Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05 Copyright (c) PNG Publications. All rights reserved. I Lance Weinhardt, PhD;CherylL.Holt,PhD,FAAHB; CarrieO’ Connor, MA; Alice F. Yan, MD,PhD;PatriciaStevens,PhD,RN,FAAN; Youfa Wang, MD,PhD; Participatory Approach Promotion inCollegeStudents: A Formative mHealth Text Messagingfor Physical Activity Am JHealth Behav Correspondence DrYan; Recreation, UniversityofWisconsin-Milwaukee. consin-Milwaukee, Milwaukee, WI. Sara Luelloff, University Joseph J.ZilberSchoolofPublic Health,UniversityofWis University of Wisconsin-Milwaukee, Milwaukee, WI. Hui Xie, WI. TiffanyFeller, Joseph J.ZilberSchoolofPublicHealth, ment ofBiophysics,MedicalCollege ofWisconsin,Milwaukee, of , College Park,MD. Carrie O’ Connor, Depart kee, WI. Cheryl L. Holt, Associate Professor, Maryland School Public Health, University of Wisconsin-Milwaukee, Milwau NY. LanceWeinhardt,Professor, Joseph J.Zilber School of versity at Buffalo-The State University of New York, Buffalo, Health, School ofPublicHealthandProfessions,Uni Professor, DepartmentofEpidemiologyandEnvironmental versity of Wisconsin-Milwaukee, Milwaukee, WI. Youfa Wang, kee, WI. Patricia Stevens, Professor,CollegeofNursing,Uni of Public Health, University of Wisconsin-Milwaukee, Milwau J. ZilberSchool Yan, Assistant Professor,Joseph Alice Fang mended physicalactivity guidelines, 27%ofninth-gradersfail to meet recom Whereas highschooltocollege. from progressively creases is particularly notedinyouthwhoseactivity de low population participationlevels persist. This Tiffany Feller, BA;HuiXie,MA;SaraLuelloff,MS were uniformly enthusiastic abouta text to manage the data. ti qualitative analysis was used Atlas. group discussionswasconducted. framework analysisoftranscribedfocus foci. A for directing thediscussion and data for System wasadopted Response ence Audi An ing aparticipatoryapproach. us focus groups(N=33)wereconducted college studentsample. assess feasibility and acceptabilityin a users’ preferences,and es, understand physical activitypromotiontextmessag Objectives long-term weightmanagement.Yet,long-term unfavorably tivity is ameansofmaintaininggoodhealthand that physicalac t isawell-establishedpremise collection to ensure confidentiality ensure to collection : To .™ 2015;39(3):395-408 developmobile-based [email protected] Results

Methods : Participants 3 56%–80%of : Five 1,2 ------

efforts atthisimportantdevelopmentalstage. efforts promotion interventiontotarget exercise centered college student- is important to design aneffective lifelong health. affecting hood, thereby in emerging adulthood, continueintolateradult habits, such asasedentarylifestyle established ety and depression. and self-esteem, mental health outcomes, cal activity is associated with better short-term physi and mentalhealthsuggeststhatincreased betweenphysicalactivity amining therelationship anddepression. stress riskfor college alsocanbeaperiodofincreased tes disease, cardiovascular riskforobesity, students atamarkedlyincreased dramatic physical activity decline places college days).The onatleast 3 ofthe7previous exercise or 30minutesofmoderate 20 minutesofvigorous week(at least levelsduringtheprevious exercise for healthy did not meet the minimum requirement Association activity. physical college studentsdonotengageinregular tablishing andmonitoringr a high value on messages related to es tailored messages.Participantsplaced preferred positive,supportivepersonally age regular physical activity. They also intervention toencour message-based college students ;participatoryapproach; tance ofsuchanintervention. results support the feasibility and accep text messaging was well received. The goals achievable DOI: http://dx.doi.org/10.5993/AJHB.39.3.12 Am JHealthBehav. Key words 10 and breast andcoloncancers. andbreast 4,5 Further, theAmericanCollegeHealth 6 foundthat49.6%of college students : physical activity; 16-19 20-22 and reduced stress, anxi stress, andreduced . 2015;39(3):395-408 Conclusions 13,14 7,8 Moreover, critical health 15 stroke, suchaselevatedmood Existingevidenceex

9 type2diabe 11,12 ealistic and

: mHealth Inaddition, 23,24 mHealth Thus, it 395 ------; Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05

396 what empirical evidence, if any, guidedcontent developed text messages and how researchers unclear gaps inknowledge.First, it remains are terventions haveshownpositive results, iors, physical activity promotion, to self-management, studies related in promising communication modalityproved back, immediateprompts, byproviding herence healthcommunication. It tailored because it allows for in-the-moment, personally tractive as amodality for behavioral interventions theory. to cognitivesociallearning and social support) central action, reinforcement minders, andre whichincludesperiodicprompts process, have accesstoexpensivetechnology. people may not settings where resource-limited cessibility, and personalconvenience, Copyrighttext messaging. interventions tomobiledevicesusingpromotion use (c) time.Youngintake, andscreen SMS adults’broad PNG beverage their physical activity, sugar-sweetened fer textmessagesoverpaperdiariestomonitor Publications. etal Shapiro Facebook, email, or talking on a . suchas or SMS)overothercommunicationforms, toasShortMessageService, (otherwise referred ing 110textsdaily. All owners ages18to 29 universally text, rightsership exceeds90%. Center reserved.them intotheirdailylives.The use mobilephonesextensively,andintegrate time.” Many people, particularly young adults, education, and/or feedback in “realprompts, health behavior changes and promoting services means of delivering healthcare promising tophysicalactivity. and goalsettingasrelated , self- self-efficacy, enhance an interventionshould manyyouths.Such to reach thatcanbescaled socially supportiveapproaches livery. limiting theirfeasibility for large-scale de thereby timeandpersonnelintensive, interventions are Moreover, traditional face-to-face and telephone achallenge. remains recommendations treatment ity. physical activ with success in increasing relate pectancy, self-monitoring, and goal setting cor ex outcome support, social motivation, benefits, exercise self-efficacy, barrier including constructs, trials, ity promotion activity interventions. sis for many general weight loss, diet and physical Model (TTM) theoretical inCollegeStudents MessagingforPhysicalActivityPromotion mHealth Text Although include lowcost, SMS advantages Mobile Health(mHealth)hasemerged asa Social Cognitive Theory(SCT) 27,33,34 49 67 suggeststheimportanceofshiftinghealth 59,60 andweightloss. 37

Thus, the need is clear for cost-effective, Thus,theneedis clear for cost-effective, found thatUSadults’mobilephoneown However, modifyingpooradherence

55 and reinforcement. lends itself to constructs (eg, cues to recent 50 foundthatyoungpeoplealsopre theory-based text message in 28-32 44 27 They prefer textmessaging Theyprefer 42 68,69 In reviewing physical activ Inreviewing majorcognitivebehavioral Young adultcellphone 26 form the theoretical ba the theoretical form 58,64-66 61 This primary health 25 nutritionbehav and the Trans 25,56,57 Pew Research increases ad increases 51 instantac 54 51-53 SMSisat TheSMS 43 56,70 38-41 averag even in 58 there there 35,36 feed with 45-49 62-64 to ------

es, whatisneededinmHealthinterventionsa onexpert-led,content-driven messag that relied traditional intervention development approaches the behavioral intervention. Fourth, unlike the framework to guide explicitly employ a theoretical found thatofthe34studies, 26 (76.5%) did not bile phone-based healthbehaviorinterventions, theory based. cal activityinterventionsare to be theory-based, acknowledged thatbehavioralinterventionsneed messagecontent. appropriate accurateandage- design anddeliverytoensure tomessage thoughtfulapproach acreative, quires to 160 characters) for health communication re method(SMSislimited the useofthisabbreviated communication appealstocollegestudents, based ofmobilephone- nature although theinformal ofinterventiondevelopment.Second, ent reporting andtranspar thorough require change research Evidence-based advancementsin health behavior intervention, the toreplicate thelevelofdetailrequired provide development. cording to studentfeedback. cording transcripts; and (5) modifying text messages ac messages inparticular; (4) analyzing focusgroup SMS interventions in general, and the set of text to discuss messages; (3) conducting focusgroups feedbackonthesetext student sampletoprovide a college geted tocollege students; (2) recruiting physicalactivity tar 100 text messages promoting of set a developing (1) were: study formative this public university in the US. Steps in Midwestern, inalarge tivity among collegestudentsenrolled physicalac text messageinterventiontopromote manner er-centered METHODS dent sample. physicalactivityinacollegestu saging topromote and(3) assess thefeasibility and acceptabilityoftextmes features; message text specific to regard in preferences users’ Model (TTM);(2)understand Social Cognitive Theory and the Transtheoretical text message contentguided by activity promotion physical develop (1) to: were aims specific study’s mote physical activity among college students. The theory-based text messaging interventiontopro ofour message designandparticipatoryprocesses gaps by outlining development activities, SMS these mHealthbehavioralinterventionknowledge ery frequency. message style and deliv regarding ers’ preferences understandus interventions will help researchers participants in the early design phase of mHealth appealing totarget audiences. and evaluation) so that intervention messages are volving participants in intervention design, testing participatory, The studywasconductedina study, we aimed to address In this formative 71 user-centered approach user-centered 58 Indeed, published evaluations rarely Indeed, publishedevaluationsrarely with recent notableexceptions. with recent

Buhi et al, 76 butmany prior toimplementing a large 77 in their review of mo intheir review 75 ad hoc 75

physi Involvingtargeted Third, itiswidely Third, participatory, , ratherthan 78,79

(ie, in us 71-74 ------

Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05 Copyright (c) PNG Publications. All rights reserved. Am JHealth Behav contemplation,preparation, ing precontemplation, betweenseveralstages,includ orrelapse progress inwhichindividuals change isadynamicprocess 87-89 forchange. (TTM) stagesofmotivational readiness Model to a diversity of Transtheoretical geared in collegestudents. intensityphysicalactivity moderate tovigorous regulation self-efficacy Barrier studies. Inter previous of net andtextmessaging-basedbehavioralchange findings on based constructs and goalchecking physical activity (cue toaction), self-monitoring opportunitiesfor cial support,environmental so outcome expectancy,motivationalregulation, constructs: barrier self-efficacy, goal-setting skills, acters inlength. Theory-driven textmessagesofupto160char activity promotion. interventions, ofSMS-basedbehaviorchange review ic literature Text MessageDevelopment We developedthetextmessagesafterasystemat checking Self-monitoring andgoal activity (cuetoaction) opportunities for physical Surrounding environmental Social support Motivational regulation Outcome expectancy Goal settingskills Barrier self-efficacy Theoretical construct TheTTM 84,85 were the 2 strongest predictors for predictors the 2strongest were 52 26 focusingonthoseaboutphysical proposes that exercise behavior thatexercise proposes 80,81 .™ 27,32 70 Examples of 86

All reflected the 7 theoretical theoretical 7 the reflected All 2015;39(3):395-408 We SocialCognitive created The text messages also were Thetextmessagesalsowere (Table 1). We (Table weightedthe 82,83 Don’t forget tologinyourstepsorphysicalactivityonline. started great,howmanystepshaveyoubeenabletogetsofar? in yoursteporphysicalactivityonline. a. Monday-Friday! Boot CampatRecreationCenterRoom104from5-5:50pm, There isstilltimetoregister!! a. you arealmostthere! help keepyoumotivatedtoreachyourgoal! a. your bodyisalsorequired. look good. you going. a. great. Don’t loseit:exercise. keep yourhearthealthy! a. throughout thedayinstead! If youdon’t havetime,trywalkingalittlebitmultipletimes a. day: Ifyouhaveadeskjob,standupandwalkeveryhour. Recreation Center? a chanceyoucanstillgetyourworkoutinattheKlotsche closer toyour10,000steps! a. Example ofSMScontent Howareyour10,000stepscomingalong?Don’t forget tolog Saturday April 6istheUN World Water Day5KRun/Walk. Familymembersorfriendsareagreatsourceofsupportto Goingforawalkisgreatstressreliever! You don’t havetogetall10,000stepsatonce! Motivationiswhatgetsyoustarted.Habitkeeps Skiptheelevatorandtakestairstoday, itwillgetyou Theoretical ConstructandNumber andmotivational Short MessageService

b. c. Exercise-Somemotivationrequired.Oh,

Don’t lookgoodtoexercise.Exercise c. Table 1 Tips onhowtoreach10,000stepsa - - - - - c. You areinshape, andyou’relooking DOI: http://dx.doi.org/10.5993/AJHB.39.3.12 participation inanotherphysicalactivity current and speakEnglish.Exclusion criteriaincluded experience with text messaging; (5) ability to read with text messaging capability; (4) comfort and ownsandusesapersonalmobile device currently (3) years; 18 ≥ age (2) student; college full-time a classes. ment flyers also were distributed to students in the sample. Recruit aheterogeneous hoping torecruit a wide range of classes (eg, art, science, health), large classes(>35students)targeted. We included were identified on the basis of size, with medium or minutes) aboutthestudy.Undergraduate classes 5 (around tants tomakein-classpresentations assis toallow trained research their approval contacted class instructors and obtained staff protocol, recruitment classroom standard an media social nouncements (eg, Facebook, Twitter). F and flyers, courses, college in Recruitment andSample action, andmaintenance. b. b. Inclusion criteria were: (1) currently enrolled as enrolled currently (1) were: criteria Inclusion We participants using announcements recruited Chanceofrain?Isthere It’s timetojointheFREE b. (SMS)Contentby Hopeyourdayhas b. b. Don’t giveup, Getsteppingto b.

representing construct (Total SMS=100) Number ofSMS 25 10 30 15 10 5 5 ollowing a Yan etal 90 study 397 - - - Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05

398 data for the graphically fo displayed as aggregate toeachofthe100textmessageswere but reactions with the group, notshared Demographic datawere Point) collates them. (Turning software response the audience sent toahostcomputerwherein are keyontheirclickerkeypad.Answers appropriate oropinionbypushingthe ing their circumstances reflect answer an select individually Participants with a questionthat has several possible answers. slide Ohio). ARS works by generatingaprojected LLC.,Youngstown, Technologies, 5.2, Turning Point opinions aboutthetextmessages(Turning their to register es todemographicquestionsand 1), to convey their as respons a “clicker” (Figure to deviceoftenreferred control hand-held remote System (ARS).Participantsused ARS,a Response accomplished with the assistanceof an Audience discussion onthe100textmessages. SMS interventiondiscussion;and(3)voting completion ofademographicsurvey;(2)general (1) parts: 3 Copyrighthad group focus Each used. was guide discussion group A standardized room. ference 90 to 120 minutes in a small con approximately lasted focus group comments onanotepad.Each (c)sistant). Two co-facilitators summarized individual PNG as moderators (onemaleandonefemaleresearch 2013 by 2 trained pants each) conducted in March Publications.of Data Collection All recruited. ticipants were rights A total of 33 par focus groups. was collected from continueduntil no newinformation recruitment methodology, qualitativeresearch with standard reserved. study. Consistent or research program promotion inCollegeStudents MessagingforPhysicalActivityPromotion mHealth Text The first and third parts of the focus group were were group focus the of parts third and first The The 33collegestudentsparticipated in a total 5 audio-recorded focus groups (6to8partici focusgroups 5 audio-recorded

Data CollectionEquipment:AudienceResponseSystems(Clicker) Figure 1 91 ------

moderate or vigorous physicalactivity after class moderate orvigorous aration stage) or (4) physicalactivity participation” again regular stage); (3) “I have madeadecisionto start/to start physicalactivity” (contemplation gage inregular thinking aboutit, but havenot yet decided to en stage);(2)“Iam participation” (precontemplation physicalactivity intention ofengaginginregular no have “I (1) change: to readiness their described participants toselectoneof4statementsthatbest behaviorchange cal Modelofexercise The secondquestion,basedontheTranstheoreti week)?” Possible were: (1) responses Yes; or (2) No. (3daysper exercise minutes ofvigorous-intensity moder (5 days perweek) or 20–60 ate-intensity exercise of minutes 30–60 do you “Do asking: by can College of Sports Medicine recommendations intensityandduration,following Ameri frequency, activity individuals’ determined question first The questions about their personal physical activities. 2 ity, as well as SMSusage.Then,theyanswered collegestanding, sex, race/ethnic about current questions Theyanswered withthegroup. shared not were survey usingtheirclickers.Theresults participants completeda2-minuteanonymous compensatedwitha$15gift card. were collected. Participants any data were pant before eachpartici consentwasobtainedfrom informed participants’ privacy.Writtenity, andprotected confidential ensured context, discussion group a within findings on effects contagion the mitigated clicker facilitated anonymous voting data, which ended.Inthisstudy,the sis afterthefocusgroup for further to generate data reports searcher the incomingdatainadatabase,allowingre to discuss. The host stored cus group Demographic survey “I have already engaged in “I have already .

At the focus group’s start, At thefocusgroup’s 93-95

asked (prep analy 92 ------

Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05 Copyright (c) PNG Publications. All rights reserved. would beoptimal. ofinterventiontextmessages day andfrequency back aboutlogged-in steps), and what times of the monitoring via stepcountsandSMSfeed ercise ex and motivational messages, real-time prompts a physicalactivity intervention (eg,SMSreminder mightbeusedin different physicalactivity, how intervention forpromoting ability of anSMSinterventionversusaface-to-face in a engaged completing the (actionstage). timeregularly” or inmyleisure Am JHealth Behav at least 3 of the 5fo across themes thatoccurred included matrices final identified, were themes all organized intomatrices. themes thatwere collapsedinto meetings duringwhichcodes were scheduledconsensus teamheldregularly research the viewed the coding. During the codingprocess, while thestudyprincipalinvestigatorre software, pendently usingAtlas.ti 7 assistants codedthetranscriptsinde ate research ing constantcomparison. andco-facilitator involv notes. The analysis was an iterative process input moderator with verified transcribed and were audio recordings cus group Krueger andCasey, on the“framework analysis” method describedby behaviorchange. exercise for physical activity levels, and readiness reported SMS usage,self- sample demographics,cellphone generated for General descriptivestatistics were for Windows,Chicago, Ill.). version20;SPSS, the Statistical PackageforSocialSciences(SPSS Data Analyses important and discussed themes thatemerged. identified briefly team ies stud The selection of 80% was based onprevious what madeitfavorable. about elicit perceptions it asis,”then,thetextmessagewasdiscussedto at least80%oftheparticipantsvoted“Yes, Ilike it. If thetextmessage or whethertodiscard prove abouthow toim discussed toelicit perceptions it tomakebetter,”change thetextmessagewas let’s “No, voted participants the of 40% than more methods, research Based onprevious result. displayedthegroup software the TurningPoint their answers aboutanyparticular text message, with their clickers.Afterallparticipantskeyedin like it as is” or “No, let’s change it to make it better” tothetextmessagebyvoting“Yes,ate reactions I asked to give their immedi slide. Participants were team was displayed one at a time as a PowerPoint the 100textmessagesdevelopedbyresearch of thetextmessages.Each discussion regarding sages General discussion of SMS intervention Qualitative data analysis procedures were based were Qualitative data analysis procedures conducted using All quantitative analyses were conclusion, theresearch Lastly, at eachgroup’s on the100textmes Voting anddiscussion 96,97 . aswell. Then, participantsstartedthevotingand general discussionabouttheaccept demographic .™

98,99 2015;39(3):395-408 andothers. 102-104 101 Three trainedgradu Three survey,participants qualitativeanalysis 91,100,101 76,77 Thefo . Once A 35 fter

if ------participants owned a cell phone and97% used text messagingwasnearlyuniversal.All casian. Text Cau women,andalmost 70%were ticipants were ofthepar percent niors combined.Seventy-three juniors or se and 3% were sophomores, 12% were college freshmen; cent of the 33participants were for change. status, andreadiness acteristics, text message usage,physical activity 2. Resultsincludeparticipants’demographicchar Participant Characteristics RESULTS (100%) amongthe3coders. in overall agreement Further discussionresulted disagreements. plus number of agreements of agreements/total number ing phaseswasassessedwith theformula Consistency amongthe3codersduringcod summarystatementstodescribetheresults. wrote team matrices ofcollapsedthemes,theresearch final the on Based results. the for retained was it seemed of practical significance to study objectives, and in2groups, If a themeappeared cus groups. DOI: http://dx.doi.org/10.5993/AJHB.39.3.12 as a text message or visualized on the smartphone. or minutesofactivity per day,and eithersentout as steps per day mance datashouldbeformatted “ cool andconvenient. noted: participant One steps. logging enjoying cise self-monitoringtools. Theyreported using SMSwould function as virtual exer ercise activity, and loggingdailystepsorminutesofex physical thatencouraged SMSprompts receiving physical activity ical activity. would sendthemtextmessagesencouragingphys thusiastic aboutanSMS-basedinterventionthat en uniformly for changestage,participantswere of their physical activity level or gardless readiness Interventions PromotingPhysicalActivity General FeedbackaboutDesigningSMS ular physicalactivity). thattheyengaged inreg individuals self-reported in the actionstage(these stage, and 54.6%were in thepreparation contemplation stage,26%were inthe stage, 18.4% were in theprecontemplation I dard. week]). The other45.4%didnotmeetthestan [3daysper exercise minutes ofvigorous-intensity [5 days perweek] or 20–60 ate-intensity exercise physicalactivity(30–60minutes ofmoder regular for thattheymetthestandard ity, 54.6% reported per month. messages each day, which equaled1500or more than50texts more sendingorreceiving reported one-fourth of the text messaging users (27.2%) than 10 textmessagesonanaverageday.More oneto thattheysentor received pants reported (30.3%) of the partici messaging. Almost one-third Anonymous survey results are shown in Table showninTable are survey results Anonymous Ways touseSMScapabilitiesinpromoting Acceptability ofSMS-basedinterventions n terms of readiness forchange,1%was ofreadiness n terms When askedaboutdaily physical activ 101 Inter-rater reliability was 85%. reliability Inter-rater . Most participants believed that ” They also agreed that perfor ” They also agreed 105

Eighty-five per Eighty-five It isvery Yan etal . 399 Re ------Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05 400 inCollegeStudents MessagingforPhysicalActivityPromotion mHealth Text

to receive unlimited text messages eachmonth at to receive to unlimitedSMSservices thatwouldallow them participants subscribed SMS.All focus group from Participants alsowantedthe optiontounsubscribe with participants’ daily schedules. not interfere theSMS,and messageswould reading from that SMS between 9 am and 9 wanted pm to so receive Instead, participants the dayearlier for exercise.” SMS at 6 am would persuade students“to start search team expected. We thought sending the first whatthere from times differed Their preferred morning,” es at inconvenient times, such as text messag nottoreceive preferred unanimously withoutbeingpaternalistic. and positiveinnature short, subtle, to them asfeedbackSMSthatwere should be plotted against daily goals, and provided that activityperformance wasconsensus There Copyright (c) PNG Publications. All rights reserved. SMS TimingandFrequency “early birds” or Already doingregularPA (action) MadeadecisiontostartregularPA (preparation) Thinking aboutdoingregular PA (contemplation) NointentionofdoingregularPA (precontemplation) Stage ofreadiness for physicalactivitychange(PA) No Yes Engagement inregular physicalactivity(PA) Morethan100 50to100 21to50 11 to20 1to10 None Daily textmessagessentor received Other Asian/Pacific Islander Black/African American White/Caucasian Race/ethnicity Juniororsenior Sophomore Freshman College standing Women Demographics, textmessageusage,andphysicalactivity “too lateatnight” and Characteristics ofFocusGroupParticipants(N=33) “night owls” or “too early in the “on weekends.” . ol benefit could Participants Table 2 - -

references. localresource ties. They alsowantedustoprovide ioral change, andsocial support needs andcapaci for behav upon individuals’sex, stage of readiness That is,studentswanted us totailor content based personalized. if they were would bemosteffective tent 2. theme hadsub-themesasillustratedinFigure tive messagesandachievablegoals alizing text message content messages: text 100 the about discussions Message Content Focus GroupDiscussionThemesaboutText than2eachday. more no withinundated texts.Theywantedtoreceive no extra charge. However, they did not want to be Tailoring for sex Theme 1: Personalizing textmessagecon focusgroup Two majorthemesemerged from . Overall, studentsbelieved that messages . We observedsexdifferences Percentage (%) 21.2 30.3 21.2 69.7 12.1 84.8 72.7 54.6 18.4 45.4 54.6 24.2 18.2 3.0 6.1 3.1 26 and 3 1 3 emphasizing posi . Each major person - - - - - Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05 Copyright (c) PNG Publications. All rights reserved. Am JHealth Behav of kind this find not did activity physical regular to the test in competition.” Those who did not do be afterallofthistraining youcanputyourskills goals. An example of this type of message is: “May lighted training, competition and achieving higher messages that high lar physical activity preferred in regu engaged stages. Theparticipantsalready orcontemplation participants inprecontemplation with about particulartextmessagescompared dealintheirattitudes agreat ticipants differed for behavioral change. Action stage par readiness tovaryingstagesof SMSrelated pants perceived inhowpartici Similarly, we observeddifferences femaleparticipants. the end!”wonlessfavorfrom at will in alotofstepsandhelpyouwinthereward race orparticularsport?Thatisagoodwaytoget fora engagement.” Thetextmessage“Training corporated elements of “competition” and “sports parts, women did not enjoy text messages that in Unliketheir malecounter in SMSperceptions. Specifying by stage of readiness for change. ing.” [womanparticipant] “It does notmakesensetome, I don’tlike rac

.™

2015;39(3):395-408 Themes aboutTextMessageContent Figure 2 ------

DOI: http://dx.doi.org/10.5993/AJHB.39.3.12 tivity with a friendorfamily member madeit easier that physicalac them. Someparticipants thought yourgoal” appealed to keep youmotivated to reach of support to help source a great or friends, are the message“Family members, friends. Therefore, had emotional attachments to their families and socialsupportexplainedthatthey who favored lives, while others believed the opposite. Those that social support played a significantrole in their polarized.Someparticipantsbelieved support were to text messages pertaining to social responses work inthesamewayforeveryone.Participants’ capacities. lustrated inthesequotes: ofopinionis il message attractive. The difference Differentiating social supportneedsand do something.” “I like it a lot. I like something that tells me to go “You doexerciseforfun.Nottobetrained.” a competition.” “The training doesn’t necessarily have to lead to Social support for exercise does not Social support for exercise Yan etal

401 - - Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05

402 – Bo Jackson.” Par and don’tstop till you get there either.vored One examplewas “Set yourgoal high, notfa were orsarcastic aggressive tones thatwere abrasive. SMS sometimes thesemessages sounded asrhetoricalwas structured questions,because overly positivetones. or participants was to avoid pushy,sarcastic, from The overall recommendation favored. were Achievable Goals. Theme 2.EmphasizingPositiveMessagesand message was well-received Another self-efficacy. barrier crease message designedtoin was apositivelyreceived place to get in your 10,000steps!” plex) is a great down; the Klotsche Center (university athletic com ties. For example, “Don’t let bad weather get you Copyrightcouragement toparticipate in local physical activi barriers, and en tips to conquer environmental specific environment, activity physical local the to (c) vicinity. Participants likedthemessagesrelated PNGor activities within the university’s geographical resources local certain identified specifically that Publications. text messages generated were demographic, there of the to include more genericin order sages were this intervention. Although manyof the text mes All rights reserved. themessageactuallymadehersad. in thearea, that because shedid not have family and friends motivated them less. One participant indicated ferent exercise routinesorhabits,” have family nearby” plicable. Participants mentionedthatthey lessap yourgoal!” were you motivatedtoreach of support tohelpkeep source agreat friends are support messages,suchas“Familymembersor ested in their (and my) exercise goals.” ticipants explained that pants didnotlikethistypeofmessage.Somepar with afriendbecauseitmakeseasier.” personalexperienceof of aprevious her step goal!”reminded your10,000 way toreach 5K run/walkwithafriend.Thatisaneasyandfun fora registering mentioned thatthemessage“Try enjoyable. For example, one participant and more inCollegeStudents MessagingforPhysicalActivityPromotion mHealth Text Balancing positivity. fitness and equipment classes --FREEtoallstudentswithanID.” workout pool, a have “Take advantage of the Klotsche Center. They Including localcontext. goals.” much myfriendswouldbeinterested in my probably the only motivation. I don’t know how “I think that probably for exercising, you are classmates.” friends. Then,youhavepeoplewhoarejust I don’t know. You havethosewhoarebest “(When it comes) to family members or friends. On theotherhand,almost half ofthepartici or that their

They didnotlikeSMSthat “my friendsarenotinter Encouragingmessages Localcontextiskeyto so this message “friends had dif Thus, social “registering

“did not ------ticipants preferred goal-orientedmessages,aslong ticipants preferred recommendation. have aspecific sounding. Inaddition,thistextmessagedidnot condescending,orharsh cized asbeingsarcastic, was criti don’t youtry and work on yourform?” messages. Most participantsdislikedforceful high, butthatwouldmakethemlessachievable. sive. Oneparticipantsaidthatthegoalscouldbe thistextmessageastooaggres ticipants perceived quences. Specifically, participants emphasized participants that mentioning the Specifically, quences. unintendedconse “smells,” and “pain”triggered ratings.Wordsdisapproval like“cold,” “sweating,” the negativeaspectsofphysical activity had high Messages thatconveyed not toexercise. reasons flected the “negative effects” of exercise or potential thatre pants suggestedtheavoidanceofwords achievable. it wasnot asthough a day!”becauseitsounded thing yousetyourmindto;evenwalk10,000steps hand, participants did not like “You candoany the inside of your very own home!” On the other the openoutdoorsinyourlocal neighborhood, or “You allyouneedis don’tneedagymtoexercise, message was still get in10,000steps.Afavored go onashort run or walk home, so that they could college studentsto wanted amessageencouraging many stepsyoucantrack today!” One participant Let’sseehow stepsthanyoudidyesterday. more “Push yourselftowalkafew is whatwesay.”and 30 minutesofyourtimeeveryday?Alittle exercise activity level. Well-received SMS included“What is physical able aims, noting everyone hasadifferent unreason than rather goals, specific and tailored individually not meeting their goals. They preferred cated thattheywouldbefrustrated, if they were and achievable.Someindi realistic as theywere Setting realistic and achievablegoals But maybeyoudon’twanttoworkforthat.” in yourschool,family?Maybeyouare. “You’re so committed to what? Like in your life, so committed, why The message“Since you are you toward...‘Don’tstop.’No.” So, whysomeoneelse would tell you to push “I agreewith that. Andalsothe‘I.’ It’s your goal. goal.” “I think youshouldset your dream byit. Not Avoiding emphasis onthenegative Avoiding then maybeyoucanachievemore....” can doasmallthing,you10,000steps... “I have asuggestion...maybe if you say‘If you change itabit.” times Ican’tdoanything... so maybeyoucan “I don’t like the word‘anything’ because some “unpleasant sideeffectof ex . Partici . Par ------Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05 Copyright (c) PNG Publications. All rights reserved. Am JHealth Behav Discussion physical activity SMSmessagesthatcontainedunpleasant removed activity goalintosmall,achievable tasks.Lastly,we vided tips.We downthetotal dailyphysical broke Fourth,wechangedthemessagestopro direct. “numbers.” SMS contained no more than 2 specific search team simplified the structure. Therefore, one physical activitybehaviorchange.Second, the re andthestagesof for sex differences more lored tai messagessothattheywere First, werewrote in the following ways. revised sages. Messages were out ofthe100originalSMSmes removed were Message Modification toavoiddiscomfort. inorder exercising from workingout.It actually discouraged people from herofphysical pain participant saidit reminded rating. One comes gain” had a higher disapproval pain, but with pain bypeoplein great surrounded yourfortune. It says that you will soon be read physical activity. For example, the message“I just ercise” We par of using aformative describetheprocess 6 recommendations, Based onthefocusgroup en toacertainlevelitcanbefunny...” gain...I certainly don’t likeit, but it’s okay. Tak “I don’t like the wayit says with pain comes but withpaincomesgain. soon besurrounded bypeople ingreat pain, I justread your fortune.Itsaysthatyouwill question your commitment toexercising. men’s locker room butatleastIdon’thaveto Sure, exercise maymakeyousmelllikea even walk10,000stepsaday! You candoanythingyousetyour mindto; and workonyour form. Since youare socommitted,whydon’tyoutry run. could justgetitdonewithgoingfor a4-5mile 10,000 stepstoday? That’s alot,right?Or you you winthereward attheend! a goodwaytogetinlotofstepsandwillhelp Training for araceor particular sport? That is disapproval score Original textmessagesthatreceived high would cause them not to want to initiate Third, we made messages positive and wemademessagespositiveand Third, “side effects.” .™

2015;39(3):395-408 (Table 3) (Table Examples ofSMSModifications “actions” contained unpleasantphysi Removal ofmessagesthat tasks. goal intosmall,achievable daily physicalactivity Breaking downthetotal positive. sages, makingthemmore Removal ofnegativemes Simplified structure. Gender andstagetailoring. the SMS SMS contentor tailored How wemodifiedthe cal activity“sideeffects.” contained unpleasantphysi Removal ofmessagesthat cal activity“sideeffects.” or or - Table 3 - - - - - DOI: http://dx.doi.org/10.5993/AJHB.39.3.12 ing onanindividual’ssocial support needsand andhelpful. deemed appropriate which SMSwas behavioral changecould affect of someSMS, opinions aboutthe utility students haddiffering physical activitygoals. in motivating them toachievetheir and effective message-based interventionwouldbeacceptable physical activity (55%) or not(45%), believed a text dents inthesample,whetherengagedregular College stu feedback to the researchers. provide voteabouteachtextmessageand group gregated opportunitytodiscusstheag time, itprovided members’opinions; moreover,group at the same focus other of influence the without and vidually, their opinions indi allowed participants to register ty, and content. The audienceparticipation system ofacceptability, feasibili physical activityinterms text messages promoting dents’ attitudes toward collegestu ence participationsystem,weexplored gies. designandinteractive health technolo promotion health essential to advancing user-centered proves Yet, literature. mHealth research thisknowledge in provided rarely is refinement and development to physicalactivity intervention of detail related amongcollege students.Thislevel tion program phone text messages for a physical activity promo todevelopand evaluatemobile ticipatory approach Findings revealed thatmaleandfemalecollege Findings revealed by theuseofanaudi enhanced In focusgroups 106

- - - 107 and one’s stage of readiness for andone’sstageofreadiness SMS removed little exerciseiswhatwesay. minutes ofyourtimeeveryday? A with thefollowingSMS: What is30 Removed originalSMSandreplaced your goal. up, everystepwillgetyoucloserto with thefollowingSMS:Don’t give Removed originalSMSandreplaced moderate run. lot, right? You couldgetitdonewitha Revised to:10,000stepssoundlikea stages. physical activitypreparationoraction Send thisSMStomaleparticipantsin example ofSMSremoved Example oftherevised SMSor SMS removed 108,109 Depend Yan etal 403 ------Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05

404 hypoth which isconsistentwith the theory-based positive (gain frames) rather thanthenegative, messagesemphasizing the participants preferred people. ships withmore partner similar mindsets, andenablesusto form instantaccesstopeopleof everyday lives,provides tivity because it touches countless aspects of our populationphysicalac potentialtoincrease great activity opportunities. forpeoplewhoengageinvariousphysical erence ref and alocalsearch network toolcouldprovide grammable. pro applicationsbecausetheyare context-aware forbuilding platform a particularlyappropriate of personalization. are the relevance indicates connection tophysicalactivity resources local a have to SMS prefer users that finding Our activity. physical students’ college influences port whichsocialsup and themechanismsthrough range of social support sources, amine a broader should ex mHealth research and friends. Future Copyright physicalactivity than do family port forregular social sup more etc.) may provide support groups, worked publics”(eg,Facebook,Twitter, online (c) we the explore world of emerging new media. “Net PNG campusactivities or organizations, nordid from thepotentialsocial supportderived not explore Publications. (ie, families andfriends). Wesupport sources did social to ourinitially limited constructregarding social supporttextmessagesmaybeattributed physicalactivity. gaged inregular All en among those already prevention and relapse rightsactivity ininactivepeople,aswell as maintenance physical boththeadoptionof regular it addresses reserved.quently guided physical activity interventions, as Model has fre TheTranstheoretical the literature. opinions aboutSMScontentisalsoconsistentwith sports facilities. men dominatedneighborhoodplained thatyoung sports;andthey ex in competitive, unstructured go tooutdoorfacilities to joinotheryoungwomen this as well. Female high schoolstudentsdid not among adolescentgirls. A qualitative study noted negatively perceived text message strategies were In anotherstudy,competition-basedmobilephone gagement,” incontrasttotheir male counterparts. es thathighlighted“competition” and “sports en textmessag who participatedinthisstudyrejected ticular individual. guide theselectionoftext messages for any par andlocalcontextshould support circumstances, forbehaviorchange,social sex, stageofreadiness loring tai message for need the highlight findings These helpful. physical activity in SMS wasconsidered ity. Specifying localvenuesandopportunitiesfor physicalactiv and friendsmayfailtopromote family from that assumespositivereinforcement to whomheorshelooksforsocial support, SMS inCollegeStudents MessagingforPhysicalActivityPromotion mHealth Text Another important finding of this study was that We suspectthatambivalentbeliefs regarding female students Consistent with theliterature, 110 and suggestthat baseline assessment of 114 Indeed,asmartphone-basedsocial 111 That stage of readiness affected affected Thatstageofreadiness 115 116 Mobiletechnologyhas

112,113

------Based on goal-setting research, pinpointinganul Based ongoal-settingresearch, fundamental to the SMS we developed. ules were and integratingthemintodailyweeklysched interventions. mHealth asseeninrecent cal activitypromotion, back messages. SMS using a gain frame optimize physical activity belief, consistent withmessage-framingtheory, that supported findings Our activity. physical ate would cause them not to want to of initi exercise” empha sized that mentioning the “unpleasant side effect participants Specifically, consequences. and “pain”hadthepotential to trigger unintended “cold,”“sweating,” “smells,” our studythewords activity benefits (eg, “Let’s Move!”). For example, in gain-framedmessagesemphasize abetes), whereas the risk of lack obesity of anddi activity increases messages emphasizethecostsofbeinginactive(eg, ture. behavioral and social-cognitive litera ed incurrent sive thanloss-ormixed-framemessagessupport persua more esis that gain-framed messages are provides definitive guidelines for optimal SMS optimal for guidelines definitive provides is notknown. ty toalarger, diversebodyofcollegestudents more acceptabili sions and paper and pencil journaling, discus onone-to-oneorgroup tervention relying traditional in intervention overamore promotion SMS physical activity mobile technology-delivered a thissamplefavored daily lives.Finally, whereas their own mobile phones duringthe course of their SMSon ticipants’ experiencesactuallyreceiving ofPowerPointslides. Weform par didnotexplore wesimulatedSMSinthe college students.Third, mHealth studies among insight for future provide if collected, would social media). This information, flyers, courses, (college strategy recruitment tive mation to draw conclusions aboutthemost effec infor sufficient collect not did we Second, sults. the generalizability of our re limitations narrow in physicalactivity may haveself-selected. These of whitewomen.Volunteers interested whowere comprised involving asmallsamplepredominately research lowing limitations. First, this is formative physicalactivity. forincreasing promise and mobile phone-based SMSfeedbackholdsgreat physicalactivity self-monitoring erometer-based distance feedback For example,theFitbit provides ous activity makingactivity are intomini-, being transformed phones and mobile by(tri-axial) accelerometers, replaced as pedometersbeing nological developments,such into practical and manageablesteps. and skills organizing physicalactivityinformation for important are mini-goals achievable and cific, itdown intosmall,spe timate goalandbreaking Goal setting, Although we cannot conclude that thisstudy conclude we cannot Although fol the with interpreted be should findings Our 120-122 110 Inthephysicalactivitydomain,loss-framed , andcalories. are recognized asprinciplesforphysi recognized are monitors are commercially commercially monitorsare 123,124 118 self-monitoring, Setting realistic goals foraction Settingrealistic

self-monitoring easier. Numer 126 Thecombinationofaccel 119 118 andfeed available. New tech New on steps, 125 117 58 ------

Delivered by Ingenta to IP: 192.168.39.210 on: Thu, 30 Sep 2021 19:11:05 Copyright (c) PNG Publications. All rights reserved. how intervention delivery and communication are how interventiondeliveryandcommunicationare applied and ing how health behavior theories are equately. Suchmetrics can behelpfulindetermin in placetoanalyzemobilehealthinterventionsad testing. Well-planned evaluationmetrics need tobe developmentandpre careful and tonerequires content, of target population, timing, frequency, SMS-basedinterventionsinterms highly relevant of ofSMS.Thecreation inperceptions ferences toinvestigatesexdif volved inmHealthprojects of maleandfemalecollegestudentsshouldbein opment of mHealth interventions. Equal numbers somethoughtsonthedevel content, weventure Am JHealth Behav 5. 4. 3. 2. 1. References study. Conflict ofInterestStatement kee. attheUniversityofWisconsin-Milwauview Board Human SubjectsStatement innovations. ers studyingthispopulationtodevelopmHealth research at minimalcost,itisincumbentupon largetechnology isnumbersof able people to reach mobile students embracemobiletechnology,and ies to scale. tions than theothergroups; on eHealth interven preference may havedifferent physical activityand for obesityandlackofregular vantaged communitieswhomaybeathigherrisk disad (3) includes individuals from environments); obtainedinparticipants’natural time are in real sampling ofparticipants’behaviorsandopinions mentary assessment (EMA) rather than simulated methods (eg, ecological mo assessment gates userexperiencewithreal-time Messenger,(SMS, Facebook, Twitter); (2) investi etc)andvarious channels clips, voice,picture, usingvariousmodalities (text, video be delivered messagescan how physicalactivity-promoting ripe forinnovation. atic decision-makingovertime, can beusedfor modeling, simulation and system technologies. byusingmobile operationalized andstrengthened The authors declare no conflict of interest of this by the Institutional Re The studywas approved examines (1) that: research future for call We American CollegeHealthAssociation. AmericanCollege Centers for Disease Control and Prevention. National col Youth andPrevention. Centers forDiseaseControl risk MA,CurranKM.Changes in Caspersen CJ, Pereira physi in Decline SY,al. Kimm NW,et Glynn AM, Kriska MMWR MorbMortalWklyRep lege healthriskbehaviorsurvey —United States, 1995. tal WklyRep behavior surveillance - United States. 2000;32(9):1601–1609. age. sex and cross-sectional intheUnitedStates,by physical activity patterns cence. cal activityinblackgirls and whitegirls during adoles N EnglJMed 130 127,128 . 2005;55(SS–5):23–26. Because the vast majority of college .™ Certain mobile phone features Certain mobile phone features

. 2002;347(10):709–715. 2015;39(3):395-408 . 1997;46(SS–6):21–23. 77 129

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