u arizona teen sms study

7/29/2019 u Arizona Teen Sms Study

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Podcast available online

at www.jneb.org Research Article

Texting for Health: The Use of Participatory Methods

to Develop Healthy Lifestyle Messages for TeensMelanie Hingle, PhD, MPH, RD1; Mimi Nichter, PhD2; Melanie Medeiros, MA2;Samantha Grace, BA2

ABSTRACT

Objective: To develop and test messages and a mobile phone delivery protocol designed to influence thenutrition and physical activity knowledge, attitudes, and behavior of adolescents.

Design: Nine focus groups, 4 classroom discussions, and an 8-week pilot study exploring message content,format, origin, and message delivery were conducted over 12 months using a multistage, youth-participatory approach.

Setting: Youth programs at 11 locations in Arizona.

Participants: Recruitment was coordinated through youth educators and leaders. Eligible teens were12-18 years old and enrolled in youth programs between fall 2009 and 2010.

Phenomenon of Interest: Adolescent preferences for messages and delivery of messages.

Analysis: Qualitative data analysis procedures to generate themes from field notes.Results: One hundred seventy-seven adolescents participated in focus groups (n 59), discussions (n 86), and a pilot study (n 32). Youth preferred messages with an active voice that referenced teens andrecommended specific, achievable behaviors; messages should come from nutrition professionals deliveredas a text message, at a frequency of# 2 messages/day.

Conclusions and Implications: More than 300 messages and a delivery protocol were successfully de-veloped and tested in partnership with adolescents. Future research should address scalability of texting in-terventions; explore dose associated with changes in knowledge, attitudes, and behaviors; and offercustomized message subscription options.

Key Words: adolescents, mobile health, diet, health education, community-based participatory research(J Nutr Educ Behav. 2013;45:12-19.)

INTRODUCTION

The high prevalence of obesity in ado-lescents continues to be a significantpublic health challenge.1 Specificfood items and food consumption be-haviors are associated with increasedobesity risk in youth, including inade-quate intake of calcium-rich food,fruit, juice, and vegetables; breakfastskipping; increased eating frequency;and high consumption of sweetened

beverages, total calories, and dietaryfat.2 Recent survey data suggest thatless than 10% of adolescents met na-

tional guidelines for vegetable con-sumption or remained under therecommended limit for discretionarycalories (ie, food high in added sugarsand fats).3 At the same time, therehave been population-wide increasesin consumption of food away fromhome,3 increased sweetened beverageconsumption,4 and increased snack-ing between meals on high-caloriefood,5 all of which potentially displacelower-calorie, more nutrient-dense

choices. Low levels of moderate-to-vigorous physical activity exhibitedby adolescents and a high proportion

of time spent engaged in sedentary be-haviors (specifically, television view-ing) have also been associated withobesity risk.2 Taken together, thesedata suggest specific areas of focusaround which a nutrition educationand physical activity promotion pro-gram may be structured.

A broad range of intervention strat-egies has been used to prevent child-hood obesity, and current evidenceremains insufficient to determine

which intervention components con-tribute to beneficial outcomes inadolescents.6 The current consensusis that intervention programs target-ing adolescents combat obesity withlimited, short-lived success. Themajority of traditional approachesemployed to date have relied onexpert-led fitness and nutrition educa-tion programs delivered within theschool setting.7,8 New approaches areneeded to effectively engage teens inage-appropriate, teen-centric, relevant

activities that can be sustained

1Department of Nutritional Sciences, University of Arizona, Tucson, AZ2School of Anthropology, University of Arizona, Tucson, AZ

Address for correspondence: Melanie Hingle, PhD, MPH, RD, University of Arizona,

Department of Nutritional Sciences, 1177 E 4th St, Shantz Bldg, Room 328, Tucson,

AZ, 85721; Phone: (520) 621-3087; Fax: (520) 626-3446; E-mail: [email protected]

2013 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR

http://dx.doi.org/10.1016/j.jneb.2012.05.001

12 Journal of Nutrition Education and Behavior Volume 45, Number 1, 2013
mailto:[email protected]://dx.doi.org/10.1016/j.jneb.2012.05.001http://dx.doi.org/10.1016/j.jneb.2012.05.001mailto:[email protected]


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beyond traditional health promotionsettings.9-11

Adolescents are heavy users of mo-bile phones and SMS (short messageservice, or text messaging) applica-tions. Indeed, national data revealthat 75% of youth between the agesof 12 and 17 years own a cell phone

and over one half of those teenssend 50 or more text messages eachday.12

Although mobile technologiespresent clinicians, educators, and re-searchers with new opportunities toreach youth with information andstrategies to promote health behaviorchange, their use as intervention toolsalso presents new challenges.13Thein-formal nature of mobile phone-basedcommunication is appealingto adoles-cents.However, theuse of this abbrevi-ated communication method (SMS islimited to 160 characters) for healthcommunication requires a creative,thoughtful approach to message de-sign and delivery to ensure accuracyof message content. Designing appeal-ingmessagesis also importantforex-ample, thosethat address health topicsof interest to teens, using a youth-friendly voice or style, and arrivingat a frequency that is acceptable to ad-olescents. Finally, it is important to de-termine youth preference for messageorigin (or sender). Despite the fact

that the majority of adolescents useSMS as their primary method of com-munication, it should not be assumedthat messages sent from outside theirsocial circles (eg, from a teacher orhealth professional) would be desir-able or even acceptable.

At present, there is little guidanceon theuse of SMS to promote nutritionand physical activity behavior changein youth for the purposes of obesityprevention. A literature search identi-fied 2 pilot studies that tested SMS as

a method to improve diet and physical

activity behaviors in children andado-lescents.14,15 The first study enrolled58 six- to eleven-year-old childrenand their parents and found no effecton children's consumption of sweet-ened beverages, physical activity, orscreen time after an 8-week, twice-daily SMS intervention.14 The second

study enrolled 120 sixteen- tonineteen-year-olds and focused specif-ically on changes in physical activityintentions over 2 weeks of daily SMS;the study found only a modest effecton intentions and on behavior atpost-measurement.15

Given the increasing prevalence ofmobile phone use among teens andthat SMS messaging is 1 of the pre-ferred forms of communication forthis age cohort, it is critical for healthresearchers and interventionists to

gain a better understanding of howand to what extent SMS can be usedto influence adolescent knowledge,attitudes, and behaviors related todiet and physical activity.

To this end, the purpose of thisstudy was to explore preferred mes-sage content, format, style (or mes-sage voice), origin, and frequencyand mode of message delivery fromthe perspective of adolescents. Usinga youth-participatory approach (ie, in-volving youth in intervention design,testing, and evaluation), this studywas designed to explore 2 questions:(1) how and to what extent populartechnology (ie, mobile phones andtext message software applications)would be an acceptable way by whichadolescents could receive messagesthat promoted healthy lifestyle be-haviors (ie, diet and physical activity);and (2) whether involving youth inthe development process would yielda series of messages that they consid-ered relevant to their lifestyles andwere easily comprehensible.

METHODS

Design

A series of focus groups, classroom dis-cussions, and an 8-week pilot studywere conducted over a period of 1year to explore message conceptsand to test messages and a message de-livery protocol. Data were collected in3 phases using a youth-participatoryapproach: Phase I, identification of

content and initial message develop-

ment; Phase II, message testing and re-finement; and Phase III, pilot-testingof a message delivery protocol usingstudy-provided mobile phones andmessages developed and refined inPhases I and II.

Recruitment

Participants were adolescents betweenthe ages of 12 and 18 years, recruitedfrom 11 youth programs. Programsthat did not explicitly focus on healthwere targeted for recruitment activi-ties; one-third of the programs en-rolled low-income populations, manyof whom were Hispanic. Programswere contacted based on previously es-tablished relationships with theUniversity of Arizona. Eligible youthwereactivemembersin1ofthe11pro-

grams during the fall of 2009 throughthe summer of 2010. In order to cap-ture a broad range of youth interestsand perspectives, participants were in-tentionally recruited from programswith diverse goals and areas of focus,including: environmental steward-ship, social justice, science and tech-nology, civic engagement, youthleadership and development, and thearts (music, dance, and design). Re-cruitment activities were coordinatedthrough program leaders, who an-

nounced the opportunity through let-ters sent home to parents. Writtenparental permission and minor assentwere obtained from youthwho wishedto participate in research activities.Permission to conduct all research ac-tivities was obtained from the Univer-sity of Arizona Institutional ReviewBoard following an expedited review.

Data Sources and Collection

The goal of Phase I was to identify nu-

trition and physical activity contentfrom which to construct messagesand to develop sample messages fortesting. Potential content was identi-fied using several strategies, including:(1) a literature search conducted bythe research team to identify behaviorsassociated with the development ofadiposity in adolescence;16,17 (2) aninformal scan of popular ormainstream consumer resources thatincluded nutrition advice andquestion-and-answer columns (eg,

Seventeen, Teen Vogue), as well as

The ubiquity of mobile

phone use among

adolescents offers an

engaging, youth-friendlyavenue through which to

promote healthy

behaviors.

Journal of Nutrition Education and Behavior Volume 45, Number 1, 2013 Hingle et al 13


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evidence-based consumer sites (eg,United States Department of Agricul-ture, Centers for Disease Control andPrevention); and, (3) a survey of ap-proximately 100 freshman college stu-dents enrolled in a general educationcourse at the University of Arizonawho were asked to submit their top 3

questions related to nutrition andphysical activity. The research teamsorted student questions into generalcategories, added additional categoriesbased on findings from the literature,and created content that representedeach category.

Over 300 messages were developedduring this phase by the researchteam. Message content addressed thefollowing topics: increased total energyintake, high energy-dense diets, in-creased intake of sweetened beverages,

low intake of fruits and vegetables,large portions, frequent consumptionof fast food and food away fromhome, physical activity, and infre-quent consumption of breakfast.

Messages were constructed usinga variety of formats and styles in orderto test which youth preferred. Threetypes of short messages (factoids)were developed for delivery as SMS,and 4 types of longer messages (polls,scenarios, quizzes, and recipes) werecreated to foster youth engagementwith the content.

In Phase II, groups of 6-10 teenswere recruited to participate in a seriesof focus groups, the purpose of whichwas to identify how youth respondedto the concept of text messaging forhealth, which content and messageformats teens thought were appealingand relevant, and to solicit their sug-gestions for unrepresented topicsaround which additional messagescould be developed. Discussions wereled by experts in qualitative research(a medical anthropology team) who

had experience in conducting focusgroups with teens, and in the analysisof qualitative data.

To guide the discussions, a semi-structured script was developed by theresearch team consisting of several ice-breaker questions, examples of differ-ent message formats, and a shortactivity thatguided participants in pro-viding feedback to make messagesmore appealing to teens. Questionsalso focused on the modality itselfand how participants thought they

and their peers would respond to such

messages on their phone. Written fieldnotes and audiorecordings were usedto document all youth responses dur-ingfocus groups. Notes were later tran-scribed and refined as interviewerslistened to audiorecordings. Focusgroup findings were used to finalizemessage categories and types, which

were brought to classroom discussiongroups for further refinement.

Four classroom discussions wereheld at a local high school during sci-ence and physical education classes.The purpose of the discussions was toensure youth were able to read andcomprehend message content, and todetermine whether message style orvoice was appealing to teens. Stu-dents (20-24 students per class) wereshown 25 messages and asked to rateeach message asfitting into 1 of 3 pos-

sible categories: 1

Cool, I want toknow more! indicated they liked themessage and it made them curious toknow more; 2 Okay, but . indi-cated they liked the message, but itneeded an adjustment to make itmore youth friendly;or 3 Next! in-dicated they did not like the message.Each message was read aloud by a stu-dent, and interviewers then asked stu-dents to explain the meaning of themessage using their own words. Theentire class then voted on the categorythat best fit what they thought aboutthe message. Students were asked toexplain why they chose to place eachmessage in a particular category, par-ticularly if they thought the messageshould not be used. Those who dis-agreed with the majority were encour-aged to provide reasons why theychose a different category. These sub-jective descriptions of their responseto and interpretation of messageswere useful to the researchers as theyprovided guidelines for what was andwas not acceptable to youth audi-

ences. As subjective responses variedacross students, the more quantitativeapproach (ie, actually counting howmany voted the message as 1, 2, or 3)was necessary to obtain some consen-sus. Messages categorized by themajority of youth as 1 or 2 wereretained for Phase III testing. Messageswith a rating of1 were included as is,and those that received a 2 wererevised based on student feedbackprior to Phase III.

Guided by Phase II findings, the re-

search team developed a message de-

livery protocol for testing in Phase III.Four youth groups participated inthis 8-week pilot study to determinewhether messages delivered viaa mobile phone represented a feasibleintervention strategy, and whethermessages and methods were acceptedby youth. Each Phase III participant

was provided with a mobile phone(Windows Mobile, HTC Touch Pro 2)forthe duration of thestudy. Althoughideally youth would have used theirown phones, the researchers hadlearned through formative researchthat many teens were unwilling to re-ceive texts if they had limited dataplans.At theinitial stage ofthe project,it was thus important for all studentsto use the same technology. The re-searchers also wanted to ensure thatstudents of all socioeconomic groups

could participate in the program.Two different software applications

were tested: in Weeks 1-4, messageswere delivered using the My Experiencesoftware application (version 0.9.1,Intel Research Seattle and Universityof Washington, Seattle, WA, 2009),which triggered messages to pop upon participants' phones at prearrangedtimes each day; during Weeks 5-8,Google's Voice-to-SMS applicationwas used to send messages at a rate of1 per day.18 An additional teasermessage was sent once a week, whichencouraged youth to interact with ad-ditional content pre-loaded onto thephone by the research team (eg, Liketo snack but want to be healthy?Check out the Recipes folder HERE tosee good stuff you can throw togetherin 3 steps or less.) Two members ofthe research team, graduate studentsin anthropology) sent the messages,and worked closely with a registereddietitian to answer any questions thatyouth texted in response. Informalinterviews were conducted with

participants at the end of 8 weeks tounderstand their experiences withthe device and delivery protocol, andto explore the extent to which youthread, liked/disliked, acted upon, orshared messages with others.

Data Analysis

Field notes and audiorecordings of allPhase II and III study activities servedas the foundations of the analysis.

Data collection and analysis were

14 Hingle et al Journal of Nutrition Education and Behavior Volume 45, Number 1, 2013


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undertaken concurrently. Data werecoded and analyzed using deductivethematic analysis, as described byBraun and Clarke.19 A codebook wasdeveloped by the research team to fa-cilitate analysis, consisting of tran-scripts of audiorecordings and fieldnotes organized by data collection

phase (II or III), date, and participat-ing youth group or program. Each da-taset was reviewed by the primaryinterviewer, followed by a secondaryinterviewer, who was present at thetime of data collection. Both inter-viewers identified recurring themes(defined as answers provided by sev-eral youth or agreed upon across themajority of focus group and exit inter-views), and met to discuss findingsand resolve any discrepancies in datacoding. Focus groups were conducted

until repetition of participants' re-sponses was observed.20 A final sum-mary report with documentation offindings and analysis from each focusgroup and discussion group was dis-tributed to the research team, whoused these data to develop the finalmessage delivery protocol.

RESULTS

Participants

Nine focus groups (n 59), 4 class-

room discussions (n 86), and an8-week pilot study (n 32) were con-ducted with a total of 177 participantsbetween the ages of 12 and 18 years.Fifty-three percent of the participantswere female. Youth were recruitedfrom local YMCA teen groups, a youthvolunteer group, a teen advocacygroup, a middle school student leader-ship club, a charter high school stu-dent leadership club, a youth cyclingclub, a youth environmental club,and science and physical education

classes at a local public high school(Table 1). Two of the discussionsgroups were composed of small friend-ship groups,21 as the site from whichthese teens were drawn was small.

Phase II Findings

Overall, focus/friendship group par-ticipants were enthusiastic about theidea of receiving nutrition and physi-cal activity messages through theirmobile phones. All message formats

were well received, however, the short

message (or factoid) format and thecategory quizzes were repeated favor-ites across all focus groups (Table 2).Youth expressed preference formessages that were short, direct, andrelevant to teens. Some participantsexpressed an interest in receiving rec-ipes as messages, but they emphasizedthat the recipes should be practicaland easy to implement without adultsupervision.

Participants wanted messages toprovide information specific to theteen demographic (eg, American girlsaged 12-19 years old drink an averageof 650 cans of soda a year!), and pre-ferred messages that included per-sonal pronouns (eg, Eating foods

high in protein helps you feel full.Want to see examples of foods thatcontain protein?), which teens per-ceived as speaking directly to us. Inaddition, teens wanted some of themessages to contain content thatthey referred to as random (eg, Car-rots were originally purple in color;or, Ears of corn have even numbersof rows) because they perceived thiscontent to be unique and fun to readand share. Also desirable were mes-sages that provided knowledge that

was

translatable

into behaviors re-

lated to nutrition, physical activity,or body weight (eg, Walking canburn 80-100 calories per mile).Many youth said that simple messagesmade them want to know more aboutcertain nutrition and exercise topics,and they suggested that teaser mes-sages be used to encourage future par-ticipants to learn more if they wished(eg, Too little sleep can lead to weightgain. Click HERE to learn more).

Message style or voice was alsoimportant to youth. Teens explainedthat they did not want to be toldwhat to do and did not like messagetones that they perceived as authori-tarian. For example, messages that in-cluded words like always or never

were generally not preferred. Rather,youth suggested these words be re-placed with verbal softeners such astry or consider.

Youth also suggested additionalthemes or topics that they wanted tolearn more about, including healthyrestaurant and convenience foodchoices, vegetarian eating, dieting forweight loss, how to build muscles orget lean (boys), nutrition to improvethe quality of one's hair and skin(girls), and how the body functions

(boys and girls).

Table 1. Demographics of Participants in Focus Groups and Discussions

Program/Site n Age range, y Male/Female

Focus Groups, summer

and fall 2009

Youth center 7 12-15 6 M, 1 F

YMCA, Site 1 3 12-14 2 M, 1 F

YMCA, Site 2 5 12-14 1 M, 4 FYMCA, Site 3 10 12-15 4 M, 6 F

Youth volunteer group 10 14-16 4 M, 1 F

Middle school 5 12-13 1 M, 4 F

Charter school 9 16-17 1 M, 8 F

Cycling club 6 13-17 3 M, 3 F

Environmental club 4 12-14 1 M, 3 F

Discussion groups, spring 2010

HS science class 22 15-16 12 M, 10 F

HS science class 24 15-16 15 M, 9 F

HS yoga class 20 16-18 9 M, 11 F

HS yoga class 20 16-18 7 M, 13 F

Pilot study, summer 20104-H 4 13-15 2 M, 2 F

Youth center 8 16-18 5 M, 3 F

YMCA 11 12-15 6 M, 5 F

Environmental club 9 12-15 4 M, 5 F

HS indicates high school.



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Although the majority of focusgroup participants reported owninga mobile phone and using SMS regu-larly, youth said they would prefer toreceive no more than 2 health-related messages per day. Finally,youth wanted these types of messagesto come from a credible source, that is,someone who was a perceived as anexpert in health or nutrition topics

such as a nutritionist.Discussion groups were used to re-

fine message content to improve com-prehension and use a writing stylethat appealed to teens. Feedbackfrom discussion groups was used tochoose final messages and revisethem prior to pilot-testing in PhaseIII (Table 3). Students participatingin classroom discussions expressedsimilar reservations to focus groupparticipants with regard to certainstyle and word choices (eg, need

to,

should,

or

recommend

). For

example, the message, The recommen-ded number of hours of sleep per day forteens is 9, was interpreted by teens astelling them what to do, and to whichmany youth responded with Whenwe get told what to do, we don'twant to do it! Messages that beganwith Did you know. were equally dis-liked, with one participant comment-ing Any sentence starting with did

you know makes me immediatelynot want to care! with nods of agree-ment from other students.

Also like their focus group counter-parts, teens in discussion groupswanted all messages to use simple, di-rect, factual language, and they madesuggestions on how to revise messagesalong these lines. For example, Re-duced-fat foods (like chips and peanutbutter) often have sugar added so thatthe calories are the same as the regularversion! was revised to read, Adver-

tisers lie to you! They say less fat, but

that means more sugar! Discussiongroups also corroborated focus groupfindings in that youth preferred mes-sages that specifically referenced teens(eg, 2 out of 5 teens don't eat break-fast!) and that they were more likelyto share these messages with friendsbecause they were personal andyou can relate to it. Surprisingly,some messages that initially seemed

to meet general youth criteria (ie, brief,direct, factual) did not rate well in dis-cussions. Two examples included Acan of regular soda has over NINE tea-spoons of sugar in it! described byteens as boring and commonknowledge, and Overweight teenshave a greater chance of having highcholesterol and high blood pressure,on which youth commented, wehear this everywhere. Longer ormore complex messages were subjectto multiple interpretations by youth

and were not as well received.

Table 2. Message Types and Selected Content from Sweetened Beverage Category

Message Type and Definition Selected Content

Factoid - Nutrition and physical activity

information in # 160 characters

A can of soda has 10 teaspoons of added sugar.

How many teaspoons of sugar are in one 12-oz. can of soda?

(a) 5 teaspoons; (b) 10 teaspoons; (c) I dont know

Did you know that one 12-oz. can of soda has 10 teaspoons of added sugar?

Poll - Participants prompted to respond withtypical habits

What is your go-to drink when youre thirsty?(a) soda; (b) water; (c) sports drink; (d) juice

Scenario - Mini-vignettes prompt participants

to make choices about nutrition or physical

activities

Jesse is tired and thirsty after school and stops at the convenience

store to buy a drink. Whats the healthiest drink choice?

(a) Fruit drink; (b) Water; (c) Energy drink; (d) Sports drink

Category Quiz - 5-item quiz that categorizes

participants depending on how they answer

each question

What kind of beverage are you?

1. Its time for breakfast, what do you eat?

2. When youre thirsty after school, where do you get your drink?

3. Whats the best color for a drink to be?

4. Everyones hanging out at your place over the weekend and

starting to get bored, do you .

5. Do you like sweet drinks?

Knowledge Quiz - 5-item quiz designed to

informally test participants basic nutritionknowledge

Energy drink IQ

1. True or false? Most energy drinks contain the same amount of caffeine(or more!) as a cup of coffee.

2. How many energy drinks are on the market?

3. Guarana is an ingredient in a lot of popular energy drinks. What is it?

4. True or false. A typical energy drink has the same amount of caffeine

as the maximum recommended amount for teens.

5. How many gallons of energy drinks do Americans consume in total

every year?

Recipe - Meal and snack ideas in 3 steps

prepared from ingredients typically found

in a kitchen

Easy breakfast smoothie: 1/8 cup orange juice; 2 bananas;

4 strawberries (ok to leave out if you dont have any); 1.5 cups of

yogurt. Break bananas into chunks and put in the blender. Add all

the other ingredients. Blend on full for 20 seconds. Pour into

glasses and enjoy!



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Messages wererevised in accordancetoyouth suggestions (Table 3).

Phase III Findings

Factoids, quizzes, and recipes werechosen as the message formats sentto youth during Phase III. Thirty-twoyouth participated in the 8-week pilotstudy. Informal, small group inter-views were used to assess acceptabilityof messages and delivery methods.

Participants reported that they en-joyed receiving the nutrition andphysical activity SMS messages. Oneyouth asserted that although someof the texts are really cool, others areboring, a sentiment with which sev-

eral others agreed, especially when

they were already familiar with the in-formation contained in the message.However, others noted that it was use-ful to have familiar information rein-forced, because it helped you tothink about it more. Random mes-

sages were rated highly by partici-pants, who reported being moreinclined to open additional study-related SMS messages and links to ad-ditional content. Several participantssaid that they showed or forwardedthe messages they liked to their familyand friends.

The use of SMS also facilitated con-versations between participants andthe research team. Participants en-joyed being able to text questionsback to the research team and receive

responses. Questions included,

How

many calories can you lose if yourun a mile? in response to Walkingcan burn about 80-100 calories permile, and Do you know if teens inother countries drink more or lesssoda than they do in the US, like

how many cans of soda will a Mexicangirl drink a year? in response to Thetypical American teenage girl drinks650 cans of soda per year!

All pilot study participants agreedthat messages that arrived via SMS (us-ing the Google Voice-to-SMS) werepreferable to those that popped upon the phone at prearranged times, asunlike preset messages, SMS allowedyouth participants to interact withthe research team through informalconversations or save them for later

to forward and share with others.

Table 3. Message Revisions Suggested by Participants in Phase II

Original Message Rationale for Modification Type of Modification Revised or New Message

Exercising helps you feel better

about yourself. It gives you

pride and confidence in your

body.

Physical activity was

suggested as an alternative

to exercise, which

sounded regimented and

not fun.Youth suggested can or

may, since these

messages may not resonate

with all youth (eg, some

might feel less confident

when they are physically

active or notice no

improvement).

Editorial Physical activity may help you

to feel better about yourself

because it can give you

a sense of confidence in

your body.

Cereal fruit milk or yogurt

for breakfast gives you

a good dose of protein and

fiber, which will keep you

fuller, longer.

Was not specific enough

regarding type of food. That

is, youth noted that some

cereals are bad for health

(sweetened ones, whichhave little protein) and that

the type of milk should be

included (2% vs skim). Youth

recommended the authors

avoid nutrition jargon.

Reduced length of message

and specified food type.

Eliminated jargon.

Eating whole-grain cereal, fruit,

and low-fat milk or yogurt for

breakfast will keep you fuller,

longer.

The average teen drinks only 1

glass of milk a day but twice

as many sodas.

Youth said: Messages that

are too complex are difficult

to understand.

Reduced length of message

and eliminated reference to

rate of soda consumption.

The average teen drinks only 1

glass of milk a day but 2

sodas.

Having too much sugar in your

diet can make you gain

weight, which puts you at

greater risk for diabetes.

Youth confused the word

diet with dieting. They

thought this message was

confusing.

Shortened the message and

made it more direct.

Eliminated jargon.

Caution: Being overweight

puts you at greater risk of

diabetes.

Teens should get 9 hours of

sleep per day.

Youth suggested we avoid

using should or need to

and use softer words

(leaving them free to make

their own choice).

Change imperative statement

to factual statement.

Nine hours of sleep each night

is recommended for teens.



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DISCUSSION

In this study,a youth-participatoryap-proach was used to engage adolescentsin developing and refining nutritionand physical activity messages thatwere appealing, relevant, and practicalfor teens to implement. Focus groups

and classroom discussions reinforcedthat teens are sensitive to certain lan-guage. For example, messages thatused a more authoritarian tone (eg,You should or You need to) wereuniversally panned by youth, whostated messages should never containthese phrases and noted that kidsdon't like being told what to do.

Comprehensible, accurate, andconcise messages designed with parti-cipant input to support healthy life-style choices has been recommended

as a single strategy to help shift dietarypatterns to supportoptimal health out-comes.22 The current study's findingssuggest these messages should be posi-tive, simple, few in number, and de-signed to be culturally appropriate fordifferent adolescent subpopulations.In order to informand motivateyouth,messages must address the reality oftoday's adolescent lifestyles.23,24 Onemethod is to directly engage youth initerative discussions about messagedesign and delivery and involve themin the development of messages sothat messages are relevant andmeaningful to the lifestyles of users.25

Few studies have explored theconstruction of messages designed topromote healthy lifestyle behaviors

through a mobile device usinga youth-participatory approach. Ina study focused on weight loss (ratherthan healthy lifestyle promotion),Woolford and colleagues exploredobese adolescent participants' per-spectives related to weight manage-ment messages, and they foundenthusiasm for SMS as a strategy tosupport weight loss efforts amongthese participants.22 Importantly, fo-cus group findings from their studywere similar to those of this study in

that teen participants desired brief,positive, encouraging messages thathad a natural tone and made spe-cific reference to the teen demo-graphic.22 Also similar, Woolford'stargeted tips (ie, SMS, which providedadvice normed and pretested withyouth) were particularly well received

by teens, who thought they could eas-ily incorporate these practical sugges-tions into their routine. Findingsfrom Woolford et al reinforce the cur-rent study's conclusions and empha-size the critical importance offormative research in the develop-ment and design of SMS messages tar-geted to youth populations.

Although overall, the informal,SMS-based approach appealed toyouth, it remains unclear whether themessages, once received, will result in

changes in diet and physical activityknowledge, attitudes, or behaviors. Asthis is an innovative methodology inthefieldof nutrition education, this re-search entailed working closely withyouth in an iterative manner in the de-velopment of messagesand identifyingan appropriate delivery modality. Thenext step will be to conduct an efficacystudy to test the impact of differentmessage doses and delivery methodson key health behaviors among adoles-cents. It is important to note that morebroadly in the field of mhealth (ie,projects using mobile technologies forpurposes of health), most programscan best be described as pilot projects,as they are relatively new in focus andscope. Measures of program successhave yet to be adequately defined.

In addition to testing the effect ofmessages on health-related outcomes,several logistical challenges requirecareful consideration when this mes-saging intervention is implementedon a larger scale. In this study,messages were manually pushed to

participants using a free, Web-basedsoftware application or automaticallysent using a preprogrammed, phone-based software application, and theparticipants carried a study-providedmobile device that included unlim-ited text messaging. A larger partici-pant population would requirea software program capable of auto-matically sending dozens or evenhundreds of text messages simulta-neously, while still retaining theinteractivity that participants found

desirable. An efficacy trial would alsoneed to address the balance betweenthe practical need to automate mes-sage delivery while still retaining thenecessary level of engagement and in-teraction with participants.

Further, rather than using study-provided phones, participants must

be willing and able to use their ownmobile devices to receive study mes-sages (ie, they must have no or fewlimitations on text messaging allow-ances). Youth using their own mobilephones may be less tolerant toward re-ceiving messages compared to youthwho are supplied with a study phone.Although there are data supportingwidespread cell phone use and mobiledevice access among youth, a clearerpicture of access across all demo-graphic groups is not yet available.

Indeed, in this study, initial data re-vealed that only 85% of youth hadcell phones, and only 10% of thoseyouth had smart phones.

Although youth enrolled in the pi-lot study were provided with studymobile phones, reports of messagesharing were not substantiated otherthan by self-report. Future studiesshould attempt to capture messagesharing more reliably as both a quanti-tative measure (eg, number of timesmessages were opened, read, or for-warded to others) as well as a qualita-tive measure (eg, preference forspecific messages among teen partici-pants and with whom they shared in-formation).

Diverse teens were purposefullyrecruited to participate in this study,representing a wide range of ages,socioeconomic backgrounds, and a va-riety of extracurricular interests. How-ever, the exploratory nature of thisresearch did not allow investigation ofage and gender differences with regardto message preferences, or cultural and

economic factors that may influencehow the messages would be receivedand acted upon. These are importantissues to explore in future studies.

IMPLICATIONS FOR

RESEARCH AND

PRACTICE

This study demonstrates a novel wayin which to engage adolescents inconversations about health using

Avoid you should and

you need to in

messages for teens.



8/8

a familiar, favored, and ubiquitouscommunication method. Ratherthan being passive recipients of top-down, expert-driven communica-tions, youth in this study had theopportunity to actively participate inthe message design process and en-gage with health information through

informal interactions with expertsand with one another, thereby in-creasing the likelihood that theyadopted the recommended behaviors.

Adolescence is characterized by in-creased ability for complex thoughtas well as increased desire for auto-nomy.23 To be maximally effective,health interventions should be de-signed to support adolescents duringtheir transition to adulthood by offer-ing developmentally appropriate in-formation and strategies. Given the

current popularity of mobile devicesamong youth, SMS messages representan opportunity to support adolescentsin their transition to adulthood by en-gaging youth with information andstrategies that foster healthy lifestylechoices and habits. Additional re-search is needed to determine whethertechnology-based interventions are aneffective, sustainable way to promotehealthy lifestyles to adolescents andhave a significant impact on behaviorsthat place youth at increased risk.

ACKNOWLEDGMENTS

This project is supported by theUnited States Department of Agricul-ture Human Nutrition and ObesityInitiative #2009-55215-05187.

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