This study demonstrates early feasibility and acceptability of text messaging to promote healthy behaviors for weight maintenance. Initial experience in message development and transmission suggests that this may offer a cost-effective means of continuing interactions following a weight loss intervention. This may be particularly useful following weight loss interventions when contact and involvement frequently declines over time, and relies less upon face-to-face encounters. Also, we found that the use of commonly available mobile phones to deliver reminders and motivate individuals may more easily be integrated into lifestyle. Individuals were able to receive text messages at various times of the day from different locations. This allowed for individuals to receive reminders and encouragement throughout the day to help positively impact routine decisions affecting behavior.
Our study offered opportunities for the participants to control the time, frequency, and type of messages that they received. Physical activity reminders and messages to avoid unhealthy eating were frequently requested. In addition, individuals varied in the frequency with which they wished to receive text messages. One future strategy may be to increase the frequency of messages around more stressful time periods (e.g., holidays that are associated with binge eating). A study on smoking cessation incorporated a similar approach prior to scheduled quit days 10
. Also, decreasing the frequency of message delivery may be appropriate over a longer duration of time to prevent fatigue of messaging.
There are several advantages to text messaging over other methods of electronic transmission of educational information. Text messaging utilizes ‘push’ technology and does not require users to prompt information retrieval. Many web-based products involve persons logging in to online services and are associated with non-usage attrition over time 24
. The availability of massive amounts of background information for review may exceed individual needs. Succinct advice on a frequent basis (e.g., daily) may be preferable or complimentary to weekly accessing health related information 25
. Finally, text messages may be superior to automated methods of audio recorded voice messages. Voice messages must be received immediately and become disruptive, and may be affected by poor reception. The popularity of text messaging arises from the speed of sending/receiving messages and the ability to read messages discretely.
The use of mobile phones is rapidly growing in the United States. Many individuals who own mobile phones do not have convenient access to the Internet, and this may represent an alternative means of establishing reach in low-income populations. In the present study, participants indicated comparable interest in text messaging and Internet-delivered modes of weight loss support. In addition, there is a high prevalence of mobile phones among younger and middle-aged persons, including minority populations. Among older adults, the use of text may be less desirable to multimedia elements available on computer or television video. However, the newer mobile phone features including images and video may have greater appeal.
We identified several challenges in the implementation of text messaging for our study. A significant number of messages were not delivered, due to a number of potential factors such as mobile phones being disconnected or inboxes being full. When messages were delivered, the response by individual participant varied. Some persons read them immediately, while others delayed in reading messages. Possibly, the notification of a new incoming text message (audio sound or vibration prompt) at a particular time of day may effectively serve as a reminder without the text being actually read. Still, we have no evidence to date to support that healthy behaviors are followed subsequent to receiving text messages. Furthermore, the long-term effect on weight maintenance remains unclear, beyond changes made in health related behaviors.
We plan to continue data collection on health behaviors and weight through 2008. As individuals gain experience in the technology, we will consider using two-way text messaging to collect data on responses to basic questions sent to participants via text messaging. To date, we have only provided training on reading and deleting text messages, and not composing or sending new messages. In the future, text messages may complement other automated counseling and feedback efforts in weight management (e.g., e-mail or Interactive Voice Response technology). Further research in this area will help determine the optimal frequency and intensity of text messaging services to engage participants over a long period of time. Additional study with a larger sample will help determine if it can serve as an effective component within a comprehensive weight loss program. Ensuring that the technology is not overly complex and burdensome to individuals remains an important concern.