The Use of Text Messaging to Promote Physical Activity in African-American College Students: A Feasibility Study

Abstract

Background:

African-American college students are less likely to meet recommended physical activity guidelines to promote health, and are at risk of overweight, obesity, and elevated blood pressure. Text messaging is an emerging international technology shown to engage college students, promote physical activity, and reduce health risks.

Purpose:

To determine the feasibility of using text messaging to promote physical activity among African-American college students enrolled in a unique course focusing on lifestyle behaviors for a healthy heart.

Sample:

A purposive sample of 11 (n=4 male, n=7 female) African-American college students aged 18–25 years with cell phones capable of receiving messages was used in this study.

Methods:

A three-week text-message protocol was piloted using web-based software to evaluate feasibility with post-hoc grouping of participants into responders and non responders. Descriptive statistics and Mann-Whitney U-tests were used to analyze group differences.

Results:

There was an attrition rate of nearly 91%. Observed engagement was 50% among responders with compliance at 44.44%. Observed engagement and compliance rates were less than 2% among nonresponders. There were no statistically significant differences in underlying variable distributions between groups. Of practical importance, it was noted that prior to texting responder means were higher for walking physical activity, and lower for body mass index, while nonresponders had higher means for vigorous physical activity.

Conclusion:

The literature review indicated that text messaging is a cost-effective technology that can be incorporated into health education courses on HBCU campuses, but this project suggested semester timing is pivotal to feasibility. Implications largely address tailoring text messages to maintain engagement and evaluating the effect of text messages on physical activity level, body mass index, and blood pressure.

INTRODUCTION

According to 2008 Physical Activity Guidelines for Americans, the health benefits of exercise include increased cardiorespiratory fitness and muscular strength and reduced blood pressure (BP) (United States Department of Health and Human Sendees [USDHHS], 2017). Physical inactivity contributes to higher rates of obesity and hypertension, adding to the global burden of disease. Avoiding a sedentary lifestyle increases individual life expectancy and prevents cardiovascular disease (CVD) which includes a group of heart and blood vessel disorders such as hypertension, heart attack and stroke (World Health Organization, 2018; Kaur & Kaur, 2015). Increasing physical activity by 1,000 kcal per week decreases the prevalence of obesity by approximately 9.3% in men and 9% in women (So, Swearingin, Robins, Lynch, & Ahmedna, 2012).

African-American college students are categorized among those who do not consistently engage in physical activity; a mere 36% meet the nationally recommended mark of 150 minutes per week of moderate-to-vigorous physical activity, shown to significantly reduce CVD risk. (Durant et al, 2014).

College marks a time when the foundations for lifelong health behaviors are laid, including physical activity (Dinger, Brittain, & Hutchinson, 2014). Body weight is known to increase during late adolescence and young adulthood (Curtis, Fuller-Rowell, Doan, Zgierska, & Ryff, 2016) placing college students at risk for overweight and obesity. A weight gain as low as five pounds caused an elevation in BP among healthy adults, with larger hikes in the presence of more abdominal fat (Covassin, 2014). CVD risk escalates with sedentary physical activity levels. Inactivity coupled with other unhealthy lifestyle behaviors, such as smoking and poor diet choices, contributes to the development of high BP.

Among minorities, the risk for obesity and high BP is pronounced, leading to negative health outcomes if not detected early (Herbert, 2015). The health profiles of overweight and obese students are worse than those of healthy students with a normal body mass index (BMI). In a 2012 study at a southeastern Historically Black College and University (HBCU), the average BP was 120 ± 14 mmHg with higher readings in African-Americans than in their non-Hispanic White counterparts (Price, Whitt-Glover, Kraus, & McKenzie, 2016).

Li et al. (2017) found that individuals can reduce their risk for overweight, obesity, and hypertension by increasing physical activity levels. Individuals’ engagement in moderate and/or vigorous physical activity aids in reducing or protecting them from developing high BP, thereby decreasing their CVD risk (Ajibade, 2011; Bell, McIntire, & Hadley, 2014). However, engaging persons in physical activity can be a challenge.

Text Messaging Evidence to Promote Physical Activity

Engaging college students using technology-based interventions, such as Facebook and, more specifically, text messaging, promotes physical activity and reduces the risk for overweight, obesity, and high BP (Napolitano, Hayes, Bennett, Ives, & Foster, 2013). Mobile text messaging has been shown to improve various aspects of healthcare, including appointment attendance, adherence to medication and therapy, and reduction of hospital readmission rates (Free et al., 2013a; Kannisto, Koivunen, & Välimäki, 2014). However, to date, very little research has assessed the feasibility of using text messaging with African-American college students.

Gandhi et al. (2017) conducted a systematic review and meta-analyses to investigate the effect of mobile health methods on secondary prevention of CVD. Twenty-one studies exclusively made use of text messaging and demonstrated improved BP, BMI, and adherence to medical therapy. Three studies assessing exercise and activity showed positive results. Chow, Ariyarathna, Islam, Thiagalingam, and Redfern (2016) highlight the fact that the text message-based intervention is one of the two most commonly used mobile health methods for delivering CVD care and effective in the areas of physical activity, weight loss, BP, and diabetes management. Buchholz, Wilbur, Ingram, and Fogg (2013) conducted a systematic review of physical activity text-messaging studies ranging from three to 52 weeks in adults. They concluded that text messaging can be used to improve physical activity outcomes. Finally, the current guidelines on electronic adherence reminders have released recommendations for text messaging as a means to reduce no-show rates in outpatient clinics and to improve patients’ and their families’ behavior change (National Guideline Clearinghouse, 2012). Technology-based platforms, especially text messaging, are a promising option, for healthcare (Free et al., 2013b).

The purpose of this project is to determine the feasibility of incorporating a text-message intervention into the regular teaching and activities of a Lifestyle Behaviors for a Healthy Heart course at a southeastern HBCU.

Theoretical Framework

The theoretical framework applied to this project is the Health Promotion Model of Dr. Nolan Pender. It defines health as “a positive dynamic state rather than the absence of disease, and health promotion is directed at increasing a patient’s level of well-being” (Nursing Theory, 2011, p. 1). It incorporates preventive measures, which are a primary focus in this project. Its crucial propositions are as follows: (a) persons commit to engaging in behaviors from which they anticipate deriving personal value and benefit; (b) positive affect toward a behavior results in greater perceived self-efficacy, which may increase the likelihood of adherence to routine physical activity by way of responding to text messaging; (c) the greater the commitment to a specific plan of action, the more likely health-promoting behaviors are maintained over time.

Individuals have characteristics and prior behaviors that influence and motivate their future health promoting behavior (Pender, 2011). Behavior-specific cognition and affect include perceived benefits of action that can be a motivating factor promoting health and physical activity. Text messaging has the potential to target this area since perceptions are amendable to change. The desired behavioral outcome involves a commitment to a plan of action resulting in the heath-promoting behavior of physical activity (Butts & Rich, 2018).

METHODS

Design

This pilot project was designed to determine the feasibility of incorporating text messaging to promote physical activity among African-American college students enrolled in a Lifestyle Behaviors for a Healthy Heart course.

Setting

The project was conducted at an HBCU in the southeastern United States. The HBCU is accredited, with an average 5,220 students (69.7% African American) enrolled annually from 2013–2016. Of that 69.7% majority 48.8% were women, and 20.9% were men (Winston-Salem State University [WSSU] Institutional Assessment & Research, 2017).

Sample

A purposive sample of 11 students (n=4 men, n=7 women) was used. The study participants were enrolled in the three-credit Lifestyle Behaviors for a Healthy Heart course. The course was developed and offered through funding from the National Institutes of Health. In keeping with the course objectives, students calculated their CVD risk factors and gained an understanding of how lifestyle behaviors contribute to chronic disease risk. Students self-selected to enroll in the course and were recruited using both electronic and hard-copy invitational flyers. Interested students were contacted, informed, and consented using either paper or electronic forms. The course instructor generated and assigned identification numbers to protect participants’ privacy and confidentiality. The project was approved by the University’s Institutional Review Board.

Inclusion criteria.

Participants were between 18–25 years old; self-reported African-American; able to read, understand, speak, and write the English language; enrolled in the course; and had a cell phone capable of receiving text messages. Non-African-American students were allowed to participate to avoid perception of partiality, but their data were not included in the analysis.

Exclusion criteria.

Individuals with major self-identified health problems or conditions and pregnant women were excluded due to possible health risks associated with physical activity and limited safeguards. Major health problems or conditions were defined as chest pain, heart disease, heart failure, lung disease, heart attack, high blood pressure, peripheral vascular disease, and stroke.

Text-Messaging Pilot Protocol

The pilot entailed three weeks of text messaging with content focused on physical activity reminders and intermittent encouraging words. The three-week timeframe was supported by findings from a three-week mobile phone intervention to promote physical activity among sedentary women (Fukuoka, Vittinghoff, Jong, & Haskell, 2010), which demonstrated an increase in participants’ average daily total steps of approximately 800, or 15% (p < 0.001).

At enrollment, participants were given the American Heart Association (AHA) Recommendations for Physical Activity in Adults handout, and the Centers for Disease Control (CDC) handout entitled General Physical Activities Defined by Level of Intensity (AHA, 2016a; CDC, n.d.). Messages were delivered in an automated fashion using a secure commercial web-to-short-messaging-service gateway called Clubtexting (2017) that allowed message preprogramming for day(s), time(s), and frequency. In week 1, text-message reminders about physical activity were sent daily; in weeks 2–3, they were sent five times a day at varying times. A compliance message was sent every evening. Reminder and compliance-message content was in keeping with the message protocol sample in Table 1. Daytime reminder messages ended with a request to reply “Okay” if read. Participants were sent a text-message compliance question every evening, inquiring whether physical activity had been completed with a request for a “Yes” or “No” response. Participants were informed in advance regarding the scope and expectation of their response text as only Yes, No, or OK. Participants were given campus health center contact information in the event of a health-related question or medical emergency since the project was not intended to assist in or provide medical triage.

Table 1.

Sample of the Text-Message Protocol

Text-Message Reminder	Text-Compliance Question
Sunday @ 8:00 am	Sunday @ 9:00 pm
Hi there! Get your physical activity first thing and you won’t have to worry about it for the rest of the day. Reply “Okay” if you read this message.	Have you done your physical activity today? Reply “Yes” or “No.”
Monday @ 9:00 am	Monday @ 9:00 pm
Hi there! Physical activity boosts your metabolism and gets your digestion moving for the whole day. Reply “Okay” if you read this message.	Have you done your physical activity today? Reply “Yes” or “No.”
Tuesday @ 10:00 am	Tuesday @ 9:00 pm
Hey dear! You will never change your life until you change something you do daily. Get active for at least 30 minutes. You can do it!!! Reply “Okay” if you read this message.	Have you done your physical activity today? Reply “Yes” or “No.”

Adopted with modification (Napolitano et al., 2013)

Assessment Measures

Text-message engagement was measured based on the number of “OK” responses received following the initial text-message reminder. Participants replied “OK” to indicate they had read the reminder.

Text-message compliance was measured by the number of “Yes/No” responses to the evening text-compliance question (Napolitano, Hayes, Bennett, Ives, & Foster, 2013), “Have you done your physical activity today? Reply Yes or No.”

Physical activity was defined according to the national 2008 guidelines as “any bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above a basal level” (US DHHS, 2017, p. 2). It was measured in terms of level and intensity using the International Physical Activity Questionnaire (IPAQ). Participants were asked how many days per week they engaged in physical activity, the types (e.g., brisk walking, swimming, jogging, treadmill), and how much time (minutes to hours) they spent on it (Craig et al., 2003; IPAQ, 2002). The IPAQ is a tool used repeatedly, and validated, to estimate the metabolic equivalents of tasks (METs). MET is a measure of the volume of activity that can be computed by weighting each type of activity by its energy requirements (Craig et al., 2003).

Blood pressure (BP) is the force created when the heart beats and squeezes and pushes blood to the aorta, arteries, and the rest of the body. Systolic BP measures pressure on the blood vessels during contraction of the heart. Diastolic BP measures the pressure in the arteries during the resting/relaxation period. Normal systolic BP is less than 120mm Hg, and normal diastolic BP is less than 80mm Hg (AHA, 2016b; WebMD, 2017). Resting BP was measured with a manual BP cuff instrument called a sphygmomanometer. Participants were allowed to rest by sitting down for 3–5 minutes then asked to place their feet flat on the floor and rest their arm horizontally at heart level. An appropriately sized BP cuff was placed around the upper arm, and BP readings were taken at rest (Williams, 2017).

Body Mass Index (BMI) is a measure of the weight of a person in kilogram (kg) divided by the square of the person’s height in meters. It is an inexpensive and easy-to-perform method of screening for weight category, specifically underweight, healthy weight, overweight, and obesity (CDC, 2017). BMI was assessed by obtaining the height and weight and calculating BMI (weight in kg) / (height in meters)2. Height was measured to the nearest quarter inch from the head with the hair pressed down to the feet. Weight was obtained to the nearest quarter of a pound using a standing calibrated scale with participants wearing light clothing and no jacket. Inches and pounds were converted to meters and kg respectively. Roughly 25% declined to remove their shoes.

Experience was assessed through a survey questionnaire administered to solicit the participant perspective. It entailed five Likert-scale items (strongly agree, agree, neutral, disagree, and strongly disagree) and two open-ended questions. The Likert-scale items addressed the themes of usefulness, time, frequency, content, and recommendation and allowed comments on each theme. The two open-ended questions inquired about the text-message schedule and anything else participants wanted to share.

Data Collection and Analysis

Data collected included age, sex, gender, ethnicity, race, hours worked per week, hours engaged in school and studying activities per week, and mobile phone numbers. Participant and parental medical history (e.g., CVD, smoking, alcohol use, high BP, heart attack, chest pain, stroke) were documented. Baseline IPAQ, BMI, and BP were measured. At the end of the text-messaging protocol, a participant experience survey was offered. Participants completed forms either in class using pen and paper or electronically using Survey Monkey. Student BP measurements were taken as a part of the class activities by medically trained personnel, and each student was given his or her results and the interpretation in writing.

The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 24. A Mann-Whitney U-test was used to examine the characteristics and differences between the groups in terms of the continuous variables (physical activity, BMI, and BP). Descriptive statistics and frequencies were used to analyze the key variables (demographic data). The means and percentages of the participants’ text-message engagement were reported.

RESULTS

Sample Characteristics

Out of 30 students recruited, 11 (57%) consented. Of those who consented, nearly 76% completed measurements and surveys prior to the start of text messaging. There was a study attrition rate of nearly 91% over three weeks that limited the analysis to baseline data. Most participants were women (n=7), and all (n=11) were Black or African-American and not Hispanic/Latino. Participants’ age ranged from 19 to 21 years, with a mean of 19.55 ± 0.82 years. The means of the participants were: total physical activity 3441.96 ± 2541.73 MET min/week; weight 83.94 ± 24.54 k; BMI 28.51 ± 7.28 Kg/m2; systolic BP 123 ± 12.99; and diastolic BP 81 ± 13.53 mmHg. Mean working hours and time spent on schoolwork were 11.68 and 35.45 hours per week, respectively (See Figure 1).

Figure 1. Participant Flow Chart.

Medical and Family History

Most participants (n=9) reported no medical history and no comorbidity. One participant indicated high BP and another disclosed use of tobacco. Two participants reported parents having no medical history, while nine indicated a parental medical history. Among them, seven reported a parent with high BP; four, diabetes; two, high cholesterol; two, tobacco use, one, a heart attack; and one alcohol use. Five participants reported comorbidities in a parent: one high BP and high cholesterol; one, high BP, diabetes, and tobacco use; one, high BP, diabetes, and heart attack; one, high BP, high cholesterol, and diabetes; and one, tobacco and alcohol.

Text-Message Engagement and Compliance

The observed pattern of text messages revealed a median of four responses that was used to designate thresholds (Polit & Beck, 2012) for the responder and nonresponder categories. Participants with four or more responses were categorized as responders, and those with less than four were categorized as nonresponders. The number of responders and nonresponders was nearly equal. Engagement among responders was 50% but less than 2% in nonresponders. Compliance was observed among responders 44.44% of the time and less than 2% among nonresponders (See Table 2).

Table 2.

Text-Message Engagement and Compliance among Responders and Nonresponders

	Responders n = 6	Nonresponders n = 5
Text-Message Engagement *
Sent/Successful Transmissions	102	85
Okay Responses	51 (50%)	1 (1.18%)
Did Not Answer	51 (51%)	84 (98.82%)
Text-Message Compliance **
Sent/Successful Transmissions	126	105
Yes/No Responses
Yes	56 (44.44%)	2 (1.9%)
No	18 (14.28%)	0
Did Not Answer	52 (41.27%)	103 (98.1%)

^*Daytime Reminder

^**Evening Message

Physical Activity

The underlying distributions of the variables between groups show no statistically significant difference in regard to total physical activity, walking, moderate and vigorous intensity (Table 3). Among responders, four reported a high level of physical activity; one, moderate; and one, low. Two nonresponders were considered to have a high level; two, moderate; and one, low.

Table 3.

Analysis of Variables between Responders and Nonresponders

	Responders	Nonresponders	Mann-Whitney U-test
Mean ± SD
Total Physical Activity (MET min/week)	3918.5 ± 2658.74	2870.1 ± 2562.32	z = −0.548, p = 0.584
Walking Intensity  (MET min/week)	2238.5 ± 1650.19	782.1 ± 776.69	z = −1.559, p = 0.119
Moderate Intensity  (MET min/week)	500 ± 528.09	552 ± 248.84	z = −0.276, p = 0.783
Vigorous Intensity  (MET min/week)	1180 ± 1257.24	1536 ± 2026.54	z = 0.000, p = 1.0
BMI (Kg/m2)	27.97 ± 6.4	29.15 ± 8.95	z = −0.183, p = 0.855
Systolic BP (mmHg)	122.67 ± 13.29	123.8 ± 14.15	z = −0.183, p = 0.854
Diastolic BP (mmHg)	76.83 ± 9.22	85.6 ± 17.3	z = −1.00, p = 0.314

Figure 2 illustrates the mean physical activity intensities between groups. Among nonresponders, mean vigorous intensity of 1536 MET min/week was clinically significant, exceeding the guideline recommendations of 1500 MET min/week. Furthermore, walking intensity in both groups exceeded the guideline recommendation of 600 MET min/week. Mean walking intensity was much higher among responders at 2238 MET min/week, indicating more time spent being physically active (Forde, n.d.).

Figure 2. Mean Physical Activity Intensities of Responders and Nonresponders.

Work and School Hours

No statistically significant difference was found between groups in terms of the underlying distributions of working hours per week and hours spent on schoolwork (Table 3). Mean working hours were comparable, while nonresponders had a higher mean of time on schoolwork at 47.75±28.87 compared to responders at 39.8±41.32.

Body Mass Index

There was no statistically or clinically significant difference in mean BMI between the groups (BMI: z = −0.183, p = 0.855). However, both groups’ mean BMI > 24.9 Kg/m2 was notable as it exceeds the recommended normal range of 18.5–24.9 (Table 3), falling into the overweight category. Two responders’ BMIs were normal; two were overweight; and two obese. Among the nonresponders, two were normal; two, overweight; and one, obese.

Blood Pressure

There was no statistically significant difference between the underlying distributions of the variables in regard to systolic and diastolic BPs (Table 3). Three responders and three nonresponders had BPs in the normal range. One responder and one nonresponder potentially had prehypertension. Two responders had readings in the range of stage-one hypertension, and one nonresponder had a reading corresponding to stage-two. Systolic BP for all participants (n=11) ranged from 109 to 142 mmHg, and diastolic BP from 64 to 92 mmHg with a median of 121 and 77 mmHg, respectively.

Participant Experience

Three participants completed the survey; one reported that the text messages were helpful. One strongly agreed, and two agreed that they found text messaging useful to promote their physical activity. All were neutral regarding the frequency: “I would have preferred to receive more than one text message per day.” Two agreed, and one was neutral about whether the content of the text messages was motivating. However, one strongly agreed, and two agreed to recommend using text messages as a reminder to promote physical activity to others. Qualitative comments included: “I loved it! it reminded me to do my everyday push-ups????”. Regarding the question, “What schedule of text reminders do you think is most helpful to remind you to be physically active?” one recommended, “in the morning”; another, “early morning”; another, “every day in AM.” These responses were similar to another participant’s response to theme time: “8:30–9:00 A.M.”

DISCUSSION

Although studies have used text messaging to promote physical activity, this study is the first to examine the efficacy of this approach among African-American college students at a southeastern HBCU. Text messaging to promote physical activity is likely feasible but not when incorporated toward the end of a semester near holidays and break, when students are focusing on final projects, papers, and exams.

Nonresponders demonstrated a low rate of text-message engagement and compliance possibly because they became accustomed to receiving messages and found it unnecessary to respond. Another study found that participants stopped reading text messages after a while (Kannisto et al., 2014). Moreover, unlike elementary, middle, or high schools that build physical education activities into the daily schedule, universities leave that choice up to students. Engagement can be promoted by such factors as perceived enjoyment, self-discipline, time, and convenience or discouraged by the physical environment, university lifestyle, exams, and academic pressure (Deliens, Deforche, Bourdeaudhuij, & Clarys, 2015). Nonresponders had higher mean times spent on school assignments per week. Such competing priorities likely affected their availability to engage in, and respond to, text messaging as well as to complete physical activity. However, caution must be taken in interpreting these results as nonresponders also had higher means of moderate and vigorous physical intensity than responders, indicating they were already active and may have felt no need to respond (Buchholz et al., 2013). Another consideration is that some nonresponders started using a different phone number without reporting it, so deducing their actual engagement and compliance is difficult. Further research is required to evaluate how these factors can be eliminated, or reduced, in evaluating text messaging that promotes physical activity. A larger sample size as well as a longer observation period, with questions on physical activity barriers and self-efficacy, is recommended.

Responders were found to have a higher mean of walking intensity, although no significant differences between the group means for vigorous intensity emerged. This result can be explained by Pender’s (2011) Health Promotion Model in that people value growth in directions viewed as positive, and attempt to achieve a personally acceptable balance between change and stability. According to the theory, individual participation can be affected by self-determination, self-efficacy, unique personal characteristics, and experience that may subsequently affect their lifestyle behavior, especially toward physical activity.

The elevated BMIs of both groups may be attributed to unhealthy eating behavior and insufficient activity. Other studies of college student populations have found unhealthy BMIs (Curtis et al., 2016; Dinger et al., 2014; Napolitano et al., 2013). Responders had slightly lower BMI values, which can be explained by their tendency to walk more. In keeping with Li et al. (2017), physical activity levels are associated with a reduced risk for overweight and obesity. According to the American Heart Association, walking is a popular form of exercise for fitness. These findings suggest the need for interventions among college students targeting BMI using text messages, which may be an important, cost-effective way to improve their physical activity, which, in turn, can improve their health and well-being and prevent CVD risk. An increase in BMI category can increase an individual’s risk of developing hypertension (Selassie et al., 2011)

The updated 2017 Guidelines for High BP in Adults were released shortly after this project ended. The new ranges placed some participants, who would have been considered normotensive under the Eighth Joint National Committee guidelines, in the category of stage one or two hypertension. The new BP ranges place more Americans in higher hypertension categories (Muntner et al., 2018), although insufficient activity, poor diet choices, and smoking, all common behaviors among college students, may contribute (Booth et al., 2017). Selassie et al. (2011) found that conversion from prehypertension to hypertension was accelerated in African-Americans. This problem calls for early adoption of healthy lifestyle interventions involving physical activity that may lower BP and delay or prevent progression to hypertension in college students. Targeting BP in the normal range can improve the health and well-being of college students and prevent risk of CVD, stroke, or chronic diseases.

In this project, students’ responses regarding their experience with the intervention were positive and indicated they would recommend it to others to promote physical activity. Napolitano et al. (2013) and Agyapong, Milnes, McLoughlin, and Farren (2013) had similar results, indicating that text messaging can be useful in delivering healthcare interventions and recommending such interventions to others. In this project, a single participant suggested a text-reminder delivery time between 8:30–9:00 A.M. Three participants suggested that messages include more varied content and use different modes of delivery alongside enticing prompts that can facilitate regularly reading the messages. Such findings suggest that text messages should be tailored to individual preferences to optimize their effect, which is in line with a previous study in which text-message timing was based on participants’ personal needs (Kannisto et al., 2014). Likewise, participants in the study by Horner, Agboola, Jethwani, Tan-McGrory, and Lopez (2017) expressed a variety of text-message preferences, yet overall wanted more control with text message frequency. As a result, suggested strategies were to make participants feel “coached” as opposed to “hassled” to promote higher retention and engagement. Such messages would be aware of name, gender, behavioral preferences, goals, barriers to enrollment, and tailored solutions. Future projects should encourage the full input of all participants to establish tailored text messages to avoid ambiguous conclusions.

Limitations

Purposive sampling and small sample size limited generalizability. Attrition constrained fuller analysis of the value of text messaging. Self-reported IPAQ did not account for under- or over- reporting physical activity, and self-reported physical activity compliance may not have been accurate. Finally, whether the course influenced response is not known.

Project strengths included the ease of web-based software use in sending text messages to large populations within a short timeframe and ability to track delivery status. This software was also convenient, with the option to preprogram messages. Finally, the cost-effectiveness of text messaging made it affordable in this setting.

Implications

Campus clinicians can incorporate text messaging into student healthcare to proactively prompt physical activity. Texting can also be used to enhance clinician-student communication and better manage chronic diseases, such as obesity, hypertension, and diabetes. Clinicians can send self-management reminders through text messaging to monitor weight, BP, and/or blood sugar daily. Bi-directionality can allow students to share abnormal readings. All of these features can lead to significant improvements in healthy lifestyle behavior and health quality and be extended beyond campus to students receiving care at pediatric and primary care centers as well as community-based healthcare settings. Texting is a cost-effective, convenient technique for both sender and receiver to support disease prevention. Furthermore, faculty can incorporate text messaging into health-education courses to remind students to remain active. Campus recreation centers can use it to raise awareness of physical activity resources and as part of a comprehensive plan to combat overweight and obesity.

Recommendations for Future Research

The intervention must be targeted at specific times to avoid students’ busy periods, such as exam times. The data collected on participants’ medical and family history must be more specific, defining which parent has a particular condition because the comorbidity of diabetes with another condition doubles the risk of CVD and may indicate a genetic predisposition in the participant. Given the many physical activity resources the university has invested in and implemented on campus, efforts should be made to increase students’ awareness and use.

CONCLUSION

This project provides insights into using text-message technology to improve physical activity among African-American college students. Text messaging may be feasible as part of a health education course if it does not conflict with end of semester activities. Additionally, tailored messages are encouraged to promote retention and engagement. Text messaging is a cost-effective approach to increase physical activity, improve body mass index and blood pressure, decrease CVD risk, and promote the health and well-being of African-American college students.