10 Uses of Texting to Improve Health

BJ Fogg & Enrique Allen

Cordura Hall, Room 122
210 Panama St
Stanford, CA 94305
{bjfogg}{enrique.allen}@stanford.edu
ABSTRACT
Most people use text messaging to stay in touch with friends. But
the options for texting go beyond individual communication. In
this paper we present 10 ways for texting to improve health
behavior. Our hope is that health professionals can see new ways
that texting can help achieve their health care goals.
Categories and Subject Descriptors
J.3 [Life and Medical Systems]: Medical Information Systems
General Terms
Design
Keywords
SMS, texting, mobile health
1. INTRODUCTION
Experimentation using texting in the health field has shown
improvement in primary care attendance rate [1], smoking
cessation [2], and sexually transmitted infection awareness [3]. As
more health professionals consider using SMS to persuade health
behavior change, this paper serves as a comprehensive overview
of texting interventions for future study. The 10 texting techniques
we present fall into 5 categories: sending information to users,
gathering information from users, user questions & expert
response, people-to-people connection, and transactions.
Table 1. The 5 Texting Categories
2. SENDING INFORMATION TO USERS
Sending info to users is the simplest way to use texting. In this
category, the end user receives messages from a health
organization, such as a County Health Department. The user does
not respond to the message. They just read the text they receive.
In this category, we see three specific techniques, as explained
below.
2.1 Educating People
An organization can send text messages to people and help them
improve their health, little by little. We call this technique
Educating People, because the purpose of the short messages is
to share tidbits of health content on a predictable schedule. For
example, each day a service can send health research findings, tips
about vitamins, or a "health fact of the day." In most situations
users will need to "opt in" to receive these educational health
messages.
Figure 1. Educating People

2.2 Notifying People
The second technique for using SMS to improve health behavior
is what we call Notifying People. In this technique, an
organization sends messages whenever a message is needed, not
on a schedule. These messages may have urgent information, such
Sending Info to Users End users receive messages
from health organizations
Gathering Info from Users Health organizations collect
data from end users
User Questions & Expert
Response
End users ask a question and
health organizations respond
People-to-People
Connection
Individual and group
conversations
Transactions

Getting things done using
SMS

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as a warning about air quality or a new epidemic. But the
notifications dont need to be urgent. For example, the CDC might
notify people about a new service offered on their web site.
We believe using SMS for notifying people will become
commonplace. At Stanford University, for instance, we've started
a campus-wide SMS notification program. The university has
asked everyone to make their mobile phone number available for
use in case of emergencies.
Figure 2. Notifying People

2.3 Reminding People
The third technique for using texting to support health behavior is
what we call "Reminding People." As with the previous two
techniques, the user receives a text message on their mobile phone
without any need to reply. In this third technique, the content of
the text message is no surprise to the user. It is simply a reminder.
For example, the reminder can be about a personal goal, like
remembering to drink water each morning. Or the SMS could be a
reminder about an appointment at the health clinic. As one can
imagine, given the ubiquity of mobile phones, texting is an
excellent way to send simple reminders that trigger health-related
behaviors.
3. GATHERING INFORMATION FROM
USERS
Mobile phones can serve as a channel for gathering information
from people. In this category everyday people are the source of
the information, instead of being the recipients. We see two
different techniques that belong to this category.
3.1 Collecting Data from People
Health organizations can learn from the people in their
stewardship. In this fourth technique, Collecting Data from
People, an organization can use SMS to get people to send data
quickly and conveniently using their mobile phones. We see two
approaches here. In one case, the organization can send out a
prompt, much like texting a one-question survey to people. As the
users respond, the organization compiles the data. In other
situations, users can be prompted by an event they experience,
such as each time they get a migraine headache. Overtime, the
data gathered can show health patterns for individuals but also for
large populations.
Figure 3. Reminding People


SMS demands little time or energy from users, making the
probability of gathering data higher than traditional surveys. The
response time for an SMS survey is also faster. In other words,
with a texting service (and access to cooperative people)
researchers can gather thousands of data points within hours. By
collecting data via SMS, health professionals can monitor medical
or environmental conditions.
3.2 Journaling by Individuals
People can use SMS to keep a personal journal related to their
health behavior. For those who already know how to text, the
mobile phone becomes the most convenient way to input health
behavior like calories consumed or steps walked each day.
Texting can also support simple writing activities like keeping a
gratitude journal.
We propose that these behavior logs and personal journals are for
the user themselves, not for large-scale data analysis by health
organizations.
The journaling technique seems to offer a two points of impact.
First, the practice of recording diet or activity will likely improve
health behavior. Next, by later accessing the collection of short
entries, people can get insight into patterns of success and failure.
Note that in this second case, people will probably need to access

their journal entries online, since entry retrieval and reading is
cumbersome on most phones today. In other words, in this
technique Journaling by Individuals -- the mobile phone is a
convenient input device, while a private web page is the place for
reading and reflection.
Figure 4. Collecting Data from People


Figure 5. Journaling by Individuals

4. USER QUESTIONS & EXPERT
RESPONSE
The next category is all about asking health-related questions and
getting answers via text messaging. This is a simple form of
interactivity. Note that most of our previous techniques had no
interactivity: the information flowed in one direction and stopped.
This new category begins to introduce more interactive SMS
techniques. In fact, starting with the techniques in this category,
all remaining techniques in this paper will involve some form of
interactivity using SMS.
In this section we describe how to use texting for health with the
simplest type of interactive texting: Users ask a question and get a
response in return. Below we describe two techniques.
4.1 Getting Answers from a Database
Thanks to Google and other online search tools, most people are
familiar with seeking answers from a database. In this case,
people use texting on their mobile phones to ask questions related
to health. In response, they receive an answer from a database.
Seeking information via the mobile phone has advantages and
drawbacks, as one can imagine. First, we describe the advantages.
The best thing about seeking health answers via SMS is
convenience. If a diner at a seafood restaurant wants to know if
swordfish has high mercury levels, she can use her mobile phone
to find the answer. Thats convenient. Within a minute or two she
has her answer, without leaving her restaurant table. No one at her
table may even realize she is seeking this information. Thats the
next big advantage of SMS answer: privacy. Or at least the
perception of privacy.
Figure 6. Getting Answers from a Database

Now, we describe the major disadvantages of using SMS for
getting answers to health questions. Besides the small screen and
limited keyboards on mobile phones, the nature of SMS compares
poorly to searches we can do on computers. In the 160 characters

available with SMS, users may not form questions that a computer
system can understand. Similarly, in the 160 character response,
users may not receive enough info or the right info. Asking
open-ended questions via SMS is likely to frustrate users.
The good news is that some organizations have found a solution.
By creating specialized texting services for health, such as sexual
health, an organization can list the specific questions in advance.
People using SMS can then select from the list of options. The
answers they receive are then more likely to satisfy.
4.2 Getting Answers from a Person
The core disadvantages of the previous technique are resolved in:
Getting Answers from a Person. In this technique, users can send
health question using SMS on their mobile phones and receive an
answer back from a real person, not a computer. The big
advantage here is that a real person can often give a more
appropriate answer than can a computer. The other major
advantage is that organizations can launch this type of service
within days no significant technical work required. All one
needs is trained people. These people can use an ordinary
computer to receive and reply to the incoming questions.
Figure 7. Getting Answers from a Person

Now for the bad news. Relying on people, rather than computer
code, limits what the service can do if the service is popular. The
service cannot scale easily; it may not be available 24/7. And
people who are tired or poorly trained may give incorrect answers
to important health questions. Furthermore, having real people
answer questions poses a greater cost for ongoing operation.
Despite what may seem like major disadvantages, this technique
is a good early step for organizations creating a new service to
improve health behavior. You can quickly launch and learn. You
can easily revise your offering, as you discover what your market
wants.
5. PEOPLE-TO-PEOPLE CONNECTIONS
We now turn to how most people today view text messaging: a
convenient way to connect people who know each other. We call
this category People-to-people connections. Thanks to the
motivational power of coaching and peer support, these personal
connections via SMS can promote health behavior. We share two
specific techniques below.
5.1 Connecting Individuals
Text messaging allows individuals to have lightweight
conversations both in real time and asynchronously. These
conversations can take many forms and have many purposes,
including interactions that promote better health behaviors.
Individual health care experts and their patients can interact via
SMS. Health coaches can stay connected with clients. Friends can
support friends.
We believe that SMS is a better channel than email for personal
connections, including health connections. Why? Because SMS
doesnt suffer from growing spam. We believe that as email
further becomes a river of garbage flooding your inbox, SMS will
become a primary channel for connecting with trusted friends and
colleagues.
Figure 8. Connecting Individuals

5.2 Connecting Groups
Text messaging not only supports one-to-one conversations but
also many-to-many discussions. This is a new phenomenon,
sparked by Twitter in 2006. Today, Twitter and its imitators allow
individuals to post messages to groups using SMS as the channel.
Group support has long been a key to changing health behavior,
and now increasingly SMS facilitates group interactions. Thats
good news. Support groups, discussion threads, and collective
action are now all possible using ordinary phones and SMS.

However, because texting for groups is new, we have yet to see
fully how SMS-based micro-blogging and status updates can
promote health. We can look to the history of how group
dynamics have supported health behavior change and translate
many of those past successes into the new phenomenon of
connecting groups via texting.
Figure 9. Connecting Groups

6. TRANSACTIONS
Mobile transactions take place all over the world and we see
future growth as people become comfortable using their phones to
access the internet and many other things.
6.1 Getting Things Done
Our final technique, Getting Things Done, is all about
transactions. As we see it, this technique is new and emerging. In
the future we believe that via SMS people will be able to set
appointments at health clinics, to buy health products and
services, and to register for exercise sessions in their community,
among other things. To get a better vision of this future, consider
all the transactions we can do today via the web. Then imagine
those things happening through SMS.
We realize that some of todays transactions on the web are
complicated, seemingly beyond what texting can do. But this
complexity can be offset by familiarity. Heres what we mean: do
those transactions in a limited channel like SMS. Even so, we also
believe the previous nine techniques we have shared are better
starting points for health organizations. As other industries, such
as mobile commerce, make inroads into SMS-based transactions,
then health organizations can follow the trails others have blazed.
Transactions typically have a structure, a series of steps we
follow. As people come to understand the structure of a
transaction online (such as purchasing a book), they gain ability to
Figure 10. Getting Things Done

7. CONCLUSION: 10 TECHNIQUES AND
BEYOND
The 10 techniques weve shared aren't likely to change much in
the coming years, even as texting gets more sophisticated or as
something comes along to replace SMS. The 10 techniques are
essentially genres: broadcast info, gather info, Q&A, group
support, and so on. Genres persist. That said, some new
techniques are likely to emerge, expanding the 10 we list in this
chapter to perhaps 15 techniques or more. The new techniques
will likely include interactions that are more like games with
characters, plot, goals, and rewards. Other new techniques may
leverage the power of group dynamics, as SMS becomes more a
group activity, thanks to Twitter and the like.
We hope that by gathering and sharing these 10 techniques we can
help organizations launch and enhance texting services for
improving health behavior. We believe texting can increase the
effective reach of health care providers while making services
more convenient for patients.
Table 2. Summary of 10 Texting Techniques
Sending Info to Users Educating People
Notifying People
Reminding People
Gathering Info from Users

Collecting Data from People
Journaling by Individuals
User Questions & Expert
Response
Getting Answers from a Database
Getting Answers from a Person
People-to-People Connection

Connecting Individuals
Connecting Groups
Transactions Getting things done

8. REFERENCES
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C.L. 2006. The use of text messaging to improve attendance in
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[2] Rogers, A., Corbett, T., Bramley, D., Riddell, T., Wills, M., R-
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[3] Levine, D., McCright, J., Dobkin, L., Woodruff, A.J.,
Klausner, J.D. 2008. SEXINFO: A Sexual Health Text Messaging
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