Development and Pilot Testing of Text Messages to Help Reduce Sugar-Sweetened Beverage Intake Among Rural Caregivers and Adolescents: Mixed Methods Study
Authors: Yuhas Maryam , Porter Kathleen J , Brock Donna-Jean P , Loyd Annie , McCormick Brittany A , Zoellner Jamie M 
Published: June 2019

Background
A high consumption of sugar-sweetened beverages (SSBs) poses significant health concerns, particularly for rural adults and adolescents. A manner in which the health of both caregivers and adolescents can be improved is by developing innovative strategies that target caregivers as the agents of change. 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
By targeting rural caregivers, this 2-phase study aimed 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 intake behavior change and examine short-term effects on SSB intake behavior.

Methods
A convergent mixed methods design was used to systematically develop and pilot-test text messages with caregivers in Southwest Virginia. In phase 1, 5 focus groups that included a card-sorting activity were conducted to explore advantages/disadvantages, language preferences (ie, tone of voice, audience, and phrase preferences), and perceived use of text messages. In phase 2, caregivers participated in a 5-week text message pilot trial that included weekly educational and personalized strategy messages and SSB intake 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 caregivers’ SSB-related practices. Caregivers also completed individual follow-up telephone interviews following the pilot trial.

Results
In phase 1, caregivers (N=33) reported that text messages were convenient, accessible, and easy to read. In addition, they preferred messages with empathetic and authoritative tones that provided useful strategies and stayed away from using absolute words (eg, always and never). In the phase 2 pilot trial (N=30), 87% of caregivers completed baseline and 77% completed follow-up assessment, suggesting a high utilization rate. Other ways in which caregivers reported benefiting from the text messages included sharing messages with family members and friends (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 (P=.003, P=.02, and P=.04, respectively). In addition, the frequency of SSB intake among caregivers and adolescents significantly decreased (P=.003 and P=.005, respectively).

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