Text message behavioral interventions: from here to where?
Introduction
Although remote communication between individuals has occurred since antiquity, through such means as smoke signals and mail couriers, and more recently through wire and radio, it was the rapid growth of cellular phones in the 1990s that allowed widespread transmission of messages to be possible. The first and still most popular form of messaging using cellular phones is short message service (SMS). SMS was invented in the late 1980s, the first text message sent in 1992, the first phone keyboard allowing efficient text typing developed in 1997, and the first inter-network text exchange being made possible in 1999 [1]. Currently, there are more than 7 billion cell phone subscribers worldwide and over 6 trillion SMS sent each year [2]. In a survey of 21 countries, around 75% of cell phone owners reported regularly sending and receiving text messages [3]. Although SMS took time to enter the US, by 2008 the number of SMS sent in the US surpassed phone calls [4] and currently an estimated three-quarters of all mobile phone owners in the US use SMS. 99% of received text messages are opened and 90% are read within three minutes of being received [5].
Section snippets
What is SMS?
The technical answer is that SMS is a packet of data up to 160 letters, numbers or symbols in the Latin alphabet sent to another cell phone through a control channel that provides ‘store-and forward’ service, where messages are sent only when the receiving phone is turned on or within range of a tower. This allows for the asynchronous receipt of and response to messages from one individual to another across most geographic boundaries. The sociologic answer is more complex, and still evolving.
Is there a role for SMS in health promotion?
The demand for tools and resources to help individuals adopt behaviors that promote health and avoid behaviors that harm health has rapidly and drastically increased in the last decade. Traditional venues of health care delivery, such as primary care, are not able to meet these demands. The average person spends only an hour per year in direct medical contact, whereas they spend thousands of hours making decisions about their health [8]. Computerized health promotion interventions through
What features are important in an SMS behavioral intervention?
Even though SMS seems like a very simple interface, especially when compared with other computerized platforms, studies to date suggest that SMS design considerations can substantially effect program potency. Orr et al. [13•] found that more frequent messaging maximized effects and Head et al. [26] reported that SMS interventions using tailored and personalized messages, and those with customized and variable frequency of contact over time mediated effect sizes. Interestingly, Head et al. did
How does one design an SMS behavioral intervention?
Although there exists no established ‘best practices’ for designing SMS behavioral interventions, there are a few useful published resources to help guide the design process. Intervention mapping is useful as a starting point to develop a framework to match behavioral goals with specific program features [34]. It describes the development process in six steps: (1) needs assessment, (2) specifying performance and change objectives, (3) selecting theory-based intervention methods and practical
What limitations exist when using SMS for behavioral interventions?
The foremost question pertaining to all computerized behavioral interventions is whether they can ever be comparable to in-person interventions. Computerized interventions lack many of the physical and non-verbal cues made available in face-to-face communication, including facial expressions and body language as well as tone and prosody of speech. Whereas some have suggested that these are essential components of the therapeutic relationship [37], others believe that computer-mediated textual
Why not just make an App?
Many believe that most of the limitations of SMS can be overcome through the use of phone applications (‘apps’) to deliver effective behavioral interventions. There is no question that Apps have the capacity to offer a more comprehensive user experience, including features such as graphical and video content and social networking. There are several issues to consider, however. First, apps require a user to proactively engage with the program. Given that most people either prefer not to change
What is the future of SMS behavioral interventions?
The pessimistic prognostication would be that more efficient forms of computerized communication would supplant SMS. Researchers are already projecting this dire future and hedging efforts by influencing scientists to focus more on behavioral principles than on communication modality [41]. A more optimistic view is that SMS is here to stay, will continue to be protected from advertisement and junk-SMS, and will become free to users due to the pressure on telecommunications companies. Although
Conclusions
SMS is a ubiquitous and frequently used communication modality that has shown promise in delivering behavioral interventions. Existing evidence suggests SMS programs should aim to optimize user engagement and persuasiveness. Future research will continue to inform what SMS features are useful to which individuals at what times for what conditions.
Conflict of interest statement
Brian Suffoletto has a financial conflict of interest. He has a copyrighted mobile text message system which is licensed to healthStratica, for which he received royalties.
References and recommended reading
Papers of particular interest, published within the period of review, have been highlighted as:
• of special interest
•• of outstanding interest
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