Why text messaging still has the edge in health behaviour change

By Gayatri Koshy, Head of mHealth

These days we are in a quest to discover the next high-tech innovative solution to public health problems. The more technologically advanced it is, the more excited we seem to get about it.

But often overlooked in this quest for digital disruption in healthcare is the humble SMS. It might be low-tech in comparison to apps and other platforms, but it is still an effective tool for health promotion. SMS messages are widely used by consumers and are proven to change health behaviours, such as stopping smoking, increasing physical activity, reducing calorie intake, adhering to medication and seeking care.

SMS vs other digital communication platforms

Text or SMS messaging is the real-time exchange of messages of up to 160 characters via mobile phones. Apps may provide a more comprehensive user experience, including graphic and video content and social networking opportunities. However, text messaging is the most widely used and least expensive function on mobile phones (Burke 2018). In fact, people are still using direct text messaging despite the exponential rise of messaging apps (Burke 2019).

Health apps currently suffer from poor long-term engagement (Wilcox et al. 2019). They depend on users downloading the app and engaging with it in a proactive way. So usage is also affected by the digital divide and the low health and technology literacy of users. SMS, on the other hand, does not require users to log in, navigate web pages or spend time entering data. It makes fewer demands on them compared to other platforms, thus removing some of the barriers to engagement (Suffoleto 2017).

Apps work best among users who are already motivated to change their behaviour. But most people either prefer not to change their behaviour or have fluctuating motivations over time. This means they may not use apps when they need them the most. In contrast, SMS messaging uses a ‘push approach’ to engage with the user, whereby they must actively choose not to engage with it if they don’t want to.

You could say that SMS text messaging is the closest to mimicking face-to-face talk (Lo 2008). It has even developed ways to indicate emotion with the help of emoticons. This is perhaps why McWhorter (2015) calls it ‘fingered speech’. SMS messaging can be seen as coming from a relatable person rather than an impersonal entity, which makes it more engaging and might be the reason why 98% of text messages are opened (Dobrilova and Techjury 2019).

While many apps have messaging features, the messages are perceived to be sent from companies rather than people. That reduces the anticipation the user may feel when they receive a message (Suffoleto 2017).

Given SMS use is so widespread, it offers a feasible way to communicate with hard-to-reach populations of varying levels of health and digital literacy, potentially reducing health inequalities at scale.

Can SMS interventions improve health behaviours?

Almost universally, published systematic reviews have shown that SMS can have a positive effect on health-related behaviours (Orr and King 2015; Hall et al. 2015). However, there are a few caveats.

Orr and King (2015) found that SMS messages are most effective for relatively simple behaviour modification, such as encouraging attendance at medical appointments and increasing medication adherence. The impact of SMS messages was weaker on more complex health behaviours, such as smoking cessation or healthy diet, and on disease prevention activity such as sunscreen use or immunisation.

A study by Mildon and Sellen (2017) on mobile phone interventions for behaviour change communication came to a similar conclusion. They suggested that brief, standardised messaging services such as SMS will be more effective for episodic behaviours (such as attendance for antenatal care or immunisation). Healthy everyday practices such as breastfeeding may seem habitual, but there are complex determinants behind them. And so, the behaviour change communication (BCC) needed to inspire them has to be intensive and multi-layered. Text messaging has a role to play in this mix.

Engagement and persuasiveness

Regardless of how they’re communicated, behaviour change interventions need to be engaging and persuasive. Engagement in this context means how well a person attends to the content of a programme over time. Persuasiveness refers to how well the content can influence someone to start and maintain a health behaviour over a period.

With SMS messaging programmes, engagement can be influenced by the language, tone and personalisation within individual messages. Engagement can also be influenced by the pattern of messaging, more specifically the frequency and timing, as well as the level of interactivity (Suffoleto 2017, Morrison et al. 2012, Hawkins 2010).

When the design of the messaging programmes is user-centred, the user is more likely to engage with the substance of the behaviour change programme. So before developing the content of an SMS programme, it’s important to determine certain user preferences. For example, how often they would like to receive messages and at what time, as well as the tone and voice and level of interactivity.

Using behavioural theory when crafting messages is known to make SMS messaging more persuasive. The more behaviour change techniques (BCTs) are used in the content, the more effective they become in influencing behaviour (Webb et al. 2010). Persuasive SMS messaging for behaviour change can provide information on the consequences of the desired behaviour, identify common barriers and provide problem-solving tips, and offer tools for self-monitoring and strategies for goal setting and action planning (Suffoleto 2017).

The future of SMS

With advances in natural language processing (NLP), computerised systems are learning to understand and respond to human language better. This will enable more meaningful interactions between humans and machines. It will be interesting to see how these advances in NLP can be leveraged so that SMS behaviour change interventions become more dynamic and adaptive to individual needs. This will increase user engagement and effectiveness in changing and maintaining health behaviours.

Access to affordable data is still a problem in many parts of the world and countries where data is expensive still rely on SMS. That said, the data gap is closing and use of instant messaging platforms like WhatsApp is increasing. These have advantages over SMS: they can handle messages over 160 characters, allow graphic and video content as well as a certain level of interactivity and are cheaper to deploy. The MomConnect maternal and child health messaging programme for all pregnant women and new mothers in South Africa shifted its delivery platform from SMS to WhatsApp in 2018 for this reason.

As we develop more high-tech health solutions, it is important to keep the end goal in mind – to improve health. This means that the design and content of any innovation must have the user at the heart of it. SMS has a way of reaching even disengaged individuals in an empathetic way and can have persuasive power if the messages are crafted right. This crucial advantage will keep the humble SMS going strong.

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.

Here at Thrive, we work with brands, partner agencies, governments and charities who want to transform lives and societies for good.

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