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Underserved women are at high risk for smoking relapse after childbirth due to their unique socioeconomic and postpartum stressors and barriers. Mobile text messaging technology allows delivery of relapse prevention programs targeted to their personal needs over time.
To describe the development of a social-cognitive theory-based and evidence-guided text messaging intervention for preventing postpartum smoking relapse among inner city women.
Guided by the cognitive-social health information processing framework, user-centered design, and health communication best practices, the intervention was developed through a systematic process that included needs assessment, followed by an iterative cycling through message drafting, health literacy evaluation and rewriting, review by target community members and a scientific advisory panel, and message revision, concluding with usability testing.
All message content was theory-grounded, derived by needs assessment analysis and evidence-based materials, reviewed and revised by the target population, health literacy experts, and scientific advisors. The final program, “Txt2Commit,” was developed as a fully automated system, designed to deliver 3 proactive messages per day for a 1-month postpartum smoking relapse intervention, with crave and lapse user-initiated message functions available when needed.
The developmental process suggests that the application of theory and best practices in the design of text messaging smoking cessation interventions is not only feasible but necessary for ensuring that the interventions are evidence based and user-centered.
Tobacco use has remained the single most important modifiable cause of adverse pregnancy outcomes in the United States. Smoking accounts for 30% of deliveries of infants with low birth weights, 8% of preterm births, and 5% of all perinatal deaths [
Although there are programs designed to motivate underserved women who are at increased risk for smoking relapse [
A key barrier that emerges for the delivery of evidence-based postpartum programs is access to the new mother.Encouragingly, due to the availability of modern technologies, one particularly well suited but under-utilized technology involves the use of mobile telephones to deliver health-related information to these hard-to-reach populations. Currently 90% of Americans own and use a mobile telephone with text messaging service and 47% of Americans use mobile phones to gain access to information on a daily basis [
One successful example of using a text messaging program for pregnant women is the “Text4baby” program, which sends targeted health messages to promote healthy pregnancies and healthy babies [
With use of a user-centered approach, the intervention development followed a series of iterative steps to ensure that all content was understandable and evidence-based. Guided by the C-SHIP framework and health communication best practices, the text messaging intervention was developed through a systematic process that included needs assessment interviews, followed by an iterative cycling through text message drafting, revision through health literacy evaluation, review by target community interviews via cognitive response interviews, scientific advisory panel evaluation and feedback, and message revision, followed in turn by usability testing of the entire program.
The order of the development processes was established from our research team’s multimedia intervention development experience [
Constructs from the C-SHIP model were used to guide the intervention development strategy and content. The C-SHIP model offers a unifying theoretical framework for assessing and addressing the psychosocial relapse factors typically experienced by postpartum women [
Participants (N=30) were recruited via flyers and staff referrals at 3 Women, Infants, and Children (WIC) clinics located in the inner city Philadelphia region. Interested women were invited to participate if they: (1) were 18 years of age or older, (2) had quit smoking for at least 1 pregnancy, and (3) had given birth to at least 1 child in the past 3 years. Interviews lasted approximately 20 minutes and included specific questions addressing the experiences, motivators, and techniques that had helped women maintain smoking abstinence after pregnancy, as well as personal, social, and environmental factors that triggered a postpartum relapse. Their mobile phone and text message use and preferences were also obtained. Upon completion of the interview, participants received a $20 gift card as compensation for their time and input.
Following an initial review of the interview transcripts, the research team developed a coding scheme based on the C-SHIP model. Responses categorized under C-SHIP were coded into 1 of the 5 psychosocial relapse risk factors. Subcategories in each domain were established as relevant themes emerged from the data. The intention behind coding responses into the C-SHIP processes was to systematically assess the major psychosocial relapse risk factors and identify the unique pattern of challenges faced by low-income, inner city women during the postpartum period.This information was used to guide the development of the Txt2commit intervention text message content.
As reported above, text message content development was grounded in the C-SHIP theoretical model and guided by a formative research approach through a needs assessment interview phase with the target population. In addition, we conducted a comprehensive literature review, as well as an evidence-based guideline search for the potential adoption of existing materials to adapt to the target population. Content component constructs included factors such as messages for increasing awareness of the risks associated with smoking on infant’s health (knowledge), techniques for controlling exposure to stressful cues that trigger the urge to lapse/relapse (affective distress), reinforcing beliefs about the woman’s ability to sustain smoking absence (self-efficacy), considering the consequences of continued smoking (decisional balance), and identifying new behaviors to be substituted for smoking-related activities (self-regulatory skills). To respond effectively to situations in which the participant required an instant message to deal with craving or lapse situations, text messages were developed to offer strategies and emotional support to cope with craving/lapse situations and strategies for how to get back on track.
To ensure that the messages were designed for a low health-literate audience, 2 health literacy experts systematically evaluated all drafted messages using software and their health literacy expertise. The program Health Literacy Advisor (Health Literacy Innovations, LLC) was used to scan and highlight the text for complex terms, complex health terms, polysyllabic words (ie, words with more than 3 syllables), and long sentences (ie, sentences with 12 or more words).The findings from the health literacy analysis were then evaluated by the 2 health literacy experts and the research team to further revise the text messages to improve readability.
Following the revisions for health literacy, the messages were reviewed and vetted by participants (N=30) recruited at the 3 WIC offices with the same eligibility criteria identical to those of the needs assessment phase.Each participant reviewed 21 messages and was asked to think aloud about the messages, paraphrase the content, and respond to other inquiries and probes using the cognitive response technique [
A multidisciplinary scientific advisory panel was convened to provide further insight into the cultural sensitivity, appropriateness, and message appeal of the intervention for the target population. The panel (N=7) was composed of smoking cessation professionals, with expertise in psychosocial behavior, health communication, WIC management, and community perspectives. Panel members were provided with a list of messages (with information on revisions made in the health literacy evaluation process and suggestions made by participants), and the C-SHIP coding guide for each message. Members of the advisory panel evaluated the appropriateness of the content of each of the messages and provided their recommended revisions to the wording and readability of each message from their individual perspective and expertise. The research team then reviewed the advisors’ comments and made necessary modifications to produce the final program.
Ten participants, with the same eligibility criteria identical to those of the needs assessment phase, were recruited to pretest the program for usability testing following the scientific advisory review phase. The program was delivered over 1 week. Participants were provided with phones equipped with text messaging service and were instructed as follows: complete (open and confirm receipt of) 7 system-initiated messages (1 per day), and initiate 3 crave (described below) and 3 lapse message requests (described below) during the 1-week testing phase. Participants were debriefed individually by research staff at the conclusion of the usability testing and received a $20 gift card as compensation for their time and input. They were asked to provide the following overall feedback: system-initiated text message understandability, cultural appropriateness of text message wording, ease of use of crave and lapse functions, and problems encountered in use of the program. Each participant was also asked to provide additional comments concerning the intrusiveness, timing, and general burden imposed by using the program. Feedback was compiled and evaluated by the research team to determine whether adjustments in the messages, system, or study procedures warranted correction or adjustment, with subsequent implementation of necessary corrections and adjustments.
The findings of the needs assessment interviews are reported elsewhere; participant characteristic information is presented in
With regard to phone habits, most participants (21/30, 70%) had a home phone, but even more were mobile phone users (25/30, 83%). In addition, 93% (28/30) of participants reported that they used their mobile phones for texting, and 83% (25/30) reported that they texted on a daily basis. However, none of the participants in this population owned a smartphone. Therefore, our intervention only used text-messaging delivery, which is compatible with all models of mobile phones. Furthermore, when inquiring about their attitudes toward text message styles for a smoking cessation/relapse program, a more formal tone of content without the use of common text messaging abbreviations was preferred because it was thought to increase the creditability of the program. Information gathered from the needs assessment interviews was synthesized by the research team to guide the drafting of the text message content.
A pool of 204 messages was initially developed based on the findings of the needs assessment and a review of the relevant literature.The emerging themes from the needs assessment content analysis were also integrated into the message drafting. The C-SHIP model provided a theoretical guide for message creation because this model indicates specific areas that are especially relevant for health interventions. Smoking facts from several evidence-based resources, including the National Cancer Institute’s fact sheet concerning the harms of smoking, were identified and extracted to be included within the messages where appropriate.
The text messaging intervention developed included 3 main components: low-frequency messages to be sent during the third trimester (1 per week for engagement before the start of the main intervention), high-frequency messages to be sent after participants had given birth (1 message per day for 1 month), and messages available upon participant request when experiencing a craving for a cigarette or a lapse into having smoked one. The messages were systematically and comprehensively developed to address each component, so that some messages were specific to the prenatal or postpartum period and some to the situation of craving or lapsing. The drafted messages were coded across the 5 C-SHIP constructs by the research team.
The initial assessment of the 204 text messages identified a number of issues, including the use of polysyllabic words, complex health terms, complex nonmedical terms, and long sentences. After the 2 health literacy experts reviewed and modified each message in collaboration with the research team, a second assessment using Health Literacy Advisor revealed a significant reduction in the following health literacy problems: a 72% reduction in polysyllabic words, 79% reduction in complex health terms, 91% reduction in complex nonmedical terms, and 47% reduction in long sentences. Most of the complex terms remaining in the text messages were words that pertained to the message content and the study, such as tobacco, smoking, and cancer. During the message review interview phase described below, these words were specifically tested and found to be readily recognized by study participants, indicating that they were not difficult to read or understand.
Messages were reviewed by 30 women at 3 different WIC clinic sites using the cognitive response interview technique.
Background variables for needs assessment and message review interview sample (N=30).
Variable |
|
Needs assessment |
Message review |
|
|
|
|
|
Hispanic | 6 (20) | 6 (20) |
|
White | 11 (37) | 4 (13.3) |
|
African American | 12 (40) | 19 (63.3) |
|
Other | 1 (3.3) | 1 (3.3) |
|
|
|
|
|
Single | 28 (93.3) | 23 (76.7) |
|
Married/cohabiting | 2 (6.7) | 4 (13.3) |
|
Separated | 0 (0) | 2 (6.7) |
|
Divorced | 0 (0) | 1 (3.3) |
|
|
|
|
|
$0-15,000 | 17 (56.7) | 18 (60) |
|
$15,000-30,000 | 10 (33.3) | 11 (36.7) |
|
$30,000-45,000 | 3 (10) | 0 (0) |
|
$45,000-60,000 | 0 (0) | 1 (3.3) |
|
|
|
|
|
8-11 years | 4 (13.3) | 5 (16.7) |
|
H.S. grad/GED | 14 (46.7) | 16 (53.3) |
|
Vocational/tech | 4 (13.3) | 2 (6.7) |
|
Some college | 6 (20) | 7 (23.3) |
|
Bachelor’s degree | 2 (6.7) | 0 (0) |
|
|
|
|
|
Medical assistance | 28 (93.3) | 24 (80) |
|
None | 2 (6.7) | 6 (20) |
Employed |
|
6 (20) | 10 (33.3) |
Home phone owner |
|
21 (70) | 14 (46.7) |
Cell phone owner |
|
25 (83.3) | 25 (83.3) |
|
|
|
|
|
Every day | 17 (56.7) | 12 (40) |
|
Some days | 5 (16.7) | 6 (20) |
|
None | 8 (26.7) | 12 (40) |
Steps and results from each development phase. 1Messages may fall under multiple categories; thus, percentages do not sum to 100%. 2Eleven messages required additional revision to fit within the 159-character limit for text messages. 3Highly rated messages received a mean rating over 4.5 (out of 5) for “Overall Helpful” and were found to be “Helpful If Stressed” by all raters. 4Messages were flagged if they received a mean rating less than 4 (out of 5) for “Overall Helpful”; these were then identified for possible removal if two-thirds or more of raters found it “Not Helpful If Stressed,” or designated “Problematic” in all other cases.
All messages were evaluated by the advisory panel in relation to the relevance of the messages to the population, as well as their coverage of factors involved in the C-SHIP framework. A final review of the advisory panel input by the research team resulted in slight modifications to 50% of the messages and 21 additional messages being eliminated.
Examples of message revision process.
Original message | Health literacy |
Participant comment | Comment revision | After advisory panel |
Research shows that female smokers lose an average of 14.5 years off their lives because of smoking. | Research shows that women who smoke lose about 14.5 years off their lives. | “It’s confusing. . . [when] it says this is about 14.5 years off their lives.” | Research shows that women who smoke live about 14.5 years less than those who don't. | Women who don't smoke live about 15 years more than women who do smoke. |
The American Lung Association reports that smoking during pregnancy accounts for 10% of all infant deaths. | The American Lung Association reports that smoking during pregnancy is the reason for 10% of all infant deaths. | "Good message. Gives people info about the risks of smoking. It makes pregnant moms think about their unborn child." | None | The American Lung Association reports that smoking during pregnancy is the reason for 10% of all infant deaths. |
Think about it. Would you rather feel tired and less energized, or healthy and rejuvenated? You're on the right path to a healthier you! |
Think about it. Would you rather feel tired and have less energy, or healthy and rejuvenated? You're on the right path to a healthier you! |
None | Would you rather feel tired and have less energy because you smoke? Or feel healthy and rejuvenated as a nonsmoker? Stay on the right path to a healthier you! |
By not smoking, you will feel healthy and fresh instead of tired and drained. Stay on the right path to a healthier you! |
Samples of final text messages across 5 C-SHIP constructs.a
Knowledge | Decisional balance | Distress | Beliefs | Self-regulation |
Kids whose parents smoke get bronchitis and pneumonia much more often. | Caring for a baby takes a lot of energy! If you do not smoke, you will feel more active during the day to play with your baby. | Feeling extra stressed and grouchy today? Try playing soft music to help you relax. It may help calm any sudden urges and relax you and your fussy baby. |
Smoking while pregnant puts your baby at higher risk for ear infections and asthma attacks. Be glad you chose to quit! |
Put away ashtrays, matches, and lighters. Trade them for things that remind you not to smoke, like a list of reasons for quitting, or a family photo. |
With each cigarette, you breathe in more than 4000 chemicals. Don’t be fooled, all forms of tobacco can hurt you and your baby. | If you hope to have more children, now is the time to quit. Smoking raises your chance of having trouble getting pregnant again. |
It is normal to feel stressed with a new baby in the household. Remember to make “me” time! |
At the end of each day, think about how you didn't smoke at all. Be thankful for that moment. It will make your thoughts of success stronger. |
Make sure your car and home are smoke free. Do it for yourself and others, especially for your baby. |
Babies whose mothers smoked during pregnancy are up to three times as likely to die from sudden infant death syndrome (SIDS) as babies of nonsmokers. |
Not smoking makes you a better role model for your kids. A child raised by a nonsmoker is less likely to start smoking. Stay smoke free for your baby. |
Do not worry if you are gaining a few pounds. Weight gain is normal when you stop smoking. Keep a healthy diet and talk to your doctor if you are concerned. | You quit smoking for a reason. Think about this reason often. It will never be less true, but it could become less important if you forget about it. |
People who lift weights have spotters. You too should have a spotter! Pick someone you trust to support you and help you to stay smoke free. |
aSome messages may fall under multiple categories.
Ten participants were recruited from the same 3 WIC clinic sites as in the interview phases to participate in a 1-week usability testing session. Each participant was provided with a mobile phone and instructions for mobile phone and message use. Each participant received 7 system-initiated messages over a 1-week period and was instructed to initiate 3 crave and 3 lapse message requests. Among the 10 enrolled participants, 8 successfully completed the testing and responded to the evaluation interview. All 8 participants identified the messages as helpful and reported being satisfied with the messages, as well as with the crave and lapse functions. They all stated that they would use the program and recommend it to others. They also suggested changes, including making the system-initiated messages more frequent (3 per day) and adding voice and video messages to the program. Based on participants’ feedback, the research team finalized the “Txt2commit” program, which provided: (1) 1 text message per week during the prenatal period (27 weeks gestation and on) to enhance and sustain program engagement, (2) 3 text messages daily during the first postpartum month, and (3) crave and lapse functions so that participants could request additional messages when feeling the need. The final program was tested in a larger feasibility pilot study, results of which will be reported elsewhere for ease of communication.
The development of the Txt2commit mobile text messaging intervention relied on a combination of theory and evidence, systematic attention to health literacy issues, and integration of a user-centered approach throughout the developmental process. This research adds to the emerging literature supporting the critical role of a comprehensive strategy for the design of mHealth interventions and highlights the value of a scientifically based health literacy focus. This study aimed to stimulate discussion among target users about how to use mobile text messaging as a platform for delivering smoking cessation interventions for underserved postpartum women, as well as demonstrate a rigorous process of development to ensure that the messages are potent, easily understood, and delivered in an effective manner. Using an iterative developmental process, a multidisciplinary team, and user input, the text messaging intervention was progressively developed and refined based on formative participatory evaluations to achieve a culturally—and linguistically—appropriate psychosocial program that provides relevant content to underserved women who quit smoking during their pregnancies.
The needs assessment, message review, and cognitive response interviews were all essential to identify gaps in women’s needs in postpartum and smoking relapse trigger stressors, which resulted in relevant and appropriate text messaging content and format. Furthermore, the health literacy review and painstaking editing significantly increased the readability and accessibility of the information. The final usability testing confirmed the preferred frequency of message delivery and the usefulness of the crave and lapse functions, prior to the final production and pilot study implementation. The intensity and functionalities of our final intervention program design is comparable to most of the studies in the text messaging smoking cessation literature, with an average of 1-5 text messages per day and the availabilities of crave and lapse functions [
As technology advances become more common as a delivery mechanism for health behavior interventions, it is important to recognize that the impact will depend on the interdigitation of well-designed content, technology, and end user input.Given advances in the field of behavior medicine, it has become increasingly clear that knowledge alone does not change behavior. Likewise, technology alone does not change behavior, but the combination of theory-based best practice approaches in content development, coupled with technology, increases access and reach and has great promise for improving outcomes through attention to evidence-based cessation barriers. The strengths of the study include the use of an established C-SHIP theoretical framework, application of health communication and health literacy best practices to guide text messaging content drafting and revision, extensive input from a community-based sample at various steps in development, and the use of a multidisciplinary expert advisory board. This approach extends our prior research, where the C-SHIP framework was successfully applied to smoking cessation and multimedia intervention behavior change studies [
This study provides insight into the systematic development of text messaging interventions for use in other behavior change contexts. The prevalence of mobile phone use and text messaging among the present underserved sample indicates the potential of text messaging as a delivery modality in a variety of health settings and behaviors. Therefore, the development concepts used in this intervention should be applicable to the development process for other health-related mHealth interventions, especially those targeted to diverse underserved populations. One important lesson learned was that although text messaging was an acceptable channel to communicate smoking relapse messages, postpartum women indicated their preference that these messages be written using formal language to highlight the credibility of the information.
As the vision of eHealth/mHealth is beginning to be actualized, development must also allow for the involvement of “consumers with diverse perspectives, circumstances, capacities, and experiences in the design of, evidence-based eHealth tools” [
cognitive-social health information processing
women, infants, and children
This study was funded by National Institute of Health grants RC1CA145063 and R01 CA104979, the American Cancer Society TURSG 02-227, and the Fox Chase Cancer Center Behavioral Research Core Facility P30CA06927. The authors thank our study advisory board (Drs Ellen Gritz, Thomas Brandon, Michael Diefenbach, Dottie Schell, Damon Vidrine, and Joanne Buzaglo) for their consulting services in the development of this investigation; Mary Anne Ryan, Janiah Sanford, Tammy Stump, Allison Todd, and Ranwa Hammamy for their technical services; and Stephanie Raivitch and Rachel Slamon from Fox Chase’s Office of Health Communications and Health Disparities for their assistance in the health literacy review. We especially are grateful to all the women who participated in the study.
None declared.