Developing Messaging Content for a Physical Activity Smartphone App Tailored to Low-Income Patients: User-Centered Design and Crowdsourcing Approach

Abstract

Background Text messaging interventions can be an effective and efficient way to improve health behavioral changes. However, most texting interventions are neither tested nor designed with diverse end users, which could reduce their impact, and there is limited evidence regarding the optimal design methodology of health text messages tailored to low-income, low–health literacy populations and non-English speakers. Objective This study aims to combine participant feedback, crowdsourced data, and researcher expertise to develop motivational text messages in English and Spanish that will be used in a smartphone app–based texting intervention that seeks to encourage physical activity in low-income minority patients with diabetes diagnoses and depression symptoms. Methods The design process consisted of 5 phases and was iterative in nature, given that the findings from each step informed the subsequent steps. First, we designed messages to increase physical activity based on the behavior change theory and knowledge from the available evidence. Second, using user-centered design methods, we refined these messages after a card sorting task and semistructured interviews (N=10) and evaluated their likeability during a usability testing phase of the app prototype (N=8). Third, the messages were tested by English- and Spanish-speaking participants on the Amazon Mechanical Turk (MTurk) crowdsourcing platform (N=134). Participants on MTurk were asked to categorize the messages into overarching theoretical categories based on the capability, opportunity, motivation, and behavior framework. Finally, each coauthor rated the messages for their overall quality from 1 to 5. All messages were written at a sixth-grade or lower reading level and culturally adapted and translated into neutral Spanish by bilingual research staff. Results A total of 200 messages were iteratively refined according to the feedback from target users gathered through user-centered design methods, crowdsourced results of a categorization test, and an expert review. User feedback was leveraged to discard unappealing messages and edit the thematic aspects of messages that did not resonate well with the target users. Overall, 54 messages were sorted into the correct theoretical categories at least 50% of the time in the MTurk categorization tasks and were rated 3.5 or higher by the research team members. These were included in the final text message bank, resulting in 18 messages per motivational category. Conclusions By using an iterative process of expert opinion, feedback from participants that were reflective of our target study population, crowdsourcing, and feedback from the research team, we were able to acquire valuable inputs for the design of motivational text messages developed in English and Spanish with a low literacy level to increase physical activity. We describe the design considerations and lessons learned for the text messaging development process and provide a novel, integrative framework for future developers of health text messaging interventions.

Conversational Physical Activity Coaches for Spanish and English Speaking Women: A User Design Study

“…Participants also indicated they preferred short and easy-to-understand messages. In line with other work ( 32 ), we recommend that the reading level should be no more than 8th grade (13–14 years) literacy. Finally, technical issues (e.g., chatbot struggled to understand answers outside of a template) impeded smooth communication.…”

The Barriers and Facilitators of eHealth-Based Lifestyle Intervention Programs for People With a Low Socioeconomic Status: Scoping Review

“…In the various stages of the development and evaluation of the intervention (ie, problem definition, development, and implementation for the study) [ 48 , 50 , 59 , 60 , 64 , 66 , 69 , 70 , 84 ], several studies involved stakeholders, which included family members, experts, key informants [ 50 , 61 , 69 , 75 , 84 , 86 ], health professionals, and end users [ 48 , 54 , 64 - 66 , 68 - 70 , 73 , 75 , 83 ]. However, some studies provided little information on the identification of stakeholders and did not clarify the level of involvement of stakeholders and end users [ 37 , 44 , 50 , 56 , 66 , 70 , 78 , 79 , 81 , 83 , 87 ].…”

“…The majority of the studies tailored the eHealth interventions in various ways to the characteristics and skills of people with a low SES [ 23 , 31 - 37 , 40 , 45 , 46 , 50 , 58 , 61 , 62 , 64 , 66 , 69 - 72 , 74 - 77 , 81 - 86 , 88 ]. One method of customizing the eHealth intervention matched the content delivery (eg, visual or text information) to the user’s language and digital literacy skills [ 34 , 50 , 54 , 61 , 64 , 66 , 69 , 70 , 75 , 80 , 84 , 86 ]. Another method tailored feedback, advice, and information to the characteristics (eg, cultural adaptations and practical advice relevant to their situation) of individuals with a low SES [ 23 , 31 , 33 , 35 - 37 , 39 , 40 , 45 - 47 , 58 , 64 , 66 , 74 , 75 , 77 , 81 - 83 , 85 ] or the timing and type of text messages (eg, feedback) [ 83 ].…”

“…The studies cited several reasons for using a certain delivery mode. Using the internet [ 23 , 31 , 33 , 42 , 44 , 45 , 55 , 56 , 61 , 63 , 66 , 79 , 81 , 86 ], smartphone apps [ 58 , 60 , 73 , 75 , 78 ], or text messages [ 34 , 35 , 50 , 70 , 71 , 75 ] offers many benefits. Internet-based [ 36 , 42 , 44 , 45 , 52 , 56 , 64 , 86 ] and text-based [ 34 , 43 , 71 , 77 , 87 ] interventions are good channels for reaching hard-to-reach groups and might be effective in changing healthy behavior [ 32 , 34 , 44 , 47 , 48 , 50 , 54 , 59 , 66 , 70 ].…”

“…Involving support persons in the intervention appears to be complicated; some participants with low SES had no support person or did not want to involve one [ 34 , 74 ]. Furthermore, Pathak et al [ 75 ] showed that participants who had no family disliked messages that alluded to family support, and the term was replaced by loved ones (similar to familial relations). The interventions [ 45 , 56 , 63 ] offered many solutions to encourage the use of social support on social media, such as team-building exercises and enlisting friends [ 45 ].…”