Behavior Change Interventions Delivered by Mobile Telephone Short-Message Service

Context

The expansion and adoption of new methods of communication provide new opportunities for delivering health behavior change interventions. This paper reviews the current research examining mobile telephone short-message service (SMS) for delivering health behavior change interventions via text messages. This service has wide population reach, can be individually tailored, and allows instant delivery with asynchronous receipt, suggesting potential as a delivery channel for health behavior interventions.

Evidence acquisition

An electronic database search was conducted for studies published between January 1990 and March 2008. Studies were included in the review if they (1) evaluated an intervention delivered primarily via SMS, (2) assessed change in health behavior using pre–post assessment, and (3) were published in English in a peer-reviewed scientific journal.

Evidence synthesis

Of 33 studies identified, 14 met the inclusion criteria. Four of the 14 studies reviewed targeted preventive health behaviors (e.g., smoking cessation), and ten focused on clinical care (e.g., diabetes self-management). Positive behavior change outcomes were observed in 13 of the 14 reviewed studies. Intervention initiation (researcher or participant), SMS dialogue initiation, tailoring of SMS content, and interactivity were found to be important features of SMS-delivered interventions. Methodologic issues with current SMS research were also identified.

Conclusions

This review suggests that SMS-delivered interventions have positive short-term behavioral outcomes. Further research is required to evaluate interventions for preventive health behaviors that incorporate features found to affect behavioral outcomes and participant acceptance. The quality of studies in this emerging field of research needs to improve to allow the full potential of this medium to be explored.

Introduction

Recent reviews have focused on the effectiveness of health behavior change interventions delivered via telephone1, 2, 3, 4 and the Internet.5, 6, 7 Researchers have suggested exploring other interactive delivery channels, such as mobile telephone short-message service (SMS),8, 9, 10, 11, 12 but no systematic reviews have been reported to date. The aim of this paper is to review the preliminary evidence of health behavior change interventions delivered via SMS texting.

Mobile telephones and SMS are becoming integrated into virtually all aspects of society.13, 14, 15, 16 In the U.S. in 2007, approximately 7,000,000,000 SMS messages were sent every month.¹⁷ In developed countries, use of SMS pervades all age groups,9, 15, 18, 19 cultures,¹⁶ and socioeconomic backgrounds.9, 15 This service allows for instantaneous delivery of short messages (maximum 160 characters) directly to individuals at any time, place, or setting. These messages are asynchronous, meaning they can be accessed at a time that suits an individual. Customized SMS messages can be tailored to individuals, which is important given that personally tailored messages are more effective for health behavior change than untailored messages.20, 21, 22, 23, 24 This medium also allows for seamless (and quantifiable) interaction between the participant and the interventionist, so that participant engagement with the intervention can be monitored and compared to exposure. Communication with SMS may also be more cost effective than other telephone or print-based interventions.19, 25

The potential of SMS may be particularly significant among population groups most likely to use mobile telephones as their primary means of communication. The highest level of mobile telephone use is among adolescents, younger adults, socioeconomically disadvantaged populations, less educated young adults, and people who rent or frequently change addresses.26, 27, 28 Further, a high level of mobile telephone use is associated with lower levels of self-rated health,²⁸ higher BMI,²⁹ and engaging in health-compromising behaviors.³⁰ Therefore, SMS presents a prime delivery channel for health behavior change interventions because it has high penetration in populations of lower sociodemographic position and populations with poorer health.

The application of SMS for behavioral intervention is new. However, there are established research agendas for using SMS to remind patients of scheduled medical appointments,31, 32, 33, 34, 35 coordinate medical staff,²⁵ deliver medical test results,36, 37, 38 and monitor patient side effects following treatment.³⁹ This review analyzes the application of SMS for delivering health behavior change interventions to establish what can be learned from research conducted to date and make recommendations for future research.