Chandler Ray

February 28, 2015

Dietetic Intern Research Project FY15
TOPIC: Text Messages for a Worksite Wellness Walking Program
Introduction
Physical inactivity is a leading health risk factor for mortality worldwide. (1) FSNE
developed WalkWays, a worksite wellness program, designed to promote physical activity
and healthy eating. Participants are taught practical ways to increase the number of steps
they take each day so that walking becomes a daily routine. The proposed text-messaging
program, Text2BActive, is a component of WalkWays designed to motivate and remind
participants to be more physically active. The content of these text messages address
people at various stages of the decision-making process to align with the Transtheoretical
Models Stages of Change. In other words, text messages will be specifically tailored to
an individuals level of knowledge and motivation. The goal of the Text2BActive program
is to encourage healthy behaviors to improve the physical, mental and emotional well
being of workers and their families.
Research suggests that mobile technology can be a powerful tool to communicate
with and motivate individuals to engage in healthy behaviors. (1) A nine-week trial
conducted by Hurling and colleagues (3) evaluated the impact of a physical activity
program based on the Internet and mobile phone technology. Healthy adults were placed
in either a test group (n=47) with access to a physical activity text-messaging program or
a control group (n=30) without support. Text messages offered participants personalized
solutions for perceived barriers, a schedule to plan exercise sessions with weekly
reminders, and a message board to share their experiences and receive feedback from
others. The test group reported a significantly greater increase in physical activity and
intention/expectation to exercise than did the control group. (3) Specifically, those with
access to a text-messaging program increased their level of moderate physical activity by
2 hours and 18 minutes per week. (3) Similarly, Fjeldsoe and colleagues (2) examined the
effectiveness of mobile devices delivering health behavior change interventions via text
messages. Positive behavior change outcomes were observed in 13 of the 14 reviewed
studies. Intervention initiation, dialogue initiation, tailoring of the content, and
interactivity were found to be necessary key features of text message-delivered
interventions. (2) To further support these findings, Stephan and Allen (5) conducted a
systematic review to analyze user satisfaction and effectiveness of text messaging
interventions to promote weight reduction and physical activity. The most frequently
measured outcome was a decrease in weight (57%) and an increase in physical activity
(43%). Additionally, text messaging was associated with healthier eating patterns,
decreased sugar-sweetened beverage intake, and decreased screen time. (5) It is important
to note that this study was developed to specifically target cardiovascular risk factors of
physical inactivity and overweight/obesity. Regardless, findings still demonstrate the
beneficial impact text messaging can have on weight control and reduction of physical
inactivity.

The existing literature shows that text messaging can serve as a beneficial and
powerful delivery channel for health behavior interventions. (5) Text messaging
programs have shown to be effective when coupled with additional strategies to increase
physical activity in healthy adults. (1) However, there is limited research on adults
specifically in the workplace. Additionally, the use of text messaging as a method to
promote physical activity has only been studied by a small group of researchers and
literature is characterized by small sample sizes. (1) Further research in this area is vital
to enable the expansion of mobile technology to promote physical activity. Despite
limited research, Text2BActive has developed ways to integrate this type of intervention
into the lifestyles of working adults in an effort to comprehensively impact participants
behavior and promote positive lifestyle changes.
Program Description
i)

Theoretical or conceptual origins

The Transtheoretical Models Stages of Change provides the theoretical basis for the
proposed texting program. This theoretical model of behavior change has been the basis
for developing effective interventions to promote behavior change. The model identifies a
continuum of five stages of readiness involved in adopting and maintaining a new
behavior. The stages of change include: precontemplation, contemplation, preparation,
action and maintenance. The curriculum incorporates text messages tailored to an
individuals readiness to change, as well as strategies and tips to facilitate changes in
behavior. In theory, Text2BActive will serve as a simple yet effective tool to move a
person to the next stage of change. This movement through the stages of change will be
reflected through increased physical activity levels and developing a positive attitude
towards exercise.
ii)

S.M.A.R.T Goals

iii)

Within 6 months of implementing Text2BActive, >75% of text message

receivers will have increased their level of physical activity by at least
2 hour per week
After participating in Text2BActive, more than half of participants will
plan to make physical activity a daily routine by engaging in at least
30 minutes of moderate-intensity aerobic activity at least 5 days per
week
Text2BActive will effectively move the majority of participants (90%)
to the next stage of change through increased physical activity levels
and developing a positive attitude towards exercise

Core Components

Participants will have the option to sign up for the Text2BActive program, which will
be encouraged during WalkWays sessions and via email. Only current WalkWays
participants will be informed about the Text2BActive program, as non-WalkWays

members will not be eligible to participate. The intent is that participants enrolled in
Text2BActive will increase their level of physical activity by receiving daily motivational
text messages. All participants in the WalkWays program will receive a text message
briefly describing the core components of the Text2BActive program. Participants will be
asked to text back yes if they want to participate in the program or no if they do not
wish to participate in the program. Those who responded yes will then be prompted to
complete a physical activity stages of change questionnaire via email or mobile phone
(this is the alternative option if computer access is limited) to assess their level of
motivation and readiness to change physical activity behavior. Participants will be asked
to complete a similar self-report questionnaire at the end of the program to measure
whether they have made progress toward behavior change. The questionnaire will be very
brief, containing only 5 yes or no questions. The questions developed for the
questionnaire include:

Are you currently physically active? (For example, walking, bicycling,

running, swimming or any other activity of similar intensity)
Do you currently engage in regular physical activity? (Regular physical
activity must include a total of 30 minutes or more per day for at least 5 days
per week)
Have you been regularly physically active for the past 6 months?
Do you plan to be more physically active within the next 6 months?
Do you feel confident in your ability to become more physically active
through the WalkWays program?

The number of yes/no responses will be used as a scoring guide that categorizes
individuals into one of the five stages of change: precontemplation, contemplation,
preparation, action or maintenance. Generally, precontemplators are inactive and not
thinking about being active, contemplators are inactive but thinking about becoming
active, and preparers are physically active but not at the recommended levels. Participants
who are in the action stage are physically active at the recommended levels but may have
been active for less than 6 months. Those in the maintenance stage are highly motivated,
physically active at the recommended levels, and have been active for more than 6
months. After completing the initial questionnaire, participants will receive 2-3 text
messages per week for the remainder of the program. Text messages delivered will
include tailored and interactive messages important to physical activity, such as
motivation, encouragement, progress, and tips. Further, text messages will consist of a
database of messages that are sent out to participants depending on what stages of change
they are in. The messages will provide motivational tips and tools to help reinforce the
information and behaviors taught through the WalkWays worksite wellness curriculum.
Some examples of sample messages developed for Text2BActive include:

Precontemplation-- Goal: to get participants to start thinking about physical

activity
o Example: Regular physical activity can improve your health and reduce
your risk of developing several diseases like type 2 diabetes, heart disease,
and stroke.

iv)

Contemplation-- Goal: To encourage participants to start being physically active

by identifying barriers to getting started and strategies for overcoming them
o Example: Looking to add more steps in your day at work? Replace a
coffee break with a brisk 10-minute walk. Ask a friend to go with you!
o Example: Need some extra motivation to jump-start your workout this
weekend? Get yourself an exercise buddy (or even a dog who needs to be
walked)!
Preparation-- Goal: To encourage your participants to be regularly physically
active
o Example: Use your pedometer and/or activity log as a reminder to take
more daily steps! The next class will be at _(place)__ from ___(time)___.
Hope to see you there!
o Example: Leave daily reminders to exercise everywhere, such as your
walking shoes by the door!
Action-- Goal: To help your participant maintain this physical activity habit over
time
o Example: Set future goals for yourself- such as participating in a fun walk
or 5km run!
Maintenance-- Goal: To help your participant prepare for any future setbacks and
increase enjoyment of physical activity
o Example: Make exercise fun! Plan to do fun activities- such as hiking or
gardening- that you enjoy as often as possible!
Basic Implementation Requirements:

Text2BActive complements direct education and information provided in the

WalkWays FSNE wellness curriculum. Text messages are targeted to working adults in
this walking based program and are behaviorally focused. The supplies needed to create
this program include a list of the participants in Walkways, including their phone numbers
and emails (which will be kept in a locked filing cabinet), and a comprehensive program
description of the WalkWays curriculum and nutrition education materials, including a
schedule of the WalkWays classes. Additional materials needed include a computer (it can
be assumed this may not be needed necessarily if people have their own laptops), a
software program to generate the database of text messages, and a phone with which to
test trial text messages. Two or three Registered Dietitians and/or health professionals
from FSNE will be in charge of developing and reviewing all text messages before they
are sent out to participants. At least two dietetic interns will assist in program
implementation and the development of text messages. A software engineer or
programmer may be needed to assist in setting up the computer software system and help
generate the data. Procurement logistics will also need to be taken into consideration,
including market research, requirements planning, and operating materials.
Evaluation Plan
i)

Rationale for evaluation

The information FSNE is looking to obtain from participants is whether or not the
Text2BActive component of the WalkWays program is successful in impacting
participants behavior and increasing their level of physical activity. In order to obtain
this information from participants and evaluate the effectiveness of the program, a posttest survey will be administered via email 6 months after implementing the Text2BActive
program. This method of evaluation was selected because it is most consistent with the
other method of assessment and communication, as participants have already filled out a
self-report questionnaire via email (or phone) when they first signed up for the program.
The pros of a web-based survey include easy-to-collect data, minimal costs, less time,
real time access, convenience for respondents, and flexibility in design. The cons of an
online survey include absence of the interviewer, survey fraud, non-delivered email or
messages rejected, possible cooperation problems, computer access, limited sampling,
and respondent availability.
ii)

Procedures for implementing the proposed evaluation plan

The responses generated from the post-survey will be collected via a designated email
created just for the purpose of gathering survey results from the Text2BActive program.
Creating a specific email just for this purpose ensures that survey results will not get
mixed up with other emails and only data pertaining to the program will be located in the
inbox. The survey will be sent out via email 6 months after the start of the Text2BActive
program. Participants will be asked to complete the questionnaire within 1 week of
receiving it. Participants will also receive a text message 2 days prior to the end of the
week reminding them to please fill out the survey. Once the information is collected, data
will be entered into the computer software system to generate the results. This task will
be done by an FSNE professional with the help of interns. Issues related to informed
consent and confidentiality will be addressed in two ways. First, an informed consent
form will be included as an email attachment for all participants to read at their leisure.
Second, all responses will be kept completely confidential by omitting names and email
addresses from the computer software system so they will not be stored with data from
the surveys. Only the researchers will see the individual survey responses and the list of
e-mail addresses of participants will be stored electronically in a password protected
folder.
iii)

Data analysis

The data to be analyzed for reported measures will be generated using the computer
software system containing a database to store and organize the text messages received.
The statistical method used to analyze this information is a matched pairs t-test. Matched
pair t-tests are often done in situations where two measurements are taken from each
respondent. The post- survey results will be compared to the pre-survey results they
completed when they started the program. The purpose of analyzing this information
using a t-test is to determine if there is a reliable difference in a participants behaviors
and level of physical activity before and after participating in the Text2BActive program.
A software engineer or programmer would be inquired on the best quantitative data
analysis software to generate these results, such as SPSS or SAS. In order to isolate the
texting program from WalkWays impacts in this data analysis and reporting, findings from

the dual intervention group (texting+ WalkWays) will be compared with the single
intervention group (only WalkWays).
This statistical method would provide information regarding the impacts of the
program, specifically whether or not the WalkWays texting program reached its intended
program objectives and outcomes. The information analyzed would allow researchers to
determine the number of adults who enrolled in Text2BActive and the impacts of the
program, for example, the % who increased their overall level of physical activity and the
% who reported increased motivation and overall desire to workout often or every day.
This data will come directly from the self-reported responses gathered from the pre- and
post-surveys. In terms of cause and effect, the results would demonstrate whether mobilebased text messaging was a successful tool in engaging busy individuals and
complementing direct nutrition education. Specifically, these findings would determine
whether Text2BActive had a positive impact on health-behavior change by sending daily
reminders to be more physically active.
The goal or intended outcome is that within 6 months of implementing the
Text2BActive program, >75% of text message receivers will have increased their level of
physical activity by at least 2 hours per week. Level of physical activity will be recorded
by participants based off of self-report and the number of steps generated while wearing
their pedometer. Using this statistical method, trained FSNE educators will calculate their
stages of change based on self-reported responses before and after the program.
Researchers will then be able to determine whether or not participants have advanced
along the stages of change continuum while using Text2BActive based on the information
gathered from the pre-survey and the 6 month post-survey. The hope is that after
analyzing the data, FSNE will be able to say that the Text2BActive program has helped
adults make physical activity a daily routine to achieve a healthy weight and improve
their overall quality of life.
Conclusion
Text2BActive is likely to be effective because it serves as a support system for
participants already in a walking program and addresses the challenges of sustaining that
effort. The combination of participating in both programs is likely to have an even greater
impact on healthy behaviors, especially those associated with physical activity.
Text2BActive has been developed to target a specific audience: working adults enrolled in
the WalkWays program. Text messages are tailored to each individuals readiness to
change, including motivation, encouragement, progress, and tips. The theoretical basis for
this program facilitates the learners progression along the stages of change and identifies
strategies in adapting and maintaining a new behavior. The existing literature supports
that text messaging has the ability to improve exercise adherence and increase physical
activity level. (2,3,5) A study conducted by research from Kansas State University and
the U.S. Centers for Disease Control and Prevention revealed that a group of Latino
adults almost quadrupled their exercise levels after receiving daily motivational texts. (4)
Along with physical activity, exercise-focused text messaging programs have helped
participants to maintain a health weight. Hurling and colleagues (3) found that those who

used a mobile phonebased motivation and action support system lost more percent of
their body fat than those who did not.
Since the Text2BActive program uses innovative technology, limited resources are
needed for the implementation of this program. Mobile phone-based behavioral change
interventions minimize face-to-face interaction, thereby increasing cost-effectiveness
through greater accessibility. (3) Since participants are part of the WalkWays program,
they already have been provided all of the materials needed to monitor and track their
steps, including a pedometer, participant workbook, and step log book. Text messages are
developed using the knowledge and expertise of Registered Dietitians and health
professionals at FSNE. The only notable cost associated with program development
includes software purchasing and employee time.
Text2BActive is predicted to be an effective approach to promote and increase
physical activity. Advancements in mobile phone technology have made it a desirable
method for health promotion and disease prevention. (5) Our hypothesis is that
Text2BActive will serve as a beneficial tool to motivate individuals to engage in more
health behaviors by sending out weekly encouragements and reminders. If Text2BActive
was to be successfully implemented, improvements would be seen in participants
exercise behaviors and levels of physical activity, as well as overall quality of life.
Works Cited
(1) Buchholz, S.W., Wilbur, J., Ingram, D., & Fogg, L. (2013, June 7). Physical
Activity Text Messaging Interventions in Adults: A Systematic Review. U.S.
National Library of Medicine. doi: 10.1111/wvn.12002.
(2) Fjeldsoe, B.S. (2009, February). Behavior Change Interventions Delivered by
Mobile Telephone Short-Message Service. American Journal of Preventive
Medicine. doi:10.1016/j.amepre.2008.09.040
(3) Hurling, R., Michael, C., Marco, D.B., Bruce, W.F., Hurst, T., Murray, P., Alannah
R., & Jaspreet, S.S. (2014, April 27). Using Internet and Mobile Phone
Technology to Deliver an Automated Physical Activity Program: Randomized
Controlled Trial." Journal of Medical Internet Research. doi: 10.2196/jmir.9.2.e7
(4) Prevention Research Centers. Centers for Disease Control and Prevention. N.p.,
09 Dec. 2014. Web. 02 Mar. 2015.<http://www.cdc.gov/chronicdisease/resources
/publications/aag/prc.htm>.
(5) Stephens, J., & Allen, J. (2014, July 1). Mobile Phone Interventions to Increase
Physical Activity and Reduce Weight: A Systematic Review. The Journal of
Cardiovascular Nursing. U.S. National Library of Medicine. doi: 10.1097/
JCN.0b013e318250a3e7

(6) Williams, A.D. (2012). Use of a text messaging program to promote adherence to
daily physical activity guidelines: A review of the literature. Bariatric Nursing
and Surgical Patient Care, 7(1), 01.