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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Text messaging as a tool for behavior change in disease prevention and management

H Cole-Lewis and T Kershaw.

Review published: 2010.

CRD summary

The authors of this review considered that the research agenda for text messaging and behaviour change should be approached with urgency as it may be an important tool for providing effective disease prevention and management support. The authors' conclusions should be treated with some caution given methodological limitations identified in the review.

Authors' objectives

To assess the effectiveness of behaviour change interventions for disease prevention or management delivered mainly through text messaging.


Electronic searches were conducted between May and June 2009 using MEDLINE, The Cochrane Library and PsycINFO databases and Google Scholar. Reference checking of retrieved articles and citation searching was conducted. Studies needed to be published in a peer-reviewed journal. Studies published in languages other than English were included only where a full-text English-language version existed.

Study selection

Eligible studies needed to be randomised or quasi-experimental controlled trials of interventions for disease prevention or management conducted in any population that used text messaging as the primary mechanism for intervention delivery. Studies were required to assess change in health behaviour, health outcomes and/or clinical outcomes using pre-post tests. Feasibility and pilot studies were eligible. Studies that used communication technologies other than text messaging were included only if the other technologies were used in a supplementary way. Interventions mainly for appointment reminders were excluded, as were adherence studies unless they targeted an ongoing preventive health behaviour.

Five studies were concerned with disease prevention and seven dealt with disease management. Disease prevention included medication adherence, weight loss, physical activity and smoking cessation. All disease-management studies targeted diabetes except for one that focused on management of asthma. Studies were conducted worldwide; only one took place in a developing country. Studies were published between 2005 and June 2009. All studies except one targeted people with a specific condition. Age ranged from 15 years to 45 years. Four studies specifically targeted adolescents and young adults. Gender was almost equally distributed in most studies. Intervention length ranged from three months to 12 months.

Outcomes analysed included adherence to vitamin C, changes in waist circumference, dietary habits, changes in physical activity, smoking, glycaemic control and glucose levels. Some studies included intermediate follow-up. No studies had long-term follow-up that extended beyond completion of the trial. Frequency of text messaging ranged from once weekly to five times a day or more. A small number of studies allowed participants to dictate the frequency of messaging. All disease prevention studies used automated messaging and, despite this, provided tailored messages in all studies except one.

The authors did not state how many reviewers were involved in the selection of studies for the review.

Assessment of study quality

Quality of study design was assessed based on nine methodological characteristics adapted from a previously published review: individual randomisation, use of a control group for comparison, isolation of text messaging technology, use of pre-post-test design, retention, equivalence of baseline groups, consideration of missing data, power analysis for sample size consideration and validity of measures. The range of possible scores was zero to 100% and no minimum was necessary for inclusion in the review.

The authors stated neither how many reviewers were involved in study assessment nor how disagreements were resolved.

Data extraction

Results of included studies were extracted as reported.

The authors did not state how data were extracted for the review.

Methods of synthesis

A narrative synthesis was conducted.

Results of the review

Twelve studies were included in the review. Sample size ranged from 16 to 1,705 participants: nine randomised controlled trials (RCTs), two crossover trials and one quasi-experimental trial. Average study design scores were 76% for disease prevention and 81% for disease management. Retention was above 80% in nine studies. Two studies specified a theoretical framework. All studies blinded participants and two studies blinded research staff. In nine studies, researchers provided increased communication with text messaging groups compared with standard care. Four of 12 studies failed to isolate the effect of the text messaging intervention. Only two studies assessed whether text messaging was as effective as other technologies for communication.

Three studies reported not having enough statistical power to detect an effect. Eight of the other nine studies found evidence to support text messaging as a tool for behaviour change in disease prevention and management. Significant behaviour change outcomes in individual studies included smoking cessation and increased frequency of blood glucose monitoring. Individual studies that investigated adherence to vitamins and physical activity showed inconclusive results.

Significant clinical outcomes noted included weight loss and decrease in haemoglobin A1c levels in adolescents and obese and non-obese adults with diabetes. Results of peak expiratory volume tests in adults with asthma did not find differences between treatment groups.

Authors' conclusions

The research agenda for text messaging and behaviour change should be approached with urgency. Text messaging may be an important tool for providing more effective disease prevention and management support.

CRD commentary

This review was underpinned by defined criteria for study design, population, intervention and outcomes. Searching encompassed a range of sources. Unpublished material was not eligible for inclusion, which risked publication bias. Exclusion of research in languages other than English may have led to material being missed. Validity was assessed. It was unclear whether more than one reviewer was involved in the processes of study selection, data extraction and validity assessment; use of more than one reviewer would have helped protect against bias and error. A narrative synthesis was appropriate given the variation between studies.

The authors' conclusions should be interpreted with some caution given the limitations identified in the conduct of the review.

Implications of the review for practice and research

Practice: The authors did not state any specific implications for practice.

Research: The authors stated that additional information on efficacy of text messaging as a tool for behaviour change could be gained from systematic reviews of non-randomised trials. Future primary studies should use rigorous methods and be sufficiently powered to quantify the effect of any behaviour change on clinical outcomes and public health. More information was needed on the aspects of text messaging that produced the best outcomes and on any long-term effects. Future studies should consider how text messages were framed for a given population and assess any ethical concerns. Cost-benefit analyses should be considered.


National Institute of Mental Health (T32 MH020031).

Bibliographic details

Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiologic Reviews 2010; 32(1): 56-69. [PMC free article: PMC3082846] [PubMed: 20354039]

Indexing Status

Subject indexing assigned by NLM


Cell Phones /utilization; Disease Management; Humans; Risk Reduction Behavior; User-Computer Interface



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 20354039


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