Can Mobile Health Applications Facilitate Meaningful Behavior Change?: Time for Answers.

Massiveproblems requirepragmatic, scalable, andevidencebased solutions. Cardiovascular disease (CVD), the world’s leading cause of death, is the epitome of such a problem in need of such a solution.1 The World Health Organization andAmericanHeart Associationhaveboth set goals of reducing CVD mortality 25% by 2025.2,3 Achieving the requisite success in CVD prevention, however, will be challenging and will require approaches and tools that (1) have proven clinical benefit, (2) can be scaled to reach a global population, and (3) are affordable. Mobile technologies provide a potentially scalable and cost-effective platform to facilitate these needs. In 2014, there were more than 5 billion mobile phone usersworldwide, representing approximately 3 of 4 adults on earth.4Mobile phones have alreadyhad a profound influence on human connectivity, commerce, media, and finance. Althoughhealthcarehasbeensomewhatslowto incorporatemobile technology, the potential effect of digital medical tools is similarly huge.5 What is still needed, however, is evidence thatmobile technologies can indeed facilitate improvements in health. Driven by this promise, an estimated $4.3 billion has already been invested in digital health technologies, supporting thecreationofmore than 100 000 iOSandAndroidhealthrelatedapps.6,7However, appproductionhasexceeded testing andevaluation.As summarized ina recentAmericanHeartAssociation scientific statement on the use of mobile health for CVD prevention,8 very few applications have undergone rigorous study, and those that have often lacked a randomized comparator. Some of these evaluations were also conducted only in selectedpatients andspecialized settings and rarely assessed long-term patient adherence, behavior change, costs, or benefits on clinical outcomes.8 In this issue of JAMA, Chow and colleagues9 report their findings from the Tobacco, Exercise and Diet Messages (TEXT ME) study—a randomized clinical trial examining the effect of a lifestyle-focused semipersonalized support program delivered by mobile phone text messaging. The authors randomly assigned patients with coronary heart disease to receive (n = 352) or not receive (n = 358) text messages that provided advice, motivation, and information on diet, physical activity, and smoking cessation. At 6 months, there were statistically significant but modest clinical reductions in levels of low-density lipoprotein cholesterol in the intervention group compared with the control group (absolute reduction of 5 mg/dL), and more sizable improvements in secondary end points including blood pressure control (proportion with blood pressure <140/90 mm Hg, 79.2% vs 54.9%), lowering of body mass index (absolute decrease of 1.3), increased exercise frequency (regular exercise, 53.8% vs 22.5%), and reduction in smoking (nonsmoking, 74.6% vs 55.9%). The simultaneous improvement in multiple CVD risk factors could significantly amplify the downstream consequences for CVD risk. Well-conducted randomized clinical trials like TEXT ME demonstrate that mobile health interventions, even simple ones, can influence patient behaviors and improve risk profiles in the short term.These findings are consistentwithother evaluations of text messaging that have demonstrated effectiveness in promoting short-term weight loss and smoking cessation.10,11 The investigators collaboratednot onlywith cliniciansandacademiciansbut alsowithpatients todevelop the messagesused in this study. Importantly, thestudyalso tracked patient use of and satisfaction with the text messages as well as the costs of the intervention, which were estimated at less than $10 per patient. The TEXTME study provides a good initial evaluation of a mobile health intervention but also highlights future work thatneeds tobedone.First, thestudywasconductedatasingle center in Australia, andmany potential participants were excluded owing to language barriers or lack of access to a mobile phone. Thus, the study is limited in its overall generalizability and requires future evaluation in broader settings and patient populations. Second, somesecondaryoutcomes, such as physical activity, were assessed by self-report, and patientswerenotblindedto interventionstatus. Integratingwearable devices that canpassivelymonitor andobjectively quantify outcomes like physical activity couldminimize reporting bias in future studies. Third, the study did not evaluate “dose effects” (would more or less texting result in better outcomes? ). Fourth, the authors evaluated the intervention as a stand-alone strategy, when multimodality interventions are often required to maximize behavior change. For example, even though close to half of the study participants reported attending structured cardiac rehabilitation before or during the trial, it was not clear whether the intervention was more or less beneficial to those in traditional programs. As the authors suggest, mobile health interventions should be evaluated when inteRelated article page 1255 Opinion