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Text messaging: A valuable mHealth tool for behavior change

Originated by: Swapna Mehta

Submitted: 05 Dec 2011

Last updated on: 19 Sep 2013

Related Health Topics: Diabetes, Obesity

Overview

The use of mobile phone technology is growing worldwide. In 2010, there were 4.6 billion mobile phone subscribers throughout the world. In addition to being used in finance and marketing industries, mobile phone technology is increasingly being used to promote health and prevent disease. (Fjeldsoe, 2009). Mobile health, also known as mhealth, is defined as the use of mobile phone technology to deliver healthcare. MHealth technologies include text messaging, video messaging, voice calling, and accessing the Internet. One study found that 8 in 10 Americans are interested in mHealth (Cellular Telecommuncations Industry Association, 2009).

Text messaging has been very popular and the most widely used form of mHealth globally. There are over two billion users, accounting for approximately 75% of cell phone users (Turrettini, 2009). In the U.S., 83% of American adults own a cell phone. Text messaging rates are high - 92% of adults with smartphones use text messaging, and 59% of adults with other phones use text messaging. (Pew American and Internet Life Project, 2011). 75% of U.S. teenagers ages 12-17 own a mobile phone and 88% of teen cell phone users use text messaging (Pew American and Internet Life Project, 2010).

In comparison with other mHealth features, text messaging is fairly inexpensive, available on almost every mobile phone, has widespread use, and does not require expertise in technology. Text messaging is applicable to behavior change interventions because it allows for tailored communication and reinforcement, support, and can be easily accessible (Fjeldsoe, 2009). The real-time feature of text messaging is a key benefit, allowing patients to get timely information and support they need to help manage their condition.

Text messaging: a growing disease management tool

Text messaging has many uses in healthcare. It can be used to remind patients to take a specific action, to provide support to patients and to encourage interactive information sharing. The widespread nature of text messaging, ease of use, real-time monitoring, and ability to capture information into a database are advantageous to using text messaging as a medical tool.

Few text message interventions are grounded in health education theories. Social cognitive theory is commonly used in these interventions. Patients can set goals, use cues to action (such as text message reminders) and reinforcement to impact behavior change.

Research has studied the use of text messaging in many conditions including diabetes, obesity, bipolar disorder and schizophrenia (Anthony, 2010). Below will include examples of text messaging uses among these conditions.

The use of text messaging in diabetes

Several studies have documented improvements in health outcomes among patients with diabetes using mobile phone interventions. A meta-analysis study of 22 studies identified common design elements of text messaging use in diabetes included data collection (e.g. blood glucose numbers), communication (e.g. providing diabetes facts via text messaging), and tailored messages based on individual characteristics and individual goals (Mulvaney et al, 2011). Additional studies using mobile phones for diabetes management have shown improvement in HB1AC measures.

The use of text messaging in obesity

Self-monitoring is an important skill for obesity management and can help increase awareness of caloric intake and physical activity. There have been obesity-related studies assessing text messaging interventions among both adults and children. In a 4 month study using text messaging to deliver information, engage adults by asking questions, and provide tips, tailored text messages were effective in promoting weight loss among adults (Patrick et al, 2009).

Another study examined the feasibility of children’s use of text messages to self-monitor intake of their sugary-sweetened beverages, physical activity and screen time. In addition to attending 3 educational sessions, children sent daily text messages for 8 weeks, and received immediate, automated feedback from the program. Support and positive reinforcement led to adherence of the text messaging program (Shapiro et al, 2008).

The use of text messaging in mental health: bipolar disorder and schizophrenia

Text messaging can be helpful in treating major life disrupting symptoms associated with diagnoses such as schizophrenia and bipolar disorder. It has been proven effective in monitoring symptoms, prompting behaviors and providing feedback. (Anthony, 2010).

Schizophrenia:

Research has shown that cognitive impairment symptoms can be enhanced via text messaging. Pijenborg et al published a study in 2007 and found patients using text messaging showed improvements in completing tasks such as taking medicine on time, complying with scheduled appointments, and attending therapy sessions.

Bipolar disorder:

Text messaging is a useful and inexpensive way to monitor moods experienced by patients with bipolar disorder. One study required patients with bipolar disorder to respond via text message to weekly prompts to rate their manic and depressive symptoms (Bopp, 2010). Approximately 90% of patients opted to use text messaging as opposed to email to respond to the ratings.

Another study asked patients to enter numerical values to describe their mood via text messaging. The data plotted moods swings, assessed medicine efficacy, and determined when the next in-office appointment should be. Charting mood swings in real time is a key benefit of text messaging. A bipolar advocate described the benefit of charting mood swings as, “to have a mood mapping text messaging service to a health professional will provide a window into your illness. This could lead to early intervention and potentially identify serious episodes of this mood disorder (Elliot 2008.

Citations

Anthony K., Nagel, Deanna Merz Nagel, and Stephen Gross (2010). The Use of Technology in Mental Health: Applications, Ethics and Practice. Springfield, Illinois: Charles C. Thomas, 2010. Print. http://psychcentral.com/lib/2010/the-use-of-technology-in-mental-health-applications-ethics-and-practice/

Bopp, JM, Miklowitz, D.J., Goodwin, GM, Stevens W., Rendell, JM & Geddes J. (2010). The longitudinal course of bipolar disorder as revealed through weekly text messaging: a feasibility study. Bipolar Disorders, 12, 327-333 http://onlinelibrary.wiley.com/doi/10.1111/j.1399-5618.2010.00807.x/abstract

Cellular Telecommunication Industry Association (2009). Press release: national study reveals MHealth has vast appeal in America. Washington, DC: Cellular Telecommunications Industry Association – The Wireless Association; 2009.http://www.ctia.org/media/press/body.cfm/prid/1877.(Accessed December 2, 2011)

Elliot, J. (2008). Monitoring mental health by text. BBC WorldNews America, Accessed December 2, 2010]. Available from: http://news.bbc.co.uk/2/hi/health/7797155.stm

Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short-message service. Am J Prev Med. 2009; 36(2): 165-173. http://www.ncbi.nlm.nih.gov/pubmed/19135907

Mulvaney, S.A., Ritterband, L.M., Bosslet, L. (2011). Mobile intervention design in diabetes: review and recommendations. Current Diabetes Report, 486-493. http://www.ncbi.nlm.nih.gov/pubmed/21960031

Patrick, K., Raab, F., Adams M., Dillon, L., Rock, M., Griswold, W., Norman, G. (2009). A text message-based intervention for weight loss: randomized controlled trial. Journal of Medical Internet Research, 11(1), e1 http://www.jmir.org/2009/1/e1/

Pew Internet: American Life Project (2010). Teens and mobile phones: text messaging explodes as teens embrace it as the centerpiece of their communication strategies with friends. [Accessed December 2, 2011] Available at: http://pewinternet.org/~/media//Files/Reports/2010/PIP-Teens-and-Mobile-2010-with-topline.pdf

Pew Internet: American Life Project (2011). American and their cell phones: mobile devices help people solve problems and store of boredom [Accessed December 2, 2011] Available at: http://pewinternet.org/~/media//Files/Reports/2011/Cell%20Phones%202011.pdf

Pijnenborg, G.H., Withaar, F.K., Evans, J.J., van den Bosch, R.J., & Brouwer, W.H. (2007). SMS text messages as a prosthetic aid in the cognitive rehabilitation of schizophrenia. Rehabilitation Psychology, 52(2). 236-240. http://www.sciencedirect.com/science/article/pii/S0090555007600944

Shapiro, J., Bauer, S., Hamer, R.M., Kordy, H., Ward, D., and Bulik, C.M. (2008). Use of text messaging for monitoring sugar-sweetened beverages, physical activity, and screen time in children: a pilot study. Journal of Nutrition Education and Behavior, 40(6), 385-391. http://www.ncbi.nlm.nih.gov/pubmed/18984496

Resources

CDC Mobile Tips and Alerts

The CDC will provide you or your patients tailored mobile tips and alerts, to help improve health. 2-3 messages will be sent on a weekly basis.

mHealth Summit

The largest event of its kind, the mHealth Summit brings together leaders in government, private sector, industry, academia, and not-for-profit organizations from across the mHealth ecosystem to advance collaboration in the use of wireless technology to improve health outcomes in the United States and abroad.

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