By Gayatri Koshy, Head of mHealth
Over the past decade, emerging mobile technologies have been harnessed to help change health behaviours and to improve health outcomes for people throughout the world. This use of mobile technology in relation to health is commonly referred to as ‘mobile health’, or ‘mHealth‘.
More recently, there has been a growing appreciation for the use of mobile phone interventions to promote behaviour change, for example in stopping smoking, reducing alcohol consumption, increasing levels of physical activity, reducing calorie intake, managing chronic diseases such as cardiovascular disease, seeking antenatal care and adhering to medication. A popular mHealth intervention for health promotion is mobile messaging (or digital messaging, as it is increasingly being called).
In this article, we will examine the various ways in which mobile messaging can be used to promote healthy behaviour change, drawing upon our own experience in the field and the latest academic research.
Mobile messaging and behaviour change
Mobile messaging interventions are popular because they can deliver cost-effective, scalable, brief, real-time and tailored messages at moments when individuals need them most. They reduce time demands on the individual, on health professionals and clinicians, and public health services.
Mobile phones offer great potential to engage with otherwise disengaged populations. With the majority of people (63 per cent, according to Statista) worldwide owning a mobile phone, there is an opportunity to support hard-to-reach populations who have limited access to primary health care.
Additionally, with mobile phones increasingly becoming the dominant mode of communication among younger people throughout the world, mobile phone messaging is an extremely effective way of engaging with a generation of young adults who are otherwise switched off from traditional media.
Mobile messaging and the developing world
In addition to the high burden of infectious diseases, the leading cause of death in low-and middle-income countries (LMICs) is non-communicable diseases, accounting for about 54 per cent of all deaths (Skolnik, 2012). Self-care management and medication adherence are aspects of chronic disease management which will improve quality of life, health outcomes and cost-effective healthcare (Hamine et al, 2015). Typically, though, only 50 per cent of patients diagnosed with chronic diseases maintain chronic disease management regimes and the extent of non-compliance is even higher in developing countries (Hamine et al, 2015).
In addition to this, the rates of maternal mortality, child mortality and HIV/AIDS are disproportionately higher in the developing world. Most of these deaths are preventable with greater access to information and healthcare. We also know that more households in developing countries own a mobile phone than have access to electricity or clean water, nearly 70 per cent of the bottom fifth of the population in developing countries own a mobile phone (World Bank/IBRD 2016).
“80 per cent of women in LMIC own a mobile phone”
With around 80 per cent of women in LMIC now owning a mobile phone (GSMA, 2019), the implementation of mHealth systems in this context could provide cost-effective delivery strategies for healthcare, bolster existing services and plug the gaps in information, access and quality of healthcare.
Obstacles in implementation
Changing health behaviours through mobile messaging is not without obstacles, especially in the developing world. Some of these obstacles concern technological or infrastructural challenges such as poor access to networks and/or electricity, malfunctioning phones, or a generally unreliable ICT environment.
It is important to understand the context of the setting. There may be high illiteracy rates, confidentiality issues due to phone sharing, or constant phone number changes. The audience may have poor motivation caused by low salaries, a lack of incentives or high work pressure. Broader health system challenges may occur such as a shortage of adequately trained staff, and failure to integrate the new technology within existing systems of care (Krah and de Kriuf 2016). Much of the success of mHealth interventions, therefore, relies on an in-depth understanding of the context and the target audience.
Can mobile messaging change health behaviours?
Overall, yes. A meta-analysis by Yang and Van Stee (2019) has shown that mHealth interventions have significantly improved health outcomes in relation to physical activity, diabetes management and antiretroviral therapy adherence.
“67 per cent of reviews concluded that SMS messages contributed to healthy behaviour”
A meta-analysis by Orr and King (2015) identified 40 reviews that addressed the use of SMS messages to enhance healthy behaviour. Overall, 67 per cent of reviews concluded that SMS messages contributed to healthy behaviour, 11 per cent concluded that it did not and 22 per cent withheld judgement on grounds of insufficient evidence.
These reviews suggest that SMS messages are most effective for relatively simple behaviour modification such as attending medical appointments (100 per cent of studies reporting positive impact) and increasing medication adherence (85 per cent of studies reporting positive impact). The impact of SMS messages on more complex health-related behaviours was mixed, however, with 65 per cent of studies showing a positive impact on the adoption of healthy lifestyle choices (such as smoking cessation or healthy diet), and 50 per cent of studies showing positive impact on disease prevention activity (such as sunscreen use or immunisation).
A Mildon and Sellen (2017) study of mobile phone interventions for behaviour change communication came to a similar conclusion. It is likely that brief, standardized messaging services using SMS for written text, or interactive voice response [IVR]) will be more effective for episodic behaviours (such as attendance for ANC or immunisation). Habitual practices, such as exclusive breastfeeding, will require more intensive and multi-faceted behaviour change communication (BCC) interventions.
Message content and design
While we know that mobile phone interventions are effective in varying degrees in changing behaviours, what do we know about the actual messages in the programmes? How do we design messages for mobile phone interventions that result in behaviour change? Can we use behaviour change techniques in order to engage, motivate and enable participants to adopt and sustain behaviours? To examine this, let us look at three aspects of messaging – content, tone and language, and then message frequency and dosage.
1. Message content
Provide information about the health problem
A review of behaviour change techniques employed by health interventions found that effective behavioural interventions gave users information about the health problem, the link between behaviour and health, causes and consequences and instruction on how to perform the behaviour (Briscoe and Aboud, 2012). For example, interventions tackling malaria informed participants about the importance of keeping mosquitoes at bay and how to use bed nets appropriately (Alaii et al, 2003; Binka et al, 1996; Lindblade et al, 2004; Panter-Brick et al, 2006; Schellenberg et al, 1999). While this review focused on interventions that provided information orally and directly to the participants, we can apply the same principles for mHealth interventions where information is sent digitally.
Give advice and support, not just reminders
A mobile messaging service that provides advice and support in addition to regular reminders is more effective than one that only sends reminders.
HelloMama, a mobile messaging project in Nigeria which sent SMS and voice messages to pregnant women, new mothers and household decision makers to improve maternal, newborn, and child health behaviours, used a behaviour change strategy that included providing advice, support and reinforcement messages in addition to regular reminders.
In addition to improvements in knowledge levels, there were increases in antenatal clinic attendance, application of chlorhexidine to the newborn stump, exclusive breastfeeding for the first six months of the baby’s life and use of family planning method to space pregnancies (Pathfinder International, 2019).
Similar mobile messaging projects in South Africa (MomConnect) and India (mMitra) have resulted in more antenatal visits, more vaginal births vs c-sections, less low birthweight babies, more timely initiation of complementary food for babies (six months), more babies receiving all their recommended vaccinations, more HIV PCR testing of infants of HIV+ women within six weeks of birth and other improved maternal, newborn and child health practices (Murthy et al, 2019; Coleman et al, 2017).
“Mobile messaging interventions can deliver cost-effective, scalable, brief, real-time and tailored messages at moments when individuals need them most”
Elsewhere, a randomised controlled trial conducted in New Zealand with 1,705 smokers found that there was a higher quit rate among those receiving messages offering smoking cessation advice, support, and distraction (28 per cent) compared to those who only received messages thanking them for participating in the study and reminding them to complete follow up (13 per cent) (Rogers et al, 2005).
Empowerment boosts health outcomes
Programmes that have empowerment messages built into the programme are more effective than programmes that don’t. The meta-analysis by Yang and Van Stee (2019) found that interventions that change an individual’s personal environment by providing resources that immediately allow the user to engage in healthy behaviours are effective in improving health outcomes.
For example, an observational study conducted in 16 study clusters in Kenya found that by providing 474 village elders with weighing scales and mobile phones, the percentage of infants whose actual birth weight information was recorded increased from 43 per cent to 97 per cent. By providing the necessary tools, pregnancy case-finding and acquisition of birth weight information can be successfully shifted to the community level (Gisore et al, 2012).
Motivational messages work
Studies have shown that interventions using motivational messages have a greater chance of changing behaviour compared with those that don’t. A UK study of 5,800 smokers found that those receiving motivational and behaviour change messages had higher rates of abstinence than those receiving non-motivational messages. The results said that 11 per cent of the intervention group hadn’t smoked after six weeks, compared with four per cent of the control group (Free et al, 2011).
Studies have also shown that utilising motivational messages can encourage participants to read subsequent messages. A qualitative study was conducted in 17 government health centres in Kenya investigating the perceptions and experiences of health workers receiving text messages on paediatric outpatient malaria case-management accompanied by “motivating” quotes. The study found that proverbs in the messages encouraged participants (health workers) to read the next message (Jones et al, 2012).
Set goals for success
A review of 13 interventions promoting smoking cessation, healthy eating and/or physical activity targeted at low-income groups found that setting goals may help people to take steps to change their behaviour by making them more aware of it. Smaller, shorter-term goals also allow people to build on small successes (Michie et al, 2009).
Provide prompts and cues to act
Messages that provide prompts or cues to act can be effective in eliciting desired behaviour. The Briscoe and Aboud (2012) review of behaviour change techniques employed by health interventions also found that all the handwashing and infant feeding interventions included in the review employed the technique of identifying and providing cues to action, such as time of day or preceding activities or the child’s signals (Curtis et al, 2001; Luby et al, 2001, 2010; Monte et al, 1997; Aboud et al, 2009).
Solve problems affecting behaviour
This involves identifying the facilitators of the desired behaviour, the internal and external barriers to performing the behaviour and the solutions to overcome the barriers. A review of behaviour change techniques employed by health interventions found that handwashing and infant feeding interventions included in the review used this technique to encourage behaviour. For example, participants who said they did not have sufficient water for washing were shown how water could be reused, and care givers were helped to try different solutions to overcome children’s refusal of food and to purchase inexpensive food (Monte et al, 1997; Lynch et al, 1994; West et al, 1995; Bhandari et al, 2004; Aboud et al, 2009).
Messages that engage users keep them interested
Fjeldsoe et al. (2009) reviewed 14 studies on the effectiveness of SMS messaging in smoking cessation interventions and diabetes management interventions. In 13 of the 14 studies there were positive behaviour change outcomes. Tailoring of SMS content and interactivity were found to be important features of SMS-delivered interventions.
Messages using multiple techniques work better
The use of behaviour change techniques such goal setting, providing prompts and problem solving in health messaging are known to have some effect in encouraging behaviour change. In addition to this, Briscoe and Aboud’s (2012) review found that the most successful interventions used three or even four categories of techniques, engaging participants at the behavioural, social, sensory and cognitive levels.
2. Tone and language
Tone and language matters
A study examining messaging preferences in goal-directed SMS programmes found 75 per cent of subjects preferred certain types of messages. Key elements were grammatically correct, free of text-speak, benefit-oriented, polite, nonaggressive and directive as opposed to passive, among others. Subtle manipulations of message structure, such as changing “Try to…” to “You may want to try to…” affected message choice (Muench et al, 2014).
Personalised messages are effective
A study of 5,800 smokers found that those receiving personalised messages based on their needs had higher rates of abstinence than those receiving automated messages. For example, by texting the word “crave”, participants with cigarette cravings would receive instant messages to distract and support them during their episode of craving. By texting the word “lapse” participants would receive text messages that encouraged them to continue with attempt to quit smoking. Of the intervention group, 11 per cent hadn’t smoked after six weeks, compared with four per cent of the control group (Free et al, 2011).
Empathetic messages are better than fear-based messages
Shen et al (2011) investigated the effectiveness of fear- versus empathy-arousing anti-smoking Public Service Announcements (PSAs). Twelve PSAs were used and were based on empathy or fear. The 260 participants were randomly assigned to each message type and watched PSAs presented in a random sequence. Results showed that empathy-arousing messages are potentially more effective than fear-arousing ones.
Gain-framed messages encourage prevention behaviours
A meta-analysis of 94 peer-reviewed published studies compared the persuasive impact of gain and loss-framed messages. Gain-framed messages were more likely than loss-framed messages to encourage prevention behaviours, particularly for skin cancer prevention, smoking cessation and physical activity (Gallagher and Updegaff, 2012).
3. Message frequency and dosage
Greater frequency of messages works better
Orr and King’s (2015) meta-analysis of SMS interventions found that studies using multiple SMS messages per day had a significantly greater effect on health behaviour change than those using a lower message frequency.
Self-management messages are best daily
In two studies (Whittaker et al, 2012; Arora et al, 2013) respondents preferred daily self-management messages (where every message is different) for a general health programme and also specifically for a diabetes management programme. In Whittaker et al (2012) the largest proportion of respondents selected one text message per day (42 per cent), with the remainder evenly spread either side of this (less than one per day: 28 per cent; 2–5 per day: 20 per cent; more than 5 per day: 9 per cent) for the optimal frequency of text messages. Daily messages have also been shown to work better in two RCTs looking at smoking cessation rates (Rogers et al, 2005; Bramley et al, 2005) as well as shown in a literature review looking at daily messages for weight loss (Shaw and Bosworth, 2012).
Reminder messages are best weekly
A study in the United States examining a mobile health intervention to support patients with diabetes (Arora et al, 2013) also measured satisfaction levels of the recipients. Regarding medication reminder messages (where every message is the same), most participants (76.6 per cent) found weekly reminders ‘about right’.
Timely messages that walk the journey of the recipient are effective
Regular messages (SMS or voice messages) reaching pregnant women and new mothers weekly or twice a week during their pregnancy or parenting journey have been found to result in more antenatal visits, more vaginal births vs c-sections, less low birthweight babies, more timely initiation of complementary food for babies (six months), more babies receiving all their recommended vaccinations, and more HIV PCR testing of infants of HIV+ (Pathfinder International 2019; Murthy et al. 2019; Coleman et al. 2017).
Rogers et al (2005) studied young smokers in New Zealand who joined a smoking cessation programme. Those who also received regular personalised text messages providing smoking cessation advice, support and distraction starting on the quit day were more likely to have quit smoking six weeks into the programme, compared to those who did not receive text messages.
Regular messaging for at least six months increases knowledge levels
Choudhury (2015) evaluated the MAMA maternal and child health messaging programme in Bangladesh (Aponjon). He found that at least six months of use of Aponjon during pregnancy was twice as effective in increasing maternal health knowledge and practice compared to three to five months of use.
mHealth interventions play a significant role in filling gaps in access, coverage and quality of health services. Through mobile messaging, mHealth interventions can reach users with vital information and support which will, in turn, increase the demand for better healthcare. For this reason, mHealth is particularly relevant in the developing world.
“The evidence has shown that mobile messaging interventions have largely found acceptance amongst users, with SMS being the most popular choice”
The qualitative study of the MomConnect programme in South Africa found that women were so enthusiastic about the messages that many saved them to use as a resource or to share with others. This illustrates the value placed on the content of mobile messages, in addition to the medium of delivery. It also highlights the role ‘content’ can play in acceptance of mobile messaging interventions and, consequently, in behaviour change.
There is significant evidence to show that mobile messaging can improve health behaviours, particularly the more simple, episodic behaviours such as clinic attendance, immunisation and medication adherence. The evidence is slightly weaker for more complex behaviours such as exclusive breastfeeding and smoking cessation. This raises the question of whether mobile messaging can employ a more nuanced messaging strategy or a more multifaceted behaviour change communication strategy to address complex behaviours.
The success of a mobile messaging programme also depends on how aligned it is to the needs of the audience. This requires an in-depth understanding of the audience, their needs, gaps in knowledge, attitudes, behaviours and practices, and their appetite for digital solutions. This means that the target audience as well as key stakeholders must play a role in the design and development of the messaging strategy as well as the messages.
Gayatri is the Head of mHealth at Thrive. With a Master of Public Health (MPH) degree, she has extensive experience working in global health projects as well as national level programmes such as India’s National AIDS Control Programme.
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