ActiveText@T2D text messaging to increase physical activity in adults with type 2 diabetes

Methodology

This prospective single-centre, single-arm feasibility study with nested qualitative component was conducted in Saudi Arabia. The study recruited adults with type 2 diabetes who owned mobile phones with SMS capability from diabetes clinics. The 6-week intervention consisted of two one-way SMS text messages per week in Arabic, developed using the Behaviour Change Wheel (BCW) framework and COM-B model. Message content was culturally tailored through expert panel review and patient-public involvement.

Participants were assessed at baseline (T0) and 3-month follow-up (T1). Feasibility outcomes included recruitment rate, retention rate, and successful message transmission. Secondary exploratory outcomes included self-reported physical activity using the Arabic International Physical Activity Questionnaire (A-IPAQ), exercise self-efficacy using the Arabic Exercise Self-Efficacy scale (ESE-A), and barriers to exercise using the Arabic version of the CDC Barriers to Being Active Quiz (BBAQ). Clinical measures (BMI and HbA1c) were extracted from medical records at baseline only.

Quantitative data were analyzed descriptively, with pre-post comparisons using non-parametric Wilcoxon signed-rank tests for paired samples to explore whether outcome measures were sensitive to change. Effect sizes were calculated as rank-biserial correlation. A nested qualitative study conducted semi-structured interviews with 11 patients and 8 nurses at follow-up, analyzed using thematic analysis following Braun and Clarke's framework. The study was registered on Protocols.io and received ethical approval. Sample size (n=52) was appropriate for a feasibility study per established guidelines.

Interventions

The ActiveText@T2D intervention delivered culturally tailored SMS text messages in Arabic to promote physical activity in Saudi adults with type 2 diabetes. Messages were sent twice weekly for 6 weeks (12 total messages), delivered via one-way SMS to participants' mobile phones. The intervention development was theory-based, informed by the Behaviour Change Wheel (BCW) framework and COM-B model (Capability, Opportunity, Motivation, Behaviour).

Message content employed behavior change techniques including information about health consequences, instruction on how to perform physical activity, credible source messaging, pros and cons evaluation, and social support. Two intervention functions were selected: education and persuasion. Content was developed through expert panel review and patient-public involvement (PPIE) to ensure cultural appropriateness for the Saudi context, addressing barriers specific to the region including high temperatures, gender considerations, and cultural traditions. No interactive features or personalized responses were included in this one-way messaging approach.

Key Findings

The study successfully demonstrated feasibility and acceptability of the ActiveText@T2D intervention. Primary feasibility outcomes were met: 84% recruitment rate (52 of 62 eligible participants consented), 75% retention rate (39 of 52 completed 3-month follow-up), and 100% successful SMS message delivery. All outcome measures (A-IPAQ, ESE-A, BBAQ) demonstrated sensitivity to change, confirming their suitability for a future definitive trial. Exploratory analysis revealed statistically significant increases in moderate physical activity (MET median increased from 80 to 1440, p<0.001, effect size r=0.86) and vigorous physical activity (MET median increased from 0 to 2880, p<0.001, effect size r=0.79), though these findings require confirmation in a controlled trial. Exercise self-efficacy significantly improved (p<0.001, effect size r=0.47), and several barriers to physical activity decreased significantly including social influence (p=0.007), fear of injury (p=0.001), lack of skill (p=0.012), and environmental concerns related to temperature extremes (p<0.001). Qualitative findings from 19 interviews (11 patients, 8 nurses) indicated broad acceptability of the intervention, with text messages serving as useful reminders and increasing awareness of the importance of physical activity for diabetes control. Both patients and healthcare professionals valued the intervention, though it highlighted a gap in clinical communication about physical activity during diabetes consultations.

Comparison with other Studies

This study adds to growing evidence supporting the feasibility and acceptability of SMS-based interventions for diabetes management in Middle Eastern populations. Previous studies in the region, including work in Oman, Egypt, Iraq, and earlier Saudi trials, have demonstrated patient acceptance of SMS interventions for diabetes education and management. However, this study is novel in specifically targeting physical activity promotion (rather than broader diabetes management) in Saudi adults with T2DM using a culturally tailored, theory-based approach.

Compared to international SMS physical activity interventions, the observed increases in moderate and vigorous physical activity align with findings from Text to Move (Agboola et al., 2016) which showed increased physical activity in US adults with T2DM. The retention rate (75%) is comparable to or better than similar feasibility studies globally. However, unlike some international studies that have shown mixed or null effects on HbA1c from SMS interventions, this study did not measure clinical outcomes at follow-up. The short 6-week intervention duration is briefer than many comparable studies (often 3-6 months), which may limit comparisons of effectiveness. The one-way messaging approach differs from more recent interactive SMS interventions that allow bidirectional communication. The study's strength lies in its rigorous theory-based development using BCW and COM-B frameworks, explicit cultural tailoring through expert and patient input, and mixed-methods design incorporating healthcare professional perspectives—features not consistently present in earlier regional SMS diabetes studies. The findings suggest similar feasibility to prior work but underscore the need for a definitive RCT to establish effectiveness in this specific cultural context.

Journal Reference

Blake H, Alsahli MJ, Chaplin WJ, Konstantinidis STh. The ActiveText@T2D text messaging behavioural intervention to increase physical activity in adults with type 2 diabetes: A prospective single-arm feasibility trial. PLOS Digit Health. 2025;4(7):e0000953. doi:10.1371/journal.pdig.0000953