Abstract
Supporting lifestyle change is an effective way of preventing recurrent events in people with cardiovascular disease (CVD). However, there is a need to develop innovative strategies that increase access to programmes for individuals at high risk of CVD. This study aimed to develop a bank of text messages designed to provide advice, motivation, and support for decreasing cardiovascular risk.
Iterative development process with mixed methods
An initial bank of 120 text messages was drafted based on behaviour change techniques, guidelines, and input from clinicians and public health experts. A questionnaire was then administered to participants (n = 53) for evaluation of message content, usefulness, and language. To test the process of delivery, a pilot study was conducted using a specifically designed computer programme that delivered messages to multiple mobile phones according to a pre-specified schedule. Data were collected regarding message timing, delivery, and usefulness.
In the qualitative questionnaire, 92% of participants found the messages easy to understand and 86% found the messages contained useful information. Positive feedback was also obtained from the pilot study. Based on these results, together with suggestions provided, several messages were reworded and an additional 44 were written. The need for semi-personalization was also identified and a random set of 103 individualized messages was created.
A final bank of 137 mobile telephone text messages designed to support behaviour change and decrease cardiovascular risk have been developed through a multistep iterative process. This provides a scientific approach for future developers of health-related text messages.
Introduction
Cardiovascular disease (CVD), including coronary heart disease (CHD), and stroke, is the leading cause of death and disease burden globally.1 Importantly, approximately half of these events occur in individuals who have a prior hospital episode for CHD.2,3 Therefore, implementation of secondary prevention strategies aimed at those at the highest risk are the most effective and cost-effective means of preventing cardiovascular events.4 However, surveys indicate poor utilization of secondary prevention and in particular poor adherence to lifestyle recommendations.5,6 Therefore, there is a need to develop innovative implementation strategies that increase access and engagement with patients once they are identified.
Mobile or cellular telephones are potentially an ideal means of providing messages that reinforce lifestyle change. Increasing numbers of people across all income, age, and ethnic groups own a mobile phone. In 2008, there were over 4 billion active mobile phone subscribers globally.7 Studies indicate mobile phone use is widespread even among disadvantaged populations where more frequent mobile phone use is associated with lower education, socioeconomic status, and poorer health.8 International mobile phone subscription rates vary internationally but in 2010 for every 100 inhabitants there were 130 mobile telephone subscriptions in the UK, 101 in Australia, 90 in the USA, and 64 in China.8 While mobile phone ownership is the highest among 18–24 year olds, global trends show increasing ownership for all age groups.9
The delivery of text messages to mobile phones using a Short Message Service (SMS) is a common, convenient, rapid, and cheap method of communication. The total number of SMS messages sent globally tripled between 2007 and 2010, from an estimated 1.8 trillion to 6.1 trillion which approximates to around 200,000 text messages being sent every second,8 providing enormous potential for health service providers. As the use of new technologies, such as SMS, grows it is important for researchers and clinicians to explore new opportunities and adapt these in order to expand access to services.10
Recent studies have evaluated the effectiveness of mobile phone text messaging to change individual health behaviours, including smoking,11 weight loss,12 and physical activity,13 to improve the medical management of diabetes,14 and to increase adherence to medications.15 The largest smoking cessation trial found biochemically verified continuous abstinence from smoking at 6 months was significantly increased in the intervention group who received motivational messages based on behaviour-change techniques as well as information on the consequences of smoking and tips on quitting successfully.11 However, previous trials do not provide explicit detail about how the text message content and language was developed and tested. One published study reports the development of picture messages for HIV prevention;16 however, there is no similar published process for written messages. Another study investigated text message reminders to improve Kenyan health workers’ adherence to malaria treatment guidelines but it provides minimal information about text message development: only 10 messages were developed and they were not explicitly based on behaviour change techniques.17 Therefore, we aimed to systematically develop and test the delivery of a bank of text messages designed to provide advice, motivation, and support aimed at decreasing cardiovascular risk in patients with CVD.
Methods
Design
An eventual bank of text messages and an electronic process for delivery was systematically developed through an iterative process and using mixed methods design (a series of quantitative and qualitative strategies) with an initial development phase, qualitative analysis, and pilot testing (Figure 1). The study was conducted at a large tertiary referral hospital in Sydney, Australia that services a diverse population from 15 local government areas. Ethics approval was obtained from the Western Sydney Local Health Network Human Research Ethics Committee.
Text message development and testing study schema.
Phase 1: initial development
The aim of phase 1 was to develop a draft bank of text messages designed to provide advice, motivation, and information. Messages were designed to encourage patients to quit smoking (if relevant), eat a healthy diet, participate in regular exercise, adhere to prescribed medication, and undertake cardiovascular risk factor monitoring. The initial messages were specifically based on a variety of behaviour change techniques18 and evidence-based health and medical information found in current national guidelines.19 These messages were drafted by authors of this paper (JR and CC) who have expertise in the delivery of CVD prevention (including lifestyle advice and the prescription of evidence-based medication). Once drafted, all messages were reviewed, commented on, and added to by all other investigators (listed as authors).
Theoretical basis messages
The initial draft bank of messages covered a range of theoretical frameworks (Table 1).18 Behaviour change techniques included: the provision of information and encouragement; prompting about consequences, intention formation, monitoring self-behaviour, and barrier identification; advice about setting graded tasks; and strategies aimed at relapse prevention and the use of prompting and cues.18 In their taxonomy, Abraham and Michie18 link these techniques to a range of underlying theoretical frameworks such as information-motivation-behavioural skills model, the theory of reasoned action, the theory of planned behaviour, social cognitive theory, control theory, and operant conditioning.
Behaviour change techniques, illustrative theoretical frameworks, and example messages
| Behaviour change technique18 | Content | Example text message |
|---|---|---|
| Provide information about behaviour health link (IMB) | General information about health outcomes in relation to behaviour | Did you know taking blood pressure & cholesterol medicines can halve your risk of a heart attack? |
| Provide information on consequences (IMB, TRA, TPB, SCogT) | Information about the benefits and costs of action or inaction | Did you know breathing in other people’s smoke for as little as 30 minutes can be harmful? |
| Prompt intention formation (IMB, TRA, TPB, SCogT) | Encourage person to decide to act or set a general goal or behavioural resolution | Write down all the reasons that you want to quit and keep the list where you will see it often |
| Prompt barrier identification (SCogT) | Identify barriers to performing the behaviour and plan to overcome them | Try identifying the triggers that make you want a cigarette and plan to avoid them |
| Provide general encouragement (SCogT) | Praising or rewarding effort or performance | The lower the cholesterol level the better, if your cholesterol is down rejoice but keep taking your tablets! |
| Set graded tasks (SCogT) | Set easy tasks and increase difficulty | Begin activity at low intensity & gradually increase |
| Provide instruction (SCogT) | Tell the person how to perform a desire behaviour and how to prepare for it | When quitting smoking – enlist your Dr’s help, try a nicotine chewing gum, patches, or inhaler |
| Prompt self-monitoring of behaviour (CT) | The person is asked to keep a record/diary | Try keeping a calendar of how often you walk and for how many minutes |
| Relapse prevention | Following initial change, help the person manage potential failure | When you are quitting smoking – if you have a bad day, don’t worry & keep trying |
| Teach to use prompts or cues (OC) | Teach the person to use environmental cues that can be used to remind them to perform a behaviour | If you crave a cigarette, try and distract yourself – try walking or something creative |
| Time management | Helping the person make time and fit the behaviour into their everyday routine | Walking up and down a flight of stairs several times is a great strengthening activity |
| Behaviour change technique18 | Content | Example text message |
|---|---|---|
| Provide information about behaviour health link (IMB) | General information about health outcomes in relation to behaviour | Did you know taking blood pressure & cholesterol medicines can halve your risk of a heart attack? |
| Provide information on consequences (IMB, TRA, TPB, SCogT) | Information about the benefits and costs of action or inaction | Did you know breathing in other people’s smoke for as little as 30 minutes can be harmful? |
| Prompt intention formation (IMB, TRA, TPB, SCogT) | Encourage person to decide to act or set a general goal or behavioural resolution | Write down all the reasons that you want to quit and keep the list where you will see it often |
| Prompt barrier identification (SCogT) | Identify barriers to performing the behaviour and plan to overcome them | Try identifying the triggers that make you want a cigarette and plan to avoid them |
| Provide general encouragement (SCogT) | Praising or rewarding effort or performance | The lower the cholesterol level the better, if your cholesterol is down rejoice but keep taking your tablets! |
| Set graded tasks (SCogT) | Set easy tasks and increase difficulty | Begin activity at low intensity & gradually increase |
| Provide instruction (SCogT) | Tell the person how to perform a desire behaviour and how to prepare for it | When quitting smoking – enlist your Dr’s help, try a nicotine chewing gum, patches, or inhaler |
| Prompt self-monitoring of behaviour (CT) | The person is asked to keep a record/diary | Try keeping a calendar of how often you walk and for how many minutes |
| Relapse prevention | Following initial change, help the person manage potential failure | When you are quitting smoking – if you have a bad day, don’t worry & keep trying |
| Teach to use prompts or cues (OC) | Teach the person to use environmental cues that can be used to remind them to perform a behaviour | If you crave a cigarette, try and distract yourself – try walking or something creative |
| Time management | Helping the person make time and fit the behaviour into their everyday routine | Walking up and down a flight of stairs several times is a great strengthening activity |
CT, control theory; IMB, information-motivation-behavioural skills model; OC, operant conditioning; SCogT, social cognitive theory; TPB, theory of planned behaviour; TRA, theory of reasoned action.
Behaviour change techniques, illustrative theoretical frameworks, and example messages
| Behaviour change technique18 | Content | Example text message |
|---|---|---|
| Provide information about behaviour health link (IMB) | General information about health outcomes in relation to behaviour | Did you know taking blood pressure & cholesterol medicines can halve your risk of a heart attack? |
| Provide information on consequences (IMB, TRA, TPB, SCogT) | Information about the benefits and costs of action or inaction | Did you know breathing in other people’s smoke for as little as 30 minutes can be harmful? |
| Prompt intention formation (IMB, TRA, TPB, SCogT) | Encourage person to decide to act or set a general goal or behavioural resolution | Write down all the reasons that you want to quit and keep the list where you will see it often |
| Prompt barrier identification (SCogT) | Identify barriers to performing the behaviour and plan to overcome them | Try identifying the triggers that make you want a cigarette and plan to avoid them |
| Provide general encouragement (SCogT) | Praising or rewarding effort or performance | The lower the cholesterol level the better, if your cholesterol is down rejoice but keep taking your tablets! |
| Set graded tasks (SCogT) | Set easy tasks and increase difficulty | Begin activity at low intensity & gradually increase |
| Provide instruction (SCogT) | Tell the person how to perform a desire behaviour and how to prepare for it | When quitting smoking – enlist your Dr’s help, try a nicotine chewing gum, patches, or inhaler |
| Prompt self-monitoring of behaviour (CT) | The person is asked to keep a record/diary | Try keeping a calendar of how often you walk and for how many minutes |
| Relapse prevention | Following initial change, help the person manage potential failure | When you are quitting smoking – if you have a bad day, don’t worry & keep trying |
| Teach to use prompts or cues (OC) | Teach the person to use environmental cues that can be used to remind them to perform a behaviour | If you crave a cigarette, try and distract yourself – try walking or something creative |
| Time management | Helping the person make time and fit the behaviour into their everyday routine | Walking up and down a flight of stairs several times is a great strengthening activity |
| Behaviour change technique18 | Content | Example text message |
|---|---|---|
| Provide information about behaviour health link (IMB) | General information about health outcomes in relation to behaviour | Did you know taking blood pressure & cholesterol medicines can halve your risk of a heart attack? |
| Provide information on consequences (IMB, TRA, TPB, SCogT) | Information about the benefits and costs of action or inaction | Did you know breathing in other people’s smoke for as little as 30 minutes can be harmful? |
| Prompt intention formation (IMB, TRA, TPB, SCogT) | Encourage person to decide to act or set a general goal or behavioural resolution | Write down all the reasons that you want to quit and keep the list where you will see it often |
| Prompt barrier identification (SCogT) | Identify barriers to performing the behaviour and plan to overcome them | Try identifying the triggers that make you want a cigarette and plan to avoid them |
| Provide general encouragement (SCogT) | Praising or rewarding effort or performance | The lower the cholesterol level the better, if your cholesterol is down rejoice but keep taking your tablets! |
| Set graded tasks (SCogT) | Set easy tasks and increase difficulty | Begin activity at low intensity & gradually increase |
| Provide instruction (SCogT) | Tell the person how to perform a desire behaviour and how to prepare for it | When quitting smoking – enlist your Dr’s help, try a nicotine chewing gum, patches, or inhaler |
| Prompt self-monitoring of behaviour (CT) | The person is asked to keep a record/diary | Try keeping a calendar of how often you walk and for how many minutes |
| Relapse prevention | Following initial change, help the person manage potential failure | When you are quitting smoking – if you have a bad day, don’t worry & keep trying |
| Teach to use prompts or cues (OC) | Teach the person to use environmental cues that can be used to remind them to perform a behaviour | If you crave a cigarette, try and distract yourself – try walking or something creative |
| Time management | Helping the person make time and fit the behaviour into their everyday routine | Walking up and down a flight of stairs several times is a great strengthening activity |
CT, control theory; IMB, information-motivation-behavioural skills model; OC, operant conditioning; SCogT, social cognitive theory; TPB, theory of planned behaviour; TRA, theory of reasoned action.
The original message content was based on these techniques because they are known to encourage beneficial behaviour.20 In addition, messages were designed to provide positive reinforcement as this is more likely to result in lasting changes in behaviour, compared to negative reinforcement.21 Given the mode of delivery was via unidirectional text message we were not able to include all of the behaviour change techniques suggested by Abraham and Michie.18 Those we were unable to include were modelling or demonstration of various behaviours, specific goal setting, rehearsal, motivational interviewing, and planning of social support.
Medical content of messages
Medical content of the messages was based on information found in current national guidelines19 and grouped into four categories: (1) general heart health information messages that include facts about CVD and information about medications and risk factors; (2) nutrition messages; (3) physical activity messages; and (4) smoking cessation messages. In keeping with behaviour change techniques,18 for each category messages were developed that aimed to provide information, prompting and reminders, instruction, and problem solving with practical suggestions and positive reinforcement. All messages are reviewed by a health professional and, in the event that a participant reports a serious medical concern, they will be advised to visit their general practitioner as soon as possible or, if more appropriate, attend their nearest emergency department or call the Australian emergency number (000).
Structure and language of messages
Each message was designed to be suitable for people of any age or gender. The maximum message length was 160 characters which is the maximum amount of text that can be sent in a text message to most mobile telephones. Language used was simple and clear with only common abbreviations. The messages were designed as one-way communication reminders to allow simple software development and to keep the intervention as cost effective as possible.
Once an initial bank of 120 messages was drafted, they were scrutinized and modified by an expert review panel made up of a multidisciplinary group of clinicians (including cardiologists, a psychologist, a physiotherapist, nurses, and public health specialists), researchers, and academics. Expert reviewers were asked to consider clinical benefit, clarity, usefulness, and grammar. The messages were then modified accordingly and the updated bank of messages was considered ready for further testing.
Phase 2: user testing
The aim of phase 2 was to test the content of the draft messages using a user qualitative survey. Each survey included two questions that required Likert responses about usefulness and readability for each of six draft messages. A final open question asked for general comment, feedback, and any suggestions for improvement. Basic demographic information such as age, gender, and previous diagnosis of CVD was collected. Consecutive participants were identified from clinical areas by the researchers. Survey responses were de-identified. At the conclusion of user testing, feedback was collated and summarized. Areas of concern were addressed and the messages were modified accordingly. The updated bank of messages was then ready for pilot testing of the messages with computerized delivery.
Phase 3: pilot testing
The aim of the pilot testing was to evaluate the messages and their delivery when they were sent to individual’s mobile telephones using a software programme. The software programme was designed to deliver the text messages to multiple mobile phones from a single remote central server. We used local work networks and approached other interested individuals who provided their mobile phone number on a voluntary basis and agreed to provide us with feedback on the programme and process. Participants provided informed consent and their mobile telephone number to the researchers and received the relevant messages via the software programme for one week. At the conclusion of the pilot study, participants were sent a questionnaire that asked specific questions about the messages, their potential impact (potential to change behaviour), the process of receiving messages (e.g. timing, personalization, and frequency), and for any further feedback. Following completion of the pilot study, the message bank and software system were refined accordingly.
The delivery of messages for the pilot testing was managed via a custom software programme that provided a computerized messaging engine developed by programmers with input from the research team. The software programme had a page to enter patient specific details including start date, mobile phone number, and inclusion/exclusion of smoking cessation messages. The programme kept a log of all messages sent to each study participant including those that failed to send. To ensure security, two firewall systems were active (Mac Operating System and Little Snitch) and only allowed traffic on designated ports. The device was also protected via the service provider’s router that had standard settings allowing no incoming connections. In addition, the computer running the software was password protected, located in a locked room, and not used for any other purpose. The messaging engine sent messages through a gateway interface, allowing them to be sent to all participants on any Australian phone network at no cost to the participant and at a bulk-rate cost (€0.10 per message). The programme can send semi-personalized messages (e.g. ‘Dear <participant’s preferred name>’). The system sends messages one at a time, one per second, and is therefore capable of sending approximately 3600 messages per hour.
Frequency, sequence, and management of text message delivery
Each participant received a random set of messages for 1 week. Messages were sent in random order, at one of four random times (9.00 a.m., 12 noon, 3.00 p.m., 5.00 p.m.) and on four random week days. Randomization was managed by the software and was programmed prior to study commencement. Non-smokers received two general heart health and medication messages, one nutritional message, and one physical activity message per week. Smokers received one general heart health and medication message, one nutritional message, one physical activity message, and one smoking cessation message per week. No message was repeated and participants were asked not to respond to messages they received. Prior to commencement, a semi-personalized ‘welcome’ SMS (Table 2) was sent to each participant to ensure the correct telephone number had been recorded and that the system was working effectively.
Examples of messages developed
| Type of message | Example |
|---|---|
| Introductory messages | Hi <NAME>, Welcome to TEXTME. We hope you enjoy the messages. If you have received this in error respond STOP to opt out |
| General cardiovascular health and medications | Check out www.heartfoundation.org.au for tips & info about preventing heart disease |
| Are you taking daily aspirin? If not discuss it with your Dr | |
| Not having support of family & friends can worsen heart disease – if you need help, don't be afraid to ask | |
| Hi <NAME>, remember – cholesterol & blood pressure lowering tablets need to be taken every day | |
| <NAME>, has your Dr checked & discussed your blood pressure with you recently? Blood pressure needs regular review | |
| Nutrition | Healthy eating means at least 5 serves of vegetables & 2 serves of fruit every day |
| <NAME>, try to choose poultry or meat trimmed of visible fat & without the skin | |
| To add interest to your meals try a new fruit, vegetable or herb | |
| Try steaming, baking or BBQ to reduce the need for excess oil when cooking | |
| Physical activity | <NAME>, track & log your daily physical activity on a calendar or diary |
| Begin activity at low intensity & gradually increase | |
| There are many ways to increase your activity levels. Try Tai Chi, pilates, gardening, yoga or dancing | |
| Hi <NAME>, why not try and use the stairs instead of the lift | |
| Smoking cessation | <NAME>, try identifying the triggers that make you want a cigarette & avoid them |
| It may take several attempts to quit, so keep trying | |
| If you crave a cigarette try & distract yourself by going for a walk or doing something creative | |
| Check out the website www.icanquit.com.au for tips & to track your progress when quitting smoking |
| Type of message | Example |
|---|---|
| Introductory messages | Hi <NAME>, Welcome to TEXTME. We hope you enjoy the messages. If you have received this in error respond STOP to opt out |
| General cardiovascular health and medications | Check out www.heartfoundation.org.au for tips & info about preventing heart disease |
| Are you taking daily aspirin? If not discuss it with your Dr | |
| Not having support of family & friends can worsen heart disease – if you need help, don't be afraid to ask | |
| Hi <NAME>, remember – cholesterol & blood pressure lowering tablets need to be taken every day | |
| <NAME>, has your Dr checked & discussed your blood pressure with you recently? Blood pressure needs regular review | |
| Nutrition | Healthy eating means at least 5 serves of vegetables & 2 serves of fruit every day |
| <NAME>, try to choose poultry or meat trimmed of visible fat & without the skin | |
| To add interest to your meals try a new fruit, vegetable or herb | |
| Try steaming, baking or BBQ to reduce the need for excess oil when cooking | |
| Physical activity | <NAME>, track & log your daily physical activity on a calendar or diary |
| Begin activity at low intensity & gradually increase | |
| There are many ways to increase your activity levels. Try Tai Chi, pilates, gardening, yoga or dancing | |
| Hi <NAME>, why not try and use the stairs instead of the lift | |
| Smoking cessation | <NAME>, try identifying the triggers that make you want a cigarette & avoid them |
| It may take several attempts to quit, so keep trying | |
| If you crave a cigarette try & distract yourself by going for a walk or doing something creative | |
| Check out the website www.icanquit.com.au for tips & to track your progress when quitting smoking |
Examples of messages developed
| Type of message | Example |
|---|---|
| Introductory messages | Hi <NAME>, Welcome to TEXTME. We hope you enjoy the messages. If you have received this in error respond STOP to opt out |
| General cardiovascular health and medications | Check out www.heartfoundation.org.au for tips & info about preventing heart disease |
| Are you taking daily aspirin? If not discuss it with your Dr | |
| Not having support of family & friends can worsen heart disease – if you need help, don't be afraid to ask | |
| Hi <NAME>, remember – cholesterol & blood pressure lowering tablets need to be taken every day | |
| <NAME>, has your Dr checked & discussed your blood pressure with you recently? Blood pressure needs regular review | |
| Nutrition | Healthy eating means at least 5 serves of vegetables & 2 serves of fruit every day |
| <NAME>, try to choose poultry or meat trimmed of visible fat & without the skin | |
| To add interest to your meals try a new fruit, vegetable or herb | |
| Try steaming, baking or BBQ to reduce the need for excess oil when cooking | |
| Physical activity | <NAME>, track & log your daily physical activity on a calendar or diary |
| Begin activity at low intensity & gradually increase | |
| There are many ways to increase your activity levels. Try Tai Chi, pilates, gardening, yoga or dancing | |
| Hi <NAME>, why not try and use the stairs instead of the lift | |
| Smoking cessation | <NAME>, try identifying the triggers that make you want a cigarette & avoid them |
| It may take several attempts to quit, so keep trying | |
| If you crave a cigarette try & distract yourself by going for a walk or doing something creative | |
| Check out the website www.icanquit.com.au for tips & to track your progress when quitting smoking |
| Type of message | Example |
|---|---|
| Introductory messages | Hi <NAME>, Welcome to TEXTME. We hope you enjoy the messages. If you have received this in error respond STOP to opt out |
| General cardiovascular health and medications | Check out www.heartfoundation.org.au for tips & info about preventing heart disease |
| Are you taking daily aspirin? If not discuss it with your Dr | |
| Not having support of family & friends can worsen heart disease – if you need help, don't be afraid to ask | |
| Hi <NAME>, remember – cholesterol & blood pressure lowering tablets need to be taken every day | |
| <NAME>, has your Dr checked & discussed your blood pressure with you recently? Blood pressure needs regular review | |
| Nutrition | Healthy eating means at least 5 serves of vegetables & 2 serves of fruit every day |
| <NAME>, try to choose poultry or meat trimmed of visible fat & without the skin | |
| To add interest to your meals try a new fruit, vegetable or herb | |
| Try steaming, baking or BBQ to reduce the need for excess oil when cooking | |
| Physical activity | <NAME>, track & log your daily physical activity on a calendar or diary |
| Begin activity at low intensity & gradually increase | |
| There are many ways to increase your activity levels. Try Tai Chi, pilates, gardening, yoga or dancing | |
| Hi <NAME>, why not try and use the stairs instead of the lift | |
| Smoking cessation | <NAME>, try identifying the triggers that make you want a cigarette & avoid them |
| It may take several attempts to quit, so keep trying | |
| If you crave a cigarette try & distract yourself by going for a walk or doing something creative | |
| Check out the website www.icanquit.com.au for tips & to track your progress when quitting smoking |
Results
Phase 1: initial development
Table 2 provides examples of the types of messages from the initial bank of 120 messages. The bank included 30 general heart health information messages that include facts about CVD, symptom management reminders, and information about medications and reminders to take prescribed medications. The general messages also included specific messages relating to biomedical risk factors including high cholesterol and blood pressure and the importance of having them assessed regularly. There were 40 nutritional messages and these included messages about nutritional facts relating to heart disease, suggestions and advice about increasing fruit and vegetable intake, suggestions for ‘snacks’ such as morning and afternoon tea, advice about avoidance/reduction of saturated fats, increasing oily fish consumption, reducing salt intake, and maintaining healthy weight. There were 30 messages relating to physical activity and these focused on facts and guidelines amd the benefits of regular physical activity and provided simple suggestions for increasing everyday physical activity. The final draft bank of messages also included 20 messages related to smoking cessation and these focused on facts and guidelines and suggestions to encourage smoking cessation.
Phase 2: user acceptance testing
In total, 53 participants were recruited for the user acceptance testing phase of the text message development. The participants (n = 53) were mostly female (60%, 32/53) and some had diagnosed CVD (28%, 15/53). In terms of age, 41% (22/53) were less than 50 years, 19% (10/53) were between 50 and 59 years, and 40% (21/53) were older than 60 years. All had completed high school education. Several participants completed surveys on more than one batch of six messages. In total, there were 404 responses across the 120 messages. Of all responses, 92% (372/404) rated the messages as easy to understand and 86% (346/404) rated the messages as useful. The scores for the various categories of messages are summarized in Table 3. Participants highlighted the importance of not sending messages about eating meat products to vegetarians and hence this was built into the software programme, along with 15 grammatical suggestions, prior to pilot testing.
Survey scores for various message categories
| Strongly agree or agree | Neutral | Disagree or strongly disagree | |
|---|---|---|---|
| General health messages | |||
| Information easy to understand (n = 84) | 74 (88) | 6 (7) | 4 (5) |
| Information was useful (n = 84) | 69 (82) | 9 (11) | 6 (7) |
| Nutrition messages | |||
| Information easy to understand (n = 177) | 163 (92) | 8 (5) | 6 (3) |
| Information was useful (n = 177) | 149 (84) | 13 (7) | 15 (8) |
| Physical activity messages | |||
| Information easy to understand (n = 81) | 77 (95) | 3 (4) | 1 (1) |
| Information was useful (n = 81) | 71 (88) | 7 (9) | 3 (4) |
| Smoking cessation message | |||
| Information easy to understand (n = 62) | 58 (93) | 4 (7) | 0 (0) |
| Information was useful (n = 62) | 57 (90) | 4 (7) | 1 (1) |
| Strongly agree or agree | Neutral | Disagree or strongly disagree | |
|---|---|---|---|
| General health messages | |||
| Information easy to understand (n = 84) | 74 (88) | 6 (7) | 4 (5) |
| Information was useful (n = 84) | 69 (82) | 9 (11) | 6 (7) |
| Nutrition messages | |||
| Information easy to understand (n = 177) | 163 (92) | 8 (5) | 6 (3) |
| Information was useful (n = 177) | 149 (84) | 13 (7) | 15 (8) |
| Physical activity messages | |||
| Information easy to understand (n = 81) | 77 (95) | 3 (4) | 1 (1) |
| Information was useful (n = 81) | 71 (88) | 7 (9) | 3 (4) |
| Smoking cessation message | |||
| Information easy to understand (n = 62) | 58 (93) | 4 (7) | 0 (0) |
| Information was useful (n = 62) | 57 (90) | 4 (7) | 1 (1) |
Values are n (%).
Survey scores for various message categories
| Strongly agree or agree | Neutral | Disagree or strongly disagree | |
|---|---|---|---|
| General health messages | |||
| Information easy to understand (n = 84) | 74 (88) | 6 (7) | 4 (5) |
| Information was useful (n = 84) | 69 (82) | 9 (11) | 6 (7) |
| Nutrition messages | |||
| Information easy to understand (n = 177) | 163 (92) | 8 (5) | 6 (3) |
| Information was useful (n = 177) | 149 (84) | 13 (7) | 15 (8) |
| Physical activity messages | |||
| Information easy to understand (n = 81) | 77 (95) | 3 (4) | 1 (1) |
| Information was useful (n = 81) | 71 (88) | 7 (9) | 3 (4) |
| Smoking cessation message | |||
| Information easy to understand (n = 62) | 58 (93) | 4 (7) | 0 (0) |
| Information was useful (n = 62) | 57 (90) | 4 (7) | 1 (1) |
| Strongly agree or agree | Neutral | Disagree or strongly disagree | |
|---|---|---|---|
| General health messages | |||
| Information easy to understand (n = 84) | 74 (88) | 6 (7) | 4 (5) |
| Information was useful (n = 84) | 69 (82) | 9 (11) | 6 (7) |
| Nutrition messages | |||
| Information easy to understand (n = 177) | 163 (92) | 8 (5) | 6 (3) |
| Information was useful (n = 177) | 149 (84) | 13 (7) | 15 (8) |
| Physical activity messages | |||
| Information easy to understand (n = 81) | 77 (95) | 3 (4) | 1 (1) |
| Information was useful (n = 81) | 71 (88) | 7 (9) | 3 (4) |
| Smoking cessation message | |||
| Information easy to understand (n = 62) | 58 (93) | 4 (7) | 0 (0) |
| Information was useful (n = 62) | 57 (90) | 4 (7) | 1 (1) |
Values are n (%).
Phase 3: pilot testing
All 16 participants reported they were happy with the semi-personalized introductory message they received. All participants were satisfied with the messages and did not find that any arrived at a delayed or an inappropriate time. Participants also reported that the messages were appropriate and all suggested that the content would inspire them to maintain a healthy lifestyle.
Following the pilot testing a few minor changes were made to the software programme. These adjustments included inserting the participant’s name on approximately 100 messages, including a semi-personalized introductory message (Table 2) welcoming the participant to the text message programme and identifying the phone number as being a hospital initiative. It was also agreed that it was important to remind future participants to save the study phone number into their mobile telephone ‘contact list’ so that they would know who had sent the message. The final bank of 137 messages included four introductory or welcoming messages, 48 general messages, 33 nutrition messages (of which a subset of 27 messages were suitable for vegetarians), 27 physical activity messages, and 25 smoking cessation messages.
Discussion
This progressive and iterative process involving researchers, clinicians, and members of the public resulted in a bank of text messages that are suitable for implementation aimed at prevention of further events in people with CVD. This study is the first known published study that has evaluated the development, acceptability, and user acceptance testing of such a series of messages. The process included formal derivation based on national guidelines and ongoing refinement based on a qualitative survey and user acceptance testing of the software programme. The eventual bank includes 137 semi-personalized text messages, including introductory messages and a range of messages in each of the categories of general information, nutrition, physical activity, and smoking cessation. This approach is feasible and resulted in useful feedback that substantially improved the original bank of text messages.
The majority of studies reporting mobile phone text-messaging interventions document outcomes rather than the process of message development. Several small studies have investigated the feasibility of sending text messages to promote healthy behaviours. However, the manuscripts provide almost no detail on content development or the process for evaluation and refinement.12,22–24 One small study does specifically report the development and pre-testing of multimedia text messages for prevention of HIV infection.16 The study included the collection of qualitative information about message usability and acceptability; however, these messages were ‘picture’ messages directed at teenage participants whereas the present study aims to develop text messages aimed at people with CVD. Another large cluster trial aiming to increase adherence to malaria treatment states that 10 key text messages were developed based on guidelines and training manuals;17 however, the processes relating to development are unclear.
The use of theory to design and describe the messages is anticipated to increase the likelihood of successful change and allow better understanding of the mechanisms of change.25 A large systematic review including 85 studies found that more extensive use of theory and behaviour change techniques was associated with larger effect sizes.26 No such review exists for text message-based interventions but we anticipate that the theory-linked methods used in this present study will increase the potential for successful behaviour change18,26 and clarification of the mechanisms of change.11,18 During the development process we decided to use semi-personalized messages to increase engagement but opted not to utilize fully personalized messages to keep costs minimal and to be suitable to older groups.7
Two systematic reviews highlight why it is important for studies to report how the content of text messages were developed.27,28 Fjeldsoe et al.27 found that most studies did not evaluate the behaviours that were targeted in the interventions and Whittaker et al.28 found that the individual effects of different delivery mechanisms could not be assessed because fundamental elements of message content were not provided. Therefore, it is suggested that future studies should explicitly describe the mechanisms used to promote behaviour change, so that effectiveness of different techniques can be assessed.27
While there is clear evidence that secondary prevention programmes in patients with CVD are effective,4 it is also apparent that these are underutilized.5 Interventions that are simple and low-cost and that use widely available technology could potentially supplement programmes and increase access to secondary prevention.29,30 There are several potential advantages associated with text messaging. Mobile phones and text messages are popular, portable, and convenient. They allow information to be delivered quickly and usually it is received instantaneously.22 This information is transmitted without the user requesting it. This contrasts with other technology-based interventions that require users to call a specific number or access a website.22 Potentially, text messaging could be used to the deliver CVD prevention information to large numbers of people, including those in poor and isolated communities.
A number of questions remain about the feasibility and efficacy of text message-based intervention programmes, particularly in older age groups who have greater cardiovascular risk. The majority of participants in this trial were female and it remains unclear whether text message-based interventions will prove equally acceptable to both genders. The messages developed and tested in this study were written in English and further research is needed to develop text messages that are suitable for diverse cultures and in different languages. In addition, further work is needed to determine how the content, level of personalization, frequency of text messages, and level of interaction between message sender and receiver are optimal. Most, importantly, a rigorous study has commenced (TEXT ME) to evaluate the effectiveness (for both genders) or otherwise of this intervention and its cost effectiveness.31
In conclusion, this study reports the development and testing of a bank of 164 mobile telephone text messages that are now suitable for clinical use. The messages were developed using theory, national guidelines, expert review, qualitative survey, and pilot testing. Text messaging for health management and prevention has enormous international potential. While future studies are needed to specifically test the effectiveness of the text messages, we report a process for development that ensures messages are evidence based, appropriate, and useful.
Acknowledgements
The authors thank all the study participants and Mr Tony Barry who was responsible for the software development.
Funding
This work was supported by a National Heart Foundation of Australia Grant-in aide (G10S5110) and a BUPA Foundation Grant. JR was funded by a Postdoctoral Fellowship co-funded by the NHMRC and National Heart Foundation (632933). MH was in receipt of a NHMRC Career Development Award (632925). SJ was funded by an NHMRC Senior Research Fellowship (1020430). GSH was funded by a New South Wales Office for Science and Medical Research, Life Sciences Research Award. CC was funded by a Career Development Fellowship co-funded by the NHMRC and National Heart Foundation and Sydney Medical Foundation Chapman Fellowship (1033478).
Conflict of interest
The authors declare they have no competing interests.
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