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In this paper, we present 10 ways for texting to improve health behavior. The techniques fall into 5 categories: sending information to users, gathering information from users, user questions and expert response, people-to-people connection, and transactions. The purpose of the short messages is to share tidbits of health content on a predictable schedule.
In this paper, we present 10 ways for texting to improve health behavior. The techniques fall into 5 categories: sending information to users, gathering information from users, user questions and expert response, people-to-people connection, and transactions. The purpose of the short messages is to share tidbits of health content on a predictable schedule.
In this paper, we present 10 ways for texting to improve health behavior. The techniques fall into 5 categories: sending information to users, gathering information from users, user questions and expert response, people-to-people connection, and transactions. The purpose of the short messages is to share tidbits of health content on a predictable schedule.
Cordura Hall, Room 122 210 Panama St Stanford, CA 94305 {bjfogg}{enrique.allen}@stanford.edu ABSTRACT Most people use text messaging to stay in touch with friends. But the options for texting go beyond individual communication. In this paper we present 10 ways for texting to improve health behavior. Our hope is that health professionals can see new ways that texting can help achieve their health care goals. Categories and Subject Descriptors J.3 [Life and Medical Systems]: Medical Information Systems General Terms Design Keywords SMS, texting, mobile health 1. INTRODUCTION Experimentation using texting in the health field has shown improvement in primary care attendance rate [1], smoking cessation [2], and sexually transmitted infection awareness [3]. As more health professionals consider using SMS to persuade health behavior change, this paper serves as a comprehensive overview of texting interventions for future study. The 10 texting techniques we present fall into 5 categories: sending information to users, gathering information from users, user questions & expert response, people-to-people connection, and transactions. Table 1. The 5 Texting Categories 2. SENDING INFORMATION TO USERS Sending info to users is the simplest way to use texting. In this category, the end user receives messages from a health organization, such as a County Health Department. The user does not respond to the message. They just read the text they receive. In this category, we see three specific techniques, as explained below. 2.1 Educating People An organization can send text messages to people and help them improve their health, little by little. We call this technique Educating People, because the purpose of the short messages is to share tidbits of health content on a predictable schedule. For example, each day a service can send health research findings, tips about vitamins, or a "health fact of the day." In most situations users will need to "opt in" to receive these educational health messages. Figure 1. Educating People
2.2 Notifying People The second technique for using SMS to improve health behavior is what we call Notifying People. In this technique, an organization sends messages whenever a message is needed, not on a schedule. These messages may have urgent information, such Sending Info to Users End users receive messages from health organizations Gathering Info from Users Health organizations collect data from end users User Questions & Expert Response End users ask a question and health organizations respond People-to-People Connection Individual and group conversations Transactions
Getting things done using SMS
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as a warning about air quality or a new epidemic. But the notifications dont need to be urgent. For example, the CDC might notify people about a new service offered on their web site. We believe using SMS for notifying people will become commonplace. At Stanford University, for instance, we've started a campus-wide SMS notification program. The university has asked everyone to make their mobile phone number available for use in case of emergencies. Figure 2. Notifying People
2.3 Reminding People The third technique for using texting to support health behavior is what we call "Reminding People." As with the previous two techniques, the user receives a text message on their mobile phone without any need to reply. In this third technique, the content of the text message is no surprise to the user. It is simply a reminder. For example, the reminder can be about a personal goal, like remembering to drink water each morning. Or the SMS could be a reminder about an appointment at the health clinic. As one can imagine, given the ubiquity of mobile phones, texting is an excellent way to send simple reminders that trigger health-related behaviors. 3. GATHERING INFORMATION FROM USERS Mobile phones can serve as a channel for gathering information from people. In this category everyday people are the source of the information, instead of being the recipients. We see two different techniques that belong to this category. 3.1 Collecting Data from People Health organizations can learn from the people in their stewardship. In this fourth technique, Collecting Data from People, an organization can use SMS to get people to send data quickly and conveniently using their mobile phones. We see two approaches here. In one case, the organization can send out a prompt, much like texting a one-question survey to people. As the users respond, the organization compiles the data. In other situations, users can be prompted by an event they experience, such as each time they get a migraine headache. Overtime, the data gathered can show health patterns for individuals but also for large populations. Figure 3. Reminding People
SMS demands little time or energy from users, making the probability of gathering data higher than traditional surveys. The response time for an SMS survey is also faster. In other words, with a texting service (and access to cooperative people) researchers can gather thousands of data points within hours. By collecting data via SMS, health professionals can monitor medical or environmental conditions. 3.2 Journaling by Individuals People can use SMS to keep a personal journal related to their health behavior. For those who already know how to text, the mobile phone becomes the most convenient way to input health behavior like calories consumed or steps walked each day. Texting can also support simple writing activities like keeping a gratitude journal. We propose that these behavior logs and personal journals are for the user themselves, not for large-scale data analysis by health organizations. The journaling technique seems to offer a two points of impact. First, the practice of recording diet or activity will likely improve health behavior. Next, by later accessing the collection of short entries, people can get insight into patterns of success and failure. Note that in this second case, people will probably need to access
their journal entries online, since entry retrieval and reading is cumbersome on most phones today. In other words, in this technique Journaling by Individuals -- the mobile phone is a convenient input device, while a private web page is the place for reading and reflection. Figure 4. Collecting Data from People
Figure 5. Journaling by Individuals
4. USER QUESTIONS & EXPERT RESPONSE The next category is all about asking health-related questions and getting answers via text messaging. This is a simple form of interactivity. Note that most of our previous techniques had no interactivity: the information flowed in one direction and stopped. This new category begins to introduce more interactive SMS techniques. In fact, starting with the techniques in this category, all remaining techniques in this paper will involve some form of interactivity using SMS. In this section we describe how to use texting for health with the simplest type of interactive texting: Users ask a question and get a response in return. Below we describe two techniques. 4.1 Getting Answers from a Database Thanks to Google and other online search tools, most people are familiar with seeking answers from a database. In this case, people use texting on their mobile phones to ask questions related to health. In response, they receive an answer from a database. Seeking information via the mobile phone has advantages and drawbacks, as one can imagine. First, we describe the advantages. The best thing about seeking health answers via SMS is convenience. If a diner at a seafood restaurant wants to know if swordfish has high mercury levels, she can use her mobile phone to find the answer. Thats convenient. Within a minute or two she has her answer, without leaving her restaurant table. No one at her table may even realize she is seeking this information. Thats the next big advantage of SMS answer: privacy. Or at least the perception of privacy. Figure 6. Getting Answers from a Database
Now, we describe the major disadvantages of using SMS for getting answers to health questions. Besides the small screen and limited keyboards on mobile phones, the nature of SMS compares poorly to searches we can do on computers. In the 160 characters
available with SMS, users may not form questions that a computer system can understand. Similarly, in the 160 character response, users may not receive enough info or the right info. Asking open-ended questions via SMS is likely to frustrate users. The good news is that some organizations have found a solution. By creating specialized texting services for health, such as sexual health, an organization can list the specific questions in advance. People using SMS can then select from the list of options. The answers they receive are then more likely to satisfy. 4.2 Getting Answers from a Person The core disadvantages of the previous technique are resolved in: Getting Answers from a Person. In this technique, users can send health question using SMS on their mobile phones and receive an answer back from a real person, not a computer. The big advantage here is that a real person can often give a more appropriate answer than can a computer. The other major advantage is that organizations can launch this type of service within days no significant technical work required. All one needs is trained people. These people can use an ordinary computer to receive and reply to the incoming questions. Figure 7. Getting Answers from a Person
Now for the bad news. Relying on people, rather than computer code, limits what the service can do if the service is popular. The service cannot scale easily; it may not be available 24/7. And people who are tired or poorly trained may give incorrect answers to important health questions. Furthermore, having real people answer questions poses a greater cost for ongoing operation. Despite what may seem like major disadvantages, this technique is a good early step for organizations creating a new service to improve health behavior. You can quickly launch and learn. You can easily revise your offering, as you discover what your market wants. 5. PEOPLE-TO-PEOPLE CONNECTIONS We now turn to how most people today view text messaging: a convenient way to connect people who know each other. We call this category People-to-people connections. Thanks to the motivational power of coaching and peer support, these personal connections via SMS can promote health behavior. We share two specific techniques below. 5.1 Connecting Individuals Text messaging allows individuals to have lightweight conversations both in real time and asynchronously. These conversations can take many forms and have many purposes, including interactions that promote better health behaviors. Individual health care experts and their patients can interact via SMS. Health coaches can stay connected with clients. Friends can support friends. We believe that SMS is a better channel than email for personal connections, including health connections. Why? Because SMS doesnt suffer from growing spam. We believe that as email further becomes a river of garbage flooding your inbox, SMS will become a primary channel for connecting with trusted friends and colleagues. Figure 8. Connecting Individuals
5.2 Connecting Groups Text messaging not only supports one-to-one conversations but also many-to-many discussions. This is a new phenomenon, sparked by Twitter in 2006. Today, Twitter and its imitators allow individuals to post messages to groups using SMS as the channel. Group support has long been a key to changing health behavior, and now increasingly SMS facilitates group interactions. Thats good news. Support groups, discussion threads, and collective action are now all possible using ordinary phones and SMS.
However, because texting for groups is new, we have yet to see fully how SMS-based micro-blogging and status updates can promote health. We can look to the history of how group dynamics have supported health behavior change and translate many of those past successes into the new phenomenon of connecting groups via texting. Figure 9. Connecting Groups
6. TRANSACTIONS Mobile transactions take place all over the world and we see future growth as people become comfortable using their phones to access the internet and many other things. 6.1 Getting Things Done Our final technique, Getting Things Done, is all about transactions. As we see it, this technique is new and emerging. In the future we believe that via SMS people will be able to set appointments at health clinics, to buy health products and services, and to register for exercise sessions in their community, among other things. To get a better vision of this future, consider all the transactions we can do today via the web. Then imagine those things happening through SMS. We realize that some of todays transactions on the web are complicated, seemingly beyond what texting can do. But this complexity can be offset by familiarity. Heres what we mean: do those transactions in a limited channel like SMS. Even so, we also believe the previous nine techniques we have shared are better starting points for health organizations. As other industries, such as mobile commerce, make inroads into SMS-based transactions, then health organizations can follow the trails others have blazed. Transactions typically have a structure, a series of steps we follow. As people come to understand the structure of a transaction online (such as purchasing a book), they gain ability to Figure 10. Getting Things Done
7. CONCLUSION: 10 TECHNIQUES AND BEYOND The 10 techniques weve shared aren't likely to change much in the coming years, even as texting gets more sophisticated or as something comes along to replace SMS. The 10 techniques are essentially genres: broadcast info, gather info, Q&A, group support, and so on. Genres persist. That said, some new techniques are likely to emerge, expanding the 10 we list in this chapter to perhaps 15 techniques or more. The new techniques will likely include interactions that are more like games with characters, plot, goals, and rewards. Other new techniques may leverage the power of group dynamics, as SMS becomes more a group activity, thanks to Twitter and the like. We hope that by gathering and sharing these 10 techniques we can help organizations launch and enhance texting services for improving health behavior. We believe texting can increase the effective reach of health care providers while making services more convenient for patients. Table 2. Summary of 10 Texting Techniques Sending Info to Users Educating People Notifying People Reminding People Gathering Info from Users
Collecting Data from People Journaling by Individuals User Questions & Expert Response Getting Answers from a Database Getting Answers from a Person People-to-People Connection
Connecting Individuals Connecting Groups Transactions Getting things done
8. REFERENCES [1] Leong K.C., Chen W.S., Leong, K.W., Mastura, I,. Mimi, O., Sheikh, M.A., Zailinawati, A.H., Ng, C.J., Phua, K.L. and Teng, C.L. 2006. The use of text messaging to improve attendance in primary care: a randomised controlled trial. Family Practice; 23: 699705. [2] Rogers, A., Corbett, T., Bramley, D., Riddell, T., Wills, M., R- B, Lin, Jones, M. 2005. Do you u smoke after txt? Results of a randomized trial of smoking cessation using mobile phone text messaging. Tobacco Control; 1-8. [3] Levine, D., McCright, J., Dobkin, L., Woodruff, A.J., Klausner, J.D. 2008. SEXINFO: A Sexual Health Text Messaging Service for San Francisco. AJPH (Mar. 2008), 393-395.