Alison L. Marshall

Behavior Change Interventions Delivered by Mobile Telephone Short-Message Service

CONTEXT The expansion and adoption of new methods of communication provide new opportunities for delivering health behavior change interventions. This paper reviews the current research examining mobile telephone short-message service (SMS) for delivering health behavior change interventions via text messages. This service has wide population reach, can be individually tailored, and allows instant delivery with asynchronous receipt, suggesting potential as a delivery channel for health behavior interventions. EVIDENCE ACQUISITION An electronic database search was conducted for studies published between January 1990 and March 2008. Studies were included in the review if they (1) evaluated an intervention delivered primarily via SMS, (2) assessed change in health behavior using pre-post assessment, and (3) were published in English in a peer-reviewed scientific journal. EVIDENCE SYNTHESIS Of 33 studies identified, 14 met the inclusion criteria. Four of the 14 studies reviewed targeted preventive health behaviors (e.g., smoking cessation), and ten focused on clinical care (e.g., diabetes self-management). Positive behavior change outcomes were observed in 13 of the 14 reviewed studies. Intervention initiation (researcher or participant), SMS dialogue initiation, tailoring of SMS content, and interactivity were found to be important features of SMS-delivered interventions. Methodologic issues with current SMS research were also identified. CONCLUSIONS This review suggests that SMS-delivered interventions have positive short-term behavioral outcomes. Further research is required to evaluate interventions for preventive health behaviors that incorporate features found to affect behavioral outcomes and participant acceptance. The quality of studies in this emerging field of research needs to improve to allow the full potential of this medium to be explored.

Measuring total and domain-specific sitting: a study of reliability and validity.

PURPOSE Although independent relationships between sitting behaviors (mainly television viewing) and health outcomes have been reported, few studies have examined the measurement properties of self-report sitting questions. This study assessed gender-specific test-retest reliability and validity of a questionnaire that assessed time spent sitting on weekdays and weekend days: 1) traveling to and from places, 2) at work, 3) watching television, 4) using a computer at home, and 5) for leisure, not including television. METHODS Test-retest reliability of domain-specific sitting time (min x d(-1)) on weekdays and weekend days was assessed using data collected on two occasions (median = 11 d apart). Validity of domain-specific self-reported sitting time on weekdays and weekend days was assessed against log data and sedentary accelerometer data. RESULTS Complete repeat questionnaire and log data were obtained from 157 women (aged 51-59 yr) and 96 men (aged 45-63 yr). Reliability coefficients were high for weekday sitting time at work, watching television, and using a computer at home (r = 0.84-0.78) but lower for weekend days across all domains (r = 0.23-0.74). Validity coefficients were highest for weekday sitting time at work and using a computer at home (r = 0.69-0.74). With the exception of computer use and watching television for women, validity of the weekend-day sitting time items was low. CONCLUSIONS This study confirms the importance of measuring domain- and day-specific sitting time. The measurement properties of questions that assess structured domain-specific and weekday sitting time were acceptable and may be used in future studies that aim to elucidate associations between domain-specific sitting and health outcomes.

Print versus website physical activity programs: A randomized trial

BACKGROUND Mediated physical activity interventions can reach large numbers of people at low cost. Programs delivered through the mail that target the stage of motivational readiness have been shown to increase activity. Communication technology (websites and e-mail) might provide a means for delivering similar programs. METHODS Randomized trial conducted between August and October 2001. Participants included staff at an Australian university (n=655; mean age=43, standard deviation, 10 years). Participants were randomized to either an 8-week, stage-targeted print program (Print) or 8-week, stage-targeted website (Web) program. The main outcome was change in self-reported physical activity. RESULTS There was no significant increase in total reported physical activity within or between groups when analyzed by intention to treat (F [1,653]=0.41, p=0.52). There was a significant increase in total physical activity reported by the Print participants who were inactive at baseline (t [1,173]=-2.21, p=0.04), and a significant decrease in the average time spent sitting on a weekday in the Web group (t [1,326]=2.2, p=0.03). CONCLUSIONS There were no differences between the Print and Web program effects on reported physical activity. The Print group demonstrated slightly larger effects and a higher level of recognition of program materials.

Associations of location and perceived environmental attributes with walking in neighborhoods.

Purpose. Ecological models highlight the importance of environmental influences. We examined associations of coastal versus noncoastal location and perceived environmental attributes with neighborhood walking, total walking, and total activity. Methods. Telephone interviews with 800 faculty and general staff of an Australian university. Results. Men were significantly more likely to walk in their neighborhood if they lived in a coastal location (odds ratio [OR] = 1.66), and they highly rated environmental “aesthetics” (OR = 1.91), “convenience” of facilities (OR = 2.20), and “access” to facilities (OR = 1.98). For women, neighborhood walking was associated with high ratings of “convenience” (OR = 3.78) but was significantly less likely if they had high ratings for “access” (OR = 0.48). For total walking and total physical activity, few significant associations emerged. Conclusions. Environmental attributes were related to walking in the neighborhood but not to more general activity indices. Understanding gender-specific environmental correlates of physical activity should be a priority.

Reliability and validity of a brief physical activity assessment for use by family doctors

Objective: To evaluate the reliability and validity of a brief physical activity assessment tool suitable for doctors to use to identify inactive patients in the primary care setting. Methods: Volunteer family doctors (n  =  8) screened consenting patients (n  =  75) for physical activity participation using a brief physical activity assessment tool. Inter-rater reliability was assessed within one week (n  =  71). Validity was assessed against an objective physical activity monitor (computer science and applications accelerometer; n  =  42). Results: The brief physical activity assessment tool produced repeatable estimates of “sufficient total physical activity”, correctly classifying over 76% of cases (κ 0.53, 95% confidence interval (CI) 0.33 to 0.72). The validity coefficient was reasonable (κ 0.40, 95% CI 0.12 to 0.69), with good percentage agreement (71%). Conclusions: The brief physical activity assessment tool is a reliable instrument, with validity similar to that of more detailed self report measures of physical activity. It is a tool that can be used efficiently in routine primary healthcare services to identify insufficiently active patients who may need physical activity advice.

Perceptions of the Physical Environment, Stage of Change for Physical Activity, and Walking among Australian Adults

Abstract Data for this study were from a population survey of 1,200 adults ages 40–60 years, sampled from the Illawarra region of New South Wales. Questionnaire items on perceptions of the environment were factor analyzed into: Aesthetic Environment and Practical Environment. For both factors, those in the Contemplation stage had more negative views of the environment than those in Maintenance. Those who walked for 0–20 min/week held more negative perceptions of their environment than those who walked for 21–120 min/week and those who walked for > 120 min/week. The health promotion implications of these findings are that environments perceived as attractive and as providing convenient access to services and facilities may influence motivational readiness for physical activity and time spent walking.

Cost-Effectiveness of a Telephone-Delivered Intervention for Physical Activity and Diet

Background Given escalating rates of chronic disease, broad-reach and cost-effective interventions to increase physical activity and improve dietary intake are needed. The cost-effectiveness of a Telephone Counselling intervention to improve physical activity and diet, targeting adults with established chronic diseases in a low socio-economic area of a major Australian city was examined. Methodology/Principal Findings A cost-effectiveness modelling study using data collected between February 2005 and November 2007 from a cluster-randomised trial that compared Telephone Counselling with a “Usual Care” (brief intervention) alternative. Economic outcomes were assessed using a state-transition Markov model, which predicted the progress of participants through five health states relating to physical activity and dietary improvement, for ten years after recruitment. The costs and health benefits of Telephone Counselling, Usual Care and an existing practice (Real Control) group were compared. Telephone Counselling compared to Usual Care was not cost-effective (

Population-Based Randomized Controlled Trial of a Stage-Targeted Physical Activity Intervention

78,489 per quality adjusted life year gained). However, the Usual Care group did not represent existing practice and is not a useful comparator for decision making. Comparing Telephone Counselling outcomes to existing practice (Real Control), the intervention was found to be cost-effective (

Randomized trial of a neighborhood environment-focused physical activity website intervention.

29,375 per quality adjusted life year gained). Usual Care (brief intervention) compared to existing practice (Real Control) was also cost-effective (

Comparative Effects of Home-and Group-Based Exercise on Balance Confidence and Balance Ability in Older Adults : Cluster Randomized Trial

12,153 per quality adjusted life year gained). Conclusions/Significance This modelling study shows that a decision to adopt a Telephone Counselling program over existing practice (Real Control) is likely to be cost-effective. Choosing the ‘Usual Care’ brief intervention over existing practice (Real Control) shows a lower cost per quality adjusted life year, but the lack of supporting evidence for efficacy or sustainability is an important consideration for decision makers. The economics of behavioural approaches to improving health must be made explicit if decision makers are to be convinced that allocating resources toward such programs is worthwhile. Trial Registration This paper uses data collected in a previous clinical trial registered at the Australian Clinical Trials Registry, Australian New Zealand Clinical Trials Registry: Anzcrt.org.au ACTRN012607000195459