Development and Pilot Testing of Text Messages to Reduce Sugar-Sweetened Beverage Intake in Rural Caregivers and Adolescents: A Mixed-Methods Study (Preprint)
Authors: Yuhas Maryam , Porter Kathleen Joyce , Brock Donna-Jean , Loyd Annie , McCormick Brittany Alexandra , Zoellner Jamie Marie 
Published: May 2019

BACKGROUND

High consumption of sugar-sweetened beverages (SSB) poses significant health concerns, particularly for rural adults and adolescents. Developing innovative strategies that target caregivers as the agents of change could be a promising way to improve both caregiver and adolescent health. Sending text messages through mobile phones has been cited as an effective way to improve behavioral outcomes, although little research has been conducted in rural areas, particularly focusing on SSB intake.

OBJECTIVE

Targeting rural caregivers, the objectives of this two phase study were to: 1) understand caregivers’ perceptions and language preferences for SSB-related text messages to inform and refine message development and delivery, and 2) evaluate the acceptability of text messages for SSB behavior change, and examine short-term effects on SSB behaviors.

METHODS

A convergent mixed-methods design was used to systematically develop and pilot test text messages with caregivers in Southwest Virginia. In phase one, five focus groups that included a card-sorting activity were conducted to explore advantages/disadvantages, language preferences (i.e., tone of voice, audience, phrase preferences), and perceived use of text messages. In phase two, caregivers participated in a 5-week text message pilot trial that included weekly educational and personalized strategy messages and SSB assessments at baseline and follow-up. Before the focus groups and after completing the pilot trial, caregivers also completed a pre-post survey that assessed SSB intake, SSB home availability, and caregiver SSB-related practices. Caregivers also completed individual follow-up telephone interviews following the pilot trial.

RESULTS

In phase one, caregivers (n=33) reported that text messages were convenient, accessible, and easy to read. Additionally, caregivers preferred messages with empathetic and authoritative tones of voice that provided useful strategies and stayed away from using absolute words (e.g., always, never). In the phase two pilot trial (n=30), 87% of caregivers completed baseline and 77% completed follow-up assessment suggesting a high utilization rate. Other ways caregivers reported benefiting from the text messages included sharing messages with family members, friends, and coworkers (80%), making mental notes (57%), and looking back at messages as reminders (50%). Caregivers reported significant improvements in home environment, parenting practices, and rulemaking around SSB (all P <0.05). Also, the frequency of SSB intake among caregivers and adolescents significantly decreased (P <0.01).

CONCLUSIONS

Spending time in the formative phases of text message development helped to understand the unique perspectives and language preferences of the target population. This study also found that delivering an intervention through text messages has the potential to improve caregiver behaviors and reduce SSB intake in rural caregivers and adolescents. Findings from this study were used to develop a larger bank of text messages, which will be used in a future study testing the effectiveness of a text message intervention targeting SSB-related caregiver behaviors.