Chandler Ray February 28, 2015Dietetic Intern Research Project FY15TOPIC: Text Messages for a Worksite Wellness Walking ProgramIntroductionPhysical inactivity is a leading health risk factor for mortality worldwide. (1) FSNE developed WalkWays, a worksite wellness program, designed to promote physical activity and healthy eating. Participants are taught practical ways to increase the number of steps they take each day so that walking becomes a daily routine. The proposed text-messaging program, Text2BActive, is a component of WalkWays designed to motivate and remind participants to be more physically active. The content of these text messages address people at various stages of the decision-making process to align with the Transtheoretical Models Stages of Change. In other words, text messages will be specifically tailored to an individuals level of knowledge and motivation. The goal of the Text2BActive program is to encourage healthy behaviors to improve the physical, mental and emotional well being of workers and their families.

Research suggests that mobile technology can be a powerful tool to communicate with and motivate individuals to engage in healthy behaviors. (1) A nine-week trial conducted by Hurling and colleagues (3) evaluated the impact of a physical activity program based on the Internet and mobile phone technology. Healthy adults were placed in either a test group (n=47) with access to a physical activity text-messaging program or a control group (n=30) without support. Text messages offered participants personalized solutions for perceived barriers, a schedule to plan exercise sessions with weekly reminders, and a message board to share their experiences and receive feedback from others. The test group reported a significantly greater increase in physical activity and intention/expectation to exercise than did the control group. (3) Specifically, those with access to a text-messaging program increased their level of moderate physical activity by 2 hours and 18 minutes per week. (3) Similarly, Fjeldsoe and colleagues (2) examined the effectiveness of mobile devices delivering health behavior change interventions via text messages.Positive behavior change outcomes were observed in 13 of the 14 reviewed studies. Intervention initiation, dialogue initiation, tailoring of the content, and interactivity were found to be necessary key features of text message-delivered interventions. (2) To further support these findings, Stephan and Allen (5) conducted a systematic review to analyze user satisfaction and effectiveness of text messaging interventions to promote weight reduction and physical activity. The most frequently measured outcome was a decrease in weight (57%) and an increase in physical activity (43%). Additionally, text messaging was associated with healthier eating patterns, decreased sugar-sweetened beverage intake, and decreased screen time. (5) It is important to note that this study was developed to specifically target cardiovascular risk factors of physical inactivity and overweight/obesity. Regardless, findings still demonstrate the beneficial impact text messaging can have on weight control and reduction of physical inactivity.

The existing literature shows that text messaging can serve as a beneficial and powerful delivery channel for health behavior interventions. (5) Text messaging programs have shown to be effective when coupled with additional strategies to increase physical activity in healthy adults. (1) However, there is limited research on adults specifically in the workplace. Additionally, the use of text messaging as a method to promote physical activity has only been studied by a small group of researchers and literature is characterized by small sample sizes. (1) Further research in this area is vital to enable the expansion of mobile technology to promote physical activity. Despite limited research, Text2BActive has developed ways to integrate this type of intervention into the lifestyles of working adults in an effort to comprehensively impact participants behavior and promote positive lifestyle changes.

Program Description

i) Theoretical or conceptual origins

The Transtheoretical Models Stages of Change provides the theoretical basis for the proposed texting program. This theoretical model of behavior change has been the basis for developing effective interventions to promote behavior change. The model identifies a continuum of five stages of readiness involved in adopting and maintaining a new behavior. The stages of change include: precontemplation, contemplation, preparation, action and maintenance. The curriculum incorporates text messages tailored to an individuals readiness to change, as well as strategies and tips to facilitate changes in behavior. In theory, Text2BActive will serve as a simple yet effective tool to move a person to the next stage of change. This movement through the stages of change will be reflected through increased physical activity levels and developing a positive attitude towards exercise.

ii) S.M.A.R.T Goals Within 6 months of implementing Text2BActive, >75% of text message receivers will have increased their level of physical activity by at least 2 hour per week After participating in Text2BActive, more than half of participants will plan to make physical activity a daily routine by engaging in at least 30 minutes of moderate-intensity aerobic activity at least 5 daysper week Text2BActive will effectively move the majority of participants (90%) to the next stage of change through increased physical activity levels and developing a positive attitude towards exercise

iii) Core Components

Participants will have the option to sign up for the Text2BActive program, which will be encouraged during WalkWays sessions and via email. Only current WalkWays participants will be informed about the Text2BActive program, as non-WalkWays members will not be eligible to participate. The intent is that participants enrolled in Text2BActive will increase their level of physical activity by receiving daily motivational text messages. All participants in the WalkWays program will receive a text message briefly describing the core components of the Text2BActive program. Participants will be asked to text back yes if they want to participate in the program or no if they do not wish to participate in the program. Those who responded yes will then be prompted to complete a physical activity stages of change questionnaire via email or mobile phone (this is the alternative option if computer access is limited) to assess their level of motivation and readiness to change physical activity behavior. Participants will be asked to complete a similar self-report questionnaire at the end of the program to measure whether they have made progress toward behavior change. The questionnaire will be very brief, containing only 5 yes or no questions. The questions developed for the questionnaire include:

Are you currently physically active? (For example, walking, bicycling, running, swimming or any other activity of similar intensity) Do you currently engage in regular physical activity? (Regular physical activity must include a total of 30 minutes or more per day for at least 5 days per week) Have you been regularly physically active for the past 6 months? Do you plan to be more physically active within the next 6 months? Do you feel confident in your ability to become more physically active through the WalkWays program?

The number of yes/no responses will be used as a scoring guide that categorizes individuals into one of the five stages of change: precontemplation, contemplation, preparation, action or maintenance. Generally, precontemplators are inactive and not thinking about being active, contemplators are inactive but thinking about becoming active, and preparers are physically active but not at the recommended levels. Participants who are in the action stage are physically active at the recommended levels but may have been active for less than 6 months. Those in the maintenance stage are highly motivated, physically active at the recommended levels, and have been active for more than 6 months. After completing the initial questionnaire, participants will receive 2-3 text messages per week for the remainder of the program. Text messages delivered will include tailored and interactive messages important to physical activity, such as motivation, encouragement, progress, and tips. Further, text messages will consist of a database of messages that are sent out to participants depending on what stages of change they are in. The messages will provide motivational tips and tools to help reinforce the information and behaviors taught through the WalkWays worksite wellness curriculum. Some examples of sample messages developed for Text2BActive include:

Precontemplation-- Goal: to get participants to start thinking about physical activity Example: Regular physical activity can improve your health and reduce your risk of developing several diseases like type 2 diabetes, heart disease, and stroke. Contemplation-- Goal: To encourage participants to start being physically active by identifying barriers to getting started and strategies for overcoming them Example: Looking to add more steps in your day at work? Replace a coffee break with a brisk 10-minute walk. Ask a friend to go with you! Example: Need some extra motivation to jump-start your workout this weekend? Get yourself an exercise buddy (or even a dog who needs to be walked)! Preparation-- Goal: To encourage your participants to be regularly physically active Example: Use your pedometer and/or activity log as a reminder to take more daily steps! The next class will be at _(place)__ from ___(time)___. Hope to see you there! Example: Leave daily reminders to exercise everywhere, such as your walking shoes by the door! Action-- Goal: To help your participant maintain this physical activity habit over time Example: Set future goals for yourself- such as participating in a fun walk or 5km run! Maintenance-- Goal: To help your participant prepare for any future setbacks and increase enjoyment of physical activity Example: Make exercise fun! Plan to do fun activities- such as hiking or gardening- that you enjoy as often as possible!

iv) Basic Implementation Requirements:

Text2BActive complements direct education and information provided in the WalkWays FSNE wellness curriculum. Text messages are targeted to working adults in this walking based program and are behaviorally focused. The supplies needed to create this program include a list of the participants in Walkways, including their phone numbers and emails (which will be kept in a locked filing cabinet), and a comprehensive program description of the WalkWays curriculum and nutrition education materials, including a schedule of the WalkWays classes. Additional materials needed include a computer (it can be assumed this may not be needed necessarily if people have their own laptops), a software program to generate the database of text messages, and a phone with which to test trial text messages. Two or three Registered Dietitians and/or health professionals from FSNE will be in charge of developing and reviewing all text messages before they are sent out to participants. At least two dietetic interns will assist in program implementation and the development of text messages. A software engineer or programmer may be needed to assist in setting up the computer software system and help generate the data. Procurement logisticswill also need to be taken into consideration, including market research, requirements planning, and operating materials.

Evaluation Plan

i) Rationale for evaluation

The information FSNE is looking to obtain from participants is whether or not the Text2BActive component of the WalkWays program is successful in impacting participants behavior and increasing their level of physical activity. In order to obtain this information from participants and evaluate the effectiveness of the program, a post-test survey will be administered via email 6 months after implementing the Text2BActive program. This method of evaluation was selected because it is most consistent with the other method of assessment and communication, as participants have already filled out a self-report questionnaire via email (or phone) when they first signed up for the program. The pros of a web-based survey include easy-to-collect data, minimal costs, less time, real time access, convenience for respondents, and flexibility in design. The cons of an online survey include absence of the interviewer, survey fraud, non-delivered email or messages rejected, possible cooperation problems, computer access, limited sampling, and respondent availability.

ii) Procedures for implementing the proposed evaluation plan The responses generated from the post-survey will be collected via a designated email created just for the purpose of gathering survey results from the Text2BActive program. Creating a specific email just for this purpose ensures that survey results will not get mixed up with other emails and only data pertaining to the program will be located in the inbox. The survey will be sent out via email 6 months after the start of the Text2BActive program. Participants will be asked to complete the questionnaire within 1 week of receiving it. Participants will also receive a text message 2 days prior to the end of the week reminding them to please fill out the survey. Once the information is collected, data will be entered into the computer software system to generate the results. This task will be done by an FSNE professional with the help of interns. Issues related to informed consent and confidentiality will be addressed in two ways. First, an informed consent form will be included as an email attachment for all participants to read at their leisure. Second, all responses will be kept completely confidential by omitting names and email addresses from the computer software system so they will not be stored with data from the surveys. Only the researchers will see the individual survey responses and the list of e-mail addresses of participants will be stored electronically in a password protected folder.

iii) Data analysis

The data to be analyzed for reported measures will be generated using the computer software system containing a database to store and organize the text messages received. The statistical method used to analyze this information is a matched pairs t-test. Matched pair t-tests are often done in situations where two measurements are taken from each respondent. The post- survey results will be compared to the pre-survey results they completed when they started the program. The purpose of analyzing this information using a t-test is to determine if there is a reliable difference in a participants behaviors and level of physical activity before and after participating in the Text2BActive program. A softwareengineer or programmer would be inquired on the best quantitative data analysis software to generate these results, such as SPSS or SAS. In order to isolate the texting program from WalkWays impacts in this data analysis and reporting, findings from the dual intervention group (texting+ WalkWays) will be compared with the single intervention group (only WalkWays).

This statistical method would provide information regarding the impacts of the program, specifically whether or not the WalkWays texting program reached its intended program objectives and outcomes. The information analyzed would allow researchers to determine the number of adults who enrolled in Text2BActive and the impacts of the program, for example, the % who increased their overall level of physical activity and the % who reported increased motivation and overall desire to workout often or every day. This data will come directly from the self-reported responses gathered from the pre- and post-surveys. In terms of cause and effect, the results would demonstrate whether mobile-based text messaging was a successful tool in engaging busy individuals and complementing direct nutrition education. Specifically, these findings would determine whether Text2BActive had a positive impact on health-behavior change by sending daily reminders to be more physically active.

The goal or intended outcome is that within 6 months of implementing the Text2BActive program, >75% of text message receivers will have increased their level of physical activity by at least 2 hours per week. Level of physical activity will be recorded by participants based off of self-report and the number of steps generated while wearing their pedometer. Using this statistical method, trained FSNE educators will calculate their stages of change based on self-reported responses before and after the program. Researchers will then be able to determine whether or not participants have advanced along the stages of change continuum while using Text2BActive based on the information gathered from the pre-survey and the 6 month post-survey. The hope is that after analyzing the data, FSNE will be able to say that the Text2BActive program has helped adults make physical activity a daily routine to achieve a healthy weight and improve their overall quality of life.

Conclusion

Text2BActive is likely to be effective because it serves as a support system for participants already in a walking program and addresses the challenges of sustaining that effort. The combination of participating in both programs is likely to have an even greater impact on healthy behaviors, especially those associated with physical activity. Text2BActive has been developed to target a specific audience: working adults enrolled in the WalkWays program. Text messages are tailored to each individuals readiness to change, including motivation, encouragement, progress, and tips. The theoretical basis for this program facilitates the learners progression along the stages of change and identifies strategies in adapting and maintaining a new behavior. The existing literature supports that text messaging has the ability to improve exercise adherence and increase physical activity level. (2,3,5) A study conducted by research from Kansas State University and the U.S. Centers for Disease Control and Prevention revealed that a group of Latino adults almost quadrupled their exercise levels after receiving daily motivational texts. (4) Along with physical activity, exercise-focused text messaging programs have helped participants to maintain a health weight. Hurling and colleagues (3) found that those who used a mobile phonebased motivation and action support system lost more percent of their body fat than those who did not.

Since the Text2BActive program uses innovative technology, limited resources are needed for the implementation of this program. Mobile phone-based behavioral change interventions minimize face-to-face interaction, thereby increasing cost-effectiveness through greater accessibility. (3) Since participants are part of the WalkWays program, they already have been provided all of the materials needed to monitor and track their steps, including a pedometer, participant workbook, and step log book. Text messages are developed using the knowledge and expertise of Registered Dietitians and health professionals at FSNE. The only notable cost associated with program development includes software purchasing and employee time.

Text2BActive is predicted to be an effective approach to promote and increase physical activity. Advancements in mobile phone technology have made it a desirable method for health promotion and disease prevention. (5) Our hypothesis is that Text2BActive will serve as a beneficial tool to motivate individuals to engage in more health behaviors by sending out weekly encouragements and reminders. If Text2BActive was to be successfully implemented, improvements would be seen in participants exercise behaviors and levels of physical activity, as well as overall quality of life.Works Cited

(1) Buchholz, S.W., Wilbur, J., Ingram, D., & Fogg, L. (2013, June 7). Physical Activity Text Messaging Interventions in Adults: A Systematic Review. U.S. National Library of Medicine. doi: 10.1111/wvn.12002.

(2) Fjeldsoe, B.S. (2009, February). Behavior Change Interventions Delivered byMobile Telephone Short-Message Service. American Journal of Preventive Medicine. doi:10.1016/j.amepre.2008.09.040

(3) Hurling, R., Michael, C., Marco, D.B., Bruce, W.F., Hurst, T., Murray, P., Alannah R., & Jaspreet, S.S. (2014, April 27). Using Internet and Mobile Phone Technology to Deliver an Automated Physical Activity Program: Randomized Controlled Trial."Journal of Medical Internet Research. doi: 10.2196/jmir.9.2.e7

(4) Prevention Research Centers. Centers for Disease Control and Prevention. N.p., 09 Dec. 2014. Web. 02 Mar. 2015..

(5) Stephens, J., & Allen, J. (2014, July 1). Mobile Phone Interventions to IncreasePhysical Activity and Reduce Weight: A Systematic Review. The Journal ofCardiovascular Nursing. U.S. National Library of Medicine. doi:10.1097/ JCN.0b013e318250a3e7

(6) Williams, A.D. (2012). Use of a text messaging program to promote adherence to daily physical activity guidelines: A review of the literature.Bariatric Nursing and Surgical Patient Care,7(1), 01.