Lifestyle-Focused Text Messaging and Coronary Heart Disease
Objective To examine the effect of a lifestyle-focused semipersonalized support program delivered by SMS text message on cardiovascular risk factors.
Clara K. Chow, MBBS, PhD1,2; Julie Redfern, PhD1; Graham S. Hillis, MBChB, PhD3,4,5; et al Jay Thakkar, MBBS2,3; Karla Santo, MBBS3; Maree L. Hackett, PhD3; Stephen Jan, PhD3; Nicholas Graves, PhD6; Laura de Keizer, BSc (Nutr)3; Tony Barry, BSc2; Severine Bompoint, BSc (Stats)3; Sandrine Stepien, MBiostat3; Robyn Whittaker, MPH7; Anthony Rodgers, MBChB, PhD3; Aravinda Thiagalingam, MBChB, PhD2,8
Author Affiliations Article Information
1The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
2Westmead Hospital, Sydney, Australia
3The George Institute for Global Health, University of Sydney, Sydney, Australia
4Royal Perth Hospital, Perth, Australia
5University of Western Australia, Perth
6Queensland University of Technology, Queensland, Australia
7University of Auckland, Auckland, New Zealand
8University of Sydney, Sydney, Australia
JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945
Conclusions and Relevance Among patients with coronary heart disease, the use of a lifestyle-focused text messaging service compared with usual care resulted in a modest improvement in LDL-C level and greater improvement in other cardiovascular disease risk factors. The duration of these effects and hence whether they result in improved clinical outcomes remain to be determined.
Intervention
The text message–based prevention program involved delivery of regular semipersonalized text messages (some messages personally addressed through a “mail-merge”–type function with the participant’s preferred name) providing advice, motivation, and information that aimed to improve diet, increase physical activity, and encourage smoking cessation (if relevant). Content for each participant was selected using a prespecified algorithm dependent on key baseline characteristics. Participants received 4 messages per week for 24 weeks. Each message was sent on 4 of 5 randomly selected weekdays and arrived at random times of the day during working hours.
A bank of messages was developed with input from investigators, clinicians, academics, and patients through a multistage iterative process previously described in detail.9 The content of messages was based on and referred to the Australian Heart Foundation Healthy Living Guidelines.10 Content was developed for 4 modules: smoking, diet, physical activity, and general cardiovascular health. The general module of messages included information generally provided by secondary prevention programs, eg, on chest pain action plans, guidelines and risk factor targets, and medications and adherence.
The message management program selected messages for each participant at random from the bank of messages from all relevant content areas as per the prespecified algorithms and using baseline data entered into the message management system—eg, nonsmokers would not be sent smoking messages, and vegetarians would not be sent information about meat. Some messages were merged with patient’s preferred names, eg, “Have you gone for your walk today Jane?” The Box provides other examples of messages. The message management system, previously described in detail,9 sent messages to participants randomized to the intervention according to our prespecified algorithms on content, frequency, and timing described above.
Examples of Text Messages Used in the TEXT ME Randomized Clinical Trial Smoking
[NAME], try identifying the triggers that make you want a cigarette & plan to avoid them.
[NAME], for many it may take several attempts to quit, so keep trying.
Diet
Did you know 90% of people don’t eat the recommended daily intake of vegetables (5 serves a day)?
Try avoiding adding salt to your foods by using other spices or herbs.
Physical Activity
Hi [NAME], don’t forget physical activity is good for you! It reduces your risk of diabetes, heart attack, stroke, and their complications.
Walking is cheap. It can be done almost anywhere. All you need is comfortable shoes & clothing.
General Cardiovascular Information
Have you got a chest pain Action Plan [NAME]? Find ideas at http://www.heartfoundation.org.au/Pages/default.aspx
Studies show that stress, worry & loneliness can increase the risk of heart disease. Please talk to a health professional if you need help.
At study entry all participants were given brief (average, 3 to 5 minutes) training, if necessary, on how to read a text message and how to delete or save messages. Participants were told not to respond to messages and informed that messages would be managed through a computerized messaging engine. Responses to all messages were monitored by study staff, but interactive communication did not occur. “Stop” messages were followed up by study staff to check if the participant wanted to stop the program. This was needed to meet legal requirements for sending bulk text messages.
We bought a bulk package of text messages from a local service provider to run the TEXT ME study. We used these costs to calculate an average cost for sending each text message.
Court House First Floor Map
Map of first floor.