Study design
This prospective, one-group, pre-post study targeted women ages 40 and older living in Stephenson County, IL.
Setting
At the time of this study, Stephenson County, in rural, northwest Illinois, had a population of 47,315 [34]. It is considered “nonmetropolitan” based on the Rural Urban Continuum Codes [35]. The county is predominantly white, non-Hispanic (87%), with a median age of 43.7 years [34]. Women living in Stephenson County have a high prevalence of chronic disease risk factors. In 2013, 36% reported having high blood pressure, 37% had high cholesterol, 38% were overweight, and 22% were obese [36]. Additionally, 46% did not meet weekly PA standards and an additional 11% were inactive [36].
This study was conducted between August 2014-January 2015 in collaboration with the Stephenson County Health Department (SCHD). This study was approved by the University of Illinois at Rockford Institutional Review Board.
Inclusion and exclusion criteria
Inclusion criteria were English-speaking, women aged 40 and older, residing in Stephenson County, owned a cell phone with texting capability, and an unlimited texting plan.
Exclusion Criteria were a self-reported diagnosis of bronchitis, pneumonia, or severe asthma, or those being treated for a severe health conditions.
Enrollment
Flyers advertising the study were placed in the grocery stores and the health department, and interested participants called the lead researcher who assessed eligibility using a checklist. Eligible women were invited to one of five enrollment meetings at SCHD. At least two follow-up calls were made to interested women who did not attend their scheduled enrollment meeting to invite them to the next meeting. A total of 56 women were screened and all met the study eligibility criteria; 44 women (78.6%) came for the enrollment appointment and were enrolled in the study. At the enrollment meetings, participants provided written consent, received a pedometer (Omron HJ-720ITC) and were trained on how to use it. In addition, they completed a series of baseline instruments detailed below and were provided educational materials on cardiovascular disease risk reduction through PA and healthy eating.
Intervention
There were two components to the 13-week, Step-2-It intervention: (i) participants used the pedometer to track and report their steps via text message daily; and (ii) participants received an informational or motivational text message daily.
Pedometer/Step Reporting: Starting in week 0, participants self-reported daily step counts via text message, and continued to do so for the duration of the 13-week intervention. Participants received a daily text reminder to report their steps. Those who did not report steps for two days in a row received a reminder phone call. Every three weeks, participants returned to SCHD to have their pedometer data downloaded. Participants received a $5 incentive for each download, for a total of $20 over 13 weeks.
Text messaging: Text messages were sent using mytapp, an online application that allowed for scheduling individual and recurring messages via a cloud service, Twilio. Text messages used for this study were limited to 160 characters and participants could choose their preferred time of day to receive texts. In week 0, the only message participants received were to remind them to report their steps. From week 1-12, in addition to the reminder to report steps, participants received one informational or motivational text message per day (7 messages/week). All participants received the same text messages each day.
Motivational messages were based on social cognitive theory [37] with the intention of increasing participant self-efficacy to engage in PA. These messages were adapted from a database of messages from a previous study to increase PA among African American breast cancer survivors [38]. Adaptations were made to the messages based on two focus groups conducted with 20 women in the target population prior to this study (unpublished study). Sample motivational messages included, “Nothing is impossible. The word itself says “I’m Possible!”and “Always focus on how far you have come, rather than how far you have left to go.”
Informational messages included local, PA-related events and resources, such as walks and low-cost walking options. Sample information messages included, “Walk for a cause – sign up for charity walks” and “Find a friend to walk with.” In addition, there were also messages that reminded women to walk. These messages included, “Check out what is going on outside, go for a walk”, “Don’t just think about it, actually go for a walk”, and “Take a quick walking break.”
Data collection and measures
Data collected for this study along with the time-points at which they were collected are described below.
Participant characteristics (collected at baseline)
Participant demographic information including age, race, education, marital status, employment, and household income; and health status information including self-reported previous diagnosis of diabetes, hypertension, high blood cholesterol, and other heart health diagnoses, medication use for chronic conditions, and tobacco use.
Physical activity questionnaire (collected at baseline and post-intervention)
Self-reported PA was assessed using seven questions from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) Physical Activity questionnaire [39]. These data were used to determine whether participants met the recommended aerobic PA levels. Questionnaire reliability and validity have been established previously [40].
Physical activity pedometer readings (collected at weeks 3,6,9, and 12) and self-reported steps (collected daily)
The primary outcome measure was number of steps. The Omron HJ-720ITC pedometer, validated in previous studies [41,42,43], was used for an objective measure of steps. Data was downloaded from the pedometers every three weeks. Participants also self-reported daily steps via text message.
Body weight (collected at baseline and postintervention)
Weight was measured using a calibrated scale at SCHD.
Intervention satisfaction (collected at post-intervention)
Was assessed using a survey that included questions on overall perceptions about Step-2-It, number of messages received, preferred message types, perceptions about the effectiveness of text messages in promoting health and PA and plans to continue PA after participating in Step-2-It. Participants were also asked about barriers to reporting steps. Participants who completed this survey received a $20 incentive.
Data analysis
Participants who completed the post-intervention assessment (35/44) were included in the analysis. Descriptive statistics were used to characterize the study population and assess post-intervention satisfaction. Baseline to post-intervention comparisons for body weight were conducted using the paired categorical Wilcoxon Sign rank test. Comparisons of BRFSS PA level was conducted using the Chi-square test. Self-reported step data were compared to downloaded step data and a Pearson correlation was calculated. Correlation testing for self-reported steps versus pedometer-recorded steps excluded observations where only one variable was present. For analyzing mean steps, missing pedometer data was filled in with self-reported step data. Mean steps by week of intervention was calculated and a box plot of mean daily steps by intervention week was produced. We compared step counts at week 0 and week 12 using a matched pair comparison.
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