfaction, and 12-week verified abstinence using urinary cotinine testing or exhaled carbon monoxide.

Results

Average age of the participants was 36 years (SD 10.7), and they were primarily male (65%, 26/40) with at least an undergraduate degree (62%, 25/40). Most participants (95%, 38/40) smoked daily and were interested in quitting in the next 7 days. As an indicator of participant interactivity, participants sent an average of 21 text messages during the 12-week intervention (SD 17.62). Of the 843 messages that participants sent to the program, only 96 messages (11.3%, 96/843) used keywords. At 12 weeks, 40% (16/40) of participants were biochemically verified (87%, 35/40, follow-up rate). The majority of participants (85%, 30/35) reported being very satisfied or extremely satisfied with the program.

Conclusions

The Vive sin Tabaco... ¡Decídete! smoking cessation mobile intervention was accepted by participants, generated high satisfaction and high text messaging interactivity, and resulted in a noteworthy cessation rate at the end of treatment. This intervention is a promising strategy for smoking cessation in Mexico. Additional testing as a formal randomized clinical trial appears warranted.

Combining Real-Time Ratings With Qualitative Interviews to Develop a Smoking Cessation Text Messaging Program for Primary Care Patients

Background

Text messaging (short message service, SMS) interventions show promise as a way to help cigarette smokers quit. Few studies have examined the effectiveness of text messaging (SMS) programs targeting smokers associated with primary care or hospital settings.

Objective

This study aimed to develop a text messaging (SMS) program targeting primary care smokers.

Methods

Adult smokers in primary care were recruited from February 2017 to April 2017. We sent patients 10 to 11 draft text messages (SMS) over 2 days and asked them to rate each message in real time. Patients were interviewed daily by telephone to discuss ratings, message preferences, and previous experiences with nicotine replacement therapy (NRT). Content analysis of interviews was directed by a step-wise text messaging (SMS) intervention development process and the Information-Motivation-Behavioral Skills model of medication adherence.

Results

We sent 149 text messages (SMS) to 15 patients. They replied with ratings for 93% (139/149) of the messages: 134 (96%, 134/139) were rated as clear or useful and 5 (4%, 5/139) as unclear or not useful. Patients’ preferences included the addition of graphics, electronic cigarette (e-cigarette) content, and use of first names. Regarding NRT, patients identified informational gaps around safety and effectiveness, preferred positively framed motivational messages, and needed behavioral skills to dose and dispose of NRT.

Conclusions

Patients recommended text message (SMS) personalization, inclusion of e-cigarette information and graphics, and identified barriers to NRT use.

Combining real-time ratings with telephone interviews is a feasible method for incorporating primary care patients’ preferences into a behavioral text messaging (SMS) program.

m-Health in Public Health Practice

Beyond the earlier skepticism that greeted its usefulness and applicability in public health practice, m-Health has continued to gain significant support and acceptability among public health practitioners in terms of the ease with which its features and reach have been harnessed to address global disease prevention and health promotion objectives. Research evidence over the past few decades suggest the positive effect of adopting m-Health in improving knowledge dissemination, creating and sustaining motivation for positive health behavior changes or practices, and empowering individuals, communities and populations to take greater responsibility for their health. This chapter examines historical and current literature evidence of m-Health application in public health practice, its impact on global population health and future prospects.

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.

Texting to Reduce Alcohol Misuse (TRAM): main findings from a randomized controlled trial of a text message intervention to reduce binge drinking among disadvantaged men

AIMS

To test the effectiveness of a theoretically based text-message intervention to reduce binge drinking among socially disadvantaged men.

DESIGN

A multi-centre parallel group, pragmatic, individually randomized controlled trial.

SETTING

Community-based study conducted in four regions of Scotland.

PARTICIPANTS

A total of 825 men aged 25-44 years recruited from socially disadvantaged areas who had two or more episodes of binge drinking (> 8 UK units on a single occasion) in the preceding 28 days: 411 men were randomized to the intervention and 414 to the control.

INTERVENTION AND COMPARATOR

A series of 112 interactive text messages was delivered by mobile phone during a 12-week period. The intervention was structured around the Health Action Process Approach, a comprehensive model which allows integration of a range of evidence-based behaviour change techniques. The control group received 89 texts on general health, with no mention of alcohol or use of behaviour change techniques.

MEASUREMENTS

The primary outcome measure was the proportion of men consuming > 8 units on three or more occasions (in the previous 28 days) at 12 months post-intervention.

FINDINGS

The proportion of men consuming > 8 units on three or more occasions (in the previous 28 days) was 41.5% in the intervention group and 47.8% in the control group. Formal analysis showed that there was no evidence that the intervention was effective [odds ratio (OR) = 0.79, 95% confidence interval (CI) = 0.57-1.08; absolute reduction 5.7%, 95% CI = -13.3 to 1.9]. The Bayes factor for this outcome was 1.3, confirming that the results were inconclusive. The retention was high and similar in intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged with the text messages: almost all (92%) replied to text messages and 67% replied more than 10 times.

CONCLUSIONS

A theoretically based text-messaging intervention aimed at reducing binge drinking in disadvantaged men was not found to reduce prevalence of binge drinking at 12-month follow-up.

Feasibility and Acceptability of a Text Message-Based Smoking Cessation Program for Young Adults in Lima, Peru: Pilot Study

Background

In Peru’s urban communities, tobacco smoking generally starts during adolescence and smoking prevalence is highest among young adults. Each year, many attempt to quit, but access to smoking cessation programs is limited. Evidence-based text messaging smoking cessation programs are an alternative that has been successfully implemented in high-income countries, but not yet in middle- and low-income countries with limited tobacco control policies.

Objective

The objective was to assess the feasibility and acceptability of an short message service (SMS) text message-based cognitive behavioral smoking cessation program for young adults in Lima, Peru.

Methods

Recruitment included using flyers and social media ads to direct young adults interested in quitting smoking to a website where interested participants completed a Google Drive survey. Inclusion criteria were being between ages 18 and 25 years, smoking at least four cigarettes per day at least 6 days per week, willing to quit in the next 30 days, owning a mobile phone, using SMS text messaging at least once in past year, and residing in Lima. Participants joined one of three phases: (1) focus groups and in-depth interviews whose feedback was used to develop the SMS text messages, (2) validating the SMS text messages, and (3) a pilot of the SMS text message-based smoking cessation program to test its feasibility and acceptability among young adults in Lima. The outcome measures included adherence to the SMS text message-based program, acceptability of content, and smoking abstinence self-report on days 2, 7, and 30 after quitting.

Results

Of 639 participants who completed initial online surveys, 42 met the inclusion criteria and 35 agreed to participate (focus groups and interviews: n=12; validate SMS text messages: n=8; program pilot: n=15). Common quit practices and beliefs emerged from participants in the focus groups and interviews informed the content, tone, and delivery schedule of the messages used in the SMS text message smoking cessation program. A small randomized controlled pilot trial was performed to test the program’s feasibility and acceptability; nine smokers were assigned to the SMS text message smoking cessation program and six to a SMS text message nutrition program. Participant retention was high: 93% (14/15) remained until day 30 after quit day. In all, 56% of participants (5/9) in the SMS text message smoking cessation program reported remaining smoke-free until day 30 after quit day and 17% of participants (1/6) in the SMS text message nutrition program reported remaining smoke-free during the entire program. The 14 participants who completed the pilot reported that they received valuable health information and approved the delivery schedule of the SMS text messages.

Conclusions

This study provides initial evidence that a SMS text message smoking cessation program is feasible and acceptable for young adults residing in Lima.

Stepwise Development a Text Messaging-Based Bullying Prevention Program for Middle School Students (BullyDown)

Background

Bullying is a significant public health issue among middle school-aged youth. Current prevention programs have only a moderate impact. Cell phone text messaging technology (mHealth) can potentially overcome existing challenges, particularly those that are structural (e.g., limited time that teachers can devote to non-educational topics). To date, the description of the development of empirically-based mHealth-delivered bullying prevention programs are lacking in the literature.

Objective

To describe the development of BullyDown, a text messaging-based bullying prevention program for middle school students, guided by the Social-Emotional Learning model.

Methods

We implemented five activities over a 12-month period: (1) national focus groups (n=37 youth) to gather acceptability of program components; (2) development of content; (3) a national Content Advisory Team (n=9 youth) to confirm content tone; and (4) an internal team test of software functionality followed by a beta test (n=22 youth) to confirm the enrollment protocol and the feasibility and acceptability of the program.

Results

Recruitment experiences suggested that Facebook advertising was less efficient than using a recruitment firm to recruit youth nationally, and recruiting within schools for the pilot test was feasible. Feedback from the Content Advisory Team suggests a preference for 2-4 brief text messages per day. Beta test findings suggest that BullyDown is both feasible and acceptable: 100% of youth completed the follow-up survey, 86% of whom liked the program.

Conclusions

Text messaging appears to be a feasible and acceptable delivery method for bullying prevention programming delivered to middle school students.

Text Messaging-Based Interventions for Smoking Cessation: A Systematic Review and Meta-Analysis

BACKGROUND

Tobacco use is one of the leading preventable global health problems producing nearly 6 million smoking-related deaths per year. Interventions delivered via text messaging (short message service, SMS) may increase access to educational and support services that promote smoking cessation across diverse populations.

OBJECTIVE

The purpose of this meta-analysis is to (1) evaluate the efficacy of text messaging interventions on smoking outcomes, (2) determine the robustness of the evidence, and (3) identify moderators of intervention efficacy.

METHODS

Electronic bibliographic databases were searched for records with relevant key terms. Studies were included if they used a randomized controlled trial (RCT) to examine a text messaging intervention focusing on smoking cessation. Raters coded sample and design characteristics, and intervention content. Summary effect sizes, using random-effects models, were calculated and potential moderators were examined.

RESULTS

The meta-analysis included 20 manuscripts with 22 interventions (N=15,593; 8128 (54%) women; mean age=29) from 10 countries. Smokers who received a text messaging intervention were more likely to abstain from smoking relative to controls across a number of measures of smoking abstinence including 7-day point prevalence (odds ratio (OR)=1.38, 95% confidence interval (CI)=1.22, 1.55, k=16) and continuous abstinence (OR=1.63, 95% CI=1.19, 2.24, k=7). Text messaging interventions were also more successful in reducing cigarette consumption relative to controls (d+=0.14, 95% CI=0.05, 0.23, k=9). The effect size estimates were biased when participants who were lost to follow-up were excluded from the analyses. Cumulative meta-analysis using the 18 studies (k=19) measuring abstinence revealed that the benefits of using text message interventions were established only after only five RCTs (k=5) involving 8383 smokers (OR=1.39, 95% CI=1.15, 1.67, P<.001). The inclusion of the subsequent 13 RCTs (k=14) with 6870 smokers did not change the established efficacy of text message interventions for smoking abstinence (OR=1.37, 95% CI=1.25, 1.51, P<.001). Smoking abstinence rates were stronger when text messaging interventions (1) were conducted in Asia, North America, or Europe, (2) sampled fewer women, and (3) recruited participants via the Internet.

CONCLUSIONS

The evidence for the efficacy of text messaging interventions to reduce smoking behavior is well-established. Using text messaging to support quitting behavior, and ultimately long-term smoking abstinence, should be a public health priority.

Mobile phone-based interventions for smoking cessation

BACKGROUND

Access to mobile phones continues to increase exponentially globally, outstripping access to fixed telephone lines, fixed computers and the Internet. Mobile phones are an appropriate and effective option for the delivery of smoking cessation support in some contexts. This review updates the evidence on the effectiveness of mobile phone-based smoking cessation interventions.

OBJECTIVES

To determine whether mobile phone-based smoking cessation interventions increase smoking cessation in people who smoke and want to quit.

SEARCH METHODS

For the most recent update, we searched the Cochrane Tobacco Addiction Group Specialised Register in April 2015. We also searched the UK Clinical Research Network Portfolio for current projects in the UK, and the ClinicalTrials.gov register for ongoing or recently completed studies. We searched through the reference lists of identified studies and attempted to contact the authors of ongoing studies. We applied no restrictions on language or publication date.

SELECTION CRITERIA

We included randomised or quasi-randomised trials. Participants were smokers of any age who wanted to quit. Studies were those examining any type of mobile phone-based intervention for smoking cessation. This included any intervention aimed at mobile phone users, based around delivery via mobile phone, and using any functions or applications that can be used or sent via a mobile phone.

DATA COLLECTION AND ANALYSIS

Review authors extracted information on risk of bias and methodological details using a standardised form. We considered participants who dropped out of the trials or were lost to follow-up to be smoking. We calculated risk ratios (RR) and 95% confidence intervals (CI) for each included study. Meta-analysis of the included studies used the Mantel-Haenszel fixed-effect method. Where meta-analysis was not possible, we presented a narrative summary and descriptive statistics.

MAIN RESULTS

This updated search identified 12 studies with six-month smoking cessation outcomes, including seven studies completed since the previous review. The interventions were predominantly text messaging-based, although several paired text messaging with in-person visits or initial assessments. Two studies gave pre-paid mobile phones to low-income human immunodeficiency virus (HIV)-positive populations - one solely for phone counselling, the other also included text messaging. One study used text messages to link to video messages. Control programmes varied widely. Studies were pooled according to outcomes - some providing measures of continuous abstinence or repeated measures of point prevalence; others only providing 7-day point prevalence abstinence. All 12 studies pooled using their most rigorous 26-week measures of abstinence provided an RR of 1.67 (95% CI 1.46 to 1.90; I(2) = 59%). Six studies verified quitting biochemically at six months (RR 1.83; 95% CI 1.54 to 2.19).

AUTHORS' CONCLUSIONS

The current evidence supports a beneficial impact of mobile phone-based smoking cessation interventions on six-month cessation outcomes. While all studies were good quality, the fact that those studies with biochemical verification of quitting status demonstrated an even higher chance of quitting further supports the positive findings. However, it should be noted that most included studies were of text message interventions in high-income countries with good tobacco control policies. Therefore, caution should be taken in generalising these results outside of this type of intervention and context.

R u a smkn m0m?: Aspects of a Text Messaging Smoking Cessation/Reduction Intervention for Younger Mothers

Introduction: Women who are younger in age are more likely to smoke during pregnancy and postpartum and tend to have less success with cessation/reduction. There is an unmet need for interventions targeted to pregnant and postpartum young women that provide them with support to quit/reduce long-term into the postpartum period and beyond.

Aims: Our study aimed to gain an in-depth understanding of the perspectives of young pregnant and postpartum women of text messaging (TM) as a conduit for smoking cessation/reduction, and to determine the appropriate content, frequency, duration and unique features needed for an effective cessation/reduction TM programme.

Methods: Six focus groups and six telephone interviews were convened with 36 pregnant and postpartum women 16–30 years of age.

Results: Three main themes were identified: 1) topic areas that women would like TM to focus on; 2) the need for messages to be tailored; and 3) the importance for the programme to take a woman-centered approach.

Conclusions: Respondents supported the idea of a TM cessation/reduction intervention and had clear programme recommendations. A personalised, woman-centered TM programme that meets a young woman's unique needs and addresses her concerns through her participation and direction is likely to empower and support her to quit/reduce.

Development and Implementation of an Interactive Text Messaging Campaign to Support Behavior Change in a Childhood Obesity Randomized Controlled Trial

Text messaging is a promising means of intervening on an array of health issues among varied populations, but little has been published about the development of such interventions. The authors describe the development and implementation of an interactive text messaging campaign for parents to support behavior change among children in a childhood obesity randomized controlled trial. The authors invited 160 parents to participate in a text messaging intervention that provided behavior change support in conjunction with health coaching phone calls and mailed materials on behavioral goals. Throughout the 1-year intervention, the authors sent 1-2 text messages per week. The first asked how the child did with a target behavior the day before; parents who replied received an immediate feedback message tailored to their response. The second included a tip about how to work toward a behavioral goal. Baseline surveys indicate that text messaging is a common means of communication for parents, and many are willing to use text messaging to support behavior change for their child. Results at 1 year indicate a high level of engagement with the text messaging intervention, with nearly two thirds responding to 75% or more of the questions they were sent by text.

From black box to toolbox: Outlining device functionality, engagement activities, and the pervasive information architecture of mHealth interventions

mHealth interventions that deliver content via mobile phones represent a burgeoning area of health behavior change. The current paper examines two themes that can inform the underlying design of mHealth interventions: (1) mobile device functionality, which represents the technological toolbox available to intervention developers; and (2) the pervasive information architecture of mHealth interventions, which determines how intervention content can be delivered concurrently using mobile phones, personal computers, and other devices. We posit that developers of mHealth interventions will be better able to achieve the promise of this burgeoning arena by leveraging the toolbox and functionality of mobile devices in order to engage participants and encourage meaningful behavior change within the context of a carefully designed pervasive information architecture.

Translating Behavioral Interventions Onto mHealth Platforms: Developing Text Message Interventions for Smoking and Alcohol

The development of mHealth applications is often driven by the investigators and developers with relatively little input from the targeted population. User input is commonly limited to "like/dislike" post- intervention consumer satisfaction ratings or device or application specific user analytics such as usability. However, to produce successful mHealth applications with lasting effects on health behaviors it is crucial to obtain user input from the start of each project and throughout development. The aim of this tutorial is to illustrate how qualitative methods in an iterative process of development have been used in two separate behavior change interventions (targeting smoking and alcohol) delivered through mobile technologies (ie, text messaging). A series of focus groups were conducted to assist in translating a face-to-face smoking cessation intervention onto a text message (short message service, SMS) delivered format. Both focus groups and an advisory panel were used to shape the delivery and content of a text message delivered intervention for alcohol risk reduction. An in vivo method of constructing message content was used to develop text message content that was consistent with the notion of texting as "fingered speech". Formative research conducted with the target population using a participatory framework led to important changes in our approach to intervention structure, content development, and delivery. Using qualitative methods and an iterative approach that blends consumer-driven and investigator-driven aims can produce paradigm-shifting, novel intervention applications that maximize the likelihood of use by the target audience and their potential impact on health behaviors.

Design and Multi-Country Validation of Text Messages for an mHealth Intervention for Primary Prevention of Progression to Hypertension in Latin America

BACKGROUND

Mobile health (mHealth) has been posited to contribute to the reduction in health gaps and has shown fast and widespread growth in developing countries. This growth demands understanding of, and preparedness for, local cultural contexts.

OBJECTIVE

To describe the design and validation of text messages (short message service, SMS) that will be used for an mHealth behavioral change intervention to prevent hypertension in three Latin American countries: Argentina, Guatemala, and Peru.

METHODS

An initial set of 64 SMS text messages were designed to promote healthy lifestyles among individuals in different stages of behavior change, addressing four key domains: salt and sodium intake, fruit and vegetable intake, consumption of high fat and sugar foods, and physical activity. The 64 SMS text messages were organized into nine subsets for field validation. In each country 36 people were recruited, half of them being male. Of the participants, 4 per country evaluated each subset of SMS text messages, which contained between 6 and 8 SMS text messages regarding different key domains and stages of change. The understanding and appeal of each SMS text message was assessed using a 7-item questionnaire. The understanding and appeal ratings were used to reach a final set of 56 SMS text messages.

RESULTS

Overall, each of the 64 SMS text messages received a total of 12 evaluations (4 per country). The majority of evaluations-742 out of a total of 767 (96.7%) valid responses-revealed an adequate understanding of the key idea contained in the SMS text message. On a scale from 1 to 10, the average appeal score was 8.7 points, with a range of 4 to 10 points. Based on their low scores, 8 SMS text messages per country were discarded. Once the final set of 56 SMS text messages was established, and based on feedback obtained in the field, wording and content of some SMS text messages were improved. Of the final set, 9, 8, and 16 of the SMS text messages were improved based on participant evaluations from Argentina, Guatemala, and Peru, respectively. Most SMS text messages selected for the final set (49/56, 88%) were the same in all countries, except for small wording differences.

CONCLUSIONS

The final set of SMS text messages produced had very high rates of understanding and appeal in three different Latin American countries. This study highlights the importance of developing and validating a package of simple, preventative SMS text messages, grounded in evidence and theory, across three different Latin American countries with active engagement of end users.

Steps in tailoring a text messaging-based smoking cessation program for young adults

Steps to develop or refine text messaging-based interventions are largely missing from the literature. Here, the authors describe steps in refining Stop My Smoking USA, a text messaging-based smoking cessation program for smokers 18-25 years old. Research activities included the following: needs assessment focus groups (n = 35); a content advisory team to affirm message acceptability (n = 10); and two beta tests to confirm technological feasibility (n = 12 and 28, respectively). Various recruitment strategies were tested to identify the optimal methods to reach young adult smokers ready to quit. Each stage of the refinement process yielded new insights, resulting in improved message content and tone, an effective recruitment strategy, and the identification and subsequent resolution of technology challenges. Findings suggest that young adults prefer messages that provide concrete behavioral strategies to overcome cravings, and which are positive in tone. Craigslist was the most efficient recruitment method and yielded a sample that was racially and economically diverse. Despite a successful beta test of initial technological feasibility, extensive problems were subsequently experienced in a beta test of the technological feasibility of the entire program. Iterative program refinement and adaptation on the basis of user input is necessary to ensure salience, while extensive field testing is required to ensure proper functioning of technology-based programs.

Texting teens in transition: the use of text messages in clinical intervention research

BACKGROUND

The rapidly growing population of young adults living with congenital heart disease (CHD), currently challenging ill-prepared cardiac care systems, presents a novel population in which to consider the use of mHealth. This methodological study was part of a larger study that tested the effectiveness of a clinic-based nursing intervention to prepare teens for transfer from pediatric to adult cardiology care. The intervention included creation of a MyHealth Passport and subsequently SMS (short message service) text messages between the intervention nurse and study participant.

OBJECTIVE

Our aim was to determine (1) the preference of teens with CHD to be contacted via text message following the nursing intervention, (2) the effectiveness of texting to collect data regarding the use of MyHealth Passport after participation in the intervention, (3) the nature of the texting interaction, and (4) the risks and benefits of texting.

METHODS

Participants were recruited through the intervention study (n=24) by either choosing to receive information from the study coordinator through text message, or texting a question to the study nurses. Inclusion criteria were age 15-17 years, diagnosed with moderate or complex heart disease, and currently being followed by the Division of Cardiology at Stollery Children's Hospital. Exclusion criteria were heart transplantation and/or less than a 6th grade reading and comprehension ability. Text message transcripts were analyzed by qualitative inductive content analysis.

RESULTS

Two-thirds of teens (16/24, 67%) chose text messaging as their preferred contact, making them eligible for the study. Texting was effective in collecting information regarding the MyHealth Passport; all but one teen had their MyHealth Passport on them, and many reported carrying it with them wherever they went. All teens reported showing their MyHealth Passport to at least one person. Seven themes were identified in the texting transcripts: mixing formal and informal language, the passive teen, interaction with health care providers, texting teens in transition, texting as a mechanism to initiate other forms of communication, affirmation, and the nurse as an educator. Benefits of texting were identified as flexibility, ability to respond over time, information presented in byte-sized amounts, and information directly related to patient questions. Risks of texting were identified as the possibility that interactions may not be in-depth, distraction of teen and researcher, and invasiveness.

CONCLUSIONS

Text messaging was useful in collecting data regarding the use of the MyHealth Passport. Text messaging resulted in conversations with the teens that were sometimes in-depth and meaningful, especially when combined with other communication modalities. Using text messaging in a manner resulting in full conversations with the patients requires more study and may benefit from protocols and the use of solid theoretical foundations that would standardize the interaction so that more conclusions could be drawn.

The medium and the message: fitting sound health promotion methodology into 160 characters

Text messaging health promotion projects continue to proliferate due to their relative low-cost, simplicity, non-intrusiveness, and proven effectiveness in several randomized controlled trials. In these past trials, participants have typically been recruited through traditional means, received the text messaging intervention, and then completed evaluation. In this issue of the Journal of Medical Internet Research, Sheoran et al have demonstrated how use of text messaging alone can be a feasible method for all three stages: recruitment, intervention, and evaluation. Use of text messages without any other modes of communication could be a key to population-level dissemination and wider uptake of health promotion messages. However, in the rush to utilize new technologies and in the brevity of 160 characters, it should not be forgotten that quality, rigour, and careful development remain essential in any health promotion practice.

Process evaluation of a mHealth program: lessons learned from Stop My Smoking USA, a text messaging-based smoking cessation program for young adults

OBJECTIVE

Report lessons learned in an RCT of Stop My Smoking (SMS) USA, a mHealth smoking cessation program for young adult smokers.

METHODS

164 18-24-year-olds were recruited nationally, online in 2011. Program evaluation data were provided at 12-week post-Quit Day.

RESULTS

(1) Inviting participants to complete a brief text messaging survey and then asking them to complete a longer online survey resulted in the highest response rate (89%). (2) The positive tone of program messages was the most commonly noted program strength. (3) Suggested improvements included more social connectivity and additional assistance overcoming stressful situations. (4) Half of intervention participants moved through the program linearly and half went through various paths that reflected multiple relapses. Suggestions to use pharmacotherapy resulted in 22% of heavy smokers to utilize it.

CONCLUSION

Participant feedback provided concrete ways in which this and other young adult-focused interventions can improve messaging and program features to be even more salient.

PRACTICE IMPLICATIONS

Future young adult mHealth interventions could: Integrate models that are flexible to different "paths" of behavior change; address stressful life events directly and comprehensively; integrate proactive messaging that promotes pharmacotherapy options; and use text messaging as a gateway to longer online surveys.

Engaging Patients through Mobile Phones: Demonstrator Services, Success Factors, and Future Opportunities in Low and Middle-income Countries

OBJECTIVES

Evolving technology and infrastructure can benefit patients even in the poorest countries through mobile health (mHealth). Yet, what makes mobile-phone-based services succeed in low and middle-income countries (LMIC) and what opportunities does the future hold that still need to be studied. We showcase demonstrator services that leverage mobile phones in the hands of patients to promote health and facilitate health care.

METHODS

We surveyed the recent biomedical literature for demonstrator services that illustrate well-considered examples of mobile phone interventions for consumer health. We draw upon those examples to discuss enabling factors, scalability, reach, and potential of mHealth as well as obstacles in LMIC.

RESULTS

Among the 227 articles returned by a PubMed search, we identified 55 articles that describe services targeting health consumers equipped with mobile phones. From those articles, we showcase 19 as demonstrator services across clinical care, prevention, infectious diseases, and population health. Services range from education, reminders, reporting, and peer support, to epidemiologic reporting, and care management with phone communication and messages. Key achievements include timely adherence to treatment and appointments, clinical effectiveness of treatment reminders, increased vaccination coverage and uptake of screening, and capacity for efficient disease surveillance. We discuss methodologies of delivery and evaluation of mobile-phone-based mHealth in LMIC, including service design, social context, and environmental factors to success.

CONCLUSION

Demonstrated promises using mobile phones in the poorest countries encourage a future in which IMIA takes a lead role in leveraging mHealth for citizen empowerment through Consumer Health Informatics.

Mobile technologies and geographic information systems to improve health care systems: a literature review

Background

A growing body of research has employed mobile technologies and geographic information systems (GIS) for enhancing health care and health information systems, but there is yet a lack of studies of how these two types of systems are integrated together into the information infrastructure of an organization so as to provide a basis for data analysis and decision support. Integration of data and technical systems across the organization is necessary for efficient large-scale implementation.

Objective

The aim of this paper is to identify how mobile technologies and GIS applications have been used, independently as well as in combination, for improving health care.

Methods

The electronic databases PubMed, BioMed Central, Wiley Online Library, Scopus, Science Direct, and Web of Science were searched to retrieve English language articles published in international academic journals after 2005. Only articles addressing the use of mobile or GIS technologies and that met a prespecified keyword strategy were selected for review.

Results

A total of 271 articles were selected, among which 220 concerned mobile technologies and 51 GIS. Most articles concern developed countries (198/271, 73.1%), and in particular the United States (81/271, 29.9%), United Kingdom (31/271, 11.4%), and Canada (14/271, 5.2%). Applications of mobile technologies can be categorized by six themes: treatment and disease management, data collection and disease surveillance, health support systems, health promotion and disease prevention, communication between patients and health care providers or among providers, and medical education. GIS applications can be categorized by four themes: disease surveillance, health support systems, health promotion and disease prevention, and communication to or between health care providers. Mobile applications typically focus on using text messaging (short message service, SMS) for communication between patients and health care providers, most prominently reminders and advice to patients. These applications generally have modest benefits and may be appropriate for implementation. Integration of health data using GIS technology also exhibit modest benefits such as improved understanding of the interplay of psychological, social, environmental, area-level, and sociodemographic influences on physical activity. The studies evaluated showed promising results in helping patients treating different illnesses and managing their condition effectively. However, most studies use small sample sizes and short intervention periods, which means limited clinical or statistical significance.

Conclusions

A vast majority of the papers report positive results, including retention rate, benefits for patients, and economic gains for the health care provider. However, implementation issues are little discussed, which means the reasons for the scarcity of large-scale implementations, which might be expected given the overwhelmingly positive results, are yet unclear. There is also little combination between GIS and mobile technologies. In order for health care processes to be effective they must integrate different kinds of existing technologies and data. Further research and development is necessary to provide integration and better understand implementation issues.

Text messaging-based smoking cessation intervention: a narrative review

INTRODUCTION

Smoking cessation interventions delivered via text messaging on mobile phones may enhance motivations to quit smoking. The goal of this narrative review is to describe the text messaging interventions' theoretical contents, frequency and duration, treatment outcome, and sample characteristics such as age and motivation to quit, to better inform the future development of this mode of intervention.

METHODS

Studies were included if text messaging was primarily used to deliver smoking cessation intervention and published in English in a peer-reviewed journal. All articles were coded by two independent raters to determine eligibility and to extract data.

RESULTS

Twenty-two studies described 15 text messaging interventions. About half of the interventions recruited adults (ages 30-40) and the other half targeted young adults (ages 18-29). Fourteen interventions sent text messages during the quit phase, 10 had a preparation phase and eight had a maintenance phase. The number of text messages and the duration of the intervention varied. All used motivational messages grounded in social cognitive behavioral theories, 11 used behavioral change techniques, and 14 used individually tailored messages. Eleven interventions also offered other smoking cessation tools. Three interventions yielded smoking cessation outcomes greater than the control condition.

CONCLUSIONS

The proliferation of text messaging in recent years suggests that text messaging interventions may have the potential to improve smoking cessation rates. Detailed summary of the interventions suggests areas for future research and clinical application. More rigorous studies are needed to identify components of the interventions that can enhance their acceptability, feasibility and efficacy.

Preventing postpartum smoking relapse among inner city women: development of a theory-based and evidence-guided text messaging intervention

Background

Underserved women are at high risk for smoking relapse after childbirth due to their unique socioeconomic and postpartum stressors and barriers. Mobile text messaging technology allows delivery of relapse prevention programs targeted to their personal needs over time.

Objective

To describe the development of a social-cognitive theory-based and evidence-guided text messaging intervention for preventing postpartum smoking relapse among inner city women.

Methods

Guided by the cognitive-social health information processing framework, user-centered design, and health communication best practices, the intervention was developed through a systematic process that included needs assessment, followed by an iterative cycling through message drafting, health literacy evaluation and rewriting, review by target community members and a scientific advisory panel, and message revision, concluding with usability testing.

Results

All message content was theory-grounded, derived by needs assessment analysis and evidence-based materials, reviewed and revised by the target population, health literacy experts, and scientific advisors. The final program, “Txt2Commit,” was developed as a fully automated system, designed to deliver 3 proactive messages per day for a 1-month postpartum smoking relapse intervention, with crave and lapse user-initiated message functions available when needed.

Conclusions

The developmental process suggests that the application of theory and best practices in the design of text messaging smoking cessation interventions is not only feasible but necessary for ensuring that the interventions are evidence based and user-centered.

Depression and cardiovascular disease

Approximately one out of every five patients with cardiovascular disease (CVD) suffers from major depressive disorder (MDD). Both MDD and depressive symptoms are risk factors for CVD incidence, severity and outcomes. Great progress has been made in understanding potential mediators between MDD and CVD, particularly focusing on health behaviors. Investigators have also made considerable strides in the diagnosis and treatment of depression among patients with CVD. At the same time, many research questions remain. In what settings is depression screening most effective for patients with CVD? What is the optimal screening frequency? Which therapies are safe and effective? How can we better integrate the care of mental health conditions with that of CVD? How do we motivate depressed patients to change health behaviors? What technological tools can we use to improve care for depression? Gaining a more thorough understanding of the links between MDD and heart disease, and how best to diagnose and treat depression among these patients, has the potential to substantially reduce morbidity and mortality from CVD.

A text messaging-based smoking cessation program for adult smokers: randomized controlled trial

BACKGROUND

Despite promising data in Western countries, there is a dearth of research into the efficacy of text messaging-based smoking cessation programs in other settings, including the Middle East, where smoking prevalence rates are higher.

OBJECTIVE

This paper reports cessation rates observed in SMS Turkey, a text messaging-based smoking cessation program for adult smokers in Ankara, Turkey.

METHODS

This study was a small-scale, parallel-group randomized controlled trial (RCT) conducted in Ankara, Turkey. Participants were adult daily smokers who were seriously thinking about quitting in the next 15 days and living in Ankara, Turkey. The text messaging intervention, SMS Turkey, provided 6 weeks of daily messages aimed at giving participants skills to help them quit smoking. Messages were sent in an automated fashion, except 2 days and 7 days after the initial quit day. On days 2 and 7, the research assistant manually assigned participants to content "paths" based on whether they were still not smoking or had relapsed. The control arm received a brochure that provided similar information about smoking cessation. The main outcome measure was self-reported 3-month sustained abstinence, verified by carbon monoxide (CO) readings. Neither participants nor researchers were blinded to arm assignment.

RESULTS

The 151 participants were randomly assigned to 1 of 2 groups: 76 to the SMS Turkey intervention group and 75 to the brochure control group. Using intention to treat, all 151 participants were included in analyses. Three-month cessation trends were not significantly higher in the intervention group: 11% intervention vs 5% control had quit (χ(2)(1)=1.4, P=.24; R(2)=2.0, 95% CI 0.62-6.3). When the sample was stratified by sex, female intervention participants (14%, n=5) were significantly more likely to have quit at 3 months than female control participants (0%, n=0; χ(2)(1)=3.7, P=.05). Among light smokers (ie, those smoking less than 20 cigarettes per day), intervention participants (17%, n=5) also were significantly more likely to have quit compared to control participants (0%, n=0; χ(2)(1)=5.3, P=.02). We noted no difference in cessation rates for males or heavy smokers. Participants experienced significant technology problems during the study. Some participants received duplicate text messages at least once during the trial; others failed to receive some program messages. Neither receiving duplicate messages (χ(2)(1)=0.12, P=.73), or missing 5 or more program messages (χ(2)(1)=0.75, P=.39) negatively affected quitting rates.

CONCLUSIONS

Although the study was not powered to detect statistically significant differences, as the primary aim was to provide estimates of effect size that could be used to better inform a power analysis for a larger trial, findings provide optimism that SMS Turkey may be able to affect quitting rates in environments with high smoking prevalence, such as Ankara, Turkey. The SMS Turkey software program did not work as well as it did 2 years previous. The system will need to be updated to maintain software compatibility with ongoing technology evolution.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00912795 http://clinicaltrials.gov/ct2/show/NCT00912795 (Archived by WebCite® at http://www.webcitation.org/6Ch1cIA8l).