title: Text Messaging for Exercise Promotion in Older Adults From an Upper-Middle-Income Country: Randomized Controlled Trial.
abstract: BACKGROUND
  Mobile technology to promote exercise is effective; however, most evidence is from studies of younger groups in high-income countries. Investigating if short message service (SMS) texting can affect exercise participation in older adults from an upper-middle-income country is important considering the proliferation of mobile phones in developing regions and the increased interest of older adults in using mobile phones.
  
  
  OBJECTIVE
  The main objective was to examine the short- and long-term effects of SMS text messaging on exercise frequency in older adults. Secondary objectives were to investigate how SMS text messages impact study participants' exercise frequency and the effects of the intervention on secondary outcomes.
  
  
  METHODS
  The Malaysian Physical Activity for Health Study (myPAtHS) was a 24-week, 2-arm, parallel randomized controlled trial conducted in urban Malaysia. Participants were recruited via health talks in resident associations and religious facilities. Older Malaysians (aged 55-70 years) who used mobile phones and did not exercise regularly were eligible to participate in the study. Participants randomly allocated to the SMS texting arm received an exercise booklet and 5 weekly SMS text messages over 12 weeks. The content of the SMS text messages was derived from effective behavior change techniques. The non-SMS texting arm participants received only the exercise booklet. Home visits were conducted to collect outcome data: (1) exercise frequency at 12 and 24 weeks, (2) secondary outcome data (exercise self-efficacy, physical activity-related energy expenditure, sitting time, body mass index, grip and leg strength) at baseline and at 12 and 24 weeks. Intention-to-treat procedures were applied for data analysis. Semistructured interviews focusing primarily on the SMS text messages and their impact on exercise frequency were conducted at weeks 12 and 24.
  
  
  RESULTS
  In total, 43 participants were randomized into the SMS texting arm (n=22) and the non-SMS texting arm (n=21). Study-unrelated injuries forced 4 participants to discontinue after a few weeks (they were not included in any analyses). Overall retention was 86% (37/43). After 12 weeks, SMS texting arm participants exercised significantly more than non-SMS texting arm participants (mean difference 1.21 times, bias-corrected and accelerated bootstrap [BCa] 95% CI 0.18-2.24). Interview analysis revealed that the SMS text messages positively influenced SMS texting arm participants who experienced exercise barriers. They described the SMS text messages as being encouraging, a push, and a reminder. After 24 weeks, there was no significant difference between the research arms (mean difference 0.74, BCa 95% CI -0.30 to 1.76). There were no significant effects for secondary outcomes.
  
  
  CONCLUSIONS
  This study provides evidence that SMS text messaging is effective in promoting exercise in older adults from an upper-middle-income country. Although the effects were not maintained when SMS text messaging ceased, the results are promising and warrant more research on behavioral mobile health interventions in other regions.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT02123342; http://clinicaltrials.gov/ct2/show/NCT02123342 (Archived by WebCite at http://www.webcitation.org/6eGSsu2EI).
authors.affiliation: Sports Centre, University of Malaya, Kuala Lumpur, Malaysia. andrematthiasmueller@gmail.com.
authors.forename: Andre Matthias
authors.identifier: http://orcid.org/0000-0001-5770-6723
authors.initials: AM
authors.lastname: Müller
authors.forename: Selina
authors.identifier: http://orcid.org/0000-0002-3090-9309
authors.initials: S
authors.lastname: Khoo
authors.forename: Tony
authors.identifier: http://orcid.org/0000-0002-2883-7270
authors.initials: T
authors.lastname: Morris
mesh_terms: D000368:Aged; D040421:Cell Phone; D015444:Exercise; D005260:Female; D006801:Humans; D008296:Malaysia; D008297:Male; D008875:Middle Aged; D020377:Self Efficacy; D017216:Telemedicine / Q000379:methods*; D060145:Text Messaging
keywords: Asia; Malaysia; behavior maintenance; exercise; health behavior; mHealth; mobile phone; older adults; physical activity; text message