SMS Text Messaging Interventions Research Articles

Evaluating and Enhancing an Educational Intervention to Reduce Smallholder Farmers' Exposure to Pesticides in Uganda Through a Digital, Systematic Approach to Behavior Change: Protocol for a Cluster-Randomized Controlled Trial.

Smallholder farmers receive educational interventions on safe pesticide handling by governmental agencies, industries, or nongovernmental organizations to reduce exposure risks. However, existing educational interventions have limited effects on changing behaviors. Targeting psychosocial determinants of behavior change in educational interventions through theory- and evidence-based approaches may enhance their effectiveness. We aim at describing the intervention development and study design of a 3-arm cluster-randomized controlled trial to assess the effects in improving safe pesticide handling and reducing pesticide exposure of (1) an existing educational intervention and (2) a newly developed SMS text messaging intervention based on the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) behavior change approach. We enrolled 539 Ugandan smallholder farmers in 12 clusters (subcounties). The clusters, each with 45 farmers, were randomly allocated to one of the three arms: (1) educational intervention, (2) educational intervention+RANAS-based SMS text messages, or (3) control group. The educational intervention comprised a 2-day workshop that targeted multiple aspects of safe pesticide handling, whereas the SMS text messages targeted the use of personal protective equipment (PPE) and were based on the RANAS approach. For intervention development in this study, this approach includes identifying psychosocial determinants of PPE use at baseline and selecting behavior change techniques to target them in SMS text messages. The primary outcomes of the study are (1) pesticide knowledge, attitude, and practice scores indicating performance throughout the educational intervention; and (2) frequency of PPE use. Secondary outcomes are the RANAS-based behavioral determinants of PPE use, the frequency of glove use, algorithm-based pesticide exposure intensity scores, and signs and symptoms of pesticide poisoning. The outcomes were assessed in structured interviews before the intervention (baseline) and at the 12-month follow-up. The effect of the interventions among the arms will be analyzed using the intervention arms and baseline measures as predictors and the follow-up measures as outcomes in linear multivariable mixed models including the clusters as random effects. The mediating psychosocial determinants of the interventions will be assessed in multiple mediation models. The study was conducted from 2020 to 2021-baseline interviews were conducted in October 2020, and the educational intervention was delivered in November 2020. The RANAS-based SMS text messages were developed based on the baseline data for relevant behavioral determinants of PPE use and sent between February 2021 and September 2021. Follow-up interviews were conducted in October 2021. Overall, 539 farmers were enrolled in the study at baseline; 8.3% (45/539) were lost to follow-up by the end of the study. This study will contribute to a better understanding of the effectiveness and behavior change mechanisms of educational interventions by using an experimental, cluster-randomized study design to improve pesticide handling among smallholder farmers. International Standard Randomised Controlled Trial Number (ISRCTN) 18237656; https://doi.org/10.1186/ISRCTN18237656. DERR1-10.2196/55238.

A digital health intervention to support patients with chronic pain during prescription opioid tapering: a pilot randomised controlled trial.

Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support. We evaluated the feasibility, acceptability, and potential efficacy of a codesigned digital health intervention to support patients with chronic pain during voluntary prescription opioid tapering. In a pilot randomised controlled trial, participants received a psychoeducational video and 28 days of text messages (2 SMS/day) in addition to their usual care (intervention) or usual care alone (control). The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy. Of 28 randomised participants, 26 completed the study (13 per group). Text message delivery was high (99.2%), but fidelity of video delivery was low (57.1%). Most participants rated the messages as useful, supportive, encouraging, and engaging; 78.5% would recommend the intervention to others; and 64.2% desired a longer intervention period. Tapering self-efficacy (Cohen d = 0.74) and pain self-efficacy (d = 0.41) were higher, and pain intensity (d = 0.65) and affective interference (d = 0.45) were lower in the intervention group at week 4. First evidence supports the feasibility, acceptability, and potentially efficacy of a psychoeducational video and SMS text messaging intervention to support patients with chronic pain during voluntary prescription opioid tapering. Definitive trials with longer intervention duration are warranted.

Developing a Text Messaging Intervention to Prevent Binge and Heavy Drinking in a Military Population: Mixed Methods Development Study.

Alcohol misuse is the fourth leading cause of death in the United States and a significant problem in the US military. Brief alcohol interventions can reduce negative alcohol outcomes in civilian and military populations, but additional scalable interventions are needed to reduce binge and heavy drinking. SMS text messaging interventions could address this need, but to date, no programs exist for military populations. We aimed to develop an SMS text messaging intervention to address binge and heavy drinking among Airmen in Technical Training in the US Air Force. We implemented a 2-phase, mixed methods study to develop the SMS text messaging intervention. In phase 1, a total of 149 respondents provided feedback about the persuasiveness of 49 expert-developed messages, preferences regarding message frequency, timing and days to receive messages, and suggested messages, which were qualitatively coded. In phase 2, a total of 283 respondents provided feedback about the persuasiveness of 77 new messages, including those developed through the refinement of messages from phase 1, which were coded and assessed based on the Behavior Change Technique Taxonomy (BCTT). For both phases, mean persuasiveness scores (range 1-5) were calculated and compared according to age (aged <21 or ≥21 years) and gender. Top-ranking messages from phase 2 were considered for inclusion in the final message library. In phase 1, top-rated message themes were about warnings about adverse outcomes (eg, impaired judgment and financial costs), recommendations to reduce drinking, and invoking values and goals. Through qualitative coding of suggested messages, we identified themes related to warnings about adverse outcomes, recommendations, prioritizing long-term goals, team and belonging, and invoking values and goals. Respondents preferred to receive 1 to 3 messages per week (124/137, 90.5%) and to be sent messages on Friday, Saturday, and Sunday (65/142, 45.8%). In phase 2, mean scores for messages in the final message library ranged from 3.31 (SD 1.29) to 4.21 (SD 0.90). Of the top 5 highest-rated messages, 4 were categorized into 2 behavior change techniques (BCTs): valued self-identity and information about health consequences. The final message library includes 28 BCTT-informed messages across 13 BCTs, with messages having similar scores across genders. More than one-fourth (8/28, 29%) of the final messages were informed by the suggested messages from phase 1. As Airmen aged <21 years face harsher disciplinary action for alcohol consumption, the program is tailored based on the US legal drinking age. This study involved members from the target population throughout 2 formative stages of intervention development to design a BCTT-informed SMS text messaging intervention to reduce binge and heavy drinking, which is now being tested in an efficacy trial. The results will determine the impact of the intervention on binge drinking and alcohol consumption in the US Air Force.

Digital Health Interventions to Enhance Tuberculosis Treatment Adherence: Scoping Review.

Digital health technologies are widely used for disease management, with their computing platforms, software, and sensors being used for health care. These technologies are developed to manage chronic diseases and infectious bacterial diseases, including tuberculosis (TB). This study aims to comprehensively review the literature on the use of digital health interventions (DHIs) for enhancing TB treatment adherence and identify major strategies for their adoption. We conducted a literature search in the PubMed, Cochrane Library, Ovid Embase, and Scopus databases for relevant studies published between January 2012 and March 2022. Studies that focused on web-based or mobile phone-based interventions, medication adherence, digital health, randomized controlled trials, digital interventions, or mobile health and ubiquitous health technology for TB treatment and related health outcomes were included. We identified 27 relevant studies and classified them according to the intervention method, a significant difference in treatment success, and health outcomes. The following interventions were emphasized: SMS text messaging interventions (8/27, 30%), medicine reminders (6/27, 22%), and web-based direct observation therapy (9/27, 33%). Digital health technology significantly promoted disease management among individuals and health care professionals. However, only a few studies addressed 2-way communication therapies, such as interactive SMS text messaging and feedback systems. This scoping review classified studies on DHIs for patients with TB and demonstrated their potential for the self-management of TB. DHIs are still being developed, and evidence on the impact of digital technologies on enhancing TB treatment adherence remains limited. However, it is necessary to encourage patients' participation in TB treatment and self-management through bidirectional communication. We emphasize the importance of developing a communication system.

Mobile Phone-Based Interventions for Smoking Cessation Among Young People: Systematic Review and Meta-Analysis.

Mobile phone-based cessation interventions have emerged as a promising alternative for smoking cessation, while evidence of the efficacy of mobile phone-based smoking cessation programs among young people is mixed. This study aimed to determine the efficacy of mobile phone-based interventions compared to usual practice or assessment-only controls on smoking cessation in young people. In this systematic review and meta-analysis, we searched Cochrane Library, Embase, PubMed, and Web of Science on March 8, 2023. We included randomized controlled trials that examined the efficacy of mobile phone-based interventions on smoking cessation in young people (age ≤30 years). The risk of bias was assessed with Cochrane Risk of Bias 2. A total of 13 eligible studies, comprising 27,240 participants, were included in this analysis. The age range of the participants was between 16 and 30 years. Nine studies were SMS text messaging interventions, and 4 studies were app-based interventions. The duration of the smoking cessation intervention varied from 5 days to 6 months. The included studies were conducted in the following countries: the United States, China, Sweden, Canada, Switzerland, and Thailand. The meta-analysis revealed that SMS text messaging interventions significantly improved continuous abstinence rates compared to inactive control conditions (risk ratio [RR] 1.51, 95% CI 1.24-1.84). The subgroup analysis showed pooled RRs of 1.90 (95% CI 1.29-2.81), 1.64 (95% CI 1.23-2.18), and 1.35 (95% CI 1.04-1.76) for continuous abstinence at the 1-, 3-, and 6- month follow-up, respectively. Pooling across 7 studies, SMS text messaging interventions showed efficacy in promoting 7-day point prevalence abstinence (PPA), with an RR of 1.83 (95% CI 1.34-2.48). The subgroup analysis demonstrated a significant impact at the 1- and 3-month follow-ups, with pooled RRs of 1.72 (95% CI 1.13-2.63) and 2.54 (95% CI 2.05-3.14), respectively, compared to inactive control conditions. However, at the 6-month follow-up, the efficacy of SMS text messaging interventions in promoting 7-day PPA was not statistically significant (RR 1.45, 95% CI 0.92-2.28). In contrast, app-based interventions did not show significant efficacy in promoting continuous abstinence or 7-day PPA. However, it is important to note that the evidence for app-based interventions was limited. SMS text messaging-based smoking cessation interventions compared to inactive controls were associated with abstinence among young people and could be considered a viable option for smoking cessation in this population. More research is needed on smoking cessation apps, especially apps that target young people. Future research should focus on identifying the most effective mobile phone-based cessation approaches and on developing strategies to increase their uptake and intention.

A Text Messaging Intervention for Priming the Affective Rewards of Exercise in Adults: Protocol for a Microrandomized Trial.

Physical activity is a critical target for health interventions, but effective interventions remain elusive. A growing body of work suggests that interventions targeting affective attitudes toward physical activity may be more effective for sustaining activity long term than those that rely on cognitive constructs alone, such as goal setting and self-monitoring. Anticipated affective response in particular is a promising target for intervention. We will evaluate the efficacy of an SMS text messaging intervention that manipulates anticipated affective response to exercise to promote physical activity. We hypothesize that reminding users of a positive postexercise affective state before their planned exercise sessions will increase their calories burned during this exercise session. We will deploy 2 forms of affective SMS text messages to explore the design space: low-reflection messages written by participants for themselves and high-reflection prompts that require users to reflect and respond. We will also explore the effect of the intervention on affective attitudes toward exercise. A total of 120 individuals will be enrolled in a 9-week microrandomized trial testing affective messages that remind users about feeling good after exercise (40% probability), control reminders (30% probability), or no message (30% probability). Two types of affective SMS text messages will be deployed: one requiring a response and the other in a read-only format. Participants will write the read-only messages themselves to ensure that the messages accurately reflect the participants' anticipated postexercise affective state. Affective attitudes toward exercise and intrinsic motivation for exercise will be measured at the beginning and end of the study. The weighted and centered least squares method will be used to analyze the effect of delivering the intervention versus not on calories burned over 4 hours around the time of the planned activity, measured by the Apple Watch. Secondary analyses will include the effect of the intervention on step count and active minutes, as well as an investigation of the effects of the intervention on affective attitudes toward exercise and intrinsic motivation for exercise. Participants will be interviewed to gain qualitative insights into intervention impact and acceptability. Enrollment began in May 2023, with 57 participants enrolled at the end of July 2023. We anticipate enrolling 120 participants. This study will provide early evidence about the effect of a repeated manipulation of anticipated affective response to exercise. The use of 2 different types of messages will yield insight into optimal design strategies for improving affective attitudes toward exercise. ClinicalTrials.gov NCT05582369; https://classic.clinicaltrials.gov/ct2/show/NCT05582369. PRR1-10.2196/46560.

User Satisfaction With a Daily Supportive Text Message Program (Text4PTSI) for Public Safety Personnel: Longitudinal Cross-Sectional Study.

Public safety personnel (PSP) are exposed to traumatic events due to their work environments, which increases the risk of mental health challenges. Providing effective and evidence-based interventions, such as SMS text messaging programs, can improve PSP's overall mental well-being with high user satisfaction rates. This study aims to evaluate users' satisfaction, receptiveness, and perceptions of a cognitive behavioral therapy (CBT)-based supportive SMS text messaging intervention (Text4PTSI). Participants self-subscribed to Text4PTSI and received unidirectional cognitive behavioral-based supportive text messages for 6 months. Participants completed a web-based survey delivered via SMS text message at enrollment, and 6 weeks, 3 months, and 6 months post enrollment. Respondents' perception and receptivity of the program were assessed using a questionnaire measured on a 5-point Likert scale. Data were collected as categorical variables, and overall satisfaction with the Text4PTSI program was measured on a scale from 0 to 100. There were 131 subscribers to the Text4PTSI program; however, only 81 subscribers responded to the survey, producing 100 survey responses across the 3 follow-up time points. The overall mean score of satisfaction was 85.12 (SD 13.35). More than half of the survey responses agreed or strongly agreed that Text4PTSI helped participants cope with anxiety (79/100 responses, 79%), depressive symptoms (72/100 responses, 72%), and loneliness (54/100 responses, 54%). Similarly, most of the survey responses agreed or strongly agreed that the Text4PTSI program made respondents feel connected to a support system, improved their overall mental well-being (84/100 responses, 84%), felt more hopeful about managing concerns about their mental health or substance use (82 out of responses, 82%), and helped enhance their overall quality of life (77/100 responses, 77%). The available survey responses suggest that the majority always read the supportive text messages (84/100 responses, 84%), took time to reflect on each message (75/100 responses, 75%), and returned to read the text messages more than once (76/100 responses, 76%). PSP who responded to the follow-up surveys reported high user satisfaction and appreciation for receiving the Text4PTSI intervention during the 6-month program. The reported satisfaction with the service provided could pave the way to ensuring a better uptake of the service with potential effectiveness to end users.

Codevelopment of a Text Messaging Intervention to Support Adherence to Adjuvant Endocrine Therapy in Women With Breast Cancer: Mixed Methods Approach.

Adjuvant endocrine therapy (AET) reduces breast cancer recurrence and mortality in women with early-stage breast cancer. Unintentional nonadherence to AET is common (eg, forgetting to take medication). Forming habits surrounding medication taking could reduce reliance on memory and improve AET adherence. SMS text messaging interventions may offer a low-cost approach for promoting medication-taking habits. To optimize the likely effectiveness of such SMS text messages, the content should be developed using a transparent approach to ensure fidelity to relevant psychological theory and with user input to increase acceptability. This study aimed to develop a pool of brief SMS text messages promoting habit formation to support AET adherence, which are acceptable to women with breast cancer and show fidelity to theory-based behavior change techniques (BCTs). According to published literature, we selected 6 BCTs derived from the habit formation model: action planning, habit formation, restructuring the physical environment, adding objects to the environment, prompts/cues, and self-monitoring of behavior. In study 1, behavior change experts (n=10) created messages, each based on 1 of the 6 BCTs, in a web-based workshop and rated the fidelity of the messages to the intended BCT. In study 2, women with experience of taking AET discussed the acceptability of the messages in a focus group (n=5), and the messages were refined following this. In study 3, women with breast cancer rated the acceptability of each message in a web-based survey (n=60). In study 4, additional behavior change experts rated the fidelity of the remaining messages to the intended BCT in a web-based survey (n=12). Finally, a consultant pharmacist reviewed a selection of messages to ensure that they did not contradict general medical advice. In study 1, 189 messages were created targeting the 6 BCTs. In total, 92 messages were removed because they were repetitious, unsuitable, or >160 characters, and 3 were removed because of low fidelity (scoring <5.5/10 on a fidelity rating scale). Following study 2, we removed 13 messages considered unacceptable to our target population. In study 3, all remaining messages scored above the midpoint on an acceptability scale (1-5); therefore, no messages were removed (mean 3.9/5, SD 0.9). Following study 4, we removed 13 messages owing to low fidelity (scoring <5.5/10 on a fidelity rating scale). All the remaining messages showed fidelity to the intended BCTs (mean 7.9/10, SD 1.3). Following the pharmacist review, 2 messages were removed, and 3 were amended. We developed a pool of 66 brief SMS text messages targeting habit formation BCTs to support AET adherence. These showed acceptability to women with breast cancer and fidelity to the intended BCTs. The delivery of the messages will be further evaluated to assess their effect on medication adherence.

Behavioral Predictors of Intention to Use a Text Messaging Reminder System Among People Living With HIV in Rural Uganda: Survey Study.

The expansion of cellular phones in sub-Saharan Africa spurred the development of SMS text message-based mobile health (mHealth) technology. Numerous SMS text message-based interventions have attempted to increase retention in care for people living with HIV in sub-Saharan Africa. Many of these interventions have failed to scale. Understanding theory-grounded factors leading to mHealth acceptability is needed to create scalable, contextually appropriate, and user-focused interventions to improve longitudinal HIV care for people living with HIV in sub-Saharan Africa. In this study, we aimed to understand the relationship between constructs from the Unified Theory of Acceptance and Use of Technology (UTAUT), constructs identified in previous qualitative research, and behavioral intention to use a novel SMS text message-based mHealth intervention designed to improve care retention among people living with HIV initiating treatment in rural Uganda. We conducted a survey of people living with HIV who were newly initiating HIV care in Mbarara, Uganda, and had agreed to use a novel SMS text message-based system that notified them of abnormal laboratory results and reminded them to return to the clinic. Survey items assessed behavioral intention to use the SMS text messaging system; constructs from UTAUT; and demographics, literacy, SMS text messaging experience, HIV status disclosure, and social support. We used factor analysis and logistic regression to estimate the relationships between UTAUT constructs and the behavioral intention to use the SMS text messaging system. A total of 249 participants completed the surveys, of whom 115 (46.2%) expressed high behavioral intention to use the SMS text messaging intervention. In a multivariable analysis, we found that performance expectancy (adjusted odds ratio [aOR] of the scaled factor score 5.69, 95% CI 2.64-12.25; P<.001), effort expectancy (aOR of the scaled factor score 4.87, 95% CI 1.75-13.51; P=.002), and social influence (measured as a 1-unit Likert score increase in the perception that clinical staff have been helpful in the use of the SMS text messaging program; aOR 3.03, 95% CI 1.21-7.54; P=.02) were significantly associated with high behavioral intention to use the SMS text messaging program. SMS text messaging experience (aOR/1-unit increase 1.48, 95% CI 1.11-1.96; P=.008) and age (aOR/1-year increase 1.07, 95% CI 1.03-1.13; P=.003) were also significantly associated with increased odds of high intention to use the system. Performance expectancy, effort expectancy, and social influence, as well as age and SMS experience, were drivers of high behavioral intention to use an SMS text messaging reminder system among people living with HIV initiating treatment in rural Uganda. These findings highlight salient factors associated with SMS intervention acceptability in this population and indicate attributes that are likely to be key to the successful development and scaling of novel mHealth interventions.

Efficacy of an mHealth Behavior Change Intervention for Promoting Physical Activity in the Workplace: Randomized Controlled Trial.

Insufficient physical activity (PA) is a well-established risk factor for several noncommunicable diseases such as cardiovascular diseases, cancer, diabetes, depression, and dementia. The World Health Organization (WHO) advises that individuals engage in 150 minutes of moderate PA per week or 75 minutes of intense PA per week. According to the WHO's latest report, 23% of adults fail to meet the minimum recommended level of PA. The percentage was even higher in a recent global study that showed 27% of adults were insufficiently active and reported a 5% increase in the prevalence trend of insufficient PA between 2001 and 2016. The study also showed the rate of insufficient PA among countries varied significantly. For instance, it was estimated that 40% were insufficiently active in the United States, and the percentage was even higher in Saudi Arabia (more than 50%). Governments are actively developing policies and methods to successfully establish a PA-inducing environment that encourages a healthy lifestyle in order to address the global steady decline in PA. The purpose of this study was to determine the effectiveness of mobile health (mHealth) interventions, particularly SMS text messaging interventions, to improve PA and decrease BMI in healthy adults in the workplace. In this parallel, 2-arm randomized controlled trial, healthy adults (N=327) were randomized to receive an mHealth intervention (tailored text messages combined with self-monitoring (intervention; n=166) or no intervention (control; n=161). Adults who were fully employed in an academic institution and had limited PA during working hours were recruited for the study. Outcomes, such as PA and BMI, were assessed at baseline and 3 months later. Results showed significant improvement in PA levels (weekly step counts) in the intervention group (β=1097, 95% CI 922-1272, P<.001). There was also a significant reduction in BMI (β=0.60, 95% CI 0.50-0.69, P<.001). Combining tailored text messages and self-monitoring interventions to improve PA and lower BMI was significantly effective and has the potential to leverage current methods to improve wellness among the public.

The Effectiveness of Smartphone App-Based Interventions for Assisting Smoking Cessation: Systematic Review and Meta-analysis.

Smoking is a leading cause of premature death globally. Quitting smoking reduces the risk of all-cause mortality by 11%-34%. Smartphone app-based smoking cessation (SASC) interventions have been developed and are widely used. However, the evidence for the effectiveness of smartphone-based interventions for smoking cessation is currently equivocal. The purpose of this study was to synthesize the evidence for the effectiveness of smartphone app-based interventions for smoking cessation. We conducted a systematic review and meta-analysis of the effectiveness of smartphone interventions for smoking cessation based on the Cochrane methodology. An electronic literature search was performed using the Cochrane Library, Web of Science, PubMed, Embase, PsycINFO, China National Knowledge Infrastructure, and Wanfang databases to identify published papers in English or Chinese (there was no time limit regarding the publication date). The outcome was the smoking abstinence rate, which was either a 7-day point prevalence abstinence rate or a continuous abstinence rate. A total of 9 randomized controlled trials involving 12,967 adults were selected for the final analysis. The selected studies from 6 countries (the United States, Spain, France, Switzerland, Canada, and Japan) were included in the meta-analysis between 2018 and 2022. Pooled effect sizes (across all follow-up time points) revealed no difference between the smartphone app group and the comparators (standard care, SMS text messaging intervention, web-based intervention, smoking cessation counseling, or apps as placebos without real function; odds ratio [OR] 1.25, 95% CI 0.99-1.56, P=.06, I2=73.6%). Based on the subanalyses, 6 trials comparing smartphone app interventions to comparator interventions reported no significant differences in effectiveness (OR 1.03, 95% CI 0.85-1.26, P=.74, I2=57.1%). However, the 3 trials that evaluated the combination of smartphone interventions combined with pharmacotherapy compared to pharmacotherapy alone found higher smoking abstinence rates in the combined intervention (OR 1.79, 95% CI 1.38-2.33, P=.74, I2=7.4%). All SASC interventions with higher levels of adherence were significantly more effective (OR 1.48, 95% CI 1.20-1.84, P<.001, I2=24.5%). This systematic review and meta-analysis did not support the effectiveness of delivering smartphone-based interventions alone to achieve higher smoking abstinence rates. However, the efficacy of smartphone-based interventions increased when combined with pharmacotherapy-based smoking cessation approaches. PROSPERO CRD42021267615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=267615.

Digital Adherence Technologies and Mobile Money Incentives for Management of Tuberculosis Medication Among People Living With Tuberculosis: Mixed Methods Formative Study.

Although there is an increasing use of digital adherence technologies (DATs), such as real-time monitors and SMS reminders in tuberculosis medication adherence, suboptimal patient engagement with various DATs has been reported. Additionally, financial constraints can limit DAT's utility. The perceived usefulness and the design mechanisms of DATs linked to mobile money financial incentives for tuberculosis medication management remain unclear. The aim of this study is to describe the perceived usefulness and design mechanisms for a DAT intervention called My Mobile Wallet, which is composed of real-time adherence monitors, SMS reminders, and mobile money incentives to support tuberculosis medication adherence in a low-income setting. This study used mixed methods approaches among persons with tuberculosis recruited from the Tuberculosis Clinic in the Mbarara Regional Referral Hospital. We purposively sampled 21 persons with tuberculosis aged 18 years and older, who owned cell phones and were able to use SMS text messaging interventions. We also enrolled 9 participants who used DATs in our previous study. We used focus group discussions with the 30 participants to solicit perceptions about the initial version of the My Mobile Walletintervention, and then iteratively refined subsequent versions of the intervention following a user-centered design approach until the beta version of the intervention that suited their needs was developed. Surveys eliciting information about participants' cell phone use and perceptions of the intervention were also administered. Content analysis was used to inductively analyze qualitative data to derive categories describing the perceived usefulness of the intervention, concerns, and design mechanisms. Stata (version 13; StataCorp) was used to analyze survey data. Participants expressed the perceived usefulness of the My Mobile Wallet intervention in terms of being reminded to take medication, supported with transport to the clinic, and money to meet other tuberculosis medication-related costs, all of which were perceived to imply care, which could create a sense of connectedness to health care workers. This could consequently cause participants to develop a self-perceived need to prove their commitment to adherence to health care workers who care for them, thereby motivating medication adherence. For fear of unintended tuberculosis status disclosure, 20 (67%) participants suggested using SMS language that is confidential-not easily related to tuberculosis. To reduce the possibilities of using the money for other competing demands, 25 (83%) participants preferred sending the money 1-2 days before the appointment to limit the time lag between receiving the money and visiting the clinic. DATs complemented with mobile money financial incentives could potentially provide acceptable approaches to remind, support, and motivate patients to adhere to taking their tuberculosis medication. ClinicalTrials.gov NCT05656287; https://clinicaltrials.gov/ct2/show/NCT05656287.

Text Messages Exchanged Between Individuals With Opioid Use Disorder and Their mHealth e-Coaches: Content Analysis Study.

Opioid use disorder (OUD) has affected 2.2 million people in the United States. About 7.2 million people reported using illicit drugs in 2019, which contributed to over 70,000 overdose deaths. SMS text messaging interventions have been shown to be effective in OUD recovery. However, the interpersonal communication between individuals in OUD treatment and a support team on digital platforms has not been well examined. This study aims to understand the communication between participants undergoing OUD recovery and their e-coaches by examining the SMS text messages exchanged from the lens of social support and the issues related to OUD treatment. A content analysis of messages exchanged between individuals recovering from OUD and members of a support team was conducted. Participants were enrolled in a mobile health intervention titled "uMAT-R," a primary feature of which is the ability for patients to instantly connect with a recovery support staff or an "e-coach" via in-app messaging. Our team analyzed dyadic text-based messages of over 12 months. In total, 70 participants' messages and 1196 unique messages were analyzed using a social support framework and OUD recovery topics. Out of 70 participants, 44 (63%) were between the ages of 31 and 50 years, 47 (67%) were female, 41 (59%) were Caucasian, and 42 (60%) reported living in unstable housing conditions. An average of 17 (SD 16.05) messages were exchanged between each participant and their e-coach. Out of 1196 messages, 64% (n=766) messages were sent by e-coaches and 36% (n=430) by participants. Messages of emotional support occurred the most, with 196 occurrences (n=9, 0.8%) and e-coaches (n=187, 15.6%). Messages of material support had 110 occurrences (participants: n=8, 0.7%; e-coaches: n=102, 8.5%). With OUD recovery topics, opioid use risk factors appeared in most (n=72) occurrences (patient: n=66, 5.5%; e-coach: n=6, 0.5%), followed by a message of avoidance of drug use 3.9% (n=47), which occurred mainly from participants. Depression was correlated with messages of social support (r=0.27; P=.02). Individuals with OUD who had mobile health needs tended to engage in instant messaging with the recovery support staff. Participants who are engaged in messaging often engage in conversations around risk factors and avoidance of drug use. Instant messaging services can be instrumental in providing the social and educational support needs of individuals recovering from OUD.

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.

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

A Mobile Phone Text Messaging Intervention to Manage Fatigue for People With Multiple Sclerosis, Spinal Cord Injury, and Stroke: Development and Usability Testing.

Fatigue significantly affects daily functioning in persons with disabilities. Fatigue management can be challenging, and the information provided during routine physician visits to manage fatigue can be overwhelming. One way to address fatigue is to increase knowledge, skills, and confidence for self-management (ie, patient activation). Self-management programs have shown promising effects in targeting fatigue in persons with disabilities. However, satisfaction with self-management programs is low for persons with disabilities, and tailoring interventions to personalized needs has been recommended. SMS text messaging is increasingly being used to implement health behavior change interventions in a person's natural environment. Little has been done to link mobile health approaches with patient activation and self-management to address fatigue in persons with disabilities. This study aimed to develop and test a mobile phone-based fatigue self-management SMS text messaging intervention targeting patient activation in 3 groups of persons with disabilities: persons with multiple sclerosis, persons who had a stroke, and persons with a spinal cord injury. We used evidence-based resources and input from a consumer advisory board (CAB; composed of 2 participants from each of the 3 disability groups) and a neurologist to develop the intervention. The study was conducted using a 4-step process: development of the initial SMS text messaging library and categorization of the content into 9 content areas, review and modification of the SMS text messages by the neurologist and CAB, integration of the content library into a digital platform, and utility testing by CAB members. A total of 6 CAB participants rated SMS text messages covering 9 domain areas of fatigue self-management with good clarity (mean ratings=3.5-5.0 out of 5) and relevance (mean ratings=3.2-5.0 out of 5). Overall, SMS text messaging content was reported by CAB participants as helpful, clear, and well suited for a mobile health intervention. The CAB reached consensus on the time of day that SMS text messages should be sent (morning) and their frequency (once per day). This feedback led the research team to narrow down the program to deliver 48 SMS text messages, 1 per day, Monday through Thursday only, a total of 4 SMS text messages per week, over a 12-week period. The final set of SMS text messages was programmed into a digital platform with a predefined delivery schedule. The usability of the intervention was high, with 55 (83%) out of 66 responses endorsing the highest rating. This study demonstrates a step-by-step process for developing a fatigue self-management SMS text messaging intervention for persons with disabilities. For this population, whose access to health services is often limited, this intervention provides an alternative delivery model to increase access to fatigue information and deliver content that aligns with the person's needs.

The Impact of a Text Messaging Service (Tonsil-Text-To-Me) on Pediatric Perioperative Tonsillectomy Outcomes: Cohort Study With a Historical Control Group.

BackgroundTonsillectomy is a common pediatric surgical procedure performed in North America. Caregivers experience complex challenges in preparing for their child’s surgery and coordinating care at home and, consequently, could benefit from access to educational resources. A previous feasibility study of Tonsil-Text-To-Me, an automated SMS text messaging service that sends 15 time-sensitive activity reminders, links to nutrition and hydration tips, pain management strategies, and guidance on monitoring for complications, showed promising results, with high levels of caregiver satisfaction and engagement.ObjectiveThis study aimed to pilot-test Tonsil-Text-To-Me in a real-world context to determine whether and how it might improve perioperative experiences and outcomes for caregivers and patients.MethodsCaregivers of children aged 3 to 14 years undergoing tonsillectomy were included. Data from a historical control group and an intervention group with the same study parameters (eg, eligibility criteria and surgery team) were compared. Measures included the Parenting Self-Agency Measure, General Health Questionnaire-12, Parents’ Postoperative Pain Measure, Client Satisfaction Questionnaire-8, and engagement analytics, as well as analgesic consumption, pain, child activity level, and health service use. Data were collected on the day before surgery, 3 days after surgery, and 14 days after surgery. Participants in the intervention group received texts starting 2 weeks before surgery up to the eighth day after surgery. Descriptive and inferential statistics were used.ResultsIn total, 51 caregivers (n=32, 63% control; n=19, 37% intervention) who were predominately women (49/51, 96%), White (48/51, 94%), and employed (42/51, 82%) participated. Intervention group caregivers had a statistically significant positive difference in Parenting Self-Agency Measure scores (P=.001). The mean postoperative pain scores were higher for the control group (mean 10.0, SD 3.1) than for the intervention group (mean 8.5, SD 3.7), both of which were still above the 6/15 threshold for clinically significant pain; however, the difference was not statistically significant (t39=1.446; P=.16). Other positive but nonsignificant trends for the intervention group compared with the control group were observed for the highest level of pain (t39=0.882; P=.38), emergency department visits (χ22=1.3; P=.52; Cramer V=0.19), and other measures. Engagement with resources linked in the texts was moderate, with all but 1 being clicked on for viewing at least once by 79% (15/19) of the participants. Participants rated the intervention as highly satisfactory across all 8 dimensions of the Client Satisfaction Questionnaire (mean 29.4, SD 3.2; out of a possible value of 32.0).ConclusionsThis cohort study with a historical control group found that Tonsil-Text-To-Me had a positive impact on caregivers’ perioperative care experience. The small sample size and unclear impacts of COVID-19 on the study design should be considered when interpreting the results. Controlled trials with larger sample sizes for evaluating SMS text messaging interventions aimed to support caregivers of children undergoing tonsillectomy surgery are warranted.

Effectiveness and Implementation of a Text Messaging Intervention to Reduce Depression and Anxiety Symptoms Among Latinx and White Adults During the COVID-19 Pandemic

Background SMS text messaging interventions are increasingly being used to help people manage mental health symptoms due to the COVID-19 pandemic. Despite the widespread adoption of SMS text messaging interventions, little is known about racial and ethnic differences in effectiveness, feasibility, and implementation factors. Objective A hybrid type 1 mixed-methods study was conducted to compare the effectiveness and implementation of the StayWell intervention for Latinx and non-Latinx White (White) adults using elements of the RE-AIM framework. Methods Adults using the StayWell intervention received daily mood inquiries and skills–based text messages for 60 days and reported symptoms via online surveys and the HealthySMS portal. Reach was assessed by the share of adults reached via distinct recruitment methods, and effectiveness was evaluated using the Personal Health Questionnaire (PHQ-8) depression scale and General Anxiety Disorder (GAD-7) scale. Adoption was assessed with user engagement, defined as the share of responses to the (60) daily mood inquiries. Implementation was evaluated based on user feedback on the number/timing of messages, the difficulty of using the program, and the System Usability Scale. Maintenance was assessed with user reports of the likelihood of continuing and recommending the program. Quantitative RE-AIM indicators were assessed using a t test for continuous outcomes and a chi-square test for categorical outcomes. Mixed-effects linear regressions examined heterogeneity among Latinx and White users in the outcomes’ (ie, PHQ-8 and GAD-7) changes over time. A thematic text analysis of responses to an open-ended question about participant experiences of the program was conducted to help contextualize differences in the effectiveness and implementation of StayWell between Latinx and White users. Results Among 398 users, 262 (65.8%) responded to the postintervention assessment. Upon completion, depressive (–1.48; P=.001) and anxiety (–1.38; P=.001) symptoms decreased among all users. Compared to White adults, Latinx adults reported an additional –1.45 (P&lt;.05) decline in PHQ-8 scores, adjusting for demographics, recruitment sample, and engagement. Among Latinx adults, StayWell resulted in a greater improvement of depression symptoms (25.8% vs 13.8% reduction; P=.02) but not in anxiety symptoms (21.2% vs 15.9% reduction; P=.23). Despite Latinx adults reporting lower usability (76.8 vs 83.9; P=.001) than White adults, they were more likely to report interest in continuing the program (7.5 vs 6.2; P=.001) and recommend StayWell to a family member or friend (7.8 vs 7.0; P=.013). Repetitive content was a critical barrier to engaging Latinx adults in StayWell; among Latinx adults, support groups and bidirectional messages were considered important program modifications. Conclusions Although anxiety and depressive symptoms decreased among all StayWell users after receiving 2 messages daily for 60 days, Latinx users experienced greater reductions in depression symptoms compared to White users. Bidirectional text messaging using contextual information and ecological momentary analysis of mood data are promising adaptations to enable the tailoring of messages and improved usability of StayWell, which may be especially effective in improving Latinx user engagement. Trial Registration ClinicalTrials.gov NCT04473599; https://clinicaltrials.gov/ct2/show/NCT04473599 Conflicts of Interest None declared.

A Self-management SMS Text Messaging Intervention for People With Inflammatory Bowel Disease: Feasibility and Acceptability Study.

BackgroundMobile health technologies can be useful for providing disease self-management information and support to people with inflammatory bowel disease (IBD).ObjectiveThe aim of this study was to test a self-management SMS text messaging intervention for people with IBD. Our goal was to examine intervention feasibility, acceptability, and engagement and to preliminarily evaluate improvements in certain self-reported health outcomes among participants.MethodsWe developed an SMS text messaging program called Text4IBD. The program sent daily support messages and resources about disease self-management over the course of a 2-week, single-group, pretest-posttest intervention to participants (N=114) diagnosed with IBD. We examined intervention feasibility, acceptability, and engagement through Text4IBD message topic recall and use of resources (ie, visiting supplemental websites recommended by the Text4IBD program). We also assessed pretest-posttest measures of IBD-related distress, self-efficacy, perceived support, use of coping strategies, and medication adherence. Analyses examined participants’ evaluations of the intervention and compared pretest-posttest changes in secondary outcomes using paired-samples statistics.ResultsApproximately all participants who completed the intervention (n=105) were receptive to Text4IBD and viewed the program as feasible and acceptable. In addition, most participants (103/105, 98.1%) recalled at least one of the message topics sent by the program, and 79% (83/105) of them self-reported engaging with at least one of the external self-management resources recommended by the Text4IBD program. Pretest-posttest results showed reduced IBD-related distress (mean 3.33, SD 0.68 vs mean 2.86, SD 0.73; P<.001) and improvements in most other secondary outcomes.ConclusionsFindings from this study highlight the value of SMS text messaging as a useful digital medium for providing support to people with IBD, particularly to those who may struggle with disease-related distress. Text4IBD was highly feasible and acceptable and may help people self-manage their IBD. Future studies should aim to evaluate this program in a randomized controlled trial in clinical settings.

A Text Messaging Intervention to Support Latinx Family Caregivers of Individuals With Dementia (CuidaTEXT): Development and Usability Study.

BackgroundLatinx family caregivers of individuals with dementia face many barriers to caregiver support access. Interventions to alleviate these barriers are urgently needed.ObjectiveThis study aimed to describe the development of CuidaTEXT, a tailored SMS text messaging intervention to support Latinx family caregivers of individuals with dementia.MethodsCuidaTEXT is informed by the stress process framework and social cognitive theory. We developed and refined CuidaTEXT using a mixed methods approach that included thematic analysis and descriptive statistics. We followed 6 user-centered design stages, namely, the selection of design principles, software vendor collaboration, evidence-based foundation, caregiver and research and clinical advisory board guidance, sketching and prototyping, and usability testing of the prototype of CuidaTEXT among 5 Latinx caregivers.ResultsCuidaTEXT is a bilingual 6-month-long SMS text messaging–based intervention tailored to caregiver needs that includes 1-3 daily automatic messages (n=244) about logistics, dementia education, self-care, social support, end of life, care of the person with dementia, behavioral symptoms, and problem-solving strategies; 783 keyword-driven text messages for further help with the aforementioned topics; live chat interaction with a coach for further help; and a 19-page reference booklet summarizing the purpose and functions of the intervention. The 5 Latinx caregivers who used the prototype of CuidaTEXT scored an average of 97 out of 100 on the System Usability Scale.ConclusionsCuidaTEXT’s prototype demonstrated high usability among Latinx caregivers. CuidaTEXT’s feasibility is ready to be tested.

Investigating Why and How Young Adults Use Protective Behavioral Strategies for Alcohol and Marijuana Use: Protocol for Developing a Randomized Controlled Trial.

BackgroundYoung adulthood is associated with increased alcohol and marijuana use compared with other developmental periods. Alcohol and marijuana use place individuals at high risk for acute and long-term negative consequences. Despite the relatively large cross-sectional and longitudinal literature on protective behavioral strategies (PBS; behaviors that individuals can use to limit consequences and reduce substance use), little is known about why young adults choose to use PBS on specific occasions or why they might use PBS differently across occasions (ie, quality and consistency). There is significant room for improvement in the conceptualization, application, and understanding of PBS.ObjectiveThis study aims to develop a novel, brief web-based and SMS text messaging intervention, with input from young adults who use alcohol and marijuana, which addresses the extent to which motivations for PBS use and nonuse (marijuana or alcohol) and the quality of PBS use (the degree of effectiveness or degree of implementation) differ when using alcohol alone versus concurrently or simultaneously with marijuana.MethodsThis research will be conducted in 2 phases. Phase 1 will involve web-based focus groups (N=100) and cognitive interviews (N=10) to determine why young adults (aged 18-24 years) use or do not use specific PBS related to alcohol and marijuana use and elicit feedback on how motivations and the quality of PBS could be incorporated into a web-based and SMS text messaging PBS intervention as well as elicit feedback on developed intervention material. In phase 2, young adults (N=200; aged 18-24 years), who typically use alcohol and marijuana for at least 2 days per week, will be randomized to either the intervention or waitlist control group. The intervention will be brief, web-based, focusing on self-selected alcohol and marijuana PBS messages and motives for using alcohol- and marijuana-related PBS, and including intervention content delivered via SMS text messages 3 days a week (random day, Friday, and Saturday) over 8 consecutive weeks. All participants will report on PBS use, motivations for PBS use (and nonuse), quality of PBS use, and alcohol and marijuana use in morning surveys timed to occur the day after the intervention SMS text messages for those in the intervention group.ResultsRecruitment and enrollment for phase 1 began in January 2022. Recruitment for phase 2 is anticipated to begin in January 2023. Upon completion of the phase 2 pilot, we will examine the feasibility, acceptability, and preliminary effect sizes of the newly developed brief web-based and SMS text messaging intervention.ConclusionsThis study will provide an in-depth understanding of young adults’ PBS use and has the potential to develop a more efficacious intervention for co-occurring or simultaneous alcohol and marijuana behaviors.Trial RegistrationClinicalTrials.gov NCT04978129; https://clinicaltrials.gov/ct2/show/NCT04978129International Registered Report Identifier (IRRID)DERR1-10.2196/37106