title: Unpacking the Black Box: A Formative Research Approach to the Development of Theory-Driven, Evidence-Based, and Culturally Safe Text Messages in Mobile Health Interventions.
abstract: BACKGROUND
  Mobile-cellular subscriptions have increased steadily over the past decade. The accessibility of SMS messages over existing mobile networks is high and has almost universal availability even on older and unsophisticated mobile phones and in geographic settings where wireless coverage is weak. There is intensive exploration of this inexpensive mobile telecommunication technology to improve health services and promote behavior change among vulnerable populations. However, a neglected area of research is the documentation and critical analysis of the formative research process required in the development and refinement of effective SMS messages.
  
  
  OBJECTIVE
  The objective of this qualitative research study was to identify major factors that may impact on the effectiveness of evidence-based SMS messages designed to reduce health inequities in hypertension management in low resource settings, including Aboriginal populations in high-income countries and rural populations in low-income countries. Specifically, we were interested in uncovering the range of mediators that impact on appropriate message content transmission and, ultimately, on health behavior improvements in a range of these sociocultural settings.
  
  
  METHODS
  Collaborative qualitative research with Canadian Aboriginal and Tanzanian participants was conducted to deconstruct the content and transmission of evidence-based health information contained in SMS messages in the context of an international research project designed to address health inequalities in hypertension, and to develop a grounded theory of the major factors that mediate the effectiveness of this communication. We also examined the interrelationship of these mediators with the three essential conditions of the behavior system of the Behavioral Change Wheel model (capability, opportunity, and motivation) and cultural safety.
  
  
  RESULTS
  Four focus groups with a total of 45 participants were conducted. Our grounded theory research revealed how discrepancies develop between the evidence-based text message created by researchers and the message received by the recipient in mobile health interventions. These discrepancies were primarily generated by six mediators of meaning in SMS messages: (1) negative or non-affirming framing of advocacies, (2) fear- or stress-inducing content, (3) oppressive or authoritarian content, (4) incongruity with cultural and traditional practices, (5) disconnect with the reality of the social determinants of health and the diversity of cultures within a population, and (6) lack of clarity and/or practicality of content. These 6 mediators of meaning provide the basis for sound strategies for message development because they impact directly on the target populations' capability, opportunity, and motivation for behavior change.
  
  
  CONCLUSIONS
  The quality of text messages impacts significantly on the effectiveness of a mobile health intervention. Our research underscores the urgent need for interventions to incorporate and evaluate the quality of SMS messages and to examine the mediators of meaning within each targeted cultural and demographic group. Reporting on this aspect of mobile health intervention research will allow researchers to move away from the current black box of SMS text message development, thus improving the transparency of the process as well as the quality of the outcomes.
authors.affiliation: Faculty of Medicine, Northern Ontario School of Medicine, Laurentian University, Sudbury, ON, Canada. mmaar@nosm.ca.
authors.forename: Marion A
authors.identifier: http://orcid.org/0000-0001-9901-1436
authors.initials: MA
authors.lastname: Maar
authors.forename: Karen
authors.identifier: http://orcid.org/0000-0003-3628-0879
authors.initials: K
authors.lastname: Yeates
authors.forename: Zsolt
authors.identifier: http://orcid.org/0000-0002-3692-5844
authors.initials: Z
authors.lastname: Toth
authors.forename: Marcia
authors.identifier: http://orcid.org/0000-0002-6822-9093
authors.initials: M
authors.lastname: Barron
authors.forename: Lisa
authors.identifier: http://orcid.org/0000-0002-2507-1206
authors.initials: L
authors.lastname: Boesch
authors.forename: Diane
authors.identifier: http://orcid.org/0000-0003-4421-1646
authors.initials: D
authors.lastname: Hua-Stewart
authors.forename: Peter
authors.identifier: http://orcid.org/0000-0002-3017-1199
authors.initials: P
authors.lastname: Liu
authors.forename: Nancy
authors.identifier: http://orcid.org/0000-0002-6140-4848
authors.initials: N
authors.lastname: Perkins
authors.forename: Jessica
authors.identifier: http://orcid.org/0000-0003-1109-7533
authors.initials: J
authors.lastname: Sleeth
authors.forename: Mary Jo
authors.identifier: http://orcid.org/0000-0001-5087-2972
authors.initials: MJ
authors.lastname: Wabano
authors.forename: Pamela
authors.identifier: http://orcid.org/0000-0001-5950-6055
authors.initials: P
authors.lastname: Williamson
authors.forename: Sheldon W
authors.identifier: http://orcid.org/0000-0001-7848-3872
authors.initials: SW
authors.lastname: Tobe
keywords: Aboriginal people; SMS; Tanzania; behavioral change wheel; cultural safety; grounded theory; mobile phone; semiotics; text messages