Enhancement of care through self-monitoring and tailored feedback via text messaging and their use in the treatment of childhood overweight

https://doi.org/10.1016/j.pec.2010.03.014Get rights and content

Abstract

Objective

This paper first illustrates the general potential of the short message service (SMS) for symptom and behavior monitoring and the provision of tailored feedback. Second, an SMS-based maintenance treatment (SMSMT) is introduced aimed at enhancing the treatment of childhood overweight.

Methods

After a 12-week cognitive behavioral group treatment (CBGT), 40 children were assigned to the SMSMT for a period of 36 weeks. Children were asked to send weekly self-monitoring data on eating behavior, exercise behavior, and emotions and received tailored feedback. The adherence to SMSMT and changes in Body Mass Index Standard Deviation Scores (BMI-SDS) during the first and second treatment phase were analysed.

Results

Children (mean age = 10.05, SD = 1.28) submitted 67% of the weekly SMS that they were expected to send in. During CBGT a significant reduction by 0.20 BMI-SDS was observed. The reduction by 0.07 BMI-SDS during the SMSMT did not reach statistical significance.

Conclusion

The results support the feasibility of SMSMT in the treatment of childhood overweight. The efficacy of the intervention needs to be demonstrated in an RCT.

Practice implications

SMSMT is a promising intervention that may extend the reach of treatment centers for childhood overweight at reasonable cost and effort.

Introduction

Over the past decades, psychotherapy research has established the overall positive effects of psychotherapeutic interventions on mental health and behavior change and well-being. However, research has also proven the shortcomings of existing treatments. A substantial proportion of individuals either do not respond to treatment, fail to fully recover or relapse after successful completion of a treatment program. Other limitations concern failure to take up treatment and high attrition and drop out rates [1].

In response to these findings, researchers and clinicians have mostly focused on developing and evaluating new programs rather than tackling these challenges in existing approaches. For example, very little is known about how to reduce barriers in the uptake of interventions, or ways to improve compliance, increase treatment adherence and retention or to reduce drop out rates. Similarly, it is unclear for many psychosocial interventions how positive effects can be maintained after treatment termination. Acknowledging that in many conditions sufferers have a considerable risk for relapse and many clients follow a chronic course of illness, the field is challenged to extend the reach of treatment providers thus allowing long-term support of their clients. Following the idea of stepped care [2], such extensions may precede regular treatment (“step-up” interventions such as prevention or early intervention programs) or follow thereafter (“step-down” interventions, e.g. relapse prevention or maintenance programs). In the light of limited health care resources, their implementation has to be realized with reasonable costs and efforts for the provider as well as for the client.

Approaches based on information and communication technologies (ICT) offer innovative possibilities to deal with some of the above-mentioned limitations [3]. Over the past years, a number of ICT-enhanced interventions aimed at an optimization of mental health care have been introduced. Systematic research is still in the beginning. However, evidence for the feasibility and efficacy of various ICT-based interventions is rapidly increasing (e.g. [3], [4], [5]). While the majority of approaches are based on Internet technology, mobile phones and the short message service (SMS) are also increasingly used [6], [7], [8]. Several specific advantages are inherent to their use: (1) SMS is accessible at almost any time and everywhere, (2) SMS is a fast and interactive medium, (3) SMS can be used with little effort, and (4) communication via SMS is inexpensive. Overall, mobile phones are becoming increasingly integrated into all areas of everyday life and thus may be an ideal device for delivering e-mental health interventions to clients.

To date, only a few studies evaluated SMS-based interventions. Promising findings have been reported for example for smoking cessation [9], diabetes [10] and adult weight loss programs [11]. A recent systematic review observed positive behavior change in 13 out of 14 studies and suggests that SMS-delivered interventions have positive short-term behavioral outcomes. However, methodological concerns were raised and more research in this field is required [8].

The main aim of the present paper is to illustrate the potential of SMS-based approaches for mental health promotion and enhancement of healthy behavior using the example of a recently developed intervention for the maintenance treatment of childhood overweight. Two specific aspects inherent to ICT-based interventions are of specific relevance in the context of this approach and should therefore be introduced at this point: firstly, the possibility to continuously monitor symptoms and health behaviors and secondly, the possibility to provide tailored feedback to support clients.

Approaches to continuously track clients’ impairment and symptoms during treatment (“outcome monitoring”) have gained a lot of attention in psychotherapy research over the last decade. ICT-based systems such as the monitoring software Web-Akquasi [12] allowing for repeated assessments of psychometric information at short time intervals (e.g. session by session) contributed substantially to the feasibility of monitoring approaches. They allow the provision of immediate feedback on the clients’ course of improvement to all involved parties who may use this information for further treatment optimization. Various outcome monitoring strategies have been introduced and evaluated with promising results (e.g. [13], [14]).

In the past years, mobile devices (e.g. mobile phones) further increased the flexibility of monitoring systems allowing for real-time data assessments practically at any time (i.e., independent of the availability of a computer). An increasing number of studies used such methods, referred to as e.g. ecological momentary assessment [15] or ambulatory assessment [16] which promises to substantially improve our knowledge on the longitudinal courses of symptoms and health behaviors and may ultimately lead to an improvement of care provision.

The use of mobile devices also appears to facilitate self-monitoring procedures which are an integral component of many therapeutic interventions, especially but not exclusively of those based on cognitive behavioral approaches. Some studies postulate that self-monitoring is a cornerstone for successful behavior change [17], [18]. However, adherence to self-monitoring has been found to be problematic [19]. Furthermore, the accuracy of paper–pencil self-monitoring data is questionable due to recall bias, delayed data entries, and missing information [20]. Using mobile phones as device for the entry of monitoring data may be better accepted and may improve participants’ compliance with self-monitoring [21], [22]. Additionally, they allow sending automated reminders in case that a client does not enter his data at a scheduled time-point. Another advantage is that time-stamps document the exact time of data entry impeding back entries and faked dates.

A number of studies indicate that personally tailored messages have greater impact on health behavior change than untailored or bulk messages [8], [23], [24]. ICT-based programs allow to flexibly adapt feedback in relation to specific client characteristics or health information a client provides.

Feedback messages may also take into account the specific treatment situation of the client. For example, it is known that many clients experience difficulties to transfer skills they learnt in the protected therapeutic environment to their everyday life. ICT-based step-down approaches may enhance this translation by reminding clients at regular intervals of strategies and skills acquired in treatment. For instance, Bauer et al. [6] introduced a SMS-delivered program for the maintenance treatment of patients with bulimia nervosa who underwent inpatient treatment. Following their discharge from treatment, patients submitted weekly text messages on key bulimic symptoms via SMS. A software program automatically analyses each incoming message according to a predefined algorithm (i.e. it compares the current symptoms to those of the previous week) and suggests a feedback message out of a large pool of pre-formulated statements which is tailored to the person's individual pattern of change. The feedback messages were formulated in an encouraging tone, provided social support, reminded patients of skills they learnt in the hospital, reinforced positive changes, and suggested alternative behaviors in case of deteriorations. The program has proven technically feasible and well-accepted by patients [25] and is currently studied in terms of its efficacy and cost-effectiveness. Recently, an adaptation of this program for the maintenance treatment of childhood overweight and obesity was developed for the purpose of the present study.

Worldwide, the incidence of overweight increased in all age groups in the last two decades. It is estimated that four out of five overweight adolescents become obese in adulthood [26]. This is an alarming number, especially when taking into account the increased health risks associated with overweight. It has been shown that treatment programs aimed at reducing overweight are more successful for children than for adults [27]. Eating habits and exercise patterns are not yet fully developed at a young age, which underlines the need for interventions addressing young age groups. A variety of interventions aimed at an improvement of nutrition, an increase of physical activity and a reduction of time spent with watching TV or playing computer games were studied (e.g. [28], [29], [30]). An essential component of successful programs seems to be the self-monitoring of relevant parameters, such as intake, expenditure, and weight [31]. Considering obesity as a chronic disease, maintenance treatments supporting patients on the long-term seem to be of special importance. However, the adherence to self-monitoring as well as the consequent implementation of modified lifestyle behaviors are known to be problematic. Moreover, dropout rates are a substantial concern [32].

This can be illustrated using the example of a short-term multidisciplinary cognitive behavioral group therapy (CBGT) entitled “The Big Friends Club (BFC)”. The BFC addresses overweight children aged 7–12 years and is conducted in groups of 8–10 children. The therapy is aimed at reducing Body Mass Index (kg/m2)-Standard Deviation Scores (BMI-SDS), preferably by maintaining weight during growth, adaptation of a healthy lifestyle and a positive self-image and improved self-esteem. The program comprises an intake session, 8 sessions for children, and a minimum of 3 sessions for parents during the first 3 months. At 6, 9, and 12 months after start of the program, follow-up visits are organized. The BFC has proven feasible and effective, however, the sustainability of these effects on the longer term was limited due to a high drop out rate of 33% at follow-up [33] which is comparable to drop out rates in other research [32]. To improve children's adherence to the program and to enhance the sustainability of the treatment effects, a SMS-based maintenance treatment (SMSMT) was performed by the Erasmus University Medical Centre to support children for 36 weeks after 3 months of the BFC.

We explored two research questions: First, we analysed the adherence of children to the SMSMT. Second, the maintenance effects of the intervention were explored by analyzing changes in children's BMI-SDS during the first phase (CBGT) and the second phase (SMSMT) of treatment.

Section snippets

The SMS-based maintenance treatment (SMSMT)

Following the completion of the 3-month intensive phase of the BFC, children were instructed to send in weekly self-monitoring data on relevant parameters (eating, exercise behavior, and emotions) in a standardized format via SMS for a period of 36 weeks. The SMS included the answers to the following monitoring questions: (1) For how many hours did you engage in physical activity during the last week? i.e. sporting, cycling, walking or playing outside; (2) How many days did you adhere to a

Adherence

On average, children stayed in the program for a duration of 32.60 weeks (SD = 9.69). During their participation, they submitted on average 67% of the expected weekly SMS (boys: 68%, girls: 66%). Ten children (25%) sent in more than 75% of the requested 36 weekly SMS. Five children (12.5%) submitted less than 25% of the requested SMS. The lowest number of submitted SMS was 4.

Maintenance effects

During their participation in the CBGT, children's BMI-SDS decreased on average by 0.20 (SD = 0.23; t(36) = 5.20, p < 0.001). A

Discussion

The field of e-mental health is growing and the consensus on its general potential to optimize health care is increasing among researchers and treatment providers. However, research in this area is still in an early phase and evidence is lacking for many promises. Potential benefits of technology-enhanced interventions include that they can extend the reach of treatment centers beyond the termination of traditional interventions. This paper introduced an SMS-based maintenance intervention for

Conflict of interest

None of the authors have any actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

Acknowledgements

We would like to thank Sint Franciscus Hospital Rotterdam, Maasstad Hospital location South Rotterdam, Atrium MC Heerlen, Gelderse Roos and Gelderse Vallei Hospital Ede, GGZ Helmond and Elkerliek Hospital Helmond, Scheper Hospital Emmen, Medical Centre Leeuwarden, Hospital Diakonessenhuis Zeist for their help with data collection.

Funding: No funding sources were involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to

References (35)

  • A. Barak et al.

    A comprehensive review and a meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions

    J Technol Hum Serv

    (2008)
  • S. Bauer et al.

    Use of text messaging in the aftercare of patients with bulimia nervosa

    Eur Eat Disord Rev

    (2003)
  • M.J. Boschen et al.

    The use of mobile telephones as adjuncts to cognitive behavioral psychotherapy

    Prof Psychol-Res Pr

    (2008)
  • J.L. Obermayer et al.

    College smoking cessation using cell phone text messaging

    J Am Coll Health

    (2004)
  • V.L. Franklin et al.

    A randomized controlled trial pf Sweet Talk, a text messaging system to support young people with diabetes

    Diabetic Med

    (2006)
  • R. Hurling et al.

    Using Internet and mobile phone technology to deliver an automated physical activity program: randomized controlled trial

    J Med Internet Res

    (2007)
  • R. Percevic et al.

    Computer supported monitoring of patient treatment response

    J Clin Psychol

    (2004)
  • Cited by (92)

    • Stress, craving and mood as predictors of early dropout from opioid agonist therapy

      2019, Drug and Alcohol Dependence
      Citation Excerpt :

      Obtaining EMA data from patients starting buprenorphine or methadone treatment could be a way to track and identify those patients whose stress and mood are not improving and who may benefit most from interventions such as antidepressant medication or behavioral therapy for psychological problems. In addition to monetary incentives given for complying with study requirements, the constant presence of a study-provided electronic device and frequent encounters with recovery-related EMA questions might have increased retention and medication adherence for some participants, similar to the effects of text-message reminders (Bauer et al., 2010; Krishna et al., 2009; Milward et al., 2014) or interventions that provide feedback based on EMA (Aharonovich et al., 2017a, b). Although maintaining a device and complying with EMA can be burdensome to some, the fact that few participants became noncompliant suggests that this burden was not a major factor contributing to nonretention.

    View all citing articles on Scopus
    View full text