Development and Pilot Testing of Text Messages to Help Reduce Sugar-Sweetened Beverage Intake Among Rural Caregivers and Adolescents: Mixed Methods Study

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.

Participants feel that text messaging is a convenient method of sending information because of timing.
"I think one advantage is that they can look at it on their own time. If it comes through at a bad time, then I can look at it later and think about it when it is convenient." More accessible Participants stated that they had their phone on them all the time or it was more accessible than other means of communication.
"You'll get right to them...I mean they've got their phone on them."; "I'm thinking of it as opposed to various in comparison to like a flier that would be in a school notebook. It may not get lost because then you would see it more regularly I guess." Easy to read, reread, and understand Participants felt that messages were a simple, easy method to send information because they were short and easy to understand. They can also be saved and reread.
"Parents don't wanna take a lot of time. They don't wanna take you know, we even have parents who can't read very well. I mean, you know so... that would be simple for them instead of, you know, [a handout] or a big long email."; "If you send me a text, most likely I'll have a phone and most likely I can reread that sucker if I need to reread it. For me that's the reason I like text better" Most plans support text messages Participants stated that most cell phone plans included a text messaging component, an unlimited text messaging component, or only a few percentages of people would not have text messaging plans.
"Nobody complains when I send a text, so..."; "I think the texts are pretty much unlimited...It's probably data that would be the issue."

Quick response
Participants stated that they would respond much more quickly to a text message than to other forms of communication.
"I know you'll get me faster if you send me a text than you will an email."

More reach
Participants felt that more people would be reached through sending text messages compared with other forms of communication.
"You'd be including more people. Most people have a cell phone now. I'm one of the few who still has a landline in their house." "There's still places that don't [have service]. I know a friend of mine that has to wait till she comes up the road."; "I lived up in [redacted]. You'd have to sit out on the porch with your arm like that. When they did have service out there you wasn't getting none." Temporary phones/numbe rs Participants stated that people in this region might have temporary phones and phone numbers that changed often.

Disadvantages of using text messages for SSB intake behavior change
"We know that from trying to get ahold of parents. They may have one phone and the next month that number doesn't work anymore. It's very difficult." Can be repetitive/peop le can easily ignore Participants felt that receiving text messages about the same behavior every week might be repetitive and it could be easy for people to ignore. "...there's probably a too often you know that people will tune it out, but I don't know what that cutoff is."

Plans have limited text messages
Participants stated that cell phones might not have an unlimited text messaging component or might get charged for receiving text messages.
"And I wonder, does everybody automatically have unlimited texting? I don't know if that's something."

Liked language and features of text messages
Memorable phrases Participants liked messages that contained phrases they themselves and their children could remember and repeat.
"It rhymed and it would be easy to remember if you were going over it with your family. That was my theory on that."; "It's like a little rhyme...I think it's something that the kids would repeat, too." Family approach Participants liked messages and phrases that targeted a family approach for drinking less SSBs.
"And I think that as a mom, we think more of the family as opposed to one child. Does that make sense? Because since you're targeting middle school, you may have younger kids and you may have older kids, whereas if you're targeting a family you can change everybody's, and then you're helping all age groups." Provides useful information Participants liked messages that provided useful advice, information, and solutions to drinking less SSB. "...for younger kids it's a way for you to know what they're doing in school, and maybe a game to play with them to just reinforce those concepts."; "And maybe getting them involved in the process of it. Informing the child or informing your family this is what you need to be looking for in order to make a healthy choice." Encouraging Participants liked encouraging messages.
"I guess I liked the fact that you're saying yeah, we get that it's hard to, but here's an alternative. You're not just saying 'stop' or 'don't do it', you're saying 'we understand it's hard, but try this'."; "'Keep reducing' kind of sounds like 'hey, you're doing it! You're doing it! Just keep going'." Honest/truthful ness Participants liked messages that were honest, truthful, to the point, and without any fluff.
"The truth about [companies] using the pics and slogans to make us buy their products. I think that is the truth."

Disliked language and features of text messages
Telling you what to do "I think tricky has been a word that has been overused a lot. It's condescending that's questioning intelligence. Questioning like you're just zombies zoned into TV and not fully putting any thought into anything." Assumptions/ making excuses Participants disliked messages that made assumptions about their SSB intake habits or made excuses for their SSB intake habits. "I'm not a victim of excuses. You just do it or you don't. It's not that it's hard. You just do it."; "The thing I didn't like about it was, like 'we know it's hard to cut back'. Like that sounds a little bit presumptuous. Why is it hard to cut back?" Use of absolute words Participants disliked words, such as always, never, or only that represented an absolute or unbounded period of time.
"Mine was the 'the labels always tell the truth'. That was something if I read that I would be skeptical automatically when I saw that 'always tells the truth'. Because I guess that one of the words that you always look for. When you see always or never you never choose those." Blame displacement Participants disliked messages that placed blame on companies or other entities for their adolescent's SSB intake behaviors.
"That's why they are in business. I don't see that as a problem. I just don't like the idea of like she mentioned blaming McDonalds...it's their fault that I eat too many french fries. No, it's my fault that I eat too many... I don't like blaming people for what I do." Use of slang or trendy words Participants disliked the use of slang or trendy words, such as fam or nah.
"I don't like the slang. Just because we're Appalachian doesn't mean we're all hicks. I took that as a negative." Use of governmental or official words