Healthy TextsRory CostiganUniversity of MarylandDietetic Intern 2014-2015

Introduction:A health program administered through text messaging provides an opportunity to increase physical activity, change behavior and promote healthy eating among hard to reach populations. Research has proven that worksite wellness programs are associated with improvements in physical activity, healthy eating behaviors, decreased absences at work and reduced health care costs. Statistics show that text messaging is the most common non-voice application Americans use on their mobile phones. Seventy-three percent of users ages 18 and above have a texting plan (Cole-Lewis, 2010). Among that population, individuals with lower income and education levels are shown to text most frequently. Statistics also show that individuals ages 18-29 send and receive an average of 87.7 text messages per day, individuals ages 30-49 send and receive 27.0 text messages per day, individuals ages 50-64 send and receive 11.4 text messages per day and individuals over the age of 65 send and receive 5 text messages on average per day (Smith, 2011). This data indicates that texting-based wellness programs are able to reach diverse groups of participants (U.S. Department of Health and Human Services 2014).Results from Voxivias texting programs, such as txt4baby, txt4kids, txt4health, care4life and txt2quit which provide users with low-cost, accessible health education messaging suggest that participants have very high levels of program satisfaction as well as improvements in physical activity, and healthy eating behaviors (U.S. Department of Health and Human Services 2014). An environmental scan by the U.S. Department of Health suggests that texting based programs impact behavior change by improving participants short-term diabetes management and clinical outcomes (increasing frequency of blood glucose monitoring and reducing HbA1c levels), treatment compliance, including both medication adherence and appointment attendance and immunization rates. Research also shows high satisfaction levels among program participants due to the low cost on the participants end and the limited time commitment (U.S. Department of Health and Human Services 2014). Through the designed Healthy Texts program, individuals will receive 3 text messages per week under three categories: physical activity text messages, fruit text messages and vegetable text messages for a total of 12 text messages per month. Participants will sign up for the text program called Healthy Texts at the beginning of the worksite wellness walking program and fill out one survey with three questions at the beginning of each class. This survey will be used to track the participants progress and to evaluate the success of the objectives. The widespread ownership of cell phones and the increase in text messaging among the United States population provides evidence that incorporating a text messaging database into a health-based program will reach all socio-economic populations including hard to reach minority subsets. Given recent evidence of text messaging programs improving participants overall health, motivation, and behavior, Healthy Texts will aim to improve participants physical activity and healthy eating habits. Improving overall health can also aid in decreasing overweight and obesity rates, chronic disease and sedentary habits.

Program Descriptioni) Theoretical or Conceptual OriginsText messaging has become a main pathway for communication in recent years. Research shows that young adults (ages 18-29) send and receive an average of 87.7 text messages per day. Within this group, non-white (African-American individuals) text more often than whites, and those with lower levels of income and education text more than those at the higher ends of the income and education scale (Smith, 2011). Many health programs, such as Voxivias texting programs, provide an opportunity to improve health knowledge, behaviors, and clinical outcomes, particularly among hard-to-reach populations. Research has shown that health text messaging programs can bring about behavior change that improves treatment compliance, including both medication adherence and appointment attendance. Healthy Texts will complement the in-person nutrition education class by reminding and encouraging participants to participate in physical activity as well as maintain healthy eating behaviors. Healthy Texts will also be used as a reinforcement plan to expose participants to healthy behaviors learned through the WalkWays program.

ii) Program objectives and intended outcomesObjective #1: Participants will spend a minimum of 30 minutes walking per day.Objective #2: Participants will consume at least one cup of fruit per day.Objective #3: Participants will consume at least two cups of vegetables per day.

iii) Core ComponentsThis texting program will send 3 text messages per week. These messages will provide information about three categories; walking, fruits and vegetables. A walking text will be used to remind the participant about walking goals or topics covered during the WalkWays session as well as helpful walking tips.Example of walking texts:1. Have you reached your walking goal today? Try taking the stairs to increase your steps!2. Keep up the walking! Walking is a healthy way to increase daily physical activity as well as reduce the risk of developing a stroke or diabetes!3. Remember, next class we will be recording your steps. Dont forget to record your steps this week!

Text messages under the fruit category will be used to encourage and remind the participant about fruit goals or topics covered during the WalkWays session as well as helpful ways to increase fruit consumption.Example of fruit text messages:1. Have you consumed fruit today? Try to consume 2 cups of fruits per day!2. Fruits are healthy snacks that are easy to pack and eat on the go! 3. Consuming fruit can help your body stay strong and fight off viruses!

Lastly, text messages under the vegetable category will be used to encourage and remind the participant about vegetable goals or topics covered during the WalkWays session as well as helpful ways to increase vegetable consumption.Example of vegetable text messages:1. Consuming a green, leafy vegetable can help keep you at a healthy weight and help with bone health! 2. Have you consumed a vegetable today? Try to consume 2 cups of vegetables per day!3. Vegetables are low in calories, which can aid in weight loss!

These texts will be used to encourage an increase in physical activity, goals set in class and healthy eating through a walking based program. The participants will also be allowed to opt out of the texting portion at anytime by notifying the instructor as well as texting stop to the texting program number. If participants decide to opt out of the program, their data will no longer be used in results as explained in the section below.

iv) Outline basic implementation requirements On the first day of class, participants will have the option of signing up for Healthy Texts where they will fill in their cell phone number next to their name. The minimum number of participants needed for this program is one participant. At each class the participant will fill out a 3-question survey, described in the evaluation plan, which will be used to evaluate the success of the objectives. The participant can choose to stop receiving text messages at any time by texting stop to the text carrier. If the participant does decide to opt out of the texting program, the participant must alert the staff member. The staff member will then highlight the participants information on the Excel sheet, to signify information is not to be to used when analyzing results. The information will not be used because the results are only to take into account information from participants who completed the full WalkWays program.

Evaluation Plani) The rationale for the evaluationOnce participants sign up for the Healthy Texts program, they will receive an assigned number, which they will keep throughout the entire program. This number will be recorded into an Excel sheet with the participants name and only used to inform participants of their number if they forget it. The numbers are used so personal information such as first and last names are not recorded on surveys. This allows the surveys to be confidential and ensures participants that personal information is not used when documenting responses from the survey. A survey sheet will be passed out at the beginning of each class with 3 questions. Participants are to write their assigned number on their survey. Under each question seven boxes will be displayed with the name of each day of the week as the title (see below for survey example). The questions at each class are as follows: What days you participate in at least 30 minutes of walking? What days did you consumes at least one cup of fruit? What days did you consume at least 2 cups of vegetables? Participants will check the box with the corresponding day they participated in each action. Participants will then add up each day they participated in each action and record the total number of days. The survey was chosen because the results are simple to record and calculate. The evaluation is also done in class; therefore, all results are collected and participants are not responsible for completing the questionnaire outside of class time. Lastly, the questionnaire is easy to fill out and only takes a short period of time, which will not delay the class or schedule.

Example SurveyParticipant Number_______ Please check the box under the day of the week you completed each action:

1. What days did you walk for at least 30 minutes? Add total number of days you participated in this action and write the total number in the box marked total days.MondayTuesdayWednesdayThursdayFridaySaturdaySundayTotal days

2. What days did you consume at least one cup of fruit? Add total number of days you participated in this action and write the total number in the box marked total days.MondayTuesdayWednesdayThursdayFridaySaturdaySundayTotal days

3. What days did you consume at least 2 cups of vegetables? Add total number of days you participated in this action and write the total number in the box marked total days.MondayTuesdayWednesdayThursdayFridaySaturdaySundayTotal days

ii) Procedures for implementing the proposed evaluation planDuring each class the instructor will collect the survey five minutes after it is passed out, allowing participants enough time to properly complete it. The questionnaire will not include any personal information or phone numbers and will be collected face down. After class, the instructor will enter the total number of days for each question into an ongoing excel spreadsheet. The spreadsheet will have a column with all the participants numbers and three rows with questions 1-3 and the date of the class. For example, if participant is assigned number 4 and answered question 1 with 4 days, question 2 with 7 days, and question 3 with 6 days, the results would be documented as 4 under question 1, 7 under question 2 and 3 under question 6 (See below for example). This information would allow the instructor to identify the number of days the participant is participating in each action. This will also allow the instructor to identify if each objective has been met. Lastly, the information can track the individuals behavior over time, which allows the instructor to identify if the participants are making healthy behavior changes.

Example set up of Excel spread sheetParticipant #Question 14/18/2015Question 24/18/2105Question 34/18/2015

#1457

#2375

#3445

#4473

iii) Data analysisThe data will be recorded through an excel sheet described in the above section. The data will show the number of days participated in each action. For example, objective #1 states; Participants will spend a minimum of 30 minutes walking per day. The excel sheet will show the number of days each participant participated in each action, which will allow the instructor to determine if the objectives have been met. From the above example participant #4 only met the second objective because he consumed at least one cup of fruit each day, yet did not met the first and third objective. The answers are also categorized by date of each class. This information could display a fluctuation of behavior change by month and season, and allows the instructor to track each participants progress from an increase or decrease in days participated in each action.

ConclusionStatistics show that individuals of all economic groups are increasing the use of text messages. Studies also show that the African-American population is the highest texting population among those with lower levels of income (Smith, 2011). This data shows that texting programs can reach a high percentage of low income minority groups as well as individuals with texting plans, allowing a wide array of individuals in different social and economic classes to be reached. Through Voxivias health program servicing txt4baby, txt4kids, txt4health, care4life and txt2quit data has shown that the text messages have improved health behaviors and outcomes in a wide array of individuals. In recent txt4health programs focusing on Type 2 diabetes awareness, physical activity, and behavior change, users have reported very high levels of program satisfaction (Smith, 2011). Most participants found that txt4health made them knowledgeable about their risk for diabetes and made them conscious of their diet and physical activity. Cole-Lewis (2010), reports that changes in physical activity were seen over 12 weeks with secondary outcomes of adherence to pedometer use (Cole-Lewis, page 59). Results from Voxivias texting programs suggest that participants have positive perceptions of the program, which leads them to positive behavior change. Participants will have the option of signing up for Healthy Texts at the first program session. Results regarding program effectiveness will be monitored weekly from the results of the survey. Healthy Texts will incorporate positive and favorable results from past text messaging based health promotion programs to provide physical activity and healthy eating information to participants.

References1. Cole-Lewis, H., and T. Kershaw. "Text Messaging as a Tool for Behavior Change in Disease Prevention and Management." Epidemiologic Reviews 32.1 (2010): 56-69. Web. 26 Feb. 2015.

2. U.S. Department of Health and Human Services. Health Resources and Services Administration. Using Health Text Messages to Improve Consumer Health Knowledge, Behaviors, and Outcomes: An Environmental Scan. Rockville, Maryland: U.S. Department of Health and Human Services, 2014.

3. Buis, Lorraine R. "Use of a Text Message Program to Raise Type 2 Diabetes Risk Awareness and Promote Health Behavior Change (Part II): Assessment of Participants' Perceptions on Efficacy." Journal of Medical Internet Research. JMIR Publications Inc., 15 Dec. 2013. Web. 26 Feb. 2015.

4. Smith, Aaron. How Americans Use Text Messaging. Pew Research Centers Internet American Life Project RSS, 18 Sept. 2011. Web. 28 Mar 2015.