Use of a Text Messaging Program to Promote Adherence to Daily Physical Activity Guidelines: A Review of the Literature

Abstract

Introduction:

Obesity has reached epidemic proportions in the United States and is a complex health problem with many biological, environmental, and psychosocial causative factors. While there are many factors which must be addressed to combat the prevalence of obesity, increasing physical activity is an important modifiable behavior. To determine if text messaging can be used as a communication tool to promote the adherence to daily physical activity guidelines in adults, a literature review was conducted.

Methods:

Five databases were searched using the search terms of text messaging*, and MeSH subheadings of cellular phones, health promotion, and health behaviors. Databases were searched from the year 1950 to present, although this topic is more relevant to this century. The literature search produced 37 articles from Medline, 68 articles from CINAHL, 8 from Cochrane, and 42 from PubMed databases. Titles were then reviewed to screen out duplicates and to verify topic relevancy. An abstract review was then completed, followed by an article review of eleven articles. After reviewing the eleven articles, five were excluded, leaving a final total of four relevant articles.

Conclusion:

After reviewing the available evidence, text messaging is an effective tool when coupled with additional strategies to increase physical activity in healthy adults and its use is highly recommended by a limited number of participants in these initial studies. However, further research of the important innovative use of text messaging for the use of promoting daily physical activity is needed to substantiate these early findings with larger, diverse samples.

Introduction

Obesity has reached epidemic proportions in the United States with the prevalence of obesity among American adults at 33.8% accounting for more than 72 million people.¹ According to the Centers for Disease Control (CDC), no states met the recent Healthy People 2010 goal of lowering obesity prevalence rate to 15% by 2010. In reality, the prevalence of obesity has actually increased significantly over the past 10 years, with no states having an obesity prevalence of more than 30% in 2000 compared with 12 states today with prevalence rates of more than 30%. An additional 34% of the adult population is overweight, which brings the total prevalence for American adults who are overweight or obese to over 68%.²

There are many public health and economic consequences to the national obesity epidemic. Obesity-related diseases, like heart disease, stroke, hypertension, type 2 diabetes, sleep apnea, and some forms of cancer, have combined to become the second leading cause of preventable death in the United States. Approximately 300,000 deaths annually may be attributable to obesity.³ Additionally, obesity cost the United States $147 billion in 2008, which represented 9.1% of all medical costs.¹ Healthcare costs for individuals who are obese are $1,429 higher than those individuals of normal weight.

With more than 68% of US adults overweight and obese, there are a variety of controllable and uncontrollable risk factors contributing to this epidemic. Sedentary lifestyles, poor diets, and a variety of genetic, behavioral, and environmental factors are leading to increasing rates of obesity-induced diabetes, cardiovascular disease, sleep apnea, and stroke. For example, the US Presidents' Challenge Physical Activity and Fitness Awards program in 2002 publicly promoted the 10,000 steps per day level for adults, but it is widely acknowledged that most American adults are unaware of this daily guideline and do not follow it. Physical inactivity in adults is one of the major modifiable risk factors contributing to the obesity epidemic with nearly 25% of adults reported as inactive nationally and 23% reported as inactive in Maryland.² Physical inactivity has long been associated with overweight and obese populations, yet this risk factor can be modified to maintain a healthy lifestyle and weight. Therefore, new, innovative, and cost effective approaches must be tried to promote daily physical activity and combat this serious epidemic.

Health information is increasingly found on the Internet, and the Internet is a powerful channel of communication for healthcare professionals. In a recent survey, it was reported that 74% of American adults used the Internet, and of those who used it, 80% of them researched online information on a variety of health topics.⁴ However, online health resources are less accessible to some populations in the United States. Individuals in rural areas, disabled individuals, the elderly, and individuals from lower socioeconomic and educational levels have multiple barriers that prevent the use of current technology.⁵ Pew (2010) posited that Latinos, African Americans, and young people were increasingly found to use mobile devices as their primary device to gather information as opposed to the Internet. This usage of mobile devices and the need to reach vulnerable populations who cannot use the Internet for their primary source of information may shift the patterns of health promotion communication toward mobile devices using text messaging.

In the relatively new field of texting and mobile health, there is early evidence to establish the effectiveness and feasibility of using marketing and messaging strategies to promote healthy behaviors in a target population. The broad use of cell phones and, specifically, texting may add another means of communication to the array of public health tools. It has been reported by the Centers for Disease Control (CDC) and others that 89% of Americans have a mobile phone, and 2.2 trillion text messages were sent in 2010 alone in the United States.⁶ It is also reported that 73% of American adults send or receive a median of 10 texts per day, while youth between the ages of 18 to 24 send or receive an average of 110 texts per day.⁷ For minorities, the use of texting is even higher. African Americans and English-speaking Hispanics send or receive a median of 20 texts per day compared with 10 texts per day for Caucasians. This broad use of technology may provide a way to connect with patients and populations in a way that has not yet been fully evaluated or applied in healthcare.

This literature review will examine the evidence regarding the use of text messaging as a health promotion tool, specifically as it aids in the adherence to daily physical activity guidelines in adults. Text messaging may have benefit for a variety of disease prevention, disease management, or other healthcare-related topics. While the use of text messaging as a health promotion tool is a relatively new concept, there are several early, high quality studies available in the literature.

Text Messaging

Text messaging is defined as a message sent in textual form, especially one designed to appear on the viewing screen of a cellular phone or pager.⁸ Short message service (SMS) refers to the exchange of messages via mobile phones limited to 160 characters per message. Advantages of text messages include the availability of messaging 24/7 on any mobile phone equipped to send or receive messages, the instant access, as well as low operating costs. It was recently reported in a study conducted by the Pew Research Center that 31% of text message users now prefer texting to voice calls.⁷ When comparing household income level, individuals earning $30,000 or less send or receive a median of 20 texts daily, while individuals earning $75,000 or more send or receive a median of 10 texts daily.⁷ The advantages and wide availability of cell phones has fueled text messaging in the United States, especially with individuals at a lower socioeconomic levels and young adults.

Similar usage is seen in categories of individuals with less than a high school education with a median of 20 texts daily compared to college level and higher sending or receiving a median of 10 texts per day. Interestingly, in recent data reported from the Health Indicator Warehouse within the Healthy People 2020 objectives, mobile device usage to access the Internet was reported at 4.92% in the obese population versus 7.43% in the non-obese population.⁹ These data point to a higher text message utilization in lower socioeconomic levels, minority populations, and youth, with Internet usage lower among the obese population. This broad use of technology may provide a way to connect with patients and unique populations in a way that has not yet been fully evaluated or applied in healthcare.

Text messaging services are now used by numerous industries for a variety of different purposes. While most users typically use text messaging for personal communication, there is increasing evidence of the utility of promoting retail sales, marketing products and services to end users, surveying customers via two-way communication, fundraising, distributing political/campaign messages, and providing emergency information through text messaging. Given the broad use of this communication medium, it is apparent that there could be applications within the healthcare industry as well.

During a review of relevant literature, it is unclear when text messaging for health promotion was first introduced. However, it is clear that it has been gaining widespread attention and evaluation. While still considered a new application of mobile health (mHealth), the use of text messaging in the healthcare industry has been the topic of several early randomized control trials and quasi-experimental studies (see Table 1). For example, Cole-Lewis and Kershaw (2010)¹⁰ demonstrated the use of text messaging as a tool for behavior change in disease prevention and management. Specifically, they reviewed 12 studies where text messaging was the primary mode of health communication. Eight of the nine sufficiently powered studies found evidence that supported text messaging as a behavior change tool. Two of the first studies were reported in the literature in 2005 and looked at the use of text messaging for asthma management and the other for smoking cessation support.¹⁰ Since these two initial studies, there have been early positive results in other text messaging applications in healthcare. To date, six other studies have focused on the use of text messaging for diabetes management, two studies on weight loss, two on physical activity, and one on vitamin adherence.¹⁰ Countless other articles have recently been in the literature on various uses of text messaging in health promotion, disease management, and administrative applications, such as appointment reminders. However, many of these studies were not adequately powered, or combined text messaging with other technologies like Internet access, making it difficult to discern the real effects of text messaging alone on study outcomes.

Table 1.

Comparison of Evidence on Text Messaging

Authors	Design	Sample size	Outcome measure	Results
Cole-Lewis and Kershaw (2010)¹⁰	Systematic review	12 studies	Weight loss, waist circumference, nutritional intake, smoking cessation, adherence to vitamin C regimen, glycemic control, PEF levels, plasma glucose levels	8 out of 9 sufficiently powered studies found evidence supporting text messaging as a behavior change tool. Effects existed across age, minority status, and nationality.
Haapala et al. (2009)¹²	RCT	125 healthy, overweight men and women	Weight loss, waist circumference	Higher weight loss, p<0.006; decreased waist circumference, p<0.0001
Hurling et al. (2007)¹¹	RCT	77 healthy men and women	Duration of physical activity (time)	Increased duration of exercise, p<0.02; decrease in percent body fat, p<0.04
Patrick et al. (2009)¹³	RCT	75 overweight men and women	Weight loss	Higher weight loss, p<0.02
Prestwich et al. (2009)¹⁴	RCT	155 men and women split into four groups	Exercise frequency	Increased exercise frequency, p<0.03

RCT, randomized control trial; PEF, peak expiratory flow.

This literature review will focus on four relevant articles, which are the highest quality of evidence and most closely relate to the primary aim of evaluating the use of text messaging for the purposes of promoting daily physical activity. Hurling et al. (2007)¹¹ studied the effects of text messaging and Internet usage on physical activity in 2007. Using a stratified randomized control trial (RCT) experimental design, the authors studied 77 healthy adults in the United Kingdom. Participants were randomized into an intervention group that received an Internet and mobile phone-based intervention or a control group that received no support. Participants were followed for 9 weeks, and results showed that the intervention group had an average of 2 hours and 18 minutes more physical activity per week than the control group (p=0.02). The intervention group also had a decrease in percentage body fat compared to the control group (p=0.04). While the study reported statistically significant results on adults' physical activity levels, texting was one component of the interventions, so it is difficult to identify the effect of text messaging only on the increase in physical activity.

Haapala et al. (2009)¹² focused on weight loss and the use of text messaging in a 1-year RCT. Using 125 healthy, overweight adults in Finland, the authors randomly assigned participants to either an intervention group using a text messaging approach or a control group with no intervention. Participants were followed up to 12 months for weight loss and waist circumference. At the end of 12 months, the intervention group lost significantly more weight (p=0.006) and had reduced their waist circumference (p=0.0001). While this study showed positive early results, the text intervention group also had face-to-face contact and Internet education, so it is difficult to determine the sole effect the text messages had on weight loss. Also, this study focused on weight loss as the primary study outcome and not daily physical activity.

Additionally, Patrick et al. (2009)¹³ studied the effects of text message intervention on weight loss. A total of 75 overweight men and women were randomized into either an intervention group that used daily text messaging or a control group that received print materials monthly. At the conclusion of the study at 4 months, the intervention group lost more weight than the control group (p=0.02). Also, 92% of the participants reported that they would recommend this intervention to others. This study included a participant satisfaction component to the evaluation, but was also focused on weight loss and not physical activity.

Finally, Prestwich et al. (2009)¹⁴ examined whether text messaging could enhance effects of implementation intentions on exercise. In an experimental design using a RCT, the authors studied 155 participants over 4 weeks. The combined intervention of text messages and stated exercise intentions increased exercise frequency (p=0.03). This study lacked adequate power and had too many study aims and intervention groups, so again it was difficult to ascertain the effects of text messaging on the physical activity. In conclusion, the use of this technology is so new, there are limited studies that were either adequately powered, focused solely on physical activity, or included text messaging alone as a study intervention. However, these few early studies, as well as others on other health-related topics like diabetes management, smoking cessation, and diet, report early positive results for using text messaging as a health promotion tool.

Recent Developments

In a recent development in November 2010, the US Health and Human Services (HHS) created a text messaging task force, entitled Text4Health.¹⁵ To encourage the development of this innovation and to advance the use of text messaging in healthcare, the task force made seven recommendations to the Secretary of HHS. Based on early successes of several government-sponsored text messaging programs, like CDC's H1N1 flu text messaging pilot, National Institutes of Health (NIH)'s mDiet project, and the largest project, Text4baby, HHS wanted to take a proactive role in exploring and defining the innovative use of text messaging for health promotion. These early projects, however, have only explored a few applications of text messaging in specific populations. These recommendations outline the broader exploration of mobile technology in healthcare and commit the Federal Government to leading these initiatives with public–private partnerships.

One of the recommendations calls for the development of evidence-based text message libraries, which would be open to the public for a variety of topics like obesity, smoking cessation, emergency preparedness, maternal/child health, heart disease, diabetes, and mental health. Their intent with this recommendation is to foster evidence-based text messages without commercial influence. This recommendation and the others presented to the Secretary of HHS lend credibility to the use of text messaging for health promotion and identify a strategic plan for further development of this innovative concept for the benefit of the public.

Conclusion

After reviewing the available evidence, text messaging can be an effective tool when coupled with additional strategies to increase physical activity in healthy adults, and its use is highly recommended by a limited number of participants in these initial studies. However, further research of the important innovative use of text messaging for the promotion of daily physical activity is needed to substantiate these early findings with larger, diverse samples. Future research should be focused on evaluating the effects of text messaging as a form of health communication on a variety of health behavior campaigns. While this literature review focused on its use promoting physical activity, text messaging could be used for a variety of health promotion campaigns, like smoking cessation, prenatal health, healthy eating, and medication reminders, to name but a few ideas. Text messaging may also be appropriate for chronic disease management, like asthma and diabetes, and is also worth further investigation. With the recent addition of the Text4Health Task Force recommendations, it is clear that the use of text messaging for the purpose of health promotion as an effective communication vehicle for public health is receiving credible, national attention. Furthermore, should the use of this technology application gain broader acceptance and respect from further evidence, nurses will need to be encouraged and educated on how to incorporate this into their practice for their populations.

Footnotes

Disclosure Statement

No competing financial interests exist.

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