Design and development of a complex narrative intervention delivered by text messages to reduce binge drinking among socially disadvantaged men

Design and development of a complex narrative intervention delivered by text messages to reduce... Background: Socially disadvantaged men are at high risk of suffering from alcohol-related harm. Disadvantaged groups are less likely to engage with health promotion. There is a need for interventions that reach large numbers at low cost and which promote high levels of engagement with the behaviour change process. The aim of this study was to design a theoretically and empirically based text message intervention to reduce binge drinking by socially disadvantaged men. Results: Following MRC guidance, the intervention was developed in four stages. Stage 1 developed a detailed behaviour change strategy based on existing literature and theory from several areas. These included the psychological theory that would underpin the intervention, alcohol brief interventions, text message interventions, effective behaviour change techniques, narratives in behaviour change interventions and communication theory. In addition, formative research was carried out. A logic model was developed to depict the pathways between intervention inputs, processes and outcomes for behaviour change. Stage 2 created a narrative which illustrated and modelled key steps in the strategy. Stage 3 rendered the intervention into a series of text messages and ensured that appropriate behavioural change techniques were incorporated. Stage 4 revised the messages to ensure comprehensive coverage of the behaviour change strategy and coherence of the narrative. It also piloted the intervention and made final revisions to it. Conclusions: The structured, systematic approach to design created a narrative intervention which had a strong theoretical and empirical basis. The use of a narrative helped make the intervention realistic and allowed key behaviour change techniques to be modelled by characters. The narrative was intended to promote engagement with the intervention. The intervention was rendered into a series of short text messages, and subsequent piloting showed they were acceptable in the target group. Delivery of an intervention by text message offers a low-cost, low-demand method that can reach large numbers of people. This approach provides a framework for the design of behaviour change interventions which could be used for interventions to tackle other health behaviours. Keywords: Behaviour change intervention, Narrative intervention, Text messages, SMS, Binge drinking, Complex intervention * Correspondence: m.a.j.irvine@dundee.ac.uk Division of Population Health Sciences, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 2 of 11 Background Results Socially disadvantaged men are at high risk of Approach to intervention design alcohol-related harm [1, 2]. Binge drinking (consumption The importance of a systematic approach to the design of more than eight UK units (64 g) of alcohol on a single of interventions is widely recognised [15–17]. This occasion) is common among young to middle-aged disad- intervention was developed following the MRC frame- vantaged men (proportion binge drinking in the most de- work [18] for complex interventions. As part of the prived areas, 17.5 vs 10.6% in least deprived areas) [3]. It is process, a logic model [19] was produced to clarify the likely to contribute to the disparity in alcohol-related relationships between the proposed mechanisms of harm [4]. Many alcohol interventions have been devel- action, the intended outputs and longer term outcomes. oped to tackle alcohol-related problems, and systematic The design process was conducted in four stages. The reviews have shown they are effective [5–8]. However, the first stage involved the design of a theoretically and uptake of public health interventions among socially dis- empirically based intervention. The starting point was a advantaged men is low [9]. Behaviour change interven- review of relevant theory and evidence, which in the tions are also less effective with disadvantaged and present study comprised alcohol interventions and low-income groups [10–13]. There is a need for a sensi- behaviour change theory and techniques. The review tive, tailored intervention which accesses and effectively identified that text messages were the most suitable reduces binge drinking in this hard-to-reach population. method for intervention delivery. This background work, This paper reports on the systematic approach taken to together with a taxonomy of intervention features [20], the design of an intervention to tackle binge drinking in informed the construction of the logic model (Fig. 1). disadvantaged men. Socially disadvantaged men were The logic model identified several issues on which identified as those living in areas of high deprivation (most further information was required for the design of the disadvantaged quintile), as defined by the Scottish Index intervention. These were explored in formative research of Multiple Deprivation (SIMD) [14]. comprising focus groups and a feasibility randomised Fig. 1 Logic model. The logic model depicts the pathways between intervention inputs, processes and outcomes for behaviour change Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 3 of 11 trial [21]. Based on the findings from this stage, an initial a weakness in some behavioural change theories. HAPA behaviour change strategy was developed. is a comprehensive model which allows integration of a The next two stages involved the translation of the range of evidence-based behaviour techniques. This behaviour change strategy into a format in which it model suggests the adoption, initiation and maintenance could be delivered to disadvantaged men. Stage 2 devel- of a new health behaviour occur as a process that oped the narrative within which the intervention could involves a motivational phase and a volitional phase. be embedded. At this stage, narrative devices were inte- Motivation can be increased by altering perceived risk of grated to become important elements of the behaviour a behaviour and the perceived benefits of changing that change strategy. The narrative-based intervention was behaviour. The volitional phase includes planning, action then rendered into a series of interactive text messages and maintenance. Perceived self-efficacy has a crucial in the third stage. This stage also exploited advantages role in achieving success throughout the process. It offered by delivering an intervention by text messages. helps in building an intention to change (motivation) as At the final stage, the text messages were reviewed, well as in implementing intentions into sustained action piloted and revised to ensure they delivered an easily (volition). Although HAPA was used as the overarching understood, coherent and comprehensive intervention. structure, the intervention also drew on other relevant Although the description of the intervention develop- social cognition and self-regulatory models, e.g. subject- ment is presented in a linear sequence, in practice, there ive norms from the theory of planned behaviour [32] was considerable iteration, with decisions taken at a later and self-monitoring from social cognitive theory [33] stage feeding back to earlier design choices. The final set and control theory [34]. of messages is included in Additional file 1 (intervention text messages). Incorporating behaviour change techniques Taxonomies of behaviour change techniques (BCTs) Stage 1: Developing the initial behaviour change strategy have been published to aid the design and reporting of Reviewing brief interventions to address alcohol-related interventions [35], including one for alcohol interven- harm tions [29]. Several techniques were incorporated into the The literature on alcohol brief interventions (ABIs) was intervention, such as providing normative information reviewed to identify effective mechanisms used in previ- about others’ behaviour and experiences and facilitating ous research. ABIs are widely used, but their mechanism goal setting and action planning. of action of is not clear [22–24], partly because interven- tions are very heterogeneous. They may contain ele- Selection of delivery method ments of motivational interviewing (MI), feedback and Given the low uptake of public health interventions advice, self-monitoring of alcohol consumption, self-help among socially disadvantaged individuals [9], a key manuals, counselling and cognitive behavioural therapy requirement of the delivery method was that it would [25–27]. Bien and colleagues [25] summarised the com- reach and engage disadvantaged men. Text messaging mon components of effective brief interventions with provides a method for delivering brief alcohol interven- the acronym FRAMES: Feedback on current consump- tions which has the potential to reach large numbers of tion, Responsibility of the individual for his drinking, individuals at low cost. Systematic reviews have shown Advice to change, Menu of change strategies, Empathy that text message interventions can successfully modify in the delivery and Self-efficacy for action. One of the adverse health behaviours [36, 37]. Mobile phone owner- reviews has suggested that effective interventions con- ship in the UK is high [38] and phone users frequently tain at least two of three elements: feedback on drinking, check their phones [39], so study participants would be advice and goal setting [28]. A more recent review found likely to open and read the messages. Previous studies that promoting self-monitoring was the only technique report that text messages are usually read soon after that appeared effective [29]. All of these components delivery [40]. Texts can reach people wherever they are were considered for inclusion in the intervention. [41]. If a participant’s phone is switched off, messages can be accessed when the phone is switched on again. Outline of the psychological theory underpinning the The use of text messaging may increase the salience of intervention an intervention [42], and almost all text messages are The Health Action Process Approach (HAPA) [30]was read within minutes of delivery [40]. Text messaging is chosen as the theoretical model to underpin the particularly suited to the target group because little intervention because it guides participants through the effort is required to receive the intervention and texts behaviour change sequence, from a starting position of can be accessed at times that suit the participants. In having no intention to change behaviour. It also addition, each text message can be read quickly and addresses the intention-behaviour gap [31] identified as re-read if desired. Men who may not want to commit Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 4 of 11 time reading leaflets or large sections of text may prefer drinker’ which came with social roles and to receive concise text messages. responsibilities (employee, husband/partner, parent). Despite this, they continued to binge drink. Logic model From the review of the literature on alcohol brief inter- ventions, psychological theory and text messaging, a With my job and responsibilities, I can’t just go out, logic model was developed (Fig. 1). This provided a I’m not working in a warehouse like I was when I was detailed specification of the problem to be addressed 18 where you can just do what you want the next day, (regular binge drinking by socially disadvantaged young it doesn’t matter. But now, during the week, it just to middle-aged men) and clarified what the intervention can’t happen, with my job the next day, I just couldn’t aimed to achieve. It also identified challenges to be function properly. (FG1, Jim, 31 years) considered, such as the lower effectiveness of health pro- motion interventions in disadvantaged groups [10–13]. For this study, the initial requirements for behaviour change were an increased awareness and personal rele-  Most men were aware of the harms associated with vance of the harms of alcohol and the benefits of moder- alcohol misuse but had low perceived personal risk. ated drinking. Altering risk perception and alcohol expectancies are prerequisites for increasing motivation to change. Setting goals and making action plans would You always regret it the next day, but come Friday, if lead to reduced drinking but only if self-efficacy for you’ve not been drinking all week, and you’re feeling action had also been increased. Further, to prevent re- good again, and somebody’s offering a night out you lapse, reduced drinking would have to be maintained. look forward to it, you’re back on the drink.(FG1 This could be achieved by increasing the salience of the Darren, 28 years) benefits of reduced drinking and developing coping skills. Thus, the short-term benefits of moderated drink- ing could be used to encourage longer term reductions. This would lead to improved health and social wellbeing  The men did not want to be preached at or told for the individual and a reduction in the costs of what to do in an intervention. alcohol-related harms for society. Formative research I always felt that nobody could dictate to you. I mean The development of the text message intervention was I live my life the way I see fit and I wouldn’t tell informed by a prior feasibility study [43], which com- anybody else what way they should live, that’s just the prised focus groups and a pilot trial. The focus groups way I am. (FG2, Alan, 50 years) gave insight into the target group’s patterns of drinking, their knowledge about alcohol-related harms and bene- The subsequent randomised controlled feasibility fits of reduced drinking. study [43, 44] showed that: The common pattern of drinking was periods of  Participants enjoyed the interactive nature of the abstinence interspersed with infrequent heavy intervention and gave carefully considered personal drinking days, i.e. binge drinking. responses to questions asked in the text messages Participants engaged with the cognitive antecedents to reducing drinking as they were discussed in the I used to go out every weekend, but I’m only once a text messages month now. That’s why I like to go out for a bucketful and that’s why I like money in my pocket to go out. Stage 2: The creation of a narrative (FG3, Mark, 38 years) Narratives are increasingly being used as a tool for be- haviour change. Hinyard and Kreuter define a narrative as ‘any cohesive and coherent story with an identifiable beginning, middle, and end that provides information Many men believed that their drinking behaviours, about scene, characters, and conflict; raises unanswered motives and desire to change were significantly questions or unresolved conflict; and provides reso- different from when they were younger. They lution’ [45]. Instead of presenting facts and arguments thought they had adopted the role of the ‘mature for changing behaviour, a narrative intervention Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 5 of 11 translates these into actions and experiences of charac- However, so that the participants would empathise with ters within a chronological series of events [46]. his experiences, he also faced disappointment and failure Information presented in a narrative has a stronger before finally achieving his goals. Dave’s fallibility was effect on knowledge, attitudes and intentions than the intended to encourage men to identify with him and his same information in a non-narrative format [47]. resilience to inspire them. He modelled the process of Narrative is particularly useful for changing perceived reflection on his drinking to encourage participants to social norms and behavioural intentions [48, 49]. To be review their own behaviour, motivations and circum- effective for behaviour change, the narrative and the stances. The steps in the behaviour change strategy that characters in it have to engage the reader, a process Dave demonstrated are shown in Table 2. Using Dave to aided if the protagonists are culturally similar to the model these steps allowed the intervention to focus on target audience [50, 51]. The narrative also has to be specific rather than general behaviours and to set them plausible and internally consistent [52]. The depiction of in a social context familiar to participants. This process a character who succeeds against the odds can boost may engender self-efficacy through vicarious experience, motivation for personal goals [53]. particularly if the men identify with the characters in the narrative. Designing the narrative Dave’s friends, like the protagonist, were also people The narrative explicitly followed the sequence of the with whom the participants could identify. They differed behaviour change strategy from motivation through ac- in drinking patterns (e.g. previous heavy drinker, regular tion to maintenance of reduced drinking. It described heavy binge drinker) and in their demographic charac- the journey of a central character, Dave, as he decided teristics (i.e. employed/unemployed, single/in a relation- that his drinking was a problem and moved from regular ship/family man). An important role of the characters binge drinking to moderated consumption. The narra- was to make the harms of alcohol more relevant and tive also included Dave’s wife Christine and a few of his concrete to the participants. These characters were more friends (Table 1). The number of named characters, and likely to fail in achieving their goals, a feature intended the background information on each, was limited to to promote empathy and elicit sympathy from partici- ensure that the study participants could follow their in- pants. One character, Alec, the previous heavy drinker, dividual stories. The narrative was written out in full was presented as an admirable role model. before considering how it could be rendered into text Narratives frequently evoke emotional responses, and messages. these can have strong effects over and above more The characters were designed to make them credible rational cognitive approaches [55]. Thus emotive topics to the participants [54] so they could form personal con- were used to increase motivation to change, e.g. one of nections with them [55]. Dave was presented as some- the character’s partner and child leave home because of one who believed he was a mature drinker (a family man problems caused by alcohol. A second character, an irre- with responsibilities) but who was still binge drinking sponsible drinker, finds a partner at the end of the frequently. He was designed to be likeable and as some- one who would succeed in changing his behaviour. Table 2 Steps to behaviour change modelled in the narrative Modelled by Dave Table 1 Characters in the narrative Self-monitoring of drinking Characters in the narrative Risk perception Main character: Changes in outcome expectancies for heavy/binge drinking Dave is a family man who is married to Christine. He initially believes he is a ‘mature’ drinker. He subsequently realises that he is a regular Increasing intention to reduce drinking binge drinker and becomes aware of the potential risks from his Subjective norms drinking. He models behaviour change techniques that are likely to work but also experiences lapses along the way. In the end, he Goal setting achieves his goal to cut down on his drinking and is satisfied with Action planning the outcome of the changes he has made. Increasing action self-efficacy Other characters (Dave’s friends): Stevie is the unmarried ‘antagonist’ character. He has few Benefits of success at sticking to the plan responsibilities; he is unemployed and lives with his mother. Stevie Relapse often encourages everyone around him to drink. Dougie has had serious alcohol-related problems in the past. He lives Coping planning with a long-suffering partner (Sadie) but has a troubled relationship. Coping self-efficacy He also tries to change his drinking but gets it wrong more often than Dave. Satisfaction with changed drinking pattern Alec was previously a heavy drinker but is now a mature, sensible drinker. He is respected by the others and is a role model for Dave. Maintenance from benefits of achieving goals Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 6 of 11 narrative because of the successful efforts he has made Specify dates and times to send messages The to reduce his drinking. messages were tailored to the day of the week. Thus, the intervention was designed so that the first text message would be sent on the Monday evening following Review of content randomisation. The feasibility study revealed that a com- To assess the completeness of the provisional interven- mon pattern is heavy drinking at the weekend followed tion, the sections of the narrative were reviewed to by sobriety during the week. Text messages sent on ensure that the key components of the behaviour change Friday and Saturday were therefore delivered in the strategy were contained in the narrative. This also iden- afternoon or early evening before the men went out tified whether the behaviour change techniques were drinking. Messages sent on Sunday were generally deliv- appropriate for the proposed mechanism of change. ered later in the evening to give the participants a little more time to recover from a hangover. Mid-week text Stage 3: Drafting the text messages messages were sent at variable times, often after the The text messages were constructed so that the main working day. character, Dave, appeared to be a recipient of the inter- The previous research offers differing views on vention. Thus, he commented on the text messages, an- message frequency. One systematic review suggests that swered questions and modelled behaviours that were retention is higher if the number of messages is varied expected from the behaviour change strategy (Table 2). over time [59], while another reported that interventions This avoided didactic delivery of the intervention, which when message frequency decreased were more effective preliminary work in the feasibility study had found to be than those with constant frequencies [37]. All of the unwelcome. To simplify the narrative, Dave was the only messages in this intervention were unique, although character who sent messages, although he discussed at some topics, e.g. self-efficacy and maintenance of a new length what was happening in the lives of the other behaviour were revisited at different stages of the inter- characters. Messages containing a narrative were identi- vention. The intervention was designed so that partici- fied either by Dave introducing himself or signing off at pants would receive at least one message every day for the end of the message. the first 5 weeks. The maximum number of messages The complete intervention was rendered in a series of sent in a day was four. From week 6 onwards, occasional 112 text messages, each with one or more of the follow- days were missed. ing purposes: Use of linked messages The text messages were often Delivering the narrative sent in pairs or groups of three or four. This device has Increasing the salience of the harms of heavy several purposes. Linked messages enabled more com- drinking and the benefits of moderated drinking plex messages to be sent as some of the reflective activ- Modelling steps in the behaviour change process ities and behaviour change strategies could not be Giving information or facts (to augment the explained in a single message. They were also used to behaviour change strategy portrayed in the extend the time the participants had to think about a narrative) topic. The first message was often used to seed an idea, Asking questions (to encourage reflection and while the follow-up text messages encouraged reflection increase the impact of intervention components) on the topic. Combinations of messages could add Increasing the impact of components of the suspense and build a storyline. Responses from charac- intervention by using anonymised quotes from the ters in the narrative were used to illustrate how the mes- feasibility study participants sages could be interpreted (e.g. for goal setting or action Adding humour (to increase engagement) planning) or to give examples of reasons for changing behaviour. Paired messages could also pose a question, Design decisions with the answer provided later in the day. The time Several studies have identified features which need to be delay between linked messages varied from 3 min to 4 h. addressed when designing text message interventions [56–58]. These include the duration of the intervention, Making the intervention acceptable Communication the frequency of sending texts, tailoring of messages to theory [60, 61] was used to enhance the acceptability of individuals, the informality of the language used and the the intervention. The name of the university was used to extent of interactivity. In addition, the prior feasibility give credibility to the study and the intervention. It was study showed that the use of linked text messages and mentioned on all written material given to the men dur- direct quotes from men in the target group were useful ing recruitment. To establish a relationship, participants techniques [43, 44]. were sent a welcoming text message which included Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 7 of 11 their first name. Text messages did not include messa- intervention had been included (i.e. the key components ging slang as it could be construed as unprofessional of HAPA, the behaviour change techniques, BCTs). coming from a credible source, i.e. a university. Commu- Initially, the broad structure of the intervention was nication theory suggests that interesting and unexpected clarified by grouping text messages by their intended statements can be used to maintain interest. Thus, function, identifying the logical progression through the humour was used throughout the intervention period. intervention (Additional file 2: Table S1). Then, individ- ual text messages were mapped to components of the Techniques to increase engagement with the texts HAPA model and to specific BCTs (Additional file 2: Tables S2 and S3). Finally, the narrative text messages Interactive items for key components of the interven- were mapped to ensure the story was coherent tion The use of interactive text messages was central to (Additional file 2: Table S4). the intervention. Mobile phone etiquette requires recip- The messages were also read by colleagues who knew rocation, so that messages which ask questions are likely the storyline of the narrative and the behaviour change to be answered [62]. The target group are frequent mo- techniques and processes that should be incorporated bile phone users and therefore likely to engage in text into the intervention. They were asked to establish message conversations. This was capitalised on by asking whether each component of the behaviour change strat- questions on the key components of the behaviour egy was addressed in sufficient detail. They also checked change strategy. For example, participants were asked: ‘If whether the reader could follow the narrative when it you made a goal to cut down a bit on your drinking, was presented as a series of text messages. This process what would it be? Text me your answer’ or ‘What would was then repeated with colleagues unfamiliar with the you do if you got into a situation where you were narrative and the intervention. Ambiguous statements expected to drink far more than you intended? Text me were modified to ensure that the unedited direct quotes your answer’. The responses to these questions provided from the feasibility study were easily understood. an indication of engagement with the intervention in real time. The feasibility study showed that participants Piloting and final revisions engaged with the cognitive antecedents to reducing Guidance on text message intervention development drinking and with important steps on the causal chain suggests that rigorous pretesting should be done with to behaviour change [44]. the target group [63], to ensure the messages are rele- vant and have the intended impact [64]. The final pilot- Quotes from the feasibility study The feasibility study ing used 24 volunteers (8 members of the target group, produced a wealth of data ‘in the participants’ own 13 post-graduate students and 3 members of university words’ both from focus groups and text message staff unconnected with the study). They were given responses from those who received the intervention background information on the study and were told that [43]. Several texts from that study were presented as the characters in the narrative were fictional. These vol- anonymised quotes from individuals describing their unteers received a copy of the text messages on paper personal experiences. For example, to increase perceived and were asked to provide written comments, both on risks of heavy drinking, one message said “John from the overall approach and on individual text messages. Dundee says ‘I’ve woke up in the cells a few times All eight of the target group members engaged with the because of drink. if i was sober it would never have hap- characters and the narrative as if they were real and pened’”. This technique was used to illustrate harms responded directly to the text messages rather than from alcohol misuse, to model new behaviours and to commenting on their appropriateness of their content. report achievements and benefits from changing behav- The post-graduate students and staff approached the iour. The quotes delivered information in the language task as an academic exercise and commented on the used by the target group and were intended to encour- readability and potential impact of the texts. However, age participants to share their own experiences. To one student changed roles partway through and began reinforce their authenticity, the quotes were not responding to the texts as if he were a participant. corrected for spelling or grammar. The volunteers’ comments gave reassurance that most texts were clear and readily understood, although a few Stage 4: Revision of the text messages needed rewording. No one identified components of the Ensure coherence of the narrative and the behaviour intervention which were missing, inappropriate or inad- change strategy equately addressed. The comments showed that the use When the intervention had been rendered into text mes- of characters made the intervention appear more realis- sages, it was reviewed to ensure that it was complete tic and less daunting. The volunteers also found the and coherent and that all of the components of the overall approach supportive. Finally, they suggested how Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 8 of 11 the narrative be amended. Several students expressed information in a non-narrative format [47]. Narrative is concern about the fate of one character, Stevie, so the particularly useful for changing perceived social norms narrative was amended to give him a happy ending. A and behavioural intentions [48, 49]. The use of a narra- second round of piloting involved new volunteers (three tive also provided an opportunity to present the inter- members of the research team) who received the text vention in a non-patronising way. A major advantage of messages on their mobile phones. This was primarily the narrative was that the lead character, Dave, could used to test the delivery system but also helped confirm model key behaviours such as action planning, relapse that the frequency and timing of the messages were recovery and coping planning. Including questions in acceptable. The final version of the text messages is sup- the text messages reinforced this by asking participants plied as Additional file 1 (Intervention text messages). to explain how they would perform similar actions [69]. This study has shown that a narrative-based interven- Discussion tion, which covers the components of a psychological A systematic approach based on theory, evidence and model (HAPA), can be fully addressed in a text message formative research was used to design a tailored text intervention. Even complex psychological constructs can message intervention to reduce binge drinking among be conveyed through a few linked text messages through socially disadvantaged men. Following the MRC frame- a careful process of design, piloting and testing. A poten- work guidance [18], the intervention was developed tial challenge arose from the process in which the behav- from a review of the target group, the health behaviour iour change strategy had to be translated into a narrative being studied and selection of the most appropriate psy- which then had to be rendered in text messages. As chological model and behaviour change techniques. The elements of the intervention could be omitted at either findings were then used to create a logic model explor- step, repeated checking was carried out to ensure fidelity ing how the intervention strategy could lead to the with the initial design. desired short- and long-term outcomes. This led to a de- cision on the delivery method and text messages and to Limitations of the study design formative research to inform intervention development. Identifying men who are socially disadvantaged may be A revised intervention incorporating a narrative was challenging. Using an area-based measure of social dis- developed and fine-tuned in further pilot testing. advantage may include individuals living in affluent areas The decision on the delivery method, text messages, which are located within postcode areas that are classi- was made because of concerns about the recruitment fied as being socially disadvantaged. Tailoring interven- and engagement of disadvantaged men in the study. So- tions to a large potentially heterogeneous group is cially disadvantaged people are seen as a hard-to-reach challenging. This was addressed through extensive pilot- group and reluctant to take part in research [65, 66]. ing during development. However, they are the most frequent users of mobile Delivering the intervention over a 12-week period phones and are more likely to use text messaging and could be seen as a weakness, by diluting the intensity of send and receive a higher number of text messages than intervention delivery. However, the extended time people with higher education and income [67, 68]. A allowed participants to reflect on the content over a lon- text message intervention, which did not require any ger period. This approach enabled the key components face-to-face contact with researchers or clinicians, was of the intervention to be revisited so that commitment thought likely to engage the target group. Further, a fea- to change could be reinforced. ture of text messaging etiquette is that texts are likely to The intervention was designed to encourage the prompt a response [62]. Thus, questions were regularly participants to respond to text messages. However, this asked on the key components of the HAPA model to intervention cannot be truly interactive, i.e. participants foster engagement. Text message questions have been will not receive replies to their responses, except in used in previous trials to promote interactivity [56, 57], exceptional circumstances, for example if they report but this is the first study to report using this device as distress. Failure to receive replies may discourage partici- part of the intervention. pants to respond as the intervention progresses. The novel feature of the design was the use of narra- A constraint in writing the text messages was the tive in a text message intervention. This was suggested permitted length of a text (160 characters). Thus, the by one of the authors (BW) to provide a structure storyline had to be fairly simple and straightforward to around which text messages could be woven, increasing be delivered in a few words. A feature of a narrative is coherence and sustaining the interest of participants. that it should provide sufficient context and information However, a narrative-based intervention also brings for participants to have an understanding of the scenario additional benefits of increased effects on knowledge, being depicted but needs to be vague in ways that attitudes and intentions compared to the same encourage participants to fill in the detail using their Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 9 of 11 imagination and based on their own life experience [54]. Authors’ contributions IKC conceived the study. IKC, LI, BW, AJM and FFS designed the intervention. Thus, the scant information presented within the text FFS advised on the use of the Health Action Process Approach. BW messages may encourage participants to embellish the suggested using a narrative intervention. IKC, LI, AJM and BW created the storyline to make it fit their personal social circumstances. characters for the narrative. LI wrote the first draft of the narrative and the text message intervention. AJM ensured the narrative incorporated all Delivering interventions by mobile phone may have components of the behaviour change strategy. LI and IKC wrote the first limitations. Some participants may not receive messages draft of the paper. All authors reviewed and contributed to the final if they have a weak phone signal or if their phones are manuscript. All authors read and approved the final manuscript. continually switched off. Having insufficient credit may Ethics approval and consent to participate deter participants from engaging with the intervention The study was approved by the East of Scotland Research Ethics Service, and some may delete messages without reading them. project reference number 13/ES/0058. This study was designed to prompt responses so that we Competing interests could monitor whether participants were opening and The authors declare that they have no competing interests. reading the text messages. Adding humour was used to maintain interest in the Publisher’sNote text messages. Although our feasibility study and pilot- Springer Nature remains neutral with regard to jurisdictional claims in ing of the intervention showed that the jokes were well published maps and institutional affiliations. received, it is possible that in a large study, some indi- Author details viduals might dislike the jokes. In general, humour Division of Population Health Sciences, University of Dundee, The should be used with care. 2 Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK. Institute of Health and Wellbeing, University of Glasgow, Mental Health and Wellbeing Academic Centre, Gartnavel Royal Hospital, 1055 Great Western Road, Conclusion Glasgow G12 0XH, UK. School of Health and Social Care, Edinburgh Napier This structured, systematic approach has led to the University, Sighthill Campus, Sighthill Court, Edinburgh EH11 4BN, UK. design of a text message intervention with a strong the- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle NE2 4AX, UK. Medical and Biological Sciences, oretical and empirical basis. The process was highly School of Medicine, University of St Andrews, North Haugh, St Andrews KY16 iterative to enable a theory of behaviour change and a 9TF, UK. set of behaviour change techniques to be embedded in a Received: 30 January 2018 Accepted: 15 May 2018 coherent narrative. These were successfully rendered in a series of short text messages. The use of a narrative helped make the intervention realistic and allowed key References 1. Mackenbach JP, Kulhanova I, Bopp M, et al. Inequalities in alcohol-related behavioural activities to be modelled by characters. 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Real time monitoring of engagement with a text message intervention to reduce binge drinking among men living in socially disadvantaged areas of Scotland. Int J Behav Med. 2017; https://doi.org/10.1007/s12529-017-9666-z. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Pilot and Feasibility Studies Springer Journals

Design and development of a complex narrative intervention delivered by text messages to reduce binge drinking among socially disadvantaged men

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Medicine & Public Health; Medicine/Public Health, general; Biomedicine, general; Statistics for Life Sciences, Medicine, Health Sciences
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Abstract

Background: Socially disadvantaged men are at high risk of suffering from alcohol-related harm. Disadvantaged groups are less likely to engage with health promotion. There is a need for interventions that reach large numbers at low cost and which promote high levels of engagement with the behaviour change process. The aim of this study was to design a theoretically and empirically based text message intervention to reduce binge drinking by socially disadvantaged men. Results: Following MRC guidance, the intervention was developed in four stages. Stage 1 developed a detailed behaviour change strategy based on existing literature and theory from several areas. These included the psychological theory that would underpin the intervention, alcohol brief interventions, text message interventions, effective behaviour change techniques, narratives in behaviour change interventions and communication theory. In addition, formative research was carried out. A logic model was developed to depict the pathways between intervention inputs, processes and outcomes for behaviour change. Stage 2 created a narrative which illustrated and modelled key steps in the strategy. Stage 3 rendered the intervention into a series of text messages and ensured that appropriate behavioural change techniques were incorporated. Stage 4 revised the messages to ensure comprehensive coverage of the behaviour change strategy and coherence of the narrative. It also piloted the intervention and made final revisions to it. Conclusions: The structured, systematic approach to design created a narrative intervention which had a strong theoretical and empirical basis. The use of a narrative helped make the intervention realistic and allowed key behaviour change techniques to be modelled by characters. The narrative was intended to promote engagement with the intervention. The intervention was rendered into a series of short text messages, and subsequent piloting showed they were acceptable in the target group. Delivery of an intervention by text message offers a low-cost, low-demand method that can reach large numbers of people. This approach provides a framework for the design of behaviour change interventions which could be used for interventions to tackle other health behaviours. Keywords: Behaviour change intervention, Narrative intervention, Text messages, SMS, Binge drinking, Complex intervention * Correspondence: m.a.j.irvine@dundee.ac.uk Division of Population Health Sciences, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 2 of 11 Background Results Socially disadvantaged men are at high risk of Approach to intervention design alcohol-related harm [1, 2]. Binge drinking (consumption The importance of a systematic approach to the design of more than eight UK units (64 g) of alcohol on a single of interventions is widely recognised [15–17]. This occasion) is common among young to middle-aged disad- intervention was developed following the MRC frame- vantaged men (proportion binge drinking in the most de- work [18] for complex interventions. As part of the prived areas, 17.5 vs 10.6% in least deprived areas) [3]. It is process, a logic model [19] was produced to clarify the likely to contribute to the disparity in alcohol-related relationships between the proposed mechanisms of harm [4]. Many alcohol interventions have been devel- action, the intended outputs and longer term outcomes. oped to tackle alcohol-related problems, and systematic The design process was conducted in four stages. The reviews have shown they are effective [5–8]. However, the first stage involved the design of a theoretically and uptake of public health interventions among socially dis- empirically based intervention. The starting point was a advantaged men is low [9]. Behaviour change interven- review of relevant theory and evidence, which in the tions are also less effective with disadvantaged and present study comprised alcohol interventions and low-income groups [10–13]. There is a need for a sensi- behaviour change theory and techniques. The review tive, tailored intervention which accesses and effectively identified that text messages were the most suitable reduces binge drinking in this hard-to-reach population. method for intervention delivery. This background work, This paper reports on the systematic approach taken to together with a taxonomy of intervention features [20], the design of an intervention to tackle binge drinking in informed the construction of the logic model (Fig. 1). disadvantaged men. Socially disadvantaged men were The logic model identified several issues on which identified as those living in areas of high deprivation (most further information was required for the design of the disadvantaged quintile), as defined by the Scottish Index intervention. These were explored in formative research of Multiple Deprivation (SIMD) [14]. comprising focus groups and a feasibility randomised Fig. 1 Logic model. The logic model depicts the pathways between intervention inputs, processes and outcomes for behaviour change Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 3 of 11 trial [21]. Based on the findings from this stage, an initial a weakness in some behavioural change theories. HAPA behaviour change strategy was developed. is a comprehensive model which allows integration of a The next two stages involved the translation of the range of evidence-based behaviour techniques. This behaviour change strategy into a format in which it model suggests the adoption, initiation and maintenance could be delivered to disadvantaged men. Stage 2 devel- of a new health behaviour occur as a process that oped the narrative within which the intervention could involves a motivational phase and a volitional phase. be embedded. At this stage, narrative devices were inte- Motivation can be increased by altering perceived risk of grated to become important elements of the behaviour a behaviour and the perceived benefits of changing that change strategy. The narrative-based intervention was behaviour. The volitional phase includes planning, action then rendered into a series of interactive text messages and maintenance. Perceived self-efficacy has a crucial in the third stage. This stage also exploited advantages role in achieving success throughout the process. It offered by delivering an intervention by text messages. helps in building an intention to change (motivation) as At the final stage, the text messages were reviewed, well as in implementing intentions into sustained action piloted and revised to ensure they delivered an easily (volition). Although HAPA was used as the overarching understood, coherent and comprehensive intervention. structure, the intervention also drew on other relevant Although the description of the intervention develop- social cognition and self-regulatory models, e.g. subject- ment is presented in a linear sequence, in practice, there ive norms from the theory of planned behaviour [32] was considerable iteration, with decisions taken at a later and self-monitoring from social cognitive theory [33] stage feeding back to earlier design choices. The final set and control theory [34]. of messages is included in Additional file 1 (intervention text messages). Incorporating behaviour change techniques Taxonomies of behaviour change techniques (BCTs) Stage 1: Developing the initial behaviour change strategy have been published to aid the design and reporting of Reviewing brief interventions to address alcohol-related interventions [35], including one for alcohol interven- harm tions [29]. Several techniques were incorporated into the The literature on alcohol brief interventions (ABIs) was intervention, such as providing normative information reviewed to identify effective mechanisms used in previ- about others’ behaviour and experiences and facilitating ous research. ABIs are widely used, but their mechanism goal setting and action planning. of action of is not clear [22–24], partly because interven- tions are very heterogeneous. They may contain ele- Selection of delivery method ments of motivational interviewing (MI), feedback and Given the low uptake of public health interventions advice, self-monitoring of alcohol consumption, self-help among socially disadvantaged individuals [9], a key manuals, counselling and cognitive behavioural therapy requirement of the delivery method was that it would [25–27]. Bien and colleagues [25] summarised the com- reach and engage disadvantaged men. Text messaging mon components of effective brief interventions with provides a method for delivering brief alcohol interven- the acronym FRAMES: Feedback on current consump- tions which has the potential to reach large numbers of tion, Responsibility of the individual for his drinking, individuals at low cost. Systematic reviews have shown Advice to change, Menu of change strategies, Empathy that text message interventions can successfully modify in the delivery and Self-efficacy for action. One of the adverse health behaviours [36, 37]. Mobile phone owner- reviews has suggested that effective interventions con- ship in the UK is high [38] and phone users frequently tain at least two of three elements: feedback on drinking, check their phones [39], so study participants would be advice and goal setting [28]. A more recent review found likely to open and read the messages. Previous studies that promoting self-monitoring was the only technique report that text messages are usually read soon after that appeared effective [29]. All of these components delivery [40]. Texts can reach people wherever they are were considered for inclusion in the intervention. [41]. If a participant’s phone is switched off, messages can be accessed when the phone is switched on again. Outline of the psychological theory underpinning the The use of text messaging may increase the salience of intervention an intervention [42], and almost all text messages are The Health Action Process Approach (HAPA) [30]was read within minutes of delivery [40]. Text messaging is chosen as the theoretical model to underpin the particularly suited to the target group because little intervention because it guides participants through the effort is required to receive the intervention and texts behaviour change sequence, from a starting position of can be accessed at times that suit the participants. In having no intention to change behaviour. It also addition, each text message can be read quickly and addresses the intention-behaviour gap [31] identified as re-read if desired. Men who may not want to commit Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 4 of 11 time reading leaflets or large sections of text may prefer drinker’ which came with social roles and to receive concise text messages. responsibilities (employee, husband/partner, parent). Despite this, they continued to binge drink. Logic model From the review of the literature on alcohol brief inter- ventions, psychological theory and text messaging, a With my job and responsibilities, I can’t just go out, logic model was developed (Fig. 1). This provided a I’m not working in a warehouse like I was when I was detailed specification of the problem to be addressed 18 where you can just do what you want the next day, (regular binge drinking by socially disadvantaged young it doesn’t matter. But now, during the week, it just to middle-aged men) and clarified what the intervention can’t happen, with my job the next day, I just couldn’t aimed to achieve. It also identified challenges to be function properly. (FG1, Jim, 31 years) considered, such as the lower effectiveness of health pro- motion interventions in disadvantaged groups [10–13]. For this study, the initial requirements for behaviour change were an increased awareness and personal rele-  Most men were aware of the harms associated with vance of the harms of alcohol and the benefits of moder- alcohol misuse but had low perceived personal risk. ated drinking. Altering risk perception and alcohol expectancies are prerequisites for increasing motivation to change. Setting goals and making action plans would You always regret it the next day, but come Friday, if lead to reduced drinking but only if self-efficacy for you’ve not been drinking all week, and you’re feeling action had also been increased. Further, to prevent re- good again, and somebody’s offering a night out you lapse, reduced drinking would have to be maintained. look forward to it, you’re back on the drink.(FG1 This could be achieved by increasing the salience of the Darren, 28 years) benefits of reduced drinking and developing coping skills. Thus, the short-term benefits of moderated drink- ing could be used to encourage longer term reductions. This would lead to improved health and social wellbeing  The men did not want to be preached at or told for the individual and a reduction in the costs of what to do in an intervention. alcohol-related harms for society. Formative research I always felt that nobody could dictate to you. I mean The development of the text message intervention was I live my life the way I see fit and I wouldn’t tell informed by a prior feasibility study [43], which com- anybody else what way they should live, that’s just the prised focus groups and a pilot trial. The focus groups way I am. (FG2, Alan, 50 years) gave insight into the target group’s patterns of drinking, their knowledge about alcohol-related harms and bene- The subsequent randomised controlled feasibility fits of reduced drinking. study [43, 44] showed that: The common pattern of drinking was periods of  Participants enjoyed the interactive nature of the abstinence interspersed with infrequent heavy intervention and gave carefully considered personal drinking days, i.e. binge drinking. responses to questions asked in the text messages Participants engaged with the cognitive antecedents to reducing drinking as they were discussed in the I used to go out every weekend, but I’m only once a text messages month now. That’s why I like to go out for a bucketful and that’s why I like money in my pocket to go out. Stage 2: The creation of a narrative (FG3, Mark, 38 years) Narratives are increasingly being used as a tool for be- haviour change. Hinyard and Kreuter define a narrative as ‘any cohesive and coherent story with an identifiable beginning, middle, and end that provides information Many men believed that their drinking behaviours, about scene, characters, and conflict; raises unanswered motives and desire to change were significantly questions or unresolved conflict; and provides reso- different from when they were younger. They lution’ [45]. Instead of presenting facts and arguments thought they had adopted the role of the ‘mature for changing behaviour, a narrative intervention Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 5 of 11 translates these into actions and experiences of charac- However, so that the participants would empathise with ters within a chronological series of events [46]. his experiences, he also faced disappointment and failure Information presented in a narrative has a stronger before finally achieving his goals. Dave’s fallibility was effect on knowledge, attitudes and intentions than the intended to encourage men to identify with him and his same information in a non-narrative format [47]. resilience to inspire them. He modelled the process of Narrative is particularly useful for changing perceived reflection on his drinking to encourage participants to social norms and behavioural intentions [48, 49]. To be review their own behaviour, motivations and circum- effective for behaviour change, the narrative and the stances. The steps in the behaviour change strategy that characters in it have to engage the reader, a process Dave demonstrated are shown in Table 2. Using Dave to aided if the protagonists are culturally similar to the model these steps allowed the intervention to focus on target audience [50, 51]. The narrative also has to be specific rather than general behaviours and to set them plausible and internally consistent [52]. The depiction of in a social context familiar to participants. This process a character who succeeds against the odds can boost may engender self-efficacy through vicarious experience, motivation for personal goals [53]. particularly if the men identify with the characters in the narrative. Designing the narrative Dave’s friends, like the protagonist, were also people The narrative explicitly followed the sequence of the with whom the participants could identify. They differed behaviour change strategy from motivation through ac- in drinking patterns (e.g. previous heavy drinker, regular tion to maintenance of reduced drinking. It described heavy binge drinker) and in their demographic charac- the journey of a central character, Dave, as he decided teristics (i.e. employed/unemployed, single/in a relation- that his drinking was a problem and moved from regular ship/family man). An important role of the characters binge drinking to moderated consumption. The narra- was to make the harms of alcohol more relevant and tive also included Dave’s wife Christine and a few of his concrete to the participants. These characters were more friends (Table 1). The number of named characters, and likely to fail in achieving their goals, a feature intended the background information on each, was limited to to promote empathy and elicit sympathy from partici- ensure that the study participants could follow their in- pants. One character, Alec, the previous heavy drinker, dividual stories. The narrative was written out in full was presented as an admirable role model. before considering how it could be rendered into text Narratives frequently evoke emotional responses, and messages. these can have strong effects over and above more The characters were designed to make them credible rational cognitive approaches [55]. Thus emotive topics to the participants [54] so they could form personal con- were used to increase motivation to change, e.g. one of nections with them [55]. Dave was presented as some- the character’s partner and child leave home because of one who believed he was a mature drinker (a family man problems caused by alcohol. A second character, an irre- with responsibilities) but who was still binge drinking sponsible drinker, finds a partner at the end of the frequently. He was designed to be likeable and as some- one who would succeed in changing his behaviour. Table 2 Steps to behaviour change modelled in the narrative Modelled by Dave Table 1 Characters in the narrative Self-monitoring of drinking Characters in the narrative Risk perception Main character: Changes in outcome expectancies for heavy/binge drinking Dave is a family man who is married to Christine. He initially believes he is a ‘mature’ drinker. He subsequently realises that he is a regular Increasing intention to reduce drinking binge drinker and becomes aware of the potential risks from his Subjective norms drinking. He models behaviour change techniques that are likely to work but also experiences lapses along the way. In the end, he Goal setting achieves his goal to cut down on his drinking and is satisfied with Action planning the outcome of the changes he has made. Increasing action self-efficacy Other characters (Dave’s friends): Stevie is the unmarried ‘antagonist’ character. He has few Benefits of success at sticking to the plan responsibilities; he is unemployed and lives with his mother. Stevie Relapse often encourages everyone around him to drink. Dougie has had serious alcohol-related problems in the past. He lives Coping planning with a long-suffering partner (Sadie) but has a troubled relationship. Coping self-efficacy He also tries to change his drinking but gets it wrong more often than Dave. Satisfaction with changed drinking pattern Alec was previously a heavy drinker but is now a mature, sensible drinker. He is respected by the others and is a role model for Dave. Maintenance from benefits of achieving goals Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 6 of 11 narrative because of the successful efforts he has made Specify dates and times to send messages The to reduce his drinking. messages were tailored to the day of the week. Thus, the intervention was designed so that the first text message would be sent on the Monday evening following Review of content randomisation. The feasibility study revealed that a com- To assess the completeness of the provisional interven- mon pattern is heavy drinking at the weekend followed tion, the sections of the narrative were reviewed to by sobriety during the week. Text messages sent on ensure that the key components of the behaviour change Friday and Saturday were therefore delivered in the strategy were contained in the narrative. This also iden- afternoon or early evening before the men went out tified whether the behaviour change techniques were drinking. Messages sent on Sunday were generally deliv- appropriate for the proposed mechanism of change. ered later in the evening to give the participants a little more time to recover from a hangover. Mid-week text Stage 3: Drafting the text messages messages were sent at variable times, often after the The text messages were constructed so that the main working day. character, Dave, appeared to be a recipient of the inter- The previous research offers differing views on vention. Thus, he commented on the text messages, an- message frequency. One systematic review suggests that swered questions and modelled behaviours that were retention is higher if the number of messages is varied expected from the behaviour change strategy (Table 2). over time [59], while another reported that interventions This avoided didactic delivery of the intervention, which when message frequency decreased were more effective preliminary work in the feasibility study had found to be than those with constant frequencies [37]. All of the unwelcome. To simplify the narrative, Dave was the only messages in this intervention were unique, although character who sent messages, although he discussed at some topics, e.g. self-efficacy and maintenance of a new length what was happening in the lives of the other behaviour were revisited at different stages of the inter- characters. Messages containing a narrative were identi- vention. The intervention was designed so that partici- fied either by Dave introducing himself or signing off at pants would receive at least one message every day for the end of the message. the first 5 weeks. The maximum number of messages The complete intervention was rendered in a series of sent in a day was four. From week 6 onwards, occasional 112 text messages, each with one or more of the follow- days were missed. ing purposes: Use of linked messages The text messages were often Delivering the narrative sent in pairs or groups of three or four. This device has Increasing the salience of the harms of heavy several purposes. Linked messages enabled more com- drinking and the benefits of moderated drinking plex messages to be sent as some of the reflective activ- Modelling steps in the behaviour change process ities and behaviour change strategies could not be Giving information or facts (to augment the explained in a single message. They were also used to behaviour change strategy portrayed in the extend the time the participants had to think about a narrative) topic. The first message was often used to seed an idea, Asking questions (to encourage reflection and while the follow-up text messages encouraged reflection increase the impact of intervention components) on the topic. Combinations of messages could add Increasing the impact of components of the suspense and build a storyline. Responses from charac- intervention by using anonymised quotes from the ters in the narrative were used to illustrate how the mes- feasibility study participants sages could be interpreted (e.g. for goal setting or action Adding humour (to increase engagement) planning) or to give examples of reasons for changing behaviour. Paired messages could also pose a question, Design decisions with the answer provided later in the day. The time Several studies have identified features which need to be delay between linked messages varied from 3 min to 4 h. addressed when designing text message interventions [56–58]. These include the duration of the intervention, Making the intervention acceptable Communication the frequency of sending texts, tailoring of messages to theory [60, 61] was used to enhance the acceptability of individuals, the informality of the language used and the the intervention. The name of the university was used to extent of interactivity. In addition, the prior feasibility give credibility to the study and the intervention. It was study showed that the use of linked text messages and mentioned on all written material given to the men dur- direct quotes from men in the target group were useful ing recruitment. To establish a relationship, participants techniques [43, 44]. were sent a welcoming text message which included Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 7 of 11 their first name. Text messages did not include messa- intervention had been included (i.e. the key components ging slang as it could be construed as unprofessional of HAPA, the behaviour change techniques, BCTs). coming from a credible source, i.e. a university. Commu- Initially, the broad structure of the intervention was nication theory suggests that interesting and unexpected clarified by grouping text messages by their intended statements can be used to maintain interest. Thus, function, identifying the logical progression through the humour was used throughout the intervention period. intervention (Additional file 2: Table S1). Then, individ- ual text messages were mapped to components of the Techniques to increase engagement with the texts HAPA model and to specific BCTs (Additional file 2: Tables S2 and S3). Finally, the narrative text messages Interactive items for key components of the interven- were mapped to ensure the story was coherent tion The use of interactive text messages was central to (Additional file 2: Table S4). the intervention. Mobile phone etiquette requires recip- The messages were also read by colleagues who knew rocation, so that messages which ask questions are likely the storyline of the narrative and the behaviour change to be answered [62]. The target group are frequent mo- techniques and processes that should be incorporated bile phone users and therefore likely to engage in text into the intervention. They were asked to establish message conversations. This was capitalised on by asking whether each component of the behaviour change strat- questions on the key components of the behaviour egy was addressed in sufficient detail. They also checked change strategy. For example, participants were asked: ‘If whether the reader could follow the narrative when it you made a goal to cut down a bit on your drinking, was presented as a series of text messages. This process what would it be? Text me your answer’ or ‘What would was then repeated with colleagues unfamiliar with the you do if you got into a situation where you were narrative and the intervention. Ambiguous statements expected to drink far more than you intended? Text me were modified to ensure that the unedited direct quotes your answer’. The responses to these questions provided from the feasibility study were easily understood. an indication of engagement with the intervention in real time. The feasibility study showed that participants Piloting and final revisions engaged with the cognitive antecedents to reducing Guidance on text message intervention development drinking and with important steps on the causal chain suggests that rigorous pretesting should be done with to behaviour change [44]. the target group [63], to ensure the messages are rele- vant and have the intended impact [64]. The final pilot- Quotes from the feasibility study The feasibility study ing used 24 volunteers (8 members of the target group, produced a wealth of data ‘in the participants’ own 13 post-graduate students and 3 members of university words’ both from focus groups and text message staff unconnected with the study). They were given responses from those who received the intervention background information on the study and were told that [43]. Several texts from that study were presented as the characters in the narrative were fictional. These vol- anonymised quotes from individuals describing their unteers received a copy of the text messages on paper personal experiences. For example, to increase perceived and were asked to provide written comments, both on risks of heavy drinking, one message said “John from the overall approach and on individual text messages. Dundee says ‘I’ve woke up in the cells a few times All eight of the target group members engaged with the because of drink. if i was sober it would never have hap- characters and the narrative as if they were real and pened’”. This technique was used to illustrate harms responded directly to the text messages rather than from alcohol misuse, to model new behaviours and to commenting on their appropriateness of their content. report achievements and benefits from changing behav- The post-graduate students and staff approached the iour. The quotes delivered information in the language task as an academic exercise and commented on the used by the target group and were intended to encour- readability and potential impact of the texts. However, age participants to share their own experiences. To one student changed roles partway through and began reinforce their authenticity, the quotes were not responding to the texts as if he were a participant. corrected for spelling or grammar. The volunteers’ comments gave reassurance that most texts were clear and readily understood, although a few Stage 4: Revision of the text messages needed rewording. No one identified components of the Ensure coherence of the narrative and the behaviour intervention which were missing, inappropriate or inad- change strategy equately addressed. The comments showed that the use When the intervention had been rendered into text mes- of characters made the intervention appear more realis- sages, it was reviewed to ensure that it was complete tic and less daunting. The volunteers also found the and coherent and that all of the components of the overall approach supportive. Finally, they suggested how Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 8 of 11 the narrative be amended. Several students expressed information in a non-narrative format [47]. Narrative is concern about the fate of one character, Stevie, so the particularly useful for changing perceived social norms narrative was amended to give him a happy ending. A and behavioural intentions [48, 49]. The use of a narra- second round of piloting involved new volunteers (three tive also provided an opportunity to present the inter- members of the research team) who received the text vention in a non-patronising way. A major advantage of messages on their mobile phones. This was primarily the narrative was that the lead character, Dave, could used to test the delivery system but also helped confirm model key behaviours such as action planning, relapse that the frequency and timing of the messages were recovery and coping planning. Including questions in acceptable. The final version of the text messages is sup- the text messages reinforced this by asking participants plied as Additional file 1 (Intervention text messages). to explain how they would perform similar actions [69]. This study has shown that a narrative-based interven- Discussion tion, which covers the components of a psychological A systematic approach based on theory, evidence and model (HAPA), can be fully addressed in a text message formative research was used to design a tailored text intervention. Even complex psychological constructs can message intervention to reduce binge drinking among be conveyed through a few linked text messages through socially disadvantaged men. Following the MRC frame- a careful process of design, piloting and testing. A poten- work guidance [18], the intervention was developed tial challenge arose from the process in which the behav- from a review of the target group, the health behaviour iour change strategy had to be translated into a narrative being studied and selection of the most appropriate psy- which then had to be rendered in text messages. As chological model and behaviour change techniques. The elements of the intervention could be omitted at either findings were then used to create a logic model explor- step, repeated checking was carried out to ensure fidelity ing how the intervention strategy could lead to the with the initial design. desired short- and long-term outcomes. This led to a de- cision on the delivery method and text messages and to Limitations of the study design formative research to inform intervention development. Identifying men who are socially disadvantaged may be A revised intervention incorporating a narrative was challenging. Using an area-based measure of social dis- developed and fine-tuned in further pilot testing. advantage may include individuals living in affluent areas The decision on the delivery method, text messages, which are located within postcode areas that are classi- was made because of concerns about the recruitment fied as being socially disadvantaged. Tailoring interven- and engagement of disadvantaged men in the study. So- tions to a large potentially heterogeneous group is cially disadvantaged people are seen as a hard-to-reach challenging. This was addressed through extensive pilot- group and reluctant to take part in research [65, 66]. ing during development. However, they are the most frequent users of mobile Delivering the intervention over a 12-week period phones and are more likely to use text messaging and could be seen as a weakness, by diluting the intensity of send and receive a higher number of text messages than intervention delivery. However, the extended time people with higher education and income [67, 68]. A allowed participants to reflect on the content over a lon- text message intervention, which did not require any ger period. This approach enabled the key components face-to-face contact with researchers or clinicians, was of the intervention to be revisited so that commitment thought likely to engage the target group. Further, a fea- to change could be reinforced. ture of text messaging etiquette is that texts are likely to The intervention was designed to encourage the prompt a response [62]. Thus, questions were regularly participants to respond to text messages. However, this asked on the key components of the HAPA model to intervention cannot be truly interactive, i.e. participants foster engagement. Text message questions have been will not receive replies to their responses, except in used in previous trials to promote interactivity [56, 57], exceptional circumstances, for example if they report but this is the first study to report using this device as distress. Failure to receive replies may discourage partici- part of the intervention. pants to respond as the intervention progresses. The novel feature of the design was the use of narra- A constraint in writing the text messages was the tive in a text message intervention. This was suggested permitted length of a text (160 characters). Thus, the by one of the authors (BW) to provide a structure storyline had to be fairly simple and straightforward to around which text messages could be woven, increasing be delivered in a few words. A feature of a narrative is coherence and sustaining the interest of participants. that it should provide sufficient context and information However, a narrative-based intervention also brings for participants to have an understanding of the scenario additional benefits of increased effects on knowledge, being depicted but needs to be vague in ways that attitudes and intentions compared to the same encourage participants to fill in the detail using their Irvine et al. Pilot and Feasibility Studies (2018) 4:105 Page 9 of 11 imagination and based on their own life experience [54]. Authors’ contributions IKC conceived the study. IKC, LI, BW, AJM and FFS designed the intervention. Thus, the scant information presented within the text FFS advised on the use of the Health Action Process Approach. BW messages may encourage participants to embellish the suggested using a narrative intervention. IKC, LI, AJM and BW created the storyline to make it fit their personal social circumstances. characters for the narrative. LI wrote the first draft of the narrative and the text message intervention. AJM ensured the narrative incorporated all Delivering interventions by mobile phone may have components of the behaviour change strategy. LI and IKC wrote the first limitations. Some participants may not receive messages draft of the paper. All authors reviewed and contributed to the final if they have a weak phone signal or if their phones are manuscript. All authors read and approved the final manuscript. continually switched off. Having insufficient credit may Ethics approval and consent to participate deter participants from engaging with the intervention The study was approved by the East of Scotland Research Ethics Service, and some may delete messages without reading them. project reference number 13/ES/0058. This study was designed to prompt responses so that we Competing interests could monitor whether participants were opening and The authors declare that they have no competing interests. reading the text messages. Adding humour was used to maintain interest in the Publisher’sNote text messages. Although our feasibility study and pilot- Springer Nature remains neutral with regard to jurisdictional claims in ing of the intervention showed that the jokes were well published maps and institutional affiliations. received, it is possible that in a large study, some indi- Author details viduals might dislike the jokes. In general, humour Division of Population Health Sciences, University of Dundee, The should be used with care. 2 Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK. Institute of Health and Wellbeing, University of Glasgow, Mental Health and Wellbeing Academic Centre, Gartnavel Royal Hospital, 1055 Great Western Road, Conclusion Glasgow G12 0XH, UK. School of Health and Social Care, Edinburgh Napier This structured, systematic approach has led to the University, Sighthill Campus, Sighthill Court, Edinburgh EH11 4BN, UK. design of a text message intervention with a strong the- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle NE2 4AX, UK. Medical and Biological Sciences, oretical and empirical basis. The process was highly School of Medicine, University of St Andrews, North Haugh, St Andrews KY16 iterative to enable a theory of behaviour change and a 9TF, UK. set of behaviour change techniques to be embedded in a Received: 30 January 2018 Accepted: 15 May 2018 coherent narrative. These were successfully rendered in a series of short text messages. The use of a narrative helped make the intervention realistic and allowed key References 1. Mackenbach JP, Kulhanova I, Bopp M, et al. Inequalities in alcohol-related behavioural activities to be modelled by characters. 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