Is Text-Messaging a Useful Adjunct
to Coach-Client Meetings?
A 2015 article in the Journal of the American Medical Association reported on a study examining the impact of semi-personalized lifestyle-focused text messaging as an intervention to modify risk factors in individuals with pre-existing heart disease.
Why might this article be of interest to ADHD coaches?
Most coaching focuses on behavior modification. If text messaging is found to be an effective intervention to support behavior change, it certainly would be a valuable tool for coaches and clients to consider. In fact, many ADHD coaches already offer either client- or coach-originated check-ins to provide reminders and/or accountability between coaching sessions. Understanding what research says about text message interventions and behavior change might help in better understanding the utility of that practice.
Chow and colleagues (2015) conducted a randomized clinical trial – a type of study considered the gold standard in health care – to examine the effect of text messaging as a behavior change intervention. The study included 352 individuals with known heart disease in the intervention group, receiving text messages in addition to usual health care, and a similar number (358) receiving just their usual care.
Those in the intervention group received 4 text messages per week for six months (approximately 96 texts); the messages were selected at random from a bank of messages about risk factors for heart disease – i.e. smoking, diet, physical activity and general heart health – semi-personalized “according to baseline characteristics (e.g. smoking)” and with the individual’s name sometimes inserted. Messages were delivered via an automated computerized message management system and were not interactive (p. 1255).
After the six month texting intervention, when compared with those receiving only usual care, the individuals receiving the text messages had modest improvements in their lipid profiles (a risk factor for heart disease) and greater improvement in other relevant risk factors – including blood pressure measurements, BMI (body-mass index), amount of exercise, and achievement of non-smoking status. The proportion of individuals achieving target guideline levels in multiple risk factors was substantially higher in the intervention (text message) group as compared to the controls (usual care only) with over 60% achieving target levels in at least 3 of 5 risk factors. For one risk factor, smoking, no improvement at all occurred in the control group; and for blood pressure, another risk factor, the control group actually worsened over time.
Chow and colleagues (2015, p. 1262) report that other research has examined the effectiveness of text messaging to change single individual health behaviors including smoking, weight loss, physical activity, adherence to asthma treatment, and others. One of the papers cited was a 2009 review of 14 studies of text-messaging behavior change interventions finding short term behavioral benefits, and also indicating that one feature missing in the Chow study – interactivity – was an important feature to consider (Fjeldsoe, Marshall & Miller, 2009).
Of note, while most of the reports of text-messaging as a behavior intervention focus on adults, at least one study examined text messaging as a support for children, ages 8-18 years of age, with diabetes (Franklin, Waller, Pagliari & Green, 2006). In this randomized controlled trial, some children received conventional treatment for diabetes and others received conventional treatment plus individualized goal setting at the monthly clinic appointments and daily text messages. The texts included a weekly reminder of the goal set at the appointment as well as tips, information or reminders tailored to age, gender and to reinforce the identified goal; these specific messages were drawn from “a database … that encompass[ed] the four main diabetes self-management tasks” (Franklin, et al., 2006, p. 1333). In relation to a comparison group, the children and teens receiving goal setting at appointments followed by daily text messages demonstrated improved self-efficacy as well as improved treatment adherence. The improvement in self-efficacy may be of particular interests to coaches.
The Chow et al. (2015) study adds to prior research by examining multiple factors impacting an outcome, using objective health measures to document findings, and including a larger sample size than most prior studies of text messaging interventions. One limitation of this study is that the health outcome measures were taken only at the beginning and cessation of the text messaging (6 months) and no longer-term follow up examined sustainability of health behavior improvements.
This study builds on prior research suggesting that text-messaging may be a beneficial behavior-change intervention. As distinct from coaching with text message support, this study used only text messaging to support behavior change, finding beneficial outcomes. The Franklin et al. (2006) study of children with diabetes is a bit more similar to coaching, including goal-setting at appointments. One could imagine that the combination of coaching and text messaging might be even more profound!
Some questions to consider:
• How do you and your clients currently use texting, email, or phone calls in between
appointments to support behavior change?
• How might you discuss, and perhaps construct, a text-messaging support
intervention with any of your clients?
• What types of individualized messages might each client find helpful?
• Would you target one behavior change, or multiple as in the Chow et al. (2015)
• This study found an effect with an intervention involving 4 text messages a week.
The pediatric diabetes study (Waller, Pagliari & Green, 2006) used daily texts.
What frequency makes sense to each client?
• Fjeldsoe and colleagues’s (2009) review of studies suggested that interactivity of
text messaging might be useful. How might you and your clients incorporate this?
• This study – as well as the diabetes study (Franklin et al., 2006) – used
semi-personalized automated text messaging. Have you, or any of your clients,
ever tried using an automated texting service? What might be the benefits and
• What else might you want to know about text messaging as an intervention?
Chow, C. K., Redfern, J., Hillis, G. S., et al. (2015). Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: A randomized clinical trial. Journal of the American Medical Association, 314(12), 1255-1263. Accessed: www.jamanetwork.com
Fjeldsoe, B. S., Marshall, A. L., & Miller, Y. D. (2009). Behavior change interventions delivered by mobile telephone short-message service. American Journal of Preventive Medicine, 36(2), 165-73. Abstract accessed at: www.ajpmonline.org
Franklin, V. L., Waller, A., Pagliari, C., Greene, S. A. (2006). A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes. Diabetic Medicine, 23(12), 1332-1338. Accessed at: www.onlinelibrary.wiley.com
Elizabeth Ahmann, ScD, RN, PCC
ACO Research Committee