Development and Pilot Testing of Text Messages to Help Reduce Sugar-Sweetened Beverage Intake Among Rural Caregivers and Adolescents: Mixed Methods Study

Abstract

Background A high consumption of sugar-sweetened beverages (SSBs) poses significant health concerns, particularly for rural adults and adolescents. A manner in which the health of both caregivers and adolescents can be improved is by developing innovative strategies that target caregivers as the agents of change. Sending text messages through mobile phones has been cited as an effective way to improve behavioral outcomes, although little research has been conducted in rural areas, particularly focusing on SSB intake. Objective By targeting rural caregivers, this 2-phase study aimed to (1) understand caregivers’ perceptions and language preferences for SSB-related text messages to inform and refine message development and delivery and (2) evaluate the acceptability of text messages for SSB intake behavior change and examine short-term effects on SSB intake behavior. Methods A convergent mixed methods design was used to systematically develop and pilot-test text messages with caregivers in Southwest Virginia. In phase 1, 5 focus groups that included a card-sorting activity were conducted to explore advantages/disadvantages, language preferences (ie, tone of voice, audience, and phrase preferences), and perceived use of text messages. In phase 2, caregivers participated in a 5-week text message pilot trial that included weekly educational and personalized strategy messages and SSB intake assessments at baseline and follow-up. Before the focus groups and after completing the pilot trial, caregivers also completed a pre-post survey that assessed SSB intake, SSB home availability, and caregivers’ SSB-related practices. Caregivers also completed individual follow-up telephone interviews following the pilot trial. Results In phase 1, caregivers (N=33) reported that text messages were convenient, accessible, and easy to read. In addition, they preferred messages with empathetic and authoritative tones that provided useful strategies and stayed away from using absolute words (eg, always and never). In the phase 2 pilot trial (N=30), 87% of caregivers completed baseline and 77% completed follow-up assessment, suggesting a high utilization rate. Other ways in which caregivers reported benefiting from the text messages included sharing messages with family members and friends (80%), making mental notes (57%), and looking back at messages as reminders (50%). Caregivers reported significant improvements in home environment, parenting practices, and rulemaking around SSB (P=.003, P=.02, and P=.04, respectively). In addition, the frequency of SSB intake among caregivers and adolescents significantly decreased (P=.003 and P=.005, respectively). Conclusions Spending time in the formative phases of text message development helped understand the unique perspectives and language preferences of the target population. Furthermore, delivering an intervention through text messages has the potential to improve caregiver behaviors and reduce SSB intake among rural caregivers and adolescents. Findings from this study were used to develop a larger bank of text messages, which would be used in a future study, testing the effectiveness of a text message intervention targeting SSB intake–related caregiver behaviors.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

“…media campaigns (6,137,(162)(163)(164)(165)(166)(167)(168)(169)(170) , community education (171)(172)(173)(174)(175)(176)(177)(178) and education in schools and childcare centres (179)(180)(181)(182)(183)(184)(185)(186)(187)(188)(189)(190)(191)(192)(193)(194)(195)(196) on the harms of excess added sugar consumption. Of the studies exploring this policy action (n 39), only eight (Table 4) addressed the impact that education interventions to reduce added sugar intake may have on NNS consumption and levels in the food supply.…”

Retention and engagement of rural caregivers of adolescents in a short message service intervention to reduce sugar-sweetened beverage intake

“…Message content, framing, and procedures for the caregiver SMS intervention underwent pilot testing that informed the current trial. 11 …”

“… 8 – 10 Targeting caregivers provides a two-fold benefit, as it may help reduce their own intake and help them decrease their child's SSB intake. 11 However, there are many challenges to reaching adolescents and their caregivers in rural areas, such as lack of access to or availability of primary prevention programs, lack of transportation to in-person programs, and the natural geographical dispersion. 12 In two systematic reviews including 32 interventions, only one study explicitly targeted a rural region, two studies effectively used scalable technology, and no study focused on adolescent caregiver behaviors and role modeling.…”

Development of a Digital Behavioral Intervention to Reduce the Consumption of Sugar-Sweetened Beverages Among Rural Appalachian Adults: Multiphased, Human-Centered Design Approach

“…Consistent with both national and Appalachia-specific data showing that SSB is the largest contributor to added sugar intake [27][28][29], excessive SSB consumption is undeniably pervasive in Appalachia. However, there are only a few known SSB consumption-specific behavioral interventions that have used digital technologies or applied HCD processes [30][31][32][33].…”