|Year : 2018 | Volume
| Issue : 4 | Page : 390-393
Designing and validation of text messages for m-Health intervention for tobacco cessation and management
Puneet Chahar, Vikrant R Mohanty, YB Aswini
Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
|Date of Web Publication||28-Feb-2019|
Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
BACKGROUND: Tobacco is a growing epidemic and tobacco-related death results in health consequences and lost economic opportunities. Tobacco cessation efforts mandate the use of multiple strategies to bring about behaviour change. AIM: To develop and validate health promotive text messages using transtheoretical model and prospect theory for behaviour change. SETTINGS AND DESIGN: The present observational study was conducted in a tertiary care hospital, Delhi among patients reporting at Tobacco Cessation Centre (TCC). METHODS: The study was divided into two phases: first involved development of text messages in local language (Hindi) using a sound theoretical basis (TTM and prospect theory) and second phase dealt with validation of the developed text messages by patients and experts in the field of tobacco cessation. STATISTICAL ANALYSIS: Descriptive statistics was obtained using the SPSS version 17. RESULTS: The sample comprised 20 males and 6 females. Average appeal score ranged from 6.1 to 9.6 (54 messages). Forty two messages out of a total of 54 messages were found to be appropriate after validation by the experts. Mean words of the final messages (42 messages) was 24.5 ± 1.3. Two hundred ninety one (90%) out of a total of 324 questionnaires showed adequate understanding of message as assessed by the reviewers. CONCLUSIONS: The current effort developed and validated health promotive text messages package to aid in tobacco cessation. The preventive text messages were grounded in evidence and sound theoretical basis and followed a standard validating procedure leading to satisfactory understanding and appeal in all domains.
Keywords: M-Health, prospect theory, text messaging, tobacco control, transtheoretical model
|How to cite this article:|
Chahar P, Mohanty VR, Aswini Y B. Designing and validation of text messages for m-Health intervention for tobacco cessation and management. Indian J Cancer 2018;55:390-3
|How to cite this URL:|
Chahar P, Mohanty VR, Aswini Y B. Designing and validation of text messages for m-Health intervention for tobacco cessation and management. Indian J Cancer [serial online] 2018 [cited 2019 Mar 20];55:390-3. Available from: http://www.indianjcancer.com/text.asp?2018/55/4/390/253298
| » Introduction|| |
Tobacco is a growing epidemic, targeting the low- and middle-income countries, leading to millions of people getting addicted to it each year. India is the second largest consumer of tobacco and the burden is evident by the Global Adult Tobacco Survey (GATS) 2009-2010 (India) which revealed that 34.6% adults are currently using tobacco. On the other hand, 46.6% smokers and 45.2% smokeless tobacco users planned or thought to quit at some point of time.
The tobacco control policies in India have been mainly in the form of tobacco legislations and comprehensive tobacco control measures (Cigarette Act-1975, COTPA-2003, and NTCP). Public awareness/mass media campaigns, tobacco control cells, training of health and social workers, and Tobacco Cessation Clinics (TCC) are the main objectives under the National Tobacco Control Programme (NTCP). Currently only 29 districts out of 42 have such TCC at district level., With lack of evaluations at various levels, it is uncertain to comment about the outreach of such existing programs in India to mobilize people towards tobacco cessation.
Conventional tobacco cessation interventions ranges from brief advice, behavioural support, motivational interviewing to pharmacotherapies like Nicotine Replacement Therapy, but these measures have inherent challenges in implementation in developing countries. Multicomponent smoking cessation interventions have been found to be effective in long-term abstinence. Therefore, it is necessary to explore novel strategies like M-health to supplement existing programmes.
M-health interventions have been effective in complimenting efforts for behaviour support in tobacco cessation at both population and individual level.,, M-health is “medical and public health practice supported by Mobile Devices (MDs), such as mobile phones and other wireless devices.” For developing countries in particular, one of the key M-health applications used to deliver health education to patients is the use of text messaging (short message service, SMS). Text messaging demonstrates strong potential as a M-health tool because of the following reasons: 1. It is available on almost every model of mobile phone, 2. cost-effective in resource poor settings, and 3. no technological expertise required. They are asynchronous and thus can be accessed at any time that is personally convenient. India is digitally growing with >1000 million users of mobile phones all over the country  and consequently provides a suitable platform for health behaviour change. Thus, smoking cessation support can be delivered to a large number of people at low cost.
Tobacco use is a behaviour deeply influenced by personal choice, cultural practices, and social influence. Therefore, tobacco cessation efforts mandate the use of multiple strategies including M-health to alleviate craving and bring about behaviour change. Text messages provide personalized smoking cessation support. But, development of text messages intervention demands understanding of personal needs, local cultural contexts, as well as the adaptation of contents, and strategies to guarantee adequate understanding and appeal by end users. Hence, keeping in mind various tobacco cessation strategies, the present study was designed with an effort
- To develop health promotive text messages using transtheoretical model (TTM) and prospect theory for behaviour change
- To validate these messages by patients and experts.
| » Methods|| |
The present study was divided into two phases: the first phase involved development of text messages in local language (Hindi) using a sound theoretical basis (TTM and prospect theory) and the second phase dealt with validation of the developed text messages by patients and experts in the field of tobacco cessation. The study was conducted in a tertiary care hospital among patients reporting at TCC. Ethical approval was obtained from the Institutional Ethical Review Board. A convenient sample of 26 patients reporting to TCC OPD in a 2 week timeframe was included in the study. Selection criteria was minimum primary education and to be able to read Hindi text. Informed consent was obtained from each participant after explaining the aims and objectives of the study.
Development of short message service text messages
Development of the SMS text messages content was based on the TTM, also known as the Stages of Change Model. According to the TTM, behaviour change occurs when the benefits (pros) of such a change come to be viewed as more important than the costs (cons) of change. Thus, the shift in pros and cons is thought to be emblematic of a progression toward behaviour change. This model proposes five stages toward behaviour change: pre-contemplation, contemplation, preparation, action, and maintenance. For the present study, these five stages were grouped into following three for the ease of developing text messages: pre-contemplation/contemplation (PC/C), preparation/action (P/A), and maintenance/relapse (M/R). TTM has been used for multiple health behaviour changes including tobacco cessation.,,, In addition to development of SMS for above stages, motivational SMS were also developed to supplement each stage of behaviour change.
Description of the text message developed
The design and validation of the SMS text messages was done to integrate the SMS portal for patients visiting the TCC at a tertiary care hospital. The M-health intervention proposed thus included three text messages/week to promote lifestyle modification that may help to change behaviour. Thus the intervention finally constituted 12 messages each in motivational, PC/C (Stage one) and P/A (Stage two). The variety of content amenable to reinforcement in M/R (stage three) was limited to six to avoid repeating content. The contents of the M-health intervention were developed with the help of recommendations from the WHO, CDC, NHS, and literature from books along with experts in tobacco cessation.,,,
Framing of text messages
Other than content and theoretical aspect, the current study also focussed on the framing of the text message. It has been proven by the prospect theory that framing of text messages have an effect on the behaviour outcome expected from the individual. Message framing is a concept where information is delivered using gain- or loss-framed language to present behavioural outcomes to appear as benefits or costs in relation to a specific reference point. Multiple studies have justified that health-preventive behaviours (tobacco cessation) would be effectively promoted if the information is gain-framed rather than loss-framed.,
Thus, a total of 54 messages were developed initially, which were then reviewed by experts for adequacy of language. A detailed description of the type of content and number of text messages required per stage of change is shown in [Table 1].
|Table 1: Domains and stages of change, type of content, and number of Short Message Service text messages per key domain|
Click here to view
Validation of short message service text messages
During the validation, two main areas were to be prioritized: SMS text message understanding and appeal. This process would lead to the elimination of some text messages (with lowest appeal score) and improvements in the wording of rest.
Design and methodology
A pre-validated questionnaire (n = 7) with open- and closed-ended questions was used for the assessment of each SMS text message. The questionnaire was divided into three sections evaluating understanding (n = 3), appeal (n = 3), and open suggestion to improve the message (n = 1). Trained interviewers administered the questionnaires in face-to-face interactions and registered the participant's answers in writing.
Understanding was evaluated by asking each participant to describe the content of the message as implicated by him/her which was written down by the interviewer in the participant's own words. Additionally, participants were asked whether they understood every word and point out the word whose meaning was not understood.
Appeal of each text message was rated on a Likertscale from 1 to 10, asking participants to assign a numerical rating from low (1, disliked the most) to high (10, liked the most).
Each participant evaluated a set of text messages selected randomly in a way that each text message was evaluated by six different participants for understanding and appeal.
Analysis of validation
The assessment of text message understanding was performed by two reviewers as in the following steps:
- Reviewers jointly examined all the written descriptions provided by participants and rated understanding of the message on a dichotomous scale (Yes/No)
- For those text messages where participants reported a lack of understanding, or where reviewer agreed that the participant did not understand the text message, the message was checked for wording and grammar
- Specific words that did not appear to be understood or were disliked by participants were identified and corrected
- The content and wording of the text messages were improved by taking into account the comments and suggestions made by the participants.
To evaluate appeal, scores were averaged and a mean appeal score per text message was used to rank the messages within the same stage of behaviour change. To reach a total of standard 42 messages, 4 messages with lowest appeal score each in motivational, PC/C set and A/P stage were eliminated.
Descriptive statistics was obtained using the SPSS version 17.0 for Windows (SPSS Inc., Chicago, IL, USA) and results were presented in the form of frequency, percentage, and mean (standard deviation).
| » Results|| |
The mean age of 26 subjects was 35.3 ± 3.5. The sample comprised 20 males and 6 females. Average appeal score ranged from 6.1 to 9.6 (54 messages). Forty two messages out of a total of 54 messages were found to be appropriate after validation by the experts. Mean words of the final messages (42 messages) was 24.5 ± 1.3. Two hundred ninety one (90%) out of a total of 324 questionnaires showed adequate understanding of message as assessed by the reviewers. Mean appeal score for all domains have been detailed in [Table 2] (42 messages).
| » Discussion|| |
Strong evidence supports the value of integrating mobile phone-based interventions into public health practice and behaviour change but implementation of such interventions are always associated with cultural and linguistic challenges.,, Low health literacy, cultural barriers, and limited English proficiency have been coined the “triple threat” to effective health communication in the past. Therefore, development of an effective health education intervention requires understanding of patient's linguistic skills and cultural norms., The current study utilised a pretested standard process for the design and validation of SMS text messages. Through this methodology we were able to obtain 42 country-specific text messages with high level of understanding and appeal for patients.
The text messages developed in the current study were supported by theoretical framework in health behaviour change. At first, the TTM enabled to develop text messages tailored to specific stages of change and guided to phrase the early versions of the messages. Secondly, the text messages were further strengthened by prospect theory which led to development of gain-framed messages.
Human behaviour is too versatile and multidimensional and a behaviour change unfolds over a period of time through a sequence of stages. Although, not being able to start at same stages of behaviour and skipping stages in some cases may be considered inherent challenges in TTM. TTM have considered a 6 month time period for defining stage of behaviour change, therefore keeping this as standard, we distributed 12 messages in pre-contemplation/contemplation and preparation/action (two messages per month) six messages in maintenance stage (one message per month; number was limited to avoid repetition of information).
Engagement phase with the end users allowed qualitative assessment of their opinions and suggestions, which further validated the text messages leading to accurate cultural and linguistic adaptations. The final set of messages showed adequate understanding and high appeal, thus they could be used for a SMS intervention trial in future.
Though the development of text messages were supported by theoretical basis and eliminated cultural and linguistic barrier by end user engagement, it had certain limitations also. Firstly, the present study was done at TCC, thus may have “hospital” or “Referral Bias” as those reporting already have higher motivational levels and thus may limit generalizability. Secondly, time and financial constraints allowed review of each text message by six people. Despite the limited number of evaluations this process was systematically repeated for all 54 messages resulting in high level of understanding and appeal. Lastly, no use of audiotapes to record the answer by the patients may have introduced observer bias and missing information.
Although, despite this limitation, registries were considered to be satisfactory by both the reviewers. We suggest that this study should be taken as a pilot work and a subsequent randomized intervention studies in multiple settings could generate the evidence about the effect of this strategy in tobacco cessation.
| » Conclusion|| |
The current effort developed and validated health promotive text messages package to aid in tobacco cessation. The preventive text messages were grounded in evidence and sound theoretical basis and followed a standard validating procedure leading to satisfactory understanding and appeal in all domains. The developed messages may be used at appropriate centres to promote tobacco cessation facilities.
We would like to thank Maulana Azad Institute of Dental Sciences, GNCT of Delhi for extending its support towards this study. We would like to thank the study participants for their cooperation in the research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Bhawna G. Burden of smoked and smokeless tobacco consumption in India - Results from the global adult tobacco survey India (GATS-india)- 2009-2010. Asian Pac J Cancer Prev 2013;14:3323-9.
Kaur J, Jain DC. Tobacco control policies in India: Implementation and challenges. Indian J Public Health 2011;55:220-7.
] [Full text]
Sebastian ST, Johnson T. Tobacco control initiatives in India: An overview. Int J Adv Health Sci 2015;1:17-20.
Aung MN, Yuasa M, Moolphate S, Kitajima T, Fukuda H, Lorga T, et al
. Challenges for smoking cessation intervention as part of primary health care services in developing countries. J Smok Cessat 2016;11:211-8.
Martín Cantera C, Puigdomènech E, Ballvé JL, Arias OL, Clemente L, Casas R, et al.
Effectiveness of multicomponent interventions in primary healthcare settings to promote continuous smoking cessation in adults: A systematic review. BMJ Open 2015;5:e008807.
Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, et al.
Smoking cessation support delivered via mobile phone text messaging (txt2stop): A single-blind, randomised trial. Lancet 2011;378:49-55.
Aveyard P, Raw M. Improving smoking cessation approaches at the individual level. Tob Control 2012;21:252-7.
Zhu SH, Lee M, Zhuang YL, Gamst A, Wolfson T. Interventions to increase smoking cessation at the population level: How much progress has been made in the last two decades? Tob Control 2012;21:110-8.
World Health Organization m Health: New Horizons for Health through Mobile Technologies: Second Global Survey on eHealth. Global Observatory for eHealth Series. Vol. 3. Geneva: WHO Press; 2011.
Diez-Canseco F, Zavala-Loayza JA, Beratarrechea A, Kanter R, Ramirez-Zea M, Rubinstein A, et al.
Design and multi-country validation of text messages for an mHealth intervention for primary prevention of progression to hypertension in Latin America. JMIR Mhealth Uhealth 2015;3:e19.
Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev 2010;32:56-69.
Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38-48.
Migneault JP, Adams TB, Read JP. Application of the transtheoretical model to substance abuse: Historical development and future directions. Drug Alcohol Rev 2005;24:437-48.
Koyun A, Eroǧlu K. The effect of transtheoretical model-based individual counseling, training, and a 6-month follow-up on smoking cessation in adult women: A randomized controlled trial. Turk J Med Sci 2016;46:105-11.
Cabral RJ, Cotton D, Semaan S, Gielen AC. Application of the transtheoretical model for HIV prevention in a facility-based and a community-level behavioral intervention research study. Health Promot Pract 2004;5:199-207.
Nidecker M, DiClemente CC, Bennett ME, Bellack AS. Application of the transtheoretical model of change: Psychometric properties of leading measures in patients with co-occurring drug abuse and severe mental illness. Addict Behav 2008;33:1021-30.
Callaghan P, Eves FF, Norman P, Chang AM, Lung CY. Applying the transtheoretical model of change to exercise in young Chinese people. Br J Health Psychol 2002;7:267-82.
Jiloha RC. Tobacco smoking: How far do the legislative control measures address the problem? Indian J Psychiatr 2012;54:64-8.
Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science 1981;211:453-8.
Fucito LM, Latimer AE, Salovey P, Toll BA. Nicotine dependence as a moderator of message framing effects on smoking cessation outcomes. Ann Behav Med 2010;39:311-7.
Gallagher KM, Updegraff JA. Health message framing effects on attitudes, intentions, and behavior: A meta-analytic review. Ann Behav Med 2012;43:101-16.
Head KJ, Noar SM, Iannarino NT, Harrington NG. Efficacy of text messaging-based interventions for health promotion: A meta-analysis. Soc Sci Med 2013;97:41-8.
Hall AK, Cole-Lewis H, Bernhardt JM. Mobile text messaging for health: A systematic review of reviews. Annu Rev Public Health 2015;36:393-415.
Whittaker R, McRobbie H, Bullen C, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2016;4:CD006611.
Singleton K, Krause EM. Understanding cultural and linguistic barriers to health literacy. Ky Nurse 2010;58:4, 6-9.
Ramos IN, Ramos KS, Boerner A, He Q, Tavera-Garcia MA. Culturally-tailored education programs to address health literacy deficits and pervasive health disparities among Hispanics in rural Shelbyville, Kentucky. J Community Med Health Educ 2013;3:20475.
Lenio JA. Analysis of the trans theoretical model of behavior change. J Stud Res 2006;5:73-87.
[Table 1], [Table 2]