The Text2LiveHealthy (T2LH) intervention is a direct education and social marketing intervention designed to increase family consumption of fruits and vegetables, increase physical activity among the entire family, and increase family consumption of water while decreasing consumption of sugary beverages. T2LH is a nutrition and physical activity digital health outreach effort that links the Integrated Nutrition Education Program (INEP) and Culture of Wellness in Preschools (COWP) youth education provided in classrooms to homes via text messaging, in order to influence behavior change for economically disadvantaged families across Colorado. There are four text message cycles in Year 1 with each cycle containing approximately 30 core texts that address the following themes: fruit and vegetable consumption, physical activity and sedentary behaviors, sugar-sweetened beverages, and water consumption. Each cycle contains approximately seven to eight core messages and two to three evaluation messages. In general, the messages are easy to use and include goal-setting for healthy behavior change, fun and easy recipes, family-friendly physical activity ideas, motivational messages, and links to resources. In Year 2, participants receive one text per week with a focus on maintaining behavior changes. In Year 3, participants receive weekly messages that focus on mindful eating, stress reduction and living an active lifestyle. In addition to the intervention messages, participants receive thematic messages based on the time of year as well as local messages for resources, for example farmer’s markets and Double Up Food Bucks and Summer Food Service Program (SFSP). 

Target Behavior: Healthy Eating, Physical Activity and Reducing Screen Time, Food Insecurity/Food Assistance  
Intervention Type: Direct Education, Social Marketing 

T2LH targets SNAP recipients and SNAP-eligible families who have preschool- or school-aged children across Colorado with a device that can receive text messages. Recruitment occurs by collaborating with SNAP-Ed implementation agencies, such as INEP and COWP, that provide programming in preschools and elementary schools. As of February 4th, 2022, there were 3,225 subscribers out of approximately 10,000 potential families. Of the subscribers 70% were English-speaking and 30% were Spanish-speaking.  

This intervention was created based on feedback from the target audience after they encountered challenges when attending in-person six-week workshops but still wanted to receive healthy eating and physical activity education. RMPRC staff collaborated with Maryland’s SNAP-Ed Text2BHealthy program initially and then developed an intervention based on the Theory of Planned Behavior change specific to the target audience in Colorado. To ensure inclusion of the large Hispanic population in Colorado, all T2LH materials were prepared in English but were translated and culturally adapted for Spanish-speaking participants. A formative evaluation was also completed in October 2017, which informed the development and evaluation of the final T2LH intervention. 

 

Setting: Child care (Learn), School (Learn) 

Target Audience: Preschool (<5 years), Elementary School, Parents/Mothers/Fathers 

Race/Ethnicity: No special focus 

T2LH includes four text message cycles in Year 1 and weekly messages in Year 2 and bi-monthly messages in Year 3. These intervention components provide supplement education, usually presented in the classrooms, to the home via text messaging in order to influence behavior change for economically disadvantaged families Additionally, messaging support healthy eating and physical activity for older adults and refugees across Colorado. The text messages sent out through T2LH are grounded in the Theory of Planned Behavior Change and are based on the following theoretical constructs from health behavior theory: knowledge, self-efficacy, intention, skills, environmental constraints, social norms, and attitudes. There are three themes: fruits and vegetables, physical activity and sedentary behaviors, and sugar-sweetened beverages and water consumption that determine the content of the text messages. Each text message developed for each theme (approximately seven to eight texts per theme in Year 1) is aligned with the theoretical constructs, and although the content of the messaging may be adapted, the underlying theoretical foundation remains intact. 

Intervention message libraries for Year 1,  Year 2 and Year 3:  

• Year 1 message library consists of four cycles with seven to eight core texts, two to four evaluation questions per cycle.   
• Year 2 message library consists of two cycles with seven to eight core texts, two to three evaluation questions per cycle. 
• Year 3 message library consists of three cycles with seven to eight core texts,  two evaluation questions   

Some items, including message library, platform protocols, sample recruitment materials, and bilingual (English and Spanish) nutrition education materials, are available on the  Culture of Wellness in Preschools website.  

T2LH conducted a formative evaluation with 21 adult participants, and all the information collected during this formative evaluation phase informed the development and evaluation of the T2LH intervention. Process data were also collected to review user-engagement with the texting content, which included capturing the number of clicks and responding to branching logic texts. An outcomes evaluation included the administration of goal-setting and behavior change evaluation texts that are completed after each texting theme. Fruit and vegetable evaluation responses indicated that participants self-reported goal-setting (81%) and increased fruit and vegetable consumption (76%) because of T2LH. Physical activity evaluation responses indicated that participants self-reported goal-setting (80%) and increased physical activity (69%) because of T2LH. Water and sugar-sweetened beverage evaluation responses indicated that participants not only self-reported goal-setting for increasing water consumption (86%) and decreasing sugary drinks (88%), they increased water consumption (83%) and decreased sugary drink consumption (85%). A qualitative study and a more rigorous longitudinal evaluation are underway to assess the acceptability and behavior change outcomes of T2LH with current subscribers.  

The unintended benefits of the intervention include: 

• The level of reported goal-setting and behavior change was much higher than anticipated 
• There were statistically significant differences (p<0.05) between Spanish and English-speaking participants in all outcomes (except in goal setting for sugary drinks) that favored Spanish-speaking families 
• The length of time that participants remained on the program was unexpected and prompted the development of a second year of intervention  

The challenges include: 

• Subscribers have a hard time using their phone to opt-in to the program 

To address this challenge, a flyer was designed showing the steps to opt–in to the program and staff were trained to help subscribers one-on-one. Additionally, sign-up sheets were used for subscribers to write down their phone number and preferred language. Potentially, partnerships between preschools and schools could further promote T2LH and improve parent recruitment. Community navigators assist with recruitment in refugee communities and partnerships with additional State Unit on Aging organizations facilitate recruitment of older adults across Colorado.

 

Evidence-based Approach: Practice-tested

Based on the SNAP-Ed Evaluation Framework, the following outcome indicators can be used to evaluate intervention progress and success.

	Readiness and Capacity – Short Term (ST)	Changes – Medium Term (MT)	Effectiveness and Maintenance – Long Term (LT)	Population Results (R)
Individual	ST1, ST3	MT1, MT3
Environmental Settings
Sectors of Influence

ST1: Healthy Eating  

• ST1a and ST1b: 81% of respondents (247/305) reported setting goals for fruit and vegetable setting.  
• ST1l: 86% of respondents (173/201) reported setting goals for drinking water instead of sugary beverages. 

ST3: Physical Activity and Reduced Sedentary Behavior 

• ST3a: 80% of respondents (176/220) reported setting goals to increase physical activity. 

MT1: Healthy Eating  

• MT1g: 83% of respondents (167/201) reported an increase in drinking water. 
• MT1h: 85% of respondents (171/201) reported drinking fewer sugar-sweetened beverages (e.g., regular soda or sports drinks). 
• MT1l and MT1m: 76% of respondents (243/320) reported an increase in the cups of fruits and vegetables consumed per day. 

MT3: Physical Activity and Reduced Sedentary Behavior  

• MT3a: 69% of respondents (152/220) reported an increase in physical activity. 

Text2LiveHealthy evaluation materials include:

• Evaluation questions:  
  • Example questions: Healthy Eating  
    • ST1: The past few weeks, we sent texts about setting a goal to eat more fruits and vegetables. Did you set a goal?  
    • MT1: The past few weeks, we sent texts about eating fruits and vegetables. Are you eating more fruits and vegetables because of these texts? 
• Formative evaluation interview guide and protocol  
• Phone interview guide and protocol  
• User-engagement evaluation protocol
• Longitudinal survey 

Text2BHealthy Colorado: An Innovative Way to Connect with Families:

https://snaped.fns.usda.gov/success-stories/text2bhealthy-colorado-innovative-way-connect-families

 

Website: The T2LH website includes an overview of T2LH, bilingual T2LH resources and tips, and testimonials.  

Contact Person(s):
Beth Watts
Phone: 303-724-4457  
Email: Elizabeth.watts@ucdenver.edu