Only a few focus group studies have been performed to understand participants’ needs and expectations for a mobile phone program as a process of program development for the prevention of chronic illnesses [8
]. Participants in this study provided valuable data to aid in the development of specific components of a mobile phone program that would motivate individuals with prediabetic conditions to increase their physical activity and improve diet-related behaviors.
The themes we identified were (1) having real-time peer social and professional support, (2) tailoring timing, frequency, and content of messages in mobile phone programs, (3) combining motivations, self-monitoring, and goal setting, and (4) identifying potential barriers and sustainability of mobile phone programs. These findings suggest that creating a mobile virtual community could be effective in engaging and sustaining participants in lifestyle change programs. This virtual community acts as a closed social network that can provide both peer and professional support to participants. It is flexible enough to provide messages and self-monitoring that are tailored to individual participants and address barriers to participation (see Multimedia Appendix 2
for the components of a mobile virtual community).
Participants indicated that the primary component of a successful mobile phone-based healthy lifestyle program was real-time peer social and professional support that would create a mobile virtual community. Through this mobile virtual community, participants could create a peer social network that would support their efforts to change their diet and physical activity and receive immediate feedback from health care providers, a designated sponsor, or a peer [13
]. Participants indicated that they would be comfortable sharing their experiences and struggles with others in their virtual community, but they would not be comfortable doing so with people outside the created virtual community. Contrary to Greene et al., participants in our study indicated that they wanted a closed social network rather than an open one [15
]. Although Greene et al. reported that Facebook enabled participants to share experiences and to receive answers to their questions or to receive direct feedback from individuals with diabetes, none of our participants mentioned an interest in open social networks such as Facebook [15
]. In addition, social support strongly relates to motivations for lifestyle change. Peer social support is well known to be a crucial motivational tool to promote physical activity [16
], particularly in women. Since a mobile phone program is very portable and participants can bring it with them wherever they go, they can receive continuous support and be connected to their peers at all times. Thus, participants in this mobile phone program may perceive the virtual mobile community as a beneficial component of the program.
Tailoring of the program is another key component of a successful mobile phone program [17
]. Frequency, timing, and content of messages, as well as goal reminders, should be tailored to an individual’s needs. Just-in-time messages or feedback at the moment of decision or action play an important role in keeping participants motivated [22
]. To monitor participants’ behaviors and send just-in-time messages, the program should have the ability of not only sending messages, but also of receiving reports from participants about their current activities and of providing feedback. A program of this capacity can send real-time, context-aware feedback and messages, and can get feedback in real time. The real-time feedback component of the program that elicits messages before patients take counterproductive actions is important to motivate then to make healthy choices [23
]. The program, therefore, must incorporate 2-way messaging. Previous programs using mobile phone technology have focused on using 1-way SMS (text messages), but this may not be sufficient for all participants. Importantly, feedback and goal setting need to be tailored to an individual based on their strength, ability, and barriers, as well as achievement of the previous goal [23
This study reinforces the need for self-monitoring; however, participants also connected this idea with broader motivations for enacting behavioral changes. Participants identified the value of competition to keep one engaged and the importance of some form of reward mechanism. The challenge for a mobile phone program is to incorporate different ways to motivate participants. The program would have to be able to engender a sense of competition, at least within participants that are so motivated, but it would also need to determine effective rewards that can be potentially tailored, both individually and over time.
Participants also identified potential barriers to initiating and sustaining engagement with the program. Fear of failing was one of the major potential barriers addressed by participants. A previous study found that women who used a mobile phone physical activity program perceived the program as a virtual coach to increase their motivation for a healthier lifestyle. Coaching is an effective approach to behavior change, but pressure from a coach or another’s expectation can create fear of failure in the participant [25
]. To minimize participants’ fears, nonjudgmental approaches, positive reinforcement, and establishing more than 1 short-term goal should be factored into the mobile phone program to mitigate fears of failing.
Age and the potential intrusiveness of mobile phones in people’s lives could also be a barrier to engagement with the program. Older participants expressed concerns about their ability to use the mobile phone technologies, especially texting, and that their lack of technical ability might limit their willingness to participate in the program. Over 25% of the participants had not used a mobile phone in the last month. For some, this was due more to lack of funds than to a dislike of mobile phones. However, a few expressed a rather strong antagonism toward the impact of mobile phones on their way of life. Given this expressed antipathy to mobile phones and the number of nonusers in the focus groups, conducting further research with only nonusers could be warranted to more fully understand this barrier.
In terms of sustaining participation in this type of program, there is limited research that has explored issues around long-term engagement in these types of programs. Participants in this study indicated that they needed to continue to value the program. Suggestions for how to maintain interest over time included keeping the program simple and user friendly. This component may be particularly important to accommodate older adults, people with less education, and people who are unfamiliar with mobile phones.
Additionally, the messages need to be short and varied over time. In addition, a system of rewards needs to immediately reflect their positive behavior change but may also need to change over time. A randomized variety of messages may help to avoid the boredom, and a program tailored to the individual’s needs could help to keep participants motivated. However, more research is needed to understand how these rewards can be incorporated into mobile phone technologies and how to modify them over time. Finally, resistance to using mobile technologies among older individuals is also a potential barrier [27
] that needs to be more fully explored. The participants’ suggestions and ideas based on their own experiences are great sources to develop the most effective components of a mobile phone-based healthy lifestyle program.
Limitations of the Study
The study results should be interpreted within the following limitations. All participants in this focus group were recruited from only 1 geographic location, San Francisco, approximately 74% of the participants were unemployed, and 49% had incomes less than $20,000. Thus, the findings in the study may not be representative of more affluent or more fully-employed populations in the United States.
Participants from a wide range of age and racial groups expressed interest in a mobile phone-based lifestyle program. A mobile phone-based lifestyle program that incorporates these identified themes may be able to help motivate participants to increase their physical activity and to improve their diet. This study can help researchers to further understand individual needs and expectations of a mobile phone program to motivate and promote healthy lifestyle modifications in sedentary and overweight or obese adults.