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u Arizona Teen Sms Study

u Arizona Teen Sms Study

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Podcast available onlineat www.jneb.org
Research Article 
Texting for Health: The Use of Participatory Methodsto Develop Healthy Lifestyle Messages for Teens
Melanie Hingle, PhD, MPH, RD
; Mimi Nichter, PhD
; Melanie Medeiros, MA
;Samantha Grace, BA
To develop and test messages and a mobile phone delivery protocol designed to influence thenutrition and physical activity knowledge, attitudes, and behavior of adolescents.
Ninefocusgroups,4classroomdiscussions,andan8-weekpilotstudyexploringmessagecontent,format, origin, and message delivery were conducted over 12 months using a multistage, youth-participatory approach.
Youth programs at 11 locations in Arizona.
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.
Qualitative data analysis procedures to generate themes from field notes.
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.
Thehighprevalenceofobesityinado-lescents continues to be asigni
cantpublic health challenge.
cfood items and food consumption be-haviors are associated with increasedobesity risk inyouth, includinginade-quate intake of calcium-rich food,fruit, juice, and vegetables; breakfastskipping; increased eating frequency;and high consumption of sweetenedbeverages, total calories, and dietaryfat.
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).
At the same time, therehave been population-wide increasesin consumption of food away fromhome,
increased sweetened beverageconsumption,
and increased snack-ingbetween meals on high-caloriefood,
allofwhichpotentiallydisplacelower-calorie, more nutrient-densechoices. Low levels of moderate-to-vigorous physical activity exhibitedby adolescents and a high proportionoftimespentengagedinsedentarybe-haviors (speci
cally, television view-ing) have also been associated withobesity risk.
Taken together, thesedata suggest speci
c areas of focusaround which a nutrition educationand physical activity promotion pro-gram may be structured.Abroadrangeofinterventionstrat-egies has been used to prevent child-hood obesity, and current evidenceremains insuf 
cient to determinewhich intervention components con-tribute to bene
cial outcomes inadolescents.
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
tnessandnutritioneduca-tion programsdelivered within theschool setting.
New approaches areneeded to effectively engage teens inage-appropriate,teen-centric,relevantactivities that can be sustained
Department of Nutritional Sciences, University of Arizona, Tucson, AZ
School of Anthropology, University of Arizona, Tucson, AZAddress 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:hinglem@u.arizona.edu
2013 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIORhttp://dx.doi.org/10.1016/j.jneb.2012.05.001
12 Journal of Nutrition Education and Behavior
Volume 45, Number 1, 2013
beyondtraditional health promotionsettings.
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 phoneand over one half of those teenssend 50 or more text messages eachday.
Although mobile technologiespresent clinicians, educators, and re-searchers with new opportunities toreach youth with information andstrategies to promote health behaviorchange,theiruseasinterventiontoolsalsopresentsnewchallenges.
Thein-formal nature of mobile phone-basedcommunicationisappealingtoadoles-cents.However,theuseofthisabbrevi-ated communication method (SMS islimited to 160 characters) for healthcommunication requires a creative,thoughtful approach to message de-sign and delivery to ensure accuracyofmessagecontent.Designingappeal-ingmessagesisalsoimportant
forex-ample,thosethataddresshealthtopicsof interest to teens, using a youth-friendly
or style, and arrivingat a frequency that is acceptable to ad-olescents.Finally,itisimportanttode-termine youth preference for messageorigin (or sender). Despite the factthat 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 guidanceontheuseofSMStopromotenutritionand physical activity behavior changein youth for the purposes of obesityprevention. A literature search identi-
ed 2 pilot studies that tested SMS asamethodtoimprovedietandphysicalactivitybehaviorsinchildrenandado-lescents.
rst 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.
The secondstudy enrolled 120 sixteen- tonineteen-year-oldsandfocusedspecif-ically on changes in physical activityintentions over 2 weeks of daily SMS;the study found only a modest effecton intentions andon behavior atpost-measurement.
Given the increasing prevalence of mobile 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 togain a better understanding of howand to what extent SMS can be usedto in
uence 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
), origin, and frequencyand mode of message delivery fromthe perspective of adolescents. Usingayouth-participatoryapproach(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.
Aseriesoffocusgroups,classroomdis-cussions, and an 8-week pilot studywere conducted over a period of 1year to explore message conceptsandtotestmessagesandamessagede-livery protocol. Data were collected in3 phases using a youth-participatoryapproach: Phase I, identi
cation of content and initial message develop-ment;PhaseII,messagetestingandre-
nement; and Phase III, pilot-testingof a message delivery protocol usingstudy-provided mobile phones andmessages developed and re
ned inPhases I and II.
Participantswereadolescentsbetweenthe 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. Programswerecontactedbasedonpreviouslyes-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 interestsandperspectives,participantswerein-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 throughlet-ters sent home to parents. Writtenparental permission and minor assentwereobtainedfromyouthwhowishedto 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-
ed using several strategies, including:(1) a literature search conducted bytheresearchteamtoidentifybehaviorsassociated with the development of adiposity in adolescence;
(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 mobilephone use amongadolescents offers anengaging, youth-friendlyavenue through which topromote healthybehaviors.
 Journal of Nutrition Education and Behavior
Volume 45, Number 1, 2013 Hingle et al 13
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 3questions related to nutrition andphysical activity. The research teamsorted student questions into generalcategories, added additional categoriesbased on
ndings from the literature,and created content that representedeach category.Over 300 messages were developedduring this phase by the researchteam. Message content addressed thefollowingtopics:increasedtotalenergyintake, 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 (
)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 teenswererecruited to participateinaseriesof 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) whohad experience in conducting focusgroups with teens, and in the analysisof qualitative data.To guide the discussions, a semi-structured script was developed by theresearchteamconsistingofseveralice-breaker questions, examples of differ-ent message formats, and a shortactivitythatguidedparticipantsinpro-viding feedback to make messagesmore appealing to teens. Questionsalso focused on the modality itself and how participants thought theyand their peers would respond to suchmessagesontheirphone.Written
eldnotes and audiorecordings were usedto document all youth responses dur-ingfocusgroups.Noteswerelatertran-scribed and re
ned as interviewerslistened to audiorecordings. Focusgroup
ndings were used to
nalizemessage categories and types, whichwere brought to classroom discussiongroups for further re
nement.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 or
was appealing to teens. Stu-dents (20-24 students per class) wereshown 25 messages and asked to rateeachmessageas
ttinginto 1of 3pos-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 itmoreyouthfriendly;or3
in-dicated they did not like the message.Eachmessage was read aloud by a stu-dent, and interviewers then asked stu-dents to explain the meaning of themessage using their own words. Theentireclassthenvotedonthecategorythat best
t 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
wereincludedasis,and those that received a
wererevised based on student feedback prior to Phase III.Guided by Phase II
ndings, 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 participantwas provided with a mobile phone(Windows Mobile, HTC Touch Pro 2)forthedurationofthestudy.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.Attheinitialstageoftheproject,it was thus important for all studentsto use the same technology. The re-searchers also wanted to ensure thatstudents of all socioeconomic groupscould participate in the program.Twodifferentsoftwareapplicationswere tested: in Weeks 1-4, messageswere delivered using the
My Experience 
software application (version 0.9.1,Intel Research Seattle and Universityof Washington, Seattle, WA, 2009),which triggered messages to
pop up
onparticipants'phonesatprearrangedtimes each day; during Weeks 5-8,Google's Voice-to-SMS applicationwas used to send messages at a rate of 1 per day.
An additional
message 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
folder HERE tosee good stuff you can throw togetherin 3 steps or less.
) Two members of the 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 withparticipants 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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