Health on the go: Can we use mobile telephone SMS to change health behaviors?
Mobile telephone short messaging service (SMS) or text messaging is part of everyday life in modern day culture. This ‘mundane’ communication method is now being used in research that is investigating flexible ways to engage and assist individuals to make healthy choices.
The reach of SMS makes it a useful method for communicating with individuals about healthy behaviors. In the United States there are more mobile telephone subscribers than landline users, and approximately seven billion SMS are sent every month. More importantly, in developed countries SMS use transcends age groups, cultures and socio-economic backgrounds. Not surprisingly, the highest users of mobile telephones are adolescents and young adults, but what might actually surprise you is that mobile phone use is also high among socioeconomically disadvantaged populations, less educated people, and people who rent or frequently change address. Interestingly, these population sub-groups also appear to suffer from poorer health than their advantaged, educated, stable counterparts, so accessing these groups via mobile telephone seems to be a logical choice. Indeed, research has shown that high mobile telephone use is associated with lower levels of self-rated health, higher Body Mass Index (BMI) and higher rates of health-compromising behaviors. Therefore, given the reach SMS has into these at-risk populations it is worthwhile to explore its potential as a method to influence health.
So far, the exploration of using SMS to influence health behaviors has been limited, but the potential is huge due to the specific capabilities of SMS. SMS allows for instantaneous delivery of short messages (maximum 160 characters) directly to individuals at any time, and in any place. Although SMS can be sent en masse, they can also be personally tailored to each individual recipient, thereby circumventing the likelihood of the message being dismissed as irrelevant (as it is often the case with mass media messages). Additionally, SMS can be read at a time suitable for each individual recipient, overcoming some of the inconvenience associated with receiving telephone calls.
The effectiveness of behavior change interventions delivered via telephone calls1 and the Internet2,3, has been investigated, however the application of SMS technology to behavioral intervention is only just emerging. Some research has investigated the use of SMS in health care administration and monitoring, such as reminding patients of scheduled appointments, coordinating medical staff, delivering medical test results and monitoring patient side-effects following treatment.
We recently published a review of research examining the application of SMS for health behavior change interventions4. We discovered that there were a large number of studies published last year (2008) that reported on developmental work of SMS programs or on SMS trials that were in progress, which indicates that research into behavior change via SMS is increasing. We examined 14 SMS-delivered behavior change interventions in our review. We found that most studies conducted to date (10/14 studies) had focused on the management of chronic diseases, predominantly using SMS as a reminder service to increase adherence to treatment programs among sick individuals (i.e. blood glucose monitoring among diabetic patients). Less than half of the studies (4/14 studies) had focused on promoting preventive behaviors to healthy individuals (i.e. smoking cessation or healthy nutrition). We found statistically significant, positive changes in behavior in more than half of the studies (8/14 studies). A further five studies demonstrated positive behavioral trends but did not have sufficient statistical power to demonstrate statistical significance, and just one study showed no change in behavior. These are promising results for the future of SMS in health behavior change research.
However, it is important at this early stage of research to acknowledge the limited number of high quality SMS intervention trials. The broad range of study designs used and the varying use of SMS characteristics in interventions (i.e. degree of tailoring, SMS dialogue initiation), limited the conclusions we could draw from our review, and highlights the need to improve the quality and rigor of future research in this area. The following methodological improvements will allow for future research to learn valuable lessons from the first generation of SMS trials:
One significant limitation of the evidence currently available is the lack of post-intervention follow-up, which is necessary to demonstrate any effects of SMS behavioral interventions on maintained behavior change.
Another requirement for future research is assessment of both the behavioral focus of the intervention (i.e., physical activity) and the associated health outcomes of the intervention (i.e. blood glucose levels).
There is also strong need to improve reporting on process measures associated with intervention delivery, such as number of SMS sent, number of SMS replies and how participants treated SMS when received.
Technology is developing at a rapid pace and there are many new mobile devices such as Personal Digital Assistants (PDA’s) and devices with Global Positioning Systems (GPS) and video calling capabilities. However, based on the principles of public health promotion it is important to examine the potential of technologies that are used by the masses as methods to disseminate health behavior programs. The widespread use of mobile telephones and the capabilities of SMS have great potential for delivering health behavior interventions. However, we are not sure yet how great that potential is.
|Authors :||Brianna Fjeldsoe, Ph.D.
School of Population Health
The University of Queensland
Alison Marshall, Ph.D.
Public Health Subject Area Coordinator
School of Public Health
Queensland University of Technology
Yvette Miller, Ph.D.
School of Psychology
The University of Queensland
Eakin E, Lawler S, Vandelanotte C, Owen N. Telephone interventions for physical activity and dietary behavior change: A systematic review. Am J Prev Med 2007; 32(5): 419-434.
Evers K, Prochaska J, Prochaska J, Driskell M, Cummins C, Velicer W. Strengths and weaknesses of health behavior change programs on the Internet. J Health Psych 2003; 8(1): 63-70.
Marcus B, Nigg C, Reibe D, Forsyth A. Interactive communication strategies: Implications for population-based physical activity promotion. Am J Prev Med 2000; 19 (2): 121-126.
Fjeldsoe B, Marshall A, Miller Y. Behavior change interventions delivered via mobile telephone short-message service. Am J Prev Med 2009; 36(2): 165-173.