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In the quest to discover the next high-technology solution to solve many health problems, proven established technologies are often overlooked in favor of more “technologically advanced” systems that have not been fully explored for their applicability to support behavior change theory, or used by consumers. Text messages or SMS is one example of an established technology still used by consumers, but often overlooked as part of the mobile health (mHealth) toolbox. The purpose of this paper is to describe the benefits of text messages as a health promotion modality and to advocate for broader scale implementation of efficacious text message programs. Text messaging reaches consumers in a ubiquitous real-time exchange, contrasting the multistep active engagement required for apps and wearables. It continues to be the most widely adopted and least expensive mobile phone function. As an intervention modality, text messaging has taught researchers substantial lessons about tailored interactive health communication; reach and engagement, particularly in low-resource settings; and embedding of behavior change models into digital health. It supports behavior change techniques such as reinforcement, prompts and cues, goal setting, feedback on performance, support, and progress review. Consumers have provided feedback to indicate that text messages can provide them with useful information, increase perceived support, enhance motivation for healthy behavior change, and provide prompts to engage in health behaviors. Significant evidence supports the effectiveness of text messages alone as part of an mHealth toolbox or in combination with health services, to support healthy behavior change. Systematic reviews have consistently reported positive effects of text message interventions for health behavior change and disease management including smoking cessation, medication adherence, and self-management of long-term conditions and health, including diabetes and weight loss. However, few text message interventions are implemented on a large scale. There is still much to be learned from investing in text messaging delivered research. When a modality is known to be effective, we should be learning from large-scale implementation. Many other technologies currently suffer from poor long-term engagement, the digital divide within society, and low health and technology literacy of users. Investing in and incorporating the learnings and lessons from large-scale text message interventions will strengthen our way forward in the quest for the ultimate digitally delivered behavior change model.

Increasing physical activity (PA) levels in adolescents aged 12 to 18 years is associated with prevention of unhealthy weight gain and improvement in cardiovascular fitness. The widespread availability of mobile health (mHealth) and wearable devices offers self-monitoring and motivational features for increasing PA levels and improving adherence to exercise programs. The aim of this scoping review was to identify the efficacy or effectiveness of mHealth intervention strategies for facilitating PA among adolescents aged 12 to 18 years. We conducted a systematic search for peer-reviewed studies published between 2008 and 2018 in the following electronic databases: PubMed, Google Scholar, PsychINFO, or SportDiscus. The search terms used included mHealth or \"mobile health\" or apps, \"physical activity\" or exercise, children or adolescents or teens or \"young adults\" or kids, and efficacy or effectiveness. Articles published outside of the date range (July 2008 to October 2018) and non-English articles were removed before abstract review. Three reviewers assessed all abstracts against the inclusion and exclusion criteria. Any uncertainties or differences in opinion were discussed as a group. The inclusion criteria were that the studies should (1) have an mHealth component, (2) target participants aged between 12 and 18 years, (3) have results on efficacy or effectiveness, and (4) assess PA-related outcomes. Reviews, abstracts only, protocols without results, and short message service text messaging-only interventions were excluded. We also extracted potentially relevant papers from reviews. At least 2 reviewers examined all full articles for fit with the criteria and extracted data for analysis. Data extracted from selected studies included study population, study type, components of PA intervention, and PA outcome results. Overall, 126 articles were initially identified. Reviewers pulled 18 additional articles from excluded review papers. Only 18 articles were passed onto full review, and 16 were kept for analysis. The included studies differed in the sizes of the study populations (11-607 participants), locations of the study sites (7 countries), study setting, and study design. Overall, 5 mHealth intervention categories were identified: website, website+wearable, app, wearable+app, and website+wearable+app. The most common measures reported were subjective weekly PA (4/13) and objective daily moderate-to-vigorous PA (5/13) of the 19 different PA outcomes assessed. Furthermore, 5 of 13 studies with a control or comparison group showed a significant improvement in PA outcomes between the intervention group and the control or comparison group. Of those 5 studies, 3 permitted isolation of mHealth intervention components in the analysis. PA outcomes for adolescents improved over time through mHealth intervention use; however, the lack of consistency in chosen PA outcome measures, paucity of significant outcomes via between-group analyses, and the various study designs that prevent separating the effects of intervention components calls into question their true effect.

Youth homelessness is a substantial issue, and many youths experiencing homelessness have mental health issues as both a cause and consequence of homelessness. These youths face many barriers to receiving traditional mental health services, and as a result, only a few youths experiencing homelessness receive any form of mental health care. This project aimed to develop and determine the feasibility and acceptability of engaging young adults (ie, individuals aged 18-24 years) experiencing homelessness in a remotely delivered mental health intervention. This intervention provided brief emotional support and coping skills, drawing from cognitive behavioral principles as an introduction into psychosocial support. The intervention was piloted in a homeless shelter network. A total of 35 young adults experiencing homelessness participated in a single-arm feasibility pilot trial. Participants received a mobile phone, a service and data plan, and 1 month of support from a coach consisting of up to 3 brief phone sessions, text messaging, and mobile mental health apps. We evaluated feasibility by looking at completion of sessions as well as the overall program and acceptability with satisfaction ratings. We also collected clinical symptoms at baseline and the end of the 1-month support period. We used validity items to identify participants who might be responding inappropriately and thus only report satisfaction ratings and clinical outcomes from valid responses. Most participants (20/35, 57%) completed all 3 of their phone sessions, with an average of 2.09 sessions (SD 1.22) completed by each participant. Participants sent an average of 15.06 text messages (SD 12.62) and received an average of 19.34 messages (SD 12.70). We found higher rates of satisfaction among the participants with valid responses, with 100% (23/23) of such participants indicating that they would recommend participation to someone else and 52% (12/23) reporting that they were very or extremely satisfied with their participation. We found very little change from pre- to posttreatment on measures of depression (d=0.27), post-traumatic stress disorder (d=0.17), and emotion regulation (d=0.10). This study demonstrated that it was feasible to engage homeless young adults in mental health services in this technology-based intervention with high rates of satisfaction. We did not find changes in clinical outcomes; however, we had a small sample size and a brief intervention. Technology might be an important avenue to reach young adults experiencing homelessness, but additional work could explore proper interventions to deliver with such a platform. ClinicalTrials.gov NCT03620682; https://clinicaltrials.gov/ct2/show/NCT03620682.

Exercise is a core recommended treatment for knee osteoarthritis (OA), yet adherence declines, particularly following cessation of clinician supervision. This study aims to evaluate whether a 24-week SMS intervention improves adherence to unsupervised home exercise in people with knee OA and obesity compared with no SMS. A two-group superiority randomized controlled trial was performed in a community setting. Participants were people aged 50 years with knee OA and BMI ≥30 kg/m who had undertaken a 12-week physiotherapist-supervised exercise program as part of a preceding clinical trial. Both groups were asked to continue their home exercise program unsupervised three times per week for 24 weeks and were randomly allocated to a behavior change theory-informed, automated, semi-interactive SMS intervention addressing exercise barriers and facilitators or to control (no SMS). Primary outcomes were self-reported home exercise adherence at 24 weeks measured by the Exercise Adherence Rating Scale (EARS) Section B (0-24, higher number indicating greater adherence) and the number of days exercised in the past week (0-3). Secondary outcomes included self-rated adherence (numeric rating scale), knee pain, physical function, quality of life, global change, physical activity, self-efficacy, pain catastrophizing, and kinesiophobia. A total of 110 participants (56 SMS group and 54 no SMS) were enrolled and 99 (90.0%) completed both primary outcomes (48/56, 86% SMS group and 51/54, 94% no SMS). At 24 weeks, the SMS group reported higher EARS scores (mean 16.5, SD 6.5 vs mean 13.3, SD 7.0; mean difference 3.1, 95% CI 0.8-5.5; P=.01) and more days exercised in the past week (mean 1.8, SD 1.2 vs mean 1.3, SD 1.2; mean difference 0.6, 95% CI 0.2-1.0; P=.01) than the control group. There was no evidence of between-group differences in secondary outcomes. An SMS program increased self-reported adherence to unsupervised home exercise in people with knee OA and obesity, although this did not translate into improved clinical outcomes. Australian New Zealand Clinical Trials Registry 12617001243303; https://tinyurl.com/y2ud7on5. RR2-10.1186/s12891-019-2801-z.

Mental health and substance use disorders are highly prevalent in justice-involved youth, yet only 8% of court-involved, nonincarcerated (CINI) youth in need of treatment receive it. Dual diagnosis (co-occurring psychiatric and substance use disorders) in justice-involved youth is highly predictive of recidivism. Identifying novel approaches, such as the use of mobile health (mHealth) technologies, to close this gap between need and receipt of behavioral health treatment for the CINI population could potentially offset rates of reoffending into adulthood. Text-messaging (short message service, SMS) interventions have demonstrated efficacy in improving treatment adherence and other associated outcomes in other vulnerable youth populations, but development and testing of mHealth interventions to improve behavioral health treatment rates and outcomes for CINI youth are lacking. This study aimed to collect qualitative data from key stakeholders to inform the development of a theoretically grounded, family-based text-messaging (SMS) intervention targeting CINI youth's behavioral health treatment engagement; additionally, the aim was to conduct end-user testing over 6 months with CINI youth and caregivers to determine intervention feasibility and acceptability. CINI youth and caregivers were referred from a California-based Juvenile Probation Department and community-based provider organizations providing services for justice-involved youth. Eligibility criteria included the following: being a justice-involved youth or a caregiver of a justice-involved youth, English speaking, youth aged 13 to 17 years old and either referred to or currently attending mental health or substance use treatment, and youth and caregiver have access to a cell phone with text-messaging capability. Overall, 28 individuals participated in focus groups and interviews-8 youth, 5 caregivers, and 15 juvenile justice (JJ) personnel. Three major themes emerged: (1) texting among JJ personnel and CINI youth and caregivers in their caseload is common but not systematic, (2) stigma and privacy are perceived as barriers to texting youth about behavioral health treatment appointments, and (3) messages should be short, simple, relatable, positive, and personalized. In total, 9 participants (7 youth and 2 caregivers) participated in end-user testing and rated the intervention as useful, helpful, and supportive. Text messaging (SMS) is an acceptable and feasible means of reminding CINI youth to attend behavioral health treatment appointments. Future implementation challenges include making text messaging (SMS) personalized and tailored but not resource intensive (eg, requiring one-to-one, 24/7 human contact) and identifying which systems will deliver and sustain the intervention. Text messaging (SMS) among justice personnel, youth, and their caregivers is already widespread, but lack of clear guidelines about privacy, confidentiality, and information sharing poses ethical conundrums. Future hybrid-type research designs that explore the efficacy of the intervention while also studying ethical, system, and policy-level factors associated with using digital health interventions to improve CINI youth outcomes is a key next step.

Mindfulness training shows promise for improving smoking cessation and lapse recovery, and between-session mobile health messages could enhance treatment engagement and effectiveness. Personalized, in-the-moment text messaging support could be particularly useful for low-income smokers with fewer smoking cessation resources. This pilot study examined the feasibility of a text messaging program (iQuit Mindfully) as an adjunct to in-person Mindfulness-Based Addiction Treatment (MBAT) for smoking cessation. A total of 71 participants were randomly assigned to MBAT (n=33) or iQuit Mindfully (n=38; MBAT + between-session text messages); of these, 70% (50/71) were African American, and 61% (43/71) had an annual household income of US $30,000 or less. All participants received 8 weekly therapist-led group counseling sessions, nicotine patches, and self-help materials. Outcomes were feasibility (attrition, engagement, and participants' ratings), participants' feedback regarding the text messaging intervention, and smoking cessation (assessed in person). Strong retention was achieved (76% [54/71] at the end of treatment, and 89% [63/71] at 1-month follow-up). In the iQuit Mindfully group, engagement was high (88% [29/33] indicated reading all or most texts, and 89% [34/38] engaged in interactive texting), and participants provided positive ratings (on a 1-10 scale, average rating for recommending the program to others was 8.4 [SD 2.5]). Participants indicated benefiting from the texts (eg, appreciating encouraging reminders, coping strategies, and social support) and suggested improvements (eg, more personalization). Overall, biochemically confirmed smoking cessation rates were 22% (12/55) at the end of treatment and 19% (12/62) at 1-month follow-up, with no differences between conditions. Living below the poverty level predicted worse cessation outcomes at 1-month follow-up among participants receiving in-person only treatment (P=.03) but not among those receiving iQuit Mindfully. Text messaging appears to be a feasible and acceptable modality for supporting mindfulness-based smoking cessation treatment. The availability of 24/7 text messaging might be particularly helpful for low-income smokers who have access to fewer cessation resources and experience significant day-to-day barriers to quitting. ClinicalTrials.gov NCT03029819; https://clinicaltrials.gov/ct2/show/NCT03029819.

Sexting is the sending or receiving of sexually explicit or sexually suggestive images or video, usually via mobile devices. Despite widespread public concern about these behaviors as they occur among adolescents, including potentially serious legal consequences, relatively little research has been done to estimate the frequency of sexting among middle and high school students. The current study contributes to this scant body of knowledge by reporting prevalence rates for sending and receiving sexually explicit images or video among a nationally representative sample of 5593 American middle and high school students. Overall, approximately 13% of students reported that they had sent a sext, while 18.5% had received a sext. About one-third of those who sext had done it just one time. Rates of asking for, being asked for, and sharing of sexts are also presented, and are broken down further by gender, sexual orientation, race, and age. Implications for preventing sexting behaviors with these results in mind are also discussed.

Of the 14.3 million Mexicans who smoke, only a minority take advantage of evidence-based approaches to smoking cessation. Mobile health interventions have the potential to increase the reach of effective cessation interventions in Mexico. This study aimed to assess the feasibility and acceptability of an innovative, personalized, and interactive smoking cessation mobile intervention developed for Mexican smokers. We recruited 40 Mexican smokers to participate in Vive sin Tabaco... ¡Decídete!, a smoking cessation program that uses a tablet-based decision support software to drive a 12-week text messaging smoking cessation program and pharmacotherapy support. Outcome measures included participant text messaging interactivity with the program, participant satisfaction, and 12-week verified abstinence using urinary cotinine testing or exhaled carbon monoxide. Average age of the participants was 36 years (SD 10.7), and they were primarily male (65%, 26/40) with at least an undergraduate degree (62%, 25/40). Most participants (95%, 38/40) smoked daily and were interested in quitting in the next 7 days. As an indicator of participant interactivity, participants sent an average of 21 text messages during the 12-week intervention (SD 17.62). Of the 843 messages that participants sent to the program, only 96 messages (11.3%, 96/843) used keywords. At 12 weeks, 40% (16/40) of participants were biochemically verified (87%, 35/40, follow-up rate). The majority of participants (85%, 30/35) reported being very satisfied or extremely satisfied with the program. The Vive sin Tabaco... ¡Decídete! smoking cessation mobile intervention was accepted by participants, generated high satisfaction and high text messaging interactivity, and resulted in a noteworthy cessation rate at the end of treatment. This intervention is a promising strategy for smoking cessation in Mexico. Additional testing as a formal randomized clinical trial appears warranted.

Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain. This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries. Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups. A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone-based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04). In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference. ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546.

Two-way interactive text messaging between patient and community health workers (CHWs) through mobile phone SMS (short message service) text messaging is a form of digital health that can potentially enhance patient engagement in young adults and families that have a child with chronic medical conditions such as diabetes mellitus, sickle cell disease, and asthma. These patients have complex needs, and a user-centered way can be useful for designing a tool to address their needs. The aim of this study was to utilize the user-centered approach of design thinking to develop a two-way interactive communication SMS text messaging tool for communication between patients or caregivers and CHWs. We applied a design thinking methodology for development of the SMS text messaging tool. We collected qualitative data from 127 patients/caregivers and 13 CHWs, health care professionals, and experts. In total, 4 iterative phases were used to design the final prototype. The design thinking process led to the final SMS text messaging tool that was transformed from a one-dimensional, template-driven prototype (phases 1 and 2) into a dynamic, interactive, and individually tailored tool (phases 3 and 4). The individualized components consider social factors that influence patients' ability to engage such as transportation issues and appointment reminders. SMS text messaging components also include operational factors to support staff such as patient contact lists, SMS text messaging templates, and technology chat support. Design thinking can develop a tool to meet the engagement needs of patients with complex health care needs and be user-friendly for health care staff.