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In March 2020, Text4Hope—a community health service—was provided to Alberta residents. This free service aims to promote psychological resilience and alleviate pandemic-associated stress, anxiety, and depression symptoms during the COVID-19 pandemic.
This study aimed to evaluate the feedback, satisfaction, experience, and perceptions of Text4Hope subscribers and to examine any differences based on gender after subscribers received 6 weeks of daily supportive text messages. Additionally, this study examined subscribers’ anticipated receptivity to technology-based medical services that could be offered during major crises, emergencies, or pandemics.
Individuals self-subscribed to Text4Hope to receive daily supportive text messages for 3 months. Subscribers were invited to complete a web-based survey at 6 weeks postintervention to provide service satisfaction–related information. Overall satisfaction was assessed on a scale of 0-10, and satisfaction scores were analyzed using a related-measures
A total of 2032 subscribers completed the baseline and 6-week surveys; 1788 (88%) were female, 219 (10.8%) were male, and 25 (1.2%) were other gender. The mean age of study participants was 44.58 years (SD 13.45 years). The mean overall satisfaction score was 8.55 (SD 1.78), suggesting high overall satisfaction with Text4Hope. The ANOVA analysis, which was conducted using the Welch test (n=1716), demonstrated that females had significantly higher mean satisfaction scores than males (8.65 vs 8.11, respectively; mean difference=0.546; 95% CI 0.19 to 0.91;
Respondents affirmed the high quality of the text messages with their positive feedback. Technology-based services can provide remotely accessible and population-level interventions that align with the recommended physical distancing practices for pandemics. Text4Hope subscriber feedback revealed high satisfaction and acceptance at 6 weeks postintervention.
RR2-10.2196/19292
On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic [
During similar crises, the effective and efficient mobilization of community resources was strongly encouraged to support and properly meet mental health needs and avoid future adverse mental health consequences [
To make the best use of resources and enhance the use of texting technology as part of routine practice in health care, it is essential to assess user satisfaction and better understand subscribers’ experiences. The assessment of user satisfaction is a quality method that affects client retention and clinical outcomes [
This study occurred in Alberta, the Canadian Province where the Text4Hope program was launched. As of July 1, 2020, Alberta had a population of 4,421,876 people, with 68% of the population aged between 15 and 64 years. Alberta has consistently consisted of more males than females (101 males per 100 females), mainly due to the large proportion of working-age males migrating to the province [
The aim of this study was to evaluate subscribers’ overall satisfaction with Text4Hope; obtain feedback about subscribers’ experiences and the impact of the texting intervention; explore the perceptions of subscribers about their anticipated receptivity toward diverse, technology-based medical services that are offered as a part of their health care during major crises, emergencies, or pandemics (such as the COVID-19 pandemic); and examine any differences that are based on gender after subscribers received 6 weeks of daily supportive text messages.
Based on previous Text4Mood research [
This cross-sectional study assessed subscribers’ satisfaction and experiences with Text4Hope and their perceptions of technology-based support after they received 6 weeks of daily text messages.
The data collection methods were fully described in the study protocol [
When bad things happen that we can’t control, we often focus on the things we can’t change. Focus on what you can control; what you can do to help yourself (or someone else) today.
What lies behind you and what lies before you are tiny matters compared to what lies within you. Have faith in yourself and success can be yours.
Set goals for today, even if they are small. Goals should be “SMART”: Specific, Measurable, Achievable, Realistic, and Timely.
The messages were uploaded to a web-based platform, which delivered automated messages at 9 AM. The first message welcomed subscribers to the service and invited them to voluntarily complete a web-based baseline survey, which was used to capture demographic and clinical information that primarily pertained to anxiety, stress, depression, and self-isolation. At 6 weeks postintervention, subscribers were invited (via a text message link) to complete a follow-up web-based survey.
The 6-week survey included standardized scales that were used for the Text4Hope baseline assessments [
Participation in the program was voluntary, and the receipt of supportive text messages was not contingent on survey completion. Subscribers could opt out of Text4Hope at any time by texting the word “STOP” to a short code number.
Six-week satisfaction data were collected between May 31 and July 12, 2020.
The study protocol [
Subscription flowchart.
The primary outcome measure was subscribers’ overall satisfaction with the Text4Hope daily supportive text messages. Overall satisfaction at 6 weeks postintervention was based on an 11-point Likert scale (0=very dissatisfied; 5=neither satisfied nor dissatisfied; 10=very satisfied). This overall satisfaction score allowed us to determine whether people liked texting-based services. If people are satisfied with the population-based services they receive, then the services are potentially feasible and can aid in future service planning during pandemics. The satisfaction scale has been used to compare service satisfaction across all addiction and mental health services in the Edmonton Zone. The reliability and validity of this scale has not been tested, although it has been in use for several years.
Secondary outcomes included the perceived impacts of and subscribers’ feedback for the daily supportive text messages at 6 weeks postintervention as well as subscribers’ anticipated receptivity to diverse, technology-based medical services (eg, telephone, videoconferencing, and email for health care) during the COVID-19 pandemic. Gender differences in both primary and secondary measures constituted the exploratory outcome measures.
In total, 44,019 individuals were subscribed to Text4Hope in May 31, 2020. We estimated that a sample size of 1775 was needed to estimate the overall mean satisfaction rate (based on an 11-point scale from 0 to 10) for the entire population with a 3% margin of error and 99% confidence.
Data were analyzed using SPSS Statistics for Windows, version 26 (IBM Corporation) [
Between May 31 and July 12, 2020, 39,672 active Text4Hope subscribers were invited to complete the 6-week survey. Of these subscribers, 3611 completed the survey, yielding a response rate of 9.1%. Of the 2032 subscribers who had available demographic information from their baseline survey and were included in further analysis, 1788 (88%) were female, 219 (10.8%) were male, and 25 (1.2%) were other gender.
Demographic and clinical characteristics of respondents at 6 weeks postintervention.
Variables | Male (n=219), n (%) | Female (n=1788), n (%) | Other gender (n=25), n (%) | Overall (N=2032), n (%) | |
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≤25 | 15 (7) | 151 (8.6) | 7 (28) | 173 (8.6) |
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26-40 | 53 (24.8) | 490 (27.7) | 12 (48) | 555 (27.7) |
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41-60 | 105 (49.1) | 891 (50.5) | 4 (16) | 1000 (49.9) |
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>60 | 41 (19.2) | 234 (13.3) | 2 (8) | 277 (13.8) |
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White | 177 (81.2) | 1492 (83.9) | 19 (76) | 1688 (83.5) |
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Indigenous | 6 (2.8) | 54 (3) | 0 (0) | 60 (3) |
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Asian | 15 (6.9) | 90 (5.1) | 1 (4) | 106 (5.2) |
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Other | 20 (9.2) | 142 (8) | 5 (20) | 167 (8.3) |
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Less than a high school diploma | 7 (4) | 35 (2.3) | 2 (8.7) | 44 (2.6) |
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High school diploma | 14 (8) | 102 (6.8) | 1 (4.3) | 117 (6.9) |
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Postsecondary education | 155 (88.1) | 1349 (90.2) | 19 (82.6) | 1523 (89.9) |
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Other education | 0 (0) | 9 (0.6) | 1 (4.3) | 10 (0.6) |
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Employed | 120 (69) | 1059 (71.5) | 12 (52.2) | 1191 (70.9) |
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Unemployed | 26 (14.9) | 177 (11.9) | 3 (13) | 206 (12.3) |
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Retired | 23 (13.2) | 151 (10.2) | 2 (8.7) | 176 (10.5) |
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Student | 4 (2.3) | 71 (4.8) | 5 (21.7) | 80 (4.8) |
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Other | 1 (0.6) | 24 (1.6) | 1 (4.3) | 26 (1.5) |
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Married/cohabiting/partnered | 112 (63.3) | 987 (66) | 11 (47.8) | 1110 (65.5) |
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Separated/divorced | 14 (7.9) | 154 (10.3) | 1 (4.3) | 169 (10) |
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Widowed | 3 (1.7) | 37 (2.5) | 1 (4.3) | 41 (2.4) |
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Single | 46 (26) | 303 (20.3) | 9 (39.1) | 358 (21.1) |
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Other | 2 (1.1) | 14 (0.9) | 1 (4.3) | 17 (1) |
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Own home | 122 (69.7) | 1037 (70.1) | 12 (52.2) | 1171 (69.8) |
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Living with family | 14 (8) | 132 (8.9) | 4 (17.4) | 150 (8.9) |
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Renting | 38 (21.7) | 300 (20.3) | 5 (21.7) | 343 (20.5) |
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Other | 1 (0.6) | 10 (0.7) | 2 (8.7) | 13 (0.8) |
Respondents were asked to rate their overall satisfaction with the daily supportive text messaging (Text4Hope) service on a scale of 0-10, in which 0 represented “very dissatisfied,” 5 represented “neither satisfied nor dissatisfied,” and 10 represented “very satisfied.” Respondents’ (n=2940) mean overall satisfaction score was 8.55 (SD 1.78), suggesting that overall, respondents’ satisfaction with the Text4Hope program was high. The ANOVA analysis, which was conducted using the Welch test (n=1716), demonstrated that females had significantly higher mean satisfaction scores than males (8.65 vs 8.11, respectively; mean difference=0.546; 95% CI 0.19 to 0.91;
In
Gender differences in the perceived impact of daily messages at 6 weeks postintervention.
Perceived impact of daily messages from Text4Hope | Male, n (%) | Female, n (%) | Other gender, n (%) | Total, n (%) | ||
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Agree | 144 (75.8) | 1177 (77.4) | 13 (61.9) | .05 | 1334 (77.1) |
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Neutral | 33 (17.4) | 284 (18.7) | 5 (23.8) | N/Ab | 322 (18.6) |
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Disagree | 13 (6.8) | 59 (3.9) | 3 (14.3) | N/A | 75 (4.3) |
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Agree | 133 (70.4) | 1162 (76.5) | 14 (66.7) | .05 | 1309 (75.8) |
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Neutral | 44 (23.3) | 297 (19.6) | 4 (19) | N/A | 345 (20) |
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Disagree | 12 (6.3) | 59 (3.9) | 3 (14.3) | N/A | 74 (4.3) |
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Agree | 103 (54.5) | 856 (56.4) | 9 (42.9) | .04 | 968 (56.1) |
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Neutral | 63 (33.3) | 561 (37) | 9 (42.9) | N/A | 633 (36.7) |
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Disagree | 23 (12.2) | 100 (6.6) | 3 (14.3) | N/A | 126 (7.3) |
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Agree | 71 (37.4) | 757 (49.9) | 9 (42.9) | .01 | 837 (48.5) |
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Neutral | 85 (44.7) | 592 (39.1) | 9 (42.9) | N/A | 686 (39.7) |
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Disagree | 34 (17.9) | 167 (11) | 3 (14.3) | N/A | 204 (11.8) |
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Agree | 144 (75.8) | 1242 (81.8) | 14 (66.7) | .05 | 1400 (81) |
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Neutral | 33 (17.4) | 211 (13.9) | 4 (19) | N/A | 248 (14.3) |
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Disagree | 13 (6.8) | 65 (4.3) | 3 (14.3) | N/A | 81 (4.7) |
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Agree | 134 (70.5) | 1133 (74.7) | 12 (57.1) | .09 | 1279 (74) |
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Neutral | 46 (24.2) | 324 (21.4) | 6 (28.6) | N/A | 376 (21.8) |
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Disagree | 10 (5.3) | 60 (4) | 3 (14.3) | N/A | 73 (4.2) |
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Agree | 136 (71.6) | 1159 (76.2) | 13 (61.9) | .06 | 1308 (75.6) |
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Neutral | 38 (20) | 289 (19) | 5 (23.8) | N/A | 332 (19.2) |
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Disagree | 16 (8.4) | 72 (4.7) | 3 (14.3) | N/A | 91 (5.3) |
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Agree | 104 (55) | 941 (62.5) | 12 (60) | .11 | 1057 (61.7) |
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Neutral | 68 (36) | 474 (31.5) | 5 (25) | N/A | 547 (31.9) |
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Disagree | 17 (9) | 90 (6) | 3 (15) | N/A | 110 (6.4) |
aBonferroni-corrected, two-tailed criteria for significance (α<.002).
bN/A: not applicable.
The results in
Most respondents (1531/1716, 89.2%) indicated that they always read the text messages, and about 20% of respondents indicated that they always or often returned to read the text messages (401/1716, 23.4%). Neither factor indicated gender differences upon analysis.
Gender differences in the feedback about Text4Hope messages at 6 weeks postintervention.
Feedback | Male, n (%) | Female, n (%) | Other gender, n (%) | Total, n (%) | ||
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Always | 131 (68.9) | 1193 (78.4) | 12 (57.1) | <.001 | 1336 (77.1) |
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Often | 55 (28.9) | 291 (19.1) | 6 (28.6) | N/Ab | 352 (20.3) |
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Sometimes | 3 (1.6) | 35 (2.3) | 2 (9.5) | N/A | 40 (2.3) |
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Rarely | 1 (0.5) | 2 (0.1) | 1 (4.8) | N/A | 4 (0.2) |
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Never | 0 (0) | 0 (0) | 0 (0) | N/A | 0 (0) |
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Always | 118 (62.8) | 1104 (72.7) | 9 (42.9) | <.001 | 1231 (71.3) |
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Often | 57 (30.3) | 347 (22.9) | 10 (47.6) | N/A | 414 (24) |
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Sometimes | 11 (5.9) | 58 (3.8) | 1 (4.8) | N/A | 70 (4.1) |
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Rarely | 1 (0.5) | 8 (0.5) | 0 (0) | N/A | 9 (0.5) |
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Never | 1 (0.5) | 1 (0.1) | 1 (4.8) | N/A | 3 (0.2) |
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Always | 128 (67.7) | 1114 (73.7) | 12 (57.1) | .09 | 1254 (72.8) |
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Often | 49 (25.9) | 300 (19.8) | 5 (23.8) | N/A | 354 (20.6) |
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Sometimes | 12 (6.3) | 92 (6.1) | 4 (19) | N/A | 108 (6.3) |
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Rarely | 0 (0) | 6 (0.4) | 0 (0) | N/A | 6 (0.3) |
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Never | 0 (0) | 0 (0) | 0 (0) | N/A | 0 (0) |
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Always | 95 (50.5) | 945 (62.4) | 12 (57.1) | <.001 | 1052 (61.1) |
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Often | 64 (34) | 386 (25.5) | 3 (14.3) | N/A | 453 (26.3) |
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Sometimes | 20 (10.6) | 163 (10.8) | 3 (14.3) | N/A | 186 (10.8) |
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Rarely | 7 (3.7) | 19 (1.3) | 2 (9.5) | N/A | 28 (1.6) |
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Never | 2 (1.1) | 1 (0.1) | 1 (4.8) | N/A | 4 (0.2) |
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Always | 161 (84.7) | 1351 (89.8) | 19 (90.5) | .61 | 1531 (89.2) |
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Often | 23 (12.1) | 125 (8.3) | 2 (9.5) | N/A | 150 (8.7) |
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Sometimes | 5 (2.6) | 25 (1.7) | 0 (0) | N/A | 30 (1.7) |
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Rarely | 1 (0.5) | 2 (0.1) | 0 (0) | N/A | 3 (0.2) |
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Never | 0 (0) | 2 (0.1) | 0 (0) | N/A | 2 (0.1) |
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Always | 7 (3.7) | 73 (4.9) | 0 (0) | .47 | 80 (4.7) |
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Often | 33 (17.4) | 287 (19.1) | 1 (4.8) | N/A | 321 (18.7) |
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Sometimes | 76 (40) | 635 (42.2) | 13 (61.9) | N/A | 724 (42.2) |
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Rarely | 46 (24.2) | 327 (21.7) | 4 (19) | N/A | 377 (22) |
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Never | 28 (14.7) | 183 (12.2) | 3 (14.3) | N/A | 214 (12.5) |
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Read text and took a positive or beneficial action | 14 (7.7) | 186 (12.7) | 1 (5) | .003 | 201 (12.1) |
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Read text and reflected on the messages | 138 (75.4) | 1119 (76.5) | 13 (65) | N/A | 1270 (76.2) |
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Read the text and took no action | 25 (13.7) | 138 (9.4) | 6 (30) | N/A | 169 (10.1) |
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Read text and took a negative or harmful action | 0 (0) | 0 (0) | 0 (0) | N/A | 0 (0) |
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Did not read the text | 2 (1.1) | 2 (0.1) | 0 (0) | N/A | 4 (0.2) |
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Other | 4 (2.2) | 18 (1.2) | 0 (0) | N/A | 22 (1.3) |
aBonferroni-corrected, two-tailed criteria for significance (α<.002).
bN/A: not applicable.
We explored subscribers’ anticipated receptivity to welcoming diverse, technology-based services as part of their health care during crisis or emergency situations, such as the COVID-19 pandemic. The results displayed in
Anticipated receptivity of subscribers to receiving diverse, technology-based services as part of their health care during crisis or emergency situations, such as the COVID-19 pandemic.
Subscribers’ anticipated receptivity to services | Male, n (%) | Female, n (%) | Other gender, n (%) | Total, n (%) | ||
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Agree | 152 (80.9) | 1220 (83.3) | 18 (85.7) | .55 | 1390 (83) |
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Neutral | 26 (13.8) | 198 (13.5) | 3 (14.3) | N/Ab | 227 (13.6) |
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Disagree | 10 (5.3) | 47 (3.2) | 0 (0) | N/A | 57 (3.4) |
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Agree | 151 (80.3) | 1176 (80.4) | 19 (90.5) | .80 | 1346 (80.5) |
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Neutral | 29 (15.4) | 229 (15.7) | 2 (9.5) | N/A | 260 (15.6) |
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Disagree | 8 (4.3) | 58 (4) | 0 (0) | N/A | 66 (3.9) |
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Agree | 159 (84.6) | 1288 (88.2) | 18 (85.7) | .12 | 1465 (87.8) |
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Neutral | 19 (10.1) | 132 (9) | 1 (4.8) | N/A | 152 (9.1) |
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Disagree | 10 (5.3) | 40 (2.7) | 2 (9.5) | N/A | 52 (3.1) |
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Agree | 106 (56.7) | 962 (65.8) | 16 (76.2) | .01 | 1084 (64.9) |
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Neutral | 45 (24.1) | 345 (23.6) | 4 (19) | N/A | 394 (23.6) |
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Disagree | 36 (19.3) | 154 (10.5) | 1 (4.8) | N/A | 191 (11.4) |
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Agree | 132 (70.2) | 1094 (74.7) | 18 (85.7) | .29 | 1244 (74.3) |
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Neutral | 42 (22.3) | 284 (19.4) | 1 (4.8) | N/A | 327 (19.5) |
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Disagree | 14 (7.4) | 87 (5.9) | 2 (9.5) | N/A | 103 (6.2) |
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Agree | 119 (63.3) | 1055 (72) | 16 (76.2) | .12 | 1190 (71.1) |
|
Neutral | 50 (26.6) | 279 (19) | 4 (19) | N/A | 333 (19.9) |
|
Disagree | 19 (10.1) | 131 (8.9) | 1 (4.8) | N/A | 151 (9) |
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Agree | 126 (67.4) | 1102 (75.4) | 17 (81) | .19 | 1245 (74.6) |
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Neutral | 44 (23.5) | 259 (17.7) | 3 (14.3) | N/A | 306 (18.3) |
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Disagree | 17 (9.1) | 100 (6.8) | 1 (4.8) | N/A | 118 (7.1) |
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Agree | 124 (66.3) | 1052 (72.2) | 17 (81) | .30 | 1193 (71.7) |
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Neutral | 44 (23.5) | 258 (17.7) | 3 (14.3) | N/A | 305 (18.3) |
|
Disagree | 19 (10.2) | 147 (10.1) | 1 (4.8) | N/A | 167 (10) |
aBonferroni-corrected, two-tailed criteria for significance (α<.002).
bN/A: not applicable.
This study provided results regarding subscribers’ satisfaction with Text4Hope after they received the texting intervention for 6 weeks. Our results revealed considerable satisfaction with Text4Hope. The total number of subscribers who completed the baseline and 6-week surveys was 2032, and a majority of subscribers were female (1788/2032, 88%). The mean age of study participants was 44.58 years. Overall service satisfaction was high, and more than 70% of subscribers agreed that Text4Hope helped them cope with stress (1334/1731, 77.1%) and anxiety (1309/1728, 75.8%), feel connected to a support system (1400/1729, 81%), manage COVID-19–related issues (1279/1728, 74%), and improve mental well-being (1308/1731, 75.6%). Similarly, subscribers agreed that the text messages were positive, affirmative, and succinct. Text messages were always or often read by 97.9% (1681/1716) of respondents, and more than 20% (401/1716, 23.4%) always or often returned to messages. Most subscribers (1471/1666, 88.3%) read the messages and either reflected upon them or took a positive action. Subscribers welcomed almost all technology-based services as part of their health care during crisis or emergency situations. Text4Hope was perceived to be effective by more female subscribers than male or other gender subscribers. The withdrawal rate for Text4Hope was approximately 10% at 6 weeks postintervention. Untailored and unilateral texting services often have high withdrawal rates that range from 0% to 57% [
Female respondents comprised the majority of the sample in our study (1788/2032, 88%). In other texting-based services, females were also highly represented (>80% of participants) [
Subscribers’ overall satisfaction with our provided service (8.55) was high. This is in line with the 95% satisfaction rate of the Text4Mood program reported by Agyapong et al [
Self-reported levels of the ability to cope with psychiatric burdens was mostly lower in Text4Hope respondents than in respondents from the Text4Mood study by Agyapong et al [
More than 70% of the people in our study reported that the Text4Hope messages were always positive (1336/1732, 77.1%), affirmative (1231/1727, 71.3%), and succinct (1254/1722, 72.8%). About 60% of respondents reported that the messages were always relevant (1052/1753, 61.1%). These results typically came from females, who are usually satisfied with texting services and actively interact with such text messages [
The number of Text4Hope respondents who reported that they always or often read the text messages was similar to that of the 2016 Agyapong et al study [
With regard to subscribers’ anticipated agreement with the provision of diverse, technology-based medical services, our respondents generally praised the use of these services during the COVID-19 pandemic and other similar crises. Compared to the other proposed technology-based medical services, our results showed that text messaging was the most highly accepted intervention, with an overall agreement rate of 87.8% (1465/1669). This could be explained by the simple nature of such programs, which is important to the end users who usually own cell phones, and by the short and easy-to-read nature of the daily text messages.
Our study reported slightly lower levels of acceptance for video consultation services for both mental and physical health compared to those for web-based counseling services. This may be attributed to the lack of required physical interaction in video consultation services, as the one-way nature of web-based counseling services is usually more accepted and welcomed by users [
This study has several limitations. For instance, there was a low response rate (9.1%) among the 6-week subscribers, which may have been due to the incentive-free and optional nature of the survey. Thus, the reported levels of satisfaction may have been skewed if there was a systematic difference in the measured features between responders and nonresponders. Notwithstanding the low response rate, our sample size exceeded the 1775 respondents needed to estimate satisfaction rates for the entire subscriber population with a 3% margin of error and 99% confidence. Consequently, our study was sufficiently powered to provide satisfaction rate estimates for the entire population of Text4Hope subscribers. Furthermore, Text4Hope has achieved a higher retention rate than those of other mental health apps that target anxiety, depression, or emotional well-being [
It is also possible that we achieved high satisfaction because people who like technology may have been drawn to the Text4Hope program. Additionally, there is potential for social desirability bias, which may have resulted in respondents reporting higher satisfaction and better perceived benefits from receiving text messages. However, this is unlikely due to the anonymous nature of the survey.
There are several other possible limitations. It is possible that our finding that texting was the most accepted mode of delivery for technology-based health services was biased, as those who liked text messaging were likely to sign up for Text4Hope and therefore participate in the survey. It would have been ideal to include a a control group for the comparison of Text4Hope subscribers’ and nonsubscribers’ anticipated receptivity to technology based medical services. Additionally, although there was a statistically significant gender difference in overall satisfaction between males and females (
In conclusion, our results indicate that texting-based programs are acceptable to end users, as high overall satisfaction was reported by subscribers of all gender identities. However, female subscribers reported significantly higher satisfaction scores than male subscribers. Our respondents affirmed the high quality of the text messages by consistently reading and rereading the text messages and providing positive feedback regarding the messages’ supportive nature. Text-based mental health support services can be easily deployed during pandemics to support at-risk populations and alleviate the negative mental health impacts that have been well-documented during uncertain times. Based on Text4Hope subscriber feedback, messages from text-based support interventions that have a 160-character limit, are written by health professionals, and are delivered daily can result in high levels of acceptance and satisfaction upon implementation.
analysis of variance
Middle East respiratory syndrome coronavirus
severe acute respiratory syndrome coronavirus
Support for this study was received from Alberta Health Services and the University of Alberta. This study was supported by grants from the Mental Health Foundation, the Calgary Health Trust, the University Hospital Foundation, the Alberta Children’s Hospital Foundation, the Royal Alexandra Hospital Foundation, and the Alberta Cancer Foundation. The funders had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, and approval of the manuscript; or the decision to submit the results for publication.
VIOA conceived and designed the study and the Text4Hope program with MH. RS drafted the initial manuscript with VIOA. AG, WV, and SS participated in data collection. All authors contributed to the study design and revised and approved the final draft of the manuscript.
None declared.