Mobile phone text messaging in improving glycaemic control for patients with type 2 diabetes mellitus: A systematic review and meta-analysis

Telemedicine-supported lifestyle intervention for glycemic control in patients with CHD and T2DM: multicenter, randomized controlled trial

Patients with coronary heart disease (CHD) and type 2 diabetes mellitus (T2DM) have a substantially increased risk for major cardiovascular events and mortality. Increasing physical activity and improving a healthy diet may effectively reduce cardiovascular risk factors; however, the effects are often transient. In a multicenter, 1:1 randomized controlled trial including 502 patients with combined CHD and T2DM (68 ± 8 years; 84% men), we assessed the effects of a home-based telemedicine-supported lifestyle intervention (exercise training, nutritional recommendations and health literacy training) with regular individualized feedback versus usual care. The study met its primary endpoint of reduced glycated hemoglobin after 6 months in favor of the lifestyle intervention group (mean between-group difference in the complete-case analysis (n = 197 and n = 193), -0.13% (95% confidence interval, -0.25 to -0.01), P = 0.04). When individualized feedback and health literacy training were discontinued after 6 months (while other telemedicine tools were maintained), no statistically significant between-group differences were observed at 12 months. At 12 months, 31 patients (6.2%) had a major adverse cardiovascular event (lifestyle intervention, n = 20 (8.0%); usual care, n = 11 (4.4%); P = 0.15), with the main reason being hospitalization for angina or revascularization (lifestyle intervention, n = 15; usual care, n = 8). There were five deaths (lifestyle intervention, n = 2; usual care, n = 3), none of which were categorized as related to the intervention. However, three events that resulted in hospitalization were categorized as potentially related to the intervention (decompensation of heart failure, vertebral disc prolapse and inguinal hernia). In conclusion, a home-based lifestyle intervention with telemedicine support showed modest effects in patients with CHD and T2DM. ClinicalTrials.gov registration: NCT03835923 .

Impact of an SMS intervention to support type 2 diabetes self-management: DiabeText clinical trial

BACKGROUND

Complications arising from uncontrolled type 2 diabetes mellitus (T2DM) pose a significant burden on individuals' wellbeing and healthcare resources. Digital interventions may play a key role in mitigating such complications by supporting patients to adequately self-manage their condition.

AIM

To assess the impact of DiabeText, a new theory-based, patient-centred, mobile health intervention integrated with electronic health records to send tailored short text messages to support T2DM self-management.

DESIGN AND SETTING

A pragmatic, phase-three, 12-month, two-arm randomised clinical trial involving primary care patients with T2DM in the Balearic Islands, Spain, including in urban and rural areas.

METHOD

In total, 742 participants with suboptimal glycaemic control (glycated haemoglobin [HbA1c] level >7.5) were randomly allocated to a control (usual care) or intervention (DiabeText) group. In addition to usual care, the DiabeText group received 167 messages focused on healthy lifestyle and medication adherence. The primary outcome was HbA1c level. Secondary outcomes were: medication possession ratio; health-related quality of life (measured using the EQ-5D-5L questionnaire); diabetes self-efficacy (measured using the Diabetes Self-Efficacy Scale [DSES]); and self-reported adherence to medication, Mediterranean diet (measured using the 14-Item Mediterranean Diet Adherence Screener [MEDAS-14]), and physical activity (measured using the International Physical Activity Questionnaire [IPAQ]).

RESULTS

Over the 12-month period, no statistically significant differences in HbA1c were observed between the intervention and the control groups (ß = -0.025 [95% confidence interval {CI} = -0.198 to 0.147; P = 0.772]). In comparison with the control group, the DiabeText group showed significant (P<0.05) improvements in self-reported medication adherence (odds ratio = 1.4; 95% CI = 1.0 to 1.9), DSES (Cohen's d = 0.35), and EQ-5D-5L (Cohen's d = 0.18) scores, but not for the rest of the secondary outcomes.

CONCLUSION

DiabeText successfully improved quality of life, diabetes self-management, and self-reported medication adherence in primary care patients with T2DM. Further research is needed to enhance its effects on physiological outcomes.

Developing a codesigned text message-based digital oral health education resource (TOOTH)

Objective

Digital health technologies offer a more equitable way of providing access to health education. This study engaged consumers and clinicians from two Australian regions with a high burden of oral disease to develop a digital oral health resource called "TOOTH" tailored for adults.

Methods

A total of three focus groups (one clinician and two consumers) were conducted to identify themes that were used to draft text message content. The study team reviewed, refined, and mapped these messages to behaviour change techniques and developed videos to support key concepts.

Results

Eight multidisciplinary clinicians (dentist, oral health therapist, dietician, cardiac nurse, and dental nurse), 75% female with a mean age of 48 ± 10 years, and seven consumers from a metropolitan and a regional area in New South Wales, 43% female with a mean age 62 ± 11.6 years participated in the focus groups. Key themes identified by clinicians included (1) limited support from medical and allied health teams for integrating oral health care into the healthcare system, (2) government-supported measures enable prevention, and (3) poor oral health of Australians. Consumers highlighted (1) barriers to accessing oral health care, (2) negative attitudes towards oral health, and (3) limited oral health-related knowledge. The final resource developed includes 81 text messages sequenced to ensure a gradual increase in knowledge and skill and five supporting videos.

Conclusions

The TOOTH resource has the potential to improve awareness and knowledge regarding oral disease prevention, enabling more equitable access to oral health education and better self-management of oral health.

Don't Forget the Humble Text Message: 25 Years of Text Messaging in Health

Since the early studies exploring the use of SMS text messaging for health intervention, text messaging has played a pivotal role in the advancement of mobile health. As an intervention modality, text messaging has provided vital learnings for the design and delivery of interventions, particularly in low-resource settings. Despite the advances in technology over the last 25 years, text messaging is still being used in largely the same way to deliver health information, behavior change interventions, and support. The strong, consistent evidence for the benefits of this type of intervention has made text messaging a routine part of health interventions around the world. Key to its success is its simplicity, alongside the benefit of being arguably the most accessible form of consumer digital health intervention. Text message interventions are well suited for public health interventions due to their low cost, vast reach, frequent use, high read rates, and ability to be tailored and personalized. Furthermore, the nature of text messaging interventions makes them ideal for the delivery of multilingual, culturally tailored interventions, which is important in the context of increasing cultural diversity in many countries internationally. Indeed, studies assessing text message-based health interventions have shown them to be effective across sociodemographic and ethnic groups and have led to their adoption into national-level health promotion programs. With a growing focus on artificial intelligence, robotics, sensors, and other advances in digital health, there is an opportunity to integrate these technologies into text messaging programs. Simultaneously, it is essential that equity remains at the forefront for digital health researchers, developers, and implementers. Ensuring digital health solutions address inequities in health experienced across the world while taking action to maximize digital inclusion will ensure the true potential of digital health is realized. Text messaging has the potential to continue to play a pivotal role in the delivery of equitable digital health tools to communities around the world for many years to come. Further new technologies can build on the humble text message, leveraging its success to advance the field of digital health. This Viewpoint presents a retrospective of text messaging in health, drawing on the example of text message-based interventions for smoking cessation, and presents evidence for the continued relevance of this mobile health modality in 2025 and beyond.

Impact of a Text Messaging Intervention as an In-Between Support to Diabetes Group Visits in Federally Qualified Health Centers: Cluster Randomized Controlled Study

Background

In the United States, 1 in 11 people receive primary care from a federally qualified health center (FQHC). Text messaging interventions (TMIs) are accessible ways to deliver health information, engage patients, and improve health outcomes in the health center setting.

Objective

We aimed to evaluate the impact of a TMI implemented with a group visit (GV) intervention among patients with type 2 diabetes mellitus (T2DM) at FQHCs on patient-reported outcomes and clinical outcomes based on patient TMI engagement.

Methods

A TMI was implemented for 11 health centers participating in a cluster randomized study of diabetes GVs in Midwestern FQHCs targeting adults with T2DM. FQHC patients participated in 6 monthly GVs either in person or online and a concurrent 25-week TMI. Outcome measures included clinical markers such as glycated hemoglobin A1c and patient-reported diabetes distress, diabetes self-care, diabetes self-efficacy, diabetes care knowledge, diabetes quality of life, diabetes social support, and TMI use and satisfaction. TMI response rate was calculated as responses to an SMS text message requesting a response divided by total messages requesting a response sent. Patients were grouped as high responders if their response rate was greater than or equal to the median response rate and low responders if their response rate was below the median. We conducted linear mixed models to compare high and low responders and within a group, adjusting for age, gender, GV attendance, and depression/anxiety at baseline.

Results

In total, 101 of 124 GV patients (81.5%) enrolled in the TMI. The average age of the population in the TMI was 53 years. Of the 101 respondents, 61 (60%) were racial or ethnic minorities, while 42 of 82 respondents (51%) had a high school diploma/General Education Development or less, and 56 of 80 respondents (71%) reported an annual income less than US $30,000. In addition, 70 of 81 respondents (86%) owned a smartphone and 74 of 80 respondents (93%) had an unlimited texting plan. The median response rate was 41% and the mean response rate was 41.6%. Adjusted models showed significantly improved diabetes knowledge (P<.001), foot care (P<.001), and exercise (P=.002) in high responders (n=34) compared to low responders (n=23) at 6 months. No group difference was found in glycated hemoglobin A1c. Within high responders, diabetes distress (P=.001), social support (P<.001), quality of life (P<.001), diabetes knowledge (P<.001), foot care (P<.001), and diet (P=.003) improved from baseline to 6 months. Low responders only improved in diabetes quality of life (P=.003) from baseline to 6 months.

Conclusions

In a FQHC safety net population participating in a combined TMI and GV intervention, our study showed improved diabetes distress, social support, knowledge, self-care, self-efficacy, and quality of life among patients highly engaged in the SMS text messaging program.

A smartphone coaching program ("Bouge Grossesse") improves daily physical activity in pregnant women

BACKGROUND

Physical activity has been shown to reduce obstetrical risks however pregnant women reduce their physical activity and sedentary behaviors increase.

OBJECTIVE

Our aim was to evaluate the impact of a smartphone application developed to increase daily physical activity in pregnant women.

METHODS

We enrolled 250 pregnant women in a prospective randomized controlled study. These women were instructed to download either an intervention application called «Bouge Grossesse» (coaching program and a pedometer; n=125) or a Placebo application (pedometer only; n=125). Primary outcome was defined as a daily increase of 2000 steps/day between day 1 and day 90 or 10 000 steps/week between week 1 and week 12. Data was analyzed with intention to treat. Secondary outcomes were the number of steps at week 12 and the evolution of quality of life measured by WHO score, EIFEL score and SPIEGEL scale, and on maternal and fetal outcomes.

RESULTS

Patients were enrolled between August 2017 and February 2019. They were retrospectively registered after September 2018. We found a significant difference in the primary outcome between the two groups in favor of the intervention group (22.4% success vs 3.2% in the control group, P<.001) but only 43 women in the intervention group (34.4%) and 16 women in the placebo group (12.8%) completed the 12-week coaching program. There were no significant differences in the SPIEGEL, EIFEL and WHO scores. The mean number of daily steps at week 12 was significantly higher in the intervention group (6900.0 vs 4371.9, P<.001).

CONCLUSION

The mobile health intervention « Bouge Grossesse » significantly increased physical activity in pregnant women but we observed a high percentage of withdrawals from the 12-week program.

TRIAL REGISTRATION

This clinical trial was registered under the number NCT03688087 ClinicalTrials.gov.

Biomarker-based text messages to promote lactation success in mothers of critically Ill infants: a randomized controlled pilot study

OBJECTIVE

Infrequent breast pumping limits mother's own milk production in mothers of infants admitted to the neonatal intensive care unit. We aimed to determine the feasibility and benefit of biomarker-based personalized text messages on pumping frequency and milk sodium levels. A secondary aim examined lactation outcomes.

STUDY DESIGN

In this randomized controlled pilot study, 51 mothers were randomized to receive personalized text messages regarding pumping frequency or standard care.

RESULTS

There were no differences in pumped milk volume or sodium level, however, there was a trend towards the intervention group pumping more frequently, which was significant on day 5 (p = 0.035), and they lactated nearly 9 days longer. Post-hoc analysis found the intervention group tended to be more likely to pump ≥ 500 mL by day14 (p = 0.08), a marker of long-term lactation success.

CONCLUSION

Personalized biomarker-based text messages are feasible and may support lactation in mothers of critically ill infants.

Text Message-Based Cessation Intervention for People Who Smoked or Used Smokeless Tobacco in India: A Feasibility Randomized Controlled Trial

INTRODUCTION

Despite the high burden of tobacco use in India, users do not have access to adequate help. This pilot trial aimed to evaluate the feasibility and acceptability of a text messaging intervention for tobacco cessation, generate preliminary estimates of its impact, and fine-tune procedures for a definitive trial.

AIMS AND METHODS

Parallel two-arm single blind individually randomized controlled pilot trial with nested qualitative study. Participants included adult current tobacco users (smoked and smokeless). Eligible and consenting participants were randomized to receive either (1) text messaging intervention (ToQuit) which covered specific content areas such as psychoeducation about consequences of tobacco use and benefits of quitting and tobacco avoidance strategies or (2) information about tobacco cessation helplines such as the helpline number and the languages in which tobacco cessation support was available (control). Feasibility data included screening and consent rates, treatment dropouts, and outcome ascertainment. The primary abstinence outcome was self-reported abstinence from tobacco in the past seven days at 3 months post-randomization. In-depth interviews were conducted with a subsample of participants primarily to collect acceptability data. The primary abstinence analysis used a chi-squared test and logistic regression (complete case), and qualitative data was analyzed using thematic analysis.

RESULTS

Ninety-eight participants were randomized into the two trial arms; 77 (79%) completed outcome evaluation. No between-arm differences in abstinence were found though findings favored the intervention (7-day abstinence: ToQuit 23%, control 19%; adjusted odds ratio 1.23, 95% confidence interval 0.38, 3.97). Participants appreciated the language, comprehensibility, and relevance of the messages; and reported overall satisfaction with and positive impact from the intervention on their lives.

CONCLUSIONS

The findings indicate the acceptability and feasibility of ToQuit and if found effective, it could be a potentially scalable first-line response to tobacco use in low-resource settings.

IMPLICATIONS

Our pilot randomized control trial provides sufficient findings supporting the acceptability and feasibility of an intervention for tobacco cessation which is suitable for a context which has a shortage of healthcare workers and for individuals who use smoked or smokeless tobacco. This is critical on a background of limited contextually relevant interventions for a problem with a high burden in low- and middle-income countries such as India.

Telephone calls and glycemic control in type 2 diabetes: A PRISMA-compliant systematic review and meta-analysis of randomized clinical trials

AIMS

In-depth and updated systematic reviews evaluating telephone calls in type 2 diabetes (T2DM) management are missing. This study aimed to assess the effect of this intervention on glycemic control in T2DM patients when compared with usual care.

METHODS

We systematically searched for randomized controlled trials (RCT) on T2DM using Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and LILACS, up to March 2021. The Risk of Bias 2.0 (Rob 2.0) tool and GRADE were used for the quality evaluation. The intervention effect was estimated by the change in glycated hemoglobin (HbA1c). PROSPERO registry CRD42020204519.

RESULTS

3545 references were reviewed and 32 were included (8598 patients). Telephone calls, all approaching education, improved HbA1c by 0.33% [95% CI, -0.48% to -0.18%; I2 = 78%; p < 0.0001] compared to usual care. A greater improvement was found when the intervention included pharmacologic modification (-0.82%, 95% CI, -1.42% to -0.22%; I2 = 92%) and when it was applied by nurses (-0.53%, 95% CI, -0.86% to -0.2%; I2 = 87%). Meta-regression showed no relationship between DM duration and HbA1c changes.

CONCLUSION

The telephone call intervention provided a benefit regarding T2DM glycemic control, especially if provided by nurses, or if associated with patient education and pharmacological treatment modification.

Effectiveness of remote monitoring for glycemic control on maternal-fetal outcomes in women with gestational diabetes mellitus: A meta-analysis

BACKGROUND

The current pandemic and future public health emergencies highlight the importance of evaluating a telehealth care model. Previous studies have reached mixed conclusions about the effectiveness of remote monitoring on glycemic control and maternal and infant outcomes in women with gestational diabetes mellitus (GDM).

OBJECTIVES

This meta-analysis aimed to evaluate the effectiveness of remote blood glucose monitoring for women with gestational diabetes mellitus and to provide evidence-based guidance on the management of women with gestational diabetes mellitus for policymakers and healthcare providers during situations such as pandemics or natural disasters.

METHODS

The Cochrane Library, PubMed, Web of Science, EBSCO, Embase, Medline, CINAHL databases, and ClinicalTrials.gov were systematically searched from their inception to July 10, 2021. Randomized controlled trials (RCTs) published in English with respect to remote blood glucose monitoring in women with GDM were included in the meta-analysis. Two independent reviewers performed data extraction and assessed the quality of the studies. Risk ratios, mean differences, 95% confidence intervals, and heterogeneity were calculated.

RESULTS

A total of 1265 participants were included in the 11 RCTs. There were no significant differences in glycemic control and maternal-fetal outcomes between the remote monitoring group and a standard care group, which included glycosylated hemoglobin (HbA1c), fasting blood glucose, mean 2-h postprandial blood glucose, caesarean birth, gestational weight gain, shoulder dystocia, neonatal hypoglycemia, and other outcomes.

CONCLUSION

This meta-analysis reveals that it is unclear if remote glucose monitoring is preferable to standard of care glucose monitoring. To improve glycemic control and maternal-fetal outcomes during the current epidemic or other natural disasters, the implementation of double-blind RCTs in the context of simulating similar disasters remains to be studied in the future.

Supporting people with type 2 diabetes in effective use of their medicine through mobile health technology integrated with clinical care (SuMMiT-D pilot): results of a feasibility randomised trial

BACKGROUND

The purpose of this 6-month intervention pilot feasibility randomised trial was to test sending brief messages using mobile phones to promote self-management through taking medication as prescribed to people with type 2 diabetes. This was to inform the design and conduct of a future large-scale United Kingdom-based clinical trial and establish the feasibility of recruitment, the technology used, follow-up, and data collection.

METHODS

A multicentre individually randomised, controlled parallel group trial in primary care, recruiting adults (≥ 35 years) with type 2 diabetes in England. Consenting participants were randomly allocated to receive short message system text messages up to four times a week, or usual care, for a period of 6 months; messages contained behavioural change techniques targeting medication use. The primary outcome was the rate of recruitment to randomisation of participants to the trial with a planned rate of 22 participants randomised per month. The study also aimed to establish the feasibility of follow-up at 6 months, with an aim of retaining more than 80% of participants. Data, including patient-reported measures, were collected at baseline and the end of the 6-month follow-up period, and a notes review was completed at 24 months.

RESULTS

The trial took place between 26 November 2018 and 30 September 2019. In total 209 participants were randomly allocated to intervention (n = 103) or usual care (n = 106). The maximum rate of monthly recruitment to the trial was 60-80 participants per month. In total, 12,734 messages were sent to participants. Of these messages, 47 were identified as having failed to be sent by the service provider. Participants sent 2,864 messages to the automated messaging system. Baseline data from medical records were available for > 90% of participants with the exception of cholesterol (78.9%). At 6 months, a further HbA1c measurement was reported for 67% of participants. In total medical record data were available at 6 months for 207 (99.0%) of participants and completed self-report data were available for 177 (84.7%) of participants.

CONCLUSION

The feasibility of a large-scale randomised evaluation of brief message intervention for people with type 2 diabetes appears to be high using this efficient design. Failure rate of sending messages is low, rapid recruitment was achieved among people with type 2 diabetes, clinical data is available on participants from routine medical records and self-report of economic measures was acceptable.

TRIAL REGISTRATION

ISCTRN ISRCTN13404264. Registered on 10 October 2018.

DiabeText, a mobile health intervention to support medication taking and healthy lifestyle in adults with type 2 diabetes: Study protocol for a randomized controlled trial

AIM

To evaluate the effectiveness of DiabeText, a low-intensity, multifaceted, mobile health (mHealth) intervention to support medication taking and lifestyle change targeted to people with type 2 diabetes (T2D).

DESIGN

Phase III, 12-months, two-arm (1:1 allocation ratio), randomized parallel-group trial.

METHODS

We will recruit 740 adults with glycated hemoglobin (A1c) >8% (>64 mmol/mol) and with at least one prescription of a non-insulin antidiabetic drug. They will be allocated to a control (usual care) group or an intervention (DiabeText messaging intervention) group. The primary outcome measure will be A1c at 12 months follow-up. Secondary outcomes will include medication possession ratio and behavioral and psychological outcomes.

DISCUSSION

Recent trials suggest that digital health interventions can effectively support diabetes self-management improving T2D control and reducing important T2D complications. In Spain this type of interventions is understudied.

IMPACT

This trial will strengthen the evidence base of the impact of mHealth interventions to support diabetes self-management. If effective, DiabeText may offer a low-cost and highly scalable strategy to improve health at the population level in a sustainable way.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05006872; Official Title: Supporting People with Type 2 Diabetes in Effective Use of their Medicine Through a System Comprising Mobile Health Technology Integrated with Clinical Care.

Diabetes Health Supervision and Treatment Strategy Based on Data Management and Analysis on eKTANG Platform

BACKGROUND

The management of diabetes-related risk factors could effectively reduce the occurrence of its complications, improve the quality of life of patients, and reduce the mortality of patients. Data analysis based on the eKTANG platform could greatly improve the efficiency of communication between patients and doctors, and strengthen the treatment and management of diabetes.

AIM

We created eKTANG to monitor patient health effectively. The eKTANG health management system aims to extensively intervene in blood glucose monitoring, nutrition, exercise, medicine, and health education to enable diabetes patients to achieve optimal treatment results.

METHODS

Diabetes patients diagnosed by Henan University Medical School included through the eKTANG platform were randomly divided into three groups: member service package group, discharge/ outpatient follow-up group, and out-of-hospital care group. We conducted intensive out-ofhospital interventions for three groups of patients for three months to help patients formulate precise blood glucose control plans and conduct training. The traditional group was compared with the eKTANG platform group, and the physiological indicators and patient compliance of the four groups were observed 6 months later.

RESULTS

In the eKTANG platform management group, the average blood glucose compliance rate increased significantly, and the percentage of average blood glucose in the range of 3.9-10.0 showed an upward trend. Fasting blood glucose and postprandial blood glucose showed a downward trend. At the same time, the number of patients per capita blood glucose monitoring showed a significant increase compared with the control group.

CONCLUSION

The establishment of the eKTANG platform can improve the efficiency of patient's medical treatment, improve their lifestyles, reduce the incidence of patient complications, and build a virtuous circle gradually. This research has strengthened the health management and autonomy of diabetic patients and improved the efficiency of treatment. It is worthy of promotion.

Comparative efficacy of digitally assisted interventions for glycated haemoglobin levels among patients with type 2 diabetes: A systematic review and component network Meta-Analysis

AIMS

To compare the efficacy of digitally assisted interventions on the glycated haemoglobin (HbA1c) levels of patients with type 2 diabetes by performing a systematic review, network meta-analysis and component network meta-analysis.

METHODS

Six databases were searched to identify eligible articles from the inception of each database until 17 March 2023. We included randomized controlled trials evaluating HbA1c levels. Data were pooled with a random-effects model under a frequentist framework. The evidence certainty was assessed using Confidence in Network MetaAnalysis (CINeMA). The PROSPERO registration number was CRD42021283815.

RESULTS

In total, 75 trials involving 9764 participants were included. Results from standard network meta-analyses of 17 interventions revealed that compared with standard care, a mobile application (MA) combined with a professional education programme and peer support education (PSE; -1.98, 95% confidence interval = -2.90 to -1.06, CINeMA score: moderate to high) significantly reduced HbA1c levels. The component analysis found that PSE (-1.50, -2.36 to -0.64), SMS (-0.33, -0.56 to -0.11), MA (-0.30, -0.56 to -0.04) and telephone calls (-0.30, -0.53 to -0.06) most effectively reduced HbA1c levels among patients with type 2 diabetes.

CONCLUSIONS

SMS and MA are the optimal digitally assisted interventions for reducing HbA1c levels. Educators can integrate digitally assisted interventions complemented by educational programmes, particularly MA combined with professional education programme and PSE, into daily care to control HbA1c. The limitations of included trials include a lack of information on allocation concealment and blinding and the fact that long-term follow-up effects were not investigated.

Efficacy of Insulin Titration Driven by SMS in Improving Glycemic Control in People with Type 2 Diabetes

AIM

To evaluate the efficacy of the self-management of insulin titration based on information received by the Short Message Service (SMS).

METHODS

A case-control study including 59 subjects in each arm with 16 weeks of follow-up was performed. The inclusion criteria were: (1) Subjects with type 2 diabetes (T2D) under basal insulin treatment; (2) Suboptimal glycemic control: HbA1c ≥ 7.5% and fasting capillary blood glucose (FCBG) > 140 mg/dL (>3 times per week). Subjects were invited to use an insulin titration service based on SMS feedback aimed at optimizing glycemic control depending on fasting blood glucose levels. Psychological aspects were evaluated in the interventional group by means of validated questionnaires (DDS, HADS and SF-12).

RESULTS

The intervention group achieved a lower mean FCBG (126 mg/dL ± 34 vs. 149 mg/dL ± 46, p = 0.001) and lower HbA1c (7.5% ± 1.3 vs. 7.9% ± 0.9, p = 0.021) than the control group. In addition, the intervention group showed a significant improvement in psychological aspects related to Emotional Burden (p = 0.031), Regimen Distress (p < 0.001), Depression (p = 0.049) and Mental Health (p < 0.01).

CONCLUSIONS

The SMS-guided titration was effective in terms of improving glucometric parameters in comparison with the standard of care and improved significant psychological aspects-mainly, the stress associated with insulin treatment.

A Culturally Adapted Diet and Physical Activity Text Message Intervention to Prevent Type 2 Diabetes Mellitus for Women of Pakistani Origin Living in Scotland: Formative Study

BACKGROUND

Individuals of South Asian origin are at an increased risk of developing type 2 diabetes mellitus (T2DM) compared with other ethnic minority groups. Therefore, there is a need to develop interventions to address, and reduce, this heightened risk.

OBJECTIVE

We undertook formative work to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland.

METHODS

We used a stepwise approach that was informed by the Six Steps in Quality Intervention Development framework, which consisted of gathering evidence through literature review and focus groups (step 1), developing a program theory for the intervention (step 2), and finally developing the content of the text messages and an accompanying delivery plan (step 3).

RESULTS

In step 1, we reviewed 12 articles and identified 3 key themes describing factors impacting on diet and physical activity in the context of T2DM prevention: knowledge on ways to prevent T2DM through diet and physical activity; cultural, social, and gender norms; and perceived level of control and sense of inevitability over developing T2DM. The key themes that emerged from the 3 focus groups with a total of 25 women were the need for interventions to provide "friendly encouragement," "companionship," and a "focus on the individual" and also for the text messages to "set achievable goals" and include "information on cooking healthy meals." We combined the findings of the focus groups and literature review to create 13 guiding principles for culturally adapting the text messages. In step 2, we developed a program theory, which specified the main determinants of change that our text messages should aim to enhance: knowledge and skills, sense of control, goal setting and planning behavior, peer support, and norms and beliefs guiding behavior. In step 3, we used both the intervention program theory and guiding principles to develop a set of 73 text messages aimed at supporting a healthy diet and 65 text messages supporting increasing physical activity.

CONCLUSIONS

We present a theory-based approach to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. This study outlines an approach that may also be applicable to the development of interventions for other ethnic minority populations in diverse settings. There is now a need to build on this formative work and undertake a feasibility trial of a text message-based diet and physical activity intervention to prevent T2DM for women of Pakistani origin living in Scotland.

Effect of Mobile Phone Text Messaging Self-Management Support for Patients With Diabetes or Coronary Heart Disease in a Chronic Disease Management Program (SupportMe) on Blood Pressure: Pragmatic Randomized Controlled Trial

BACKGROUND

Maintaining engagement and support for patients with chronic diseases is challenging. SMS text messaging programs have complemented patient care in a variety of situations. However, such programs have not been widely translated into routine care.

OBJECTIVE

We aimed to examine the implementation and utility of a customized SMS text message-based support program for patients with type 2 diabetes (T2D), coronary heart disease, or both within a chronic disease integrated care program.

METHODS

We conducted a 6-month pragmatic parallel-group, single-blind randomized controlled trial that recruited people with T2D or coronary heart disease. Intervention participants received 4 semipersonalized SMS text messages per week providing self-management support to supplement standard care. Preprogrammed algorithms customized content based on participant characteristics, and the messages were sent at random times of the day and in random order by a fully automated SMS text messaging engine. Control participants received standard care and only administrative SMS text messages. The primary outcome was systolic blood pressure. Evaluations were conducted face to face whenever possible by researchers blinded to randomization. Participants with T2D were evaluated for glycated hemoglobin level. Participant-reported experience measures were evaluated using questionnaires and focus groups and summarized using proportions and thematic analysis.

RESULTS

A total of 902 participants were randomized (n=448, 49.7% to the intervention group and n=454, 50.3% to the control group). Primary outcome data were available for 89.5% (807/902) of the participants. At 6 months, there was no difference in systolic blood pressure between the intervention and control arms (adjusted mean difference=0.9 mm Hg, 95% CI -1.1 to 2.1; P=.38). Of 642 participants with T2D, there was no difference in glycated hemoglobin (adjusted mean difference=0.1%, 95% CI -0.1% to 0.3%; P=.35). Self-reported medication adherence was better in the intervention group (relative risk=0.82, 95% CI 0.68-1.00; P=.045). Participants reported that the SMS text messages were useful (298/344, 86.6%) and easily understood (336/344, 97.7%) and motivated change (217/344, 63.1%). The lack of bidirectional messaging was identified as a barrier.

CONCLUSIONS

The intervention did not improve blood pressure in this cohort, possibly because of high clinician commitment to improved routine patient care as part of the chronic disease management program as well as favorable baseline metrics. There was high program engagement, acceptability, and perceived value. Feasibility as part of an integrated care program was demonstrated. SMS text messaging programs may supplement chronic disease management and support self-care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616001689460; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371769&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2018-025923.

Interventions to promote medication adherence for chronic diseases in India: a systematic review

Introduction

Cost-effective interventions that improve medication adherence are urgently needed to address the epidemic of non-communicable diseases (NCDs) in India. However, in low- and middle-income countries like India, there is a lack of analysis evaluating the effectiveness of adherence improving strategies. We conducted the first systematic review evaluating interventions aimed at improving medication adherence for chronic diseases in India.

Methods

A systematic search on MEDLINE, Web of Science, Scopus, and Google Scholar was conducted. Based on a PRISMA-compliant, pre-defined methodology, randomized control trials were included which: involved subjects with NCDs; were located in India; used any intervention with the aim of improving medication adherence; and measured adherence as a primary or secondary outcome.

Results

The search strategy yielded 1,552 unique articles of which 22 met inclusion criteria. Interventions assessed by these studies included education-based interventions (n = 12), combinations of education-based interventions with regular follow up (n = 4), and technology-based interventions (n = 2). Non-communicable diseases evaluated commonly were respiratory disease (n = 3), type 2 diabetes (n = 6), cardiovascular disease (n = 8) and depression (n = 2).

Conclusions

Although the vast majority of primary studies supporting the conclusions were of mixed methodological quality, patient education by CHWs and pharmacists represent promising interventions to improve medication adherence, with further benefits from regular follow-up. There is need for systematic evaluation of these interventions with high quality RCTs and their implementation as part of wider health policy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022345636, identifier: CRD42022345636.

Effects of E-health-based interventions on glycemic control for patients with type 2 diabetes: a Bayesian network meta-analysis

The high disease burden of type 2 diabetes seriously affects the quality of life of patients, and with the deep integration of the Internet and healthcare, the application of electronic tools and information technology to has become a trend for disease management. The aim of this study was to evaluate the effectiveness of different forms and durations of E-health interventions in achieving glycemic control in type 2 diabetes patients. PubMed, Embase, Cochrane, and Clinical Trials.gov were searched for randomized controlled trials reporting different forms of E-health intervention for glycemic control in type 2 diabetes patients, including comprehensive measures (CM), smartphone applications (SA), phone calls (PC), short message service (SMS), websites (W), wearable devices (WD), and usual care. The inclusion criteria were as follows: (1) adults (age≥18) with type 2 diabetes mellitus; (2) intervention period ≥1 month; (3) outcome HbA1c (%); and (4) randomized control of E-health based approaches. Cochrane tools were used to assess the risk of bias. R 4.1.2 was used to conduct the Bayesian network meta-analysis. A total of 88 studies with 13,972 type 2 diabetes patients were included. Compared to the usual care group, the SMS-based intervention was superior in reducing HbA1c levels (mean difference (MD)-0.56, 95% confidence interval (CI): -0.82 to -0.31), followed by SA (MD-0.45, 95% CI: -0.61 to -0.30), CM (MD-0.41, 95% CI: -0.57 to -0.25), W (MD-0.39, 95% CI: -0.60 to -0.18) and PC (MD-0.32, 95% CI: -0.50 to -0.14) (p < 0.05). Subgroup analysis revealed that intervention durations of ≤6 months were most effective. All type of E-health based approaches can improve glycemic control in patients with type 2 diabetes. SMS is a high-frequency, low-barrier technology that achieves the best effect in lowering HbA1c, with ≤6 months being the optimal intervention duration.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier CRD42022299896.

Patient Perspectives on a Targeted Text Messaging Campaign to Encourage Screening for Diabetes: Qualitative Study

BACKGROUND

A sizeable proportion of prediabetes and diabetes cases among adults in the United States remain undiagnosed. Patient-facing clinical decision support (CDS) tools that leverage electronic health records (EHRs) have the potential to increase diabetes screening. Given the widespread mobile phone ownership across diverse groups, text messages present a viable mode for delivering alerts directly to patients. The use of unsolicited text messages to offer hemoglobin A1c (HbA1c) screening has not yet been studied. It is imperative to gauge perceptions of "cold texts" to ensure that information and language are optimized to promote engagement with text messages that affect follow-through with health behaviors.

OBJECTIVE

This study aims to gauge the perceptions of and receptiveness to text messages to inform content that would facilitate engagement with text messages intended to initiate a mobile health (mHealth) intervention for targeted screening. Messages were designed to invite those not already diagnosed with diabetes to make a decision to take part in HbA1c screening and walk them through the steps required to perform the behavior based solely on an automated text exchange.

METHODS

In total, 6 focus groups were conducted at Wake Forest Baptist Health (WFBH) between September 2019 and February 2020. The participants were adult patients without diabetes who had completed an in-person visit at the Family and Community Medicine Clinic within the previous year. We displayed a series of text messages and asked the participants to react to the message content and suggest improvements. Content was deductively coded with respect to the Health Belief Model (HBM) and inductively coded to identify other emergent themes that could potentially impact engagement with text messages.

RESULTS

Participants (N=36) were generally receptive to the idea of receiving a text-based alert for HbA1c screening. Plain language, personalization, and content, which highlighted perceived benefits over perceived susceptibility and perceived severity, were important to participants' understanding of and receptiveness to messages. The patient-physician relationship emerged as a recurring theme in which patients either had a desire or held an assumption that their provider would be working behind the scenes throughout each step of the process. Participants needed further clarification to understand the steps involved in following through with HbA1c screening and receiving results.

CONCLUSIONS

Our findings suggest that patients may be receptive to text messages that alert them to a risk of having an elevated HbA1c in direct-to-patient alerts that use cold texting. Using plain and positive language, integrating elements of personalization, and defining new processes clearly were identified by participants as modifiable content elements that could act as facilitators that would help overcome barriers to engagement with these messages. A patient's relationship with their provider and the financial costs associated with texts and screening may affect receptiveness and engagement in this process.

Exploring determinants and strategies for implementing self-management support text messaging interventions in safety net clinics

Background

Text message-delivered interventions for chronic disease self-management have potential to reduce health disparities, yet limited research has explored implementing these interventions into clinical care. We partnered with safety net clinics to evaluate a texting intervention for type 2 diabetes called REACH (Rapid Encouragement/Education And Communications for Health) in a randomized controlled trial. Following evaluation, we explored potential implementation determinants and recommended implementation strategies.

Methods

We interviewed clinic staff (n = 14) and a subset of intervention participants (n = 36) to ask about REACH's implementation potential. Using the Consolidated Framework for Implementation Research (CFIR) as an organizing framework, we coded transcripts and used thematic analysis to derive implementation barriers and facilitators. We integrated the CFIR-ERIC (Expert Recommendations for Implementing Change) Matching Tool, interview feedback, and the literature to recommend implementation strategies.

Results

Implementation facilitators included low complexity, strong evidence and quality, available clinic resources, the need for a program to support diabetes self-management, and strong fit between REACH and both the clinics' existing workflows and patients' needs and resources. The barriers included REACH only being available in English, a lack of interoperability with electronic health record systems, patients' concerns about diabetes stigma, limited funding, and high staff turnover. Categories of recommended implementation strategies included training and education, offering flexibility and adaptation, evaluating key processes, and securing funding.

Conclusion

Text message-delivered interventions have strong potential for integration in low-resource settings as a supplement to care. Pursuing implementation can ensure patients benefit from these innovations and help close the research to practice gap.

Text messages promoting healthy lifestyle and linked with activity monitors stimulate an immediate increase in physical activity among women after gestational diabetes

AIMS

To evaluate the immediate effect of text messages promoting healthy lifestyle and supporting parenting on physical activity amongst women with recent gestational diabetes (GDM).

METHODS

Analysis of data from a pilot randomised controlled trial of a healthy lifestyle program for women with recent GDM. Intervention subjects received text messages providing motivation, reminders, information and feedback as well as an activity monitor. This sub-study examined step count in the 4 h after receipt of a text message, compared to the same time of day on other days among intervention subjects.

RESULTS

Data from 7326 days where step counts were recorded, from 31 women were analysed. The median steps in the 4 h following a text message was 1237 (IQR 18-2240) and it was 1063 (IQR 0-2038) over the same time period on comparison days where there was no message (p < 0.001). The effect was similar whether the messages pertained to physical activity or not. There was no attenuation of the response over 36-38 weeks.

CONCLUSIONS

Women with recent GDM increase their step count in the hours following positive and supportive text messages. This suggests that text messaging programs can facilitate healthy lifestyle and diabetes prevention in this population.

A New Taxonomy for Technology-Enabled Diabetes Self-Management Interventions: Results of an Umbrella Review

BACKGROUND

A 2017 umbrella review defined the technology-enabled self-management (TES) feedback loop associated with a significant reduction in A1C. The purpose of this 2021 review was to develop a taxonomy of intervention attributes in technology-enabled interventions; review recent, high-quality systematic reviews and meta-analyses to determine if the TES framework was described and if elements contribute to improved diabetes outcomes; and to identify gaps in the literature.

METHODS

We identified key technology attributes needed to describe the active ingredients of TES interventions. We searched multiple databases for English language reviews published between April 2017 and April 2020, focused on PwD (population) receiving diabetes care and education (intervention) using technology-enabled self-management (comparator) in a randomized controlled trial, that impact glycemic, behavioral/psychosocial, and other diabetes self-management outcomes. AMSTAR-2 guidelines were used to assess 50 studies for methodological quality including risk of bias.

RESULTS

The TES Taxonomy was developed to standardize the description of technology-enabled interventions; and ensure research uses the taxonomy for replication and evaluation. Of the 26 included reviews, most evaluated smartphones, mobile applications, texting, internet, and telehealth. Twenty-one meta-analyses with the TES feedback loop significantly lowered A1C.

CONCLUSIONS

Technology-enabled diabetes self-management interventions continue to be associated with improved clinical outcomes. The ongoing rapid adoption and engagement of technology makes it important to focus on uniform measures for behavioral/psychosocial outcomes to highlight healthy coping. Using the TES Taxonomy as a standard approach to describe technology-enabled interventions will support understanding of the impact technology has on diabetes outcomes.

Randomised controlled trials on prevention, diagnosis and treatment of diabetes in African countries: a systematic review

OBJECTIVES

The epidemiological transition from infectious to chronic diseases leads to novel challenges in African health systems. The prevalence of diabetes mellitus (DM) is increasing dramatically. Undiagnosed and undertreated DM leads to numerous complications including end-organ damage and death. Our objectives were to collect the best locally generated evidence on DM interventions, identify knowledge gaps and determine underexplored research areas.

DESIGN

A systematic review and meta-analysis of randomised controlled trials.

PARTICIPANTS AND SETTING

African patients in primary, secondary and tertiary prevention, diagnosis and treatment DM type 1 (DM1), type 2 (DM2) and gestational DM (GDM).

OUTCOME

All-cause mortality, glycaemic control, complications, quality of life, hospital admission, treatment adherence and costs.

DATA SOURCES

Articles published in MEDLINE Ovid, CENTRAL, CINAHL, African Journals Online and African Index Medicus and the International Clinical Trials Registry Platform in English language without time restrictions. The systematic search was last updated in October 2020.

RESULTS

Out of 3736 identified publications, we included 60 eligible studies conducted in 15 countries, 75% were conducted in urban healthcare settings, including 10 112 participants. We included 8 studies on DM1, 6 on GDM, 2 on pre-DM, 37 on mainly DM2 including 7 on DM-related complications. The design of the studied intervention was heterogeneous with a focus on educational strategies. The other studies investigated the efficacy of nutritional strategies including food supplementations, pharmacological strategies and strategies to enhance physical activity. Seven studies included interventions on DM-related complications.

CONCLUSIONS

Research activities increased in recent years, but available evidence is still not representative for all African countries. There is a big lack of evidence in primary healthcare and rural settings, implementation research, pharmacological interventions, especially in poorer countries. Nevertheless, the identified studies offer a variety of effective interventions that can inform medical care and future research.

PROSPERO REGISTRATION NUMBER

CRD42019122785.

Effects of Using a Text Message Intervention on Psychological Constructs and the Association Between Changes to Psychological Constructs and Medication Adherence in People With Type 2 Diabetes: Results From a Randomized Controlled Feasibility Study

BACKGROUND

Poor adherence to oral medications is common in people with type 2 diabetes and can lead to an increased chance of health complications. Text messages may provide an effective delivery method for an intervention; however, thus far, the majority of these interventions do not specify either a theoretical basis or propose specific mechanisms of action. This makes it hard to determine how and whether an intervention is having an effect. The text messages included in the current intervention have been developed to deliver specific behavior change techniques. These techniques are the "active ingredients" of the intervention and were selected to target psychological constructs identified as predictors of medication adherence.

OBJECTIVE

There are 2 aims of this study: (1) to assess whether a text message intervention with specified behavior change techniques can change the constructs that predict medication adherence behaviors in people with type 2 diabetes and (2) to assess whether changes to psychological constructs are associated with changes in self-reported medication adherence.

METHODS

We conducted a randomized controlled, 6-month feasibility trial. Adults prescribed oral medication for type 2 diabetes (N=209) were recruited from general practice and randomized to either receive a text message-based intervention or care as usual. Data were analyzed with repeated measures analysis of covariance and Spearman rho correlation coefficients.

RESULTS

For 8 of the 14 constructs that were measured, a significant time-by-condition interaction was found: necessity beliefs, intention, maintenance self-efficacy, recovery self-efficacy, action control, prompts and cues, social support, and satisfaction with experienced consequences all increased in the intervention group compared to the control group. Changes in action self-efficacy, intention, automaticity, maintenance self-efficacy, and satisfaction with experienced consequences were positively associated with changes in self-reported medication adherence.

CONCLUSIONS

A relatively low-cost, scalable, text message-only intervention targeting medication adherence using behavior change techniques can influence psychological constructs that predict adherence. Not only do these constructs predict self-reported medication adherence, but changes in these constructs are correlated with changes in self-reported medication adherence. These findings support the promise of text message-based interventions for medication adherence in this population and suggest likely mechanisms of action.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN13404264; https://www.isrctn.com/ISRCTN13404264.

Developing Mobile Health Interventions With Implementation in Mind: Application of the Multiphase Optimization Strategy (MOST) Preparation Phase to Diabetes Prevention Programming

With thousands of mobile health (mHealth) solutions on the market, patients and health care providers struggle to identify which solution to use and prescribe. The lack of evidence-based mHealth solutions may be because of limited research on intervention development and the continued use of traditional research methods for mHealth evaluation. The Multiphase Optimization Strategy (MOST) is a framework that aids in developing interventions that produce the best-expected outcomes (ie, effectiveness), given constraints imposed on affordability, scalability, and efficiency (also known as achieving intervention EASE). The preparation phase of the MOST highlights the importance of formative intervention development-a stage often overlooked and rarely published. The aim of the preparation phase of the MOST is to identify candidate intervention components, create a conceptual model, and define the optimization objective. Although the MOST sets these 3 targets, no guidance is provided on how to conduct quality research within the preparation phase and what specific steps can be taken to identify potential intervention components, develop the conceptual model, and achieve intervention EASE with the implementation context in mind. To advance the applicability of the MOST within the field of implementation science, this study provides an account of the methods used to develop an mHealth intervention using the MOST. Specifically, we provide an example of how to achieve the goals of the preparation phase by outlining the formative development of an mHealth-prompting intervention within a diabetes prevention program. In addition, recommendations are proposed for future researchers to consider when conducting formative research on mHealth interventions with implementation in mind. Given its considerable reach, mHealth has the potential to positively affect public health by decreasing implementation costs and improving accessibility. The MOST is well-suited for the efficient development and optimization of mHealth interventions. By using an implementation-focused lens and outlining the steps in developing an mHealth intervention using the preparation phase of the MOST, this study may guide future intervention developers toward maximizing the impact of mHealth outside academia.

A Meta-Analysis of the Effectiveness of Telemedicine in Glycemic Management among Patients with Type 2 Diabetes in Primary Care

Introduction: Telemedicine interventions are gradually being used in primary health care to help patients with type 2 diabetes receive ongoing medical guidance. The purpose of this study was to analyze the effectiveness of using telemedicine in primary health care for the management of patients with type 2 diabetes. Methods: A systematic search was conducted from database inception to August 2021 in nine databases, including PubMed, Web of Science, Cochrane Library, EMBASE, EBSCO, CNKI, Wanfang Data, VIP, and CBM. Data extraction and quality assessment were performed for studies that met the inclusion criteria. The meta-analysis was performed using Review Manager 5.4 (Cochrane) and Stata v.16.0SE (College Station, TX, USA). Results: A total of 32 articles were included in this study. Analysis showed a reduction in glycated hemoglobin, fasting glucose, and postprandial glucose after the telemedicine intervention. Systolic blood pressure and self-efficacy improved significantly, but there was no significant improvement in weight, lipid metabolism, or diabetes awareness. Subgroup analysis based on the duration of intervention showed significant improvement in glycated hemoglobin at 6 months of intervention. Conclusions: Telemedicine interventions may help patients with type 2 diabetes to effectively control blood glucose and improve self-management in primary health care. There is only moderate benefit, and the benefit may not be sustained beyond 6 months. However, the evidence for the improvement in lipid metabolism is insufficient and further studies are needed.

The Effectiveness of Mobile Phone Messaging-Based Interventions to Promote Physical Activity in Type 2 Diabetes Mellitus: Systematic Review and Meta-analysis

Background

The prevalence of type 2 diabetes mellitus (T2DM) is increasing worldwide. Physical activity (PA) is an important aspect of self-care and first line management for T2DM. SMS text messaging can be used to support self-management in people with T2DM, but the effectiveness of mobile text message–based interventions in increasing PA is still unclear.

Objective

This study aims to assess the effectiveness of mobile phone messaging on PA in people with T2DM by summarizing and pooling the findings of previous literature.

Methods

A systematic review was conducted to accomplish this objective. Search sources included 5 bibliographic databases (MEDLINE, Cochrane Library, CINAHL, Web of Science, and Embase), the search engine Google Scholar (Google Inc), and backward and forward reference list checking of the included studies and relevant reviews. A total of 2 reviewers (MA and AA) independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence evaluation. The results of the included studies were synthesized narratively and statistically, as appropriate.

Results

We included 3.8% (6/151) of the retrieved studies. The results of individual studies were contradictory regarding the effectiveness of mobile text messaging on PA. However, a meta-analysis of the results of 5 studies showed no statistically significant effect (P=.16) of text messages on PA in comparison with no intervention. A meta-analysis of the findings of 2 studies showed a nonsignificant effect (P=.14) of text messages on glycemic control. Of the 541 studies, 2 (0.4%) found a nonsignificant effect of text messages on anthropometric measures (weight and BMI).

Conclusions

We could not draw a definitive conclusion regarding the effectiveness of text messaging on PA, glycemic control, weight, or BMI among patients with T2MD, given the limited number of included studies and their high risk of bias. Therefore, there is a need for more high-quality primary studies.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020156465; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=156465

Development and Usability of a Text Messaging Program for Women With Gestational Diabetes: Mixed Methods Study

Background

Gestational diabetes mellitus (GDM) affects 5%-10% of pregnancies and can lead to serious fetal and maternal complications. SMS text messaging is an effective way to improve diabetes management outside of pregnancy, but has not been well studied in GDM.

Objective

This study aimed to perform user experience testing and assess usability and acceptability of an SMS text messaging program (Text 4 Success) for women with GDM.

Methods

An automated 2-way texting program was developed. It included (1) reminders to check blood glucose levels, (2) positive feedback to user-reported glucose levels, (3) weekly educational messages, and (4) weekly motivational messages. For the user experience testing, women received simulated messages. For the usability study, women were enrolled in the program and received messages for 2 weeks. All women participated in semistructured interviews. For women in the usability study, data from glucose measuring devices were downloaded to assess adherence to self-monitoring of blood glucose (SMBG), measured as the percentage of recommended SMBG checks performed (a secondary outcome).

Results

Ten women participated in user experience testing. Suggestions for optimization included further customization of message timing and minimization of jargon, which were incorporated. Ten women participated in the usability study. All 10 would recommend the program to other women with GDM. Participants liked the immediate feedback to glucose values. Suggestions included further flexibility of messages related to mealtimes and the ability to aggregate blood glucose data into a table or graph. Overall, adherence to SMBG testing was high at baseline (222/238 recommended checks, 93%). In comparing the week prior to the trial with the 2 weeks during the trial, there was a small but statistically insignificant difference (P=.48) in the percentage of recommended SMBG performed (median 93% [25th-75th IQR 89%-100%] vs median 97% [25th-75th IQR 92%-100%]).

Conclusions

Overall, women with GDM would recommend the Text 4 Success in GDM program and think it is helpful for GDM self-management. The program was usable and acceptable. The program may be better suited to those who have low levels of adherence to SMBG at baseline or to women at time of their diagnosis of GDM. Adaptations to the program will be made based on user suggestions. Further study of SMS text messaging to improve SMBG in GDM is needed.

Patients' Views on the Design of DiabeText, a New mHealth Intervention to Improve Adherence to Oral Antidiabetes Medication in Spain: A Qualitative Study

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is a long-term condition affecting around 10% of people worldwide. This study aimed to explore T2DM patients' views on DiabeText, a new text messaging intervention to be developed to support adherence to diabetes medication.

METHODS

A total of four focus groups were conducted with a purposive sample of people with T2DM (n = 34). The data were analysed by multiple researchers independently, and coded using thematic analysis.

RESULTS

There were two main themes that emerged: (1) "patients' perspectives on unmet needs for diabetes self-management", and (2) "acceptability and perceived utility of DiabeText". The patients identified a number of barriers for diabetes self-management, including lack of appropriate information and support with diet and physical activity. Support for medication-taking was not perceived as urgently needed, although several barriers were identified (eating outside, traveling, polymedication, dispensation at the pharmacy). The participants anticipated that the proposed intervention would present high levels of patient acceptability and perceived utility as long as its content addresses the barriers that were identified, and includes specific features (short and clear messages, and personalized information).

CONCLUSION

The proposed intervention has the potential to be well accepted and perceived as useful by T2DM patients who require support not only in terms of medication-taking, but more prominently of lifestyle behaviour.

Association Between Phthalate Exposure in Pregnancy and Gestational Diabetes: A Chinese Cross-Sectional Study

Objective

The present study aims to explore the association between phthalate exposure and the risk of gestational diabetes mellitus (GDM).

Materials and Methods

A total of 11 plasticizer metabolites were measured in patient morning urine using high-performance liquid chromatography. Furthermore, fasting blood glucose and fasting insulin were detected in first-trimester blood samples. The chemical concentration was described using the median, the metabolite concentration difference between the GDM and control groups was compared using the bootstrap method, and the correlations of the fasting blood glucose, fasting insulin, insulin resistance index, and phthalic acid ester (PAE) metabolites were analyzed using Spearman correlation analysis. The multivariate logistic regression model and predictive probability map were performed to help assess the linearity and nature of any dose–response relationship.

Results

Of the 224 women recruited for the present study, 200 met the inclusion criteria. Their measured outcomes and biomonitoring data were examined for the presence of chemicals. The results showed that the patients in the GDM group had higher mono-(2-ethylhexyl) phthalate (MEHP) and methylerythritol cyclophosphane concentrations in their bodies than the patients in the control group. Statistically significant MEHP–GDM associations were also observed (P < 0.001). The GDM and MEHP dose–response relationships were different among pregnant women aged <35 years and those aged >35 years (P < 0.001). Furthermore, gestational age >28 weeks exhibited similar changes to those aged ≤28 weeks (P = 0.059).

Conclusion

The findings of the present study add to the growing body of evidence supporting phthalate exposure as a GDM risk factor.

Feasibility and Acceptability of Community Coronavirus Disease 2019 Testing Strategies (FACTS) in a University Setting

Background

During the coronavirus disease 2019 (COVID-19) pandemic in 2020, the UK government began a mass severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing program. This study aimed to determine the feasibility and acceptability of organized regular self-testing for SARS-CoV-2.

Methods

This was a mixed-methods observational cohort study in asymptomatic students and staff at University of Oxford, who performed SARS-CoV-2 antigen lateral flow self-testing. Data on uptake and adherence, acceptability, and test interpretation were collected via a smartphone app, an online survey, and qualitative interviews.

Results

Across 3 main sites, 551 participants (25% of those invited) performed 2728 tests during a follow-up of 5.6 weeks; 447 participants (81%) completed at least 2 tests, and 340 (62%) completed at least 4. The survey, completed by 214 participants (39%), found that 98% of people were confident to self-test and believed self-testing to be beneficial. Acceptability of self-testing was high, with 91% of ratings being acceptable or very acceptable. A total of 2711 (99.4%) test results were negative, 9 were positive, and 8 were inconclusive. Results from 18 qualitative interviews with students and staff revealed that participants valued regular testing, but there were concerns about test accuracy that impacted uptake and adherence.

Conclusions

This is the first study to assess feasibility and acceptability of regular SARS-CoV-2 self-testing. It provides evidence to inform recruitment for, adherence to, and acceptability of regular SARS-CoV-2 self-testing programs for asymptomatic individuals using lateral flow tests. We found that self-testing is acceptable and people were able to interpret results accurately.

Patient-reported outcome measures for knowledge transfer and behaviour modification interventions in type 2 diabetes-the INDICA study: a multiarm cluster randomised controlled trial

OBJECTIVE

This study assesses the effectiveness of different interventions of knowledge transfer and behaviour modification to improve type 2 diabetes mellitus patients' (T2DM) reported outcomes measures (PROMs) in the long-term. Design: open, community-based pragmatic, multicentre, controlled trial with random allocation by clusters to usual care (UC) or to one of the three interventions.

PARTICIPANTS

A total of 2334 patients with uncomplicated T2DM and 211 healthcare professionals were included of 32 primary care centres.

SETTING

Primary Care Centers in Canary Islands (Spain).

INTERVENTION

The intervention for patients (PTI) included an educational group programme, logs and a web-based platform for monitoring and automated short message service (SMS). The intervention for professionals (PFI) included an educational programme, a decision support tool embedded into the electronic clinical record and periodic feedback about patients' results. A third group received both PTI and PFI (combined intervention, CBI).

OUTCOME MEASURE

Cognitive-attitudinal, behavioural, affective and health-related quality of life (HQoL) variables.

RESULTS

Compared with UC at 24 months, the PTI group significantly improved knowledge (p=0.005), self-empowerment (p=0.002), adherence to dietary recommendations (p<0.001) and distress (p=0.01). The PFI group improved at 24 months in distress (p=0.03) and at 12 months there were improvements in depression (p=0.003), anxiety (p=0.05), HQoL (p=0.005) and self-empowerment (p<0.001). The CBI group improved at 24 months in self-empowerment (p=0.008) and adherence to dietary recommendations (p=0.004) and at 12 months in knowledge (p=0.008), depression (p=0.006), anxiety (p=0.003), distress (p=0.01), HQoL (p<0.001) and neuropathic symptoms (p=0.02). Statistically significant improvements were also observed at 24 months in the proportion of patients who quit smoking for PTI and CBI (41.5% in PTI and 42.3% in CBI vs 21.2% in the UC group).

CONCLUSIONS

Assessed interventions to improve PROMs in T2DM attain effectiveness for knowledge, self-empowerment, distress, diet adherence and tobacco cessation. PTI produced the most lasting benefits.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01657227 (6 August 2012) https://clinicaltrials.gov/ct2/show/NCT01657227.

Implementation of an Automated Text Message-Based System for Tracking Patient-Reported Outcomes in Spine Surgery: An Overview of the Concept and Our Early Experience

OBJECTIVE

Text message-based interventions have been demonstrated to be a valuable monitoring tool across various conditions. Here, we aimed to describe our early experience using a newly developed text message-based platform designed to track symptoms in spine surgery patients.

METHODS

We used the Informed Mindset Medical (IMM) platform to automatically send text messages with secure and encrypted hyperlinks to enrolled patients. Patient symptoms were monitored using well-standardized functional assessments. Limited patient data and responses were stored on a Health Insurance Portability and Accountability Act-compliant SQL cloud-based server database.

RESULTS

In 3 months, 101 patients scheduled for elective spine surgery accepted participation in our pilot study. Overall, 71.2% of the enrolled patients responded to at least 1 preoperative baseline questionnaire. The response rates were similar across attendings, questionnaire bundles (cervical vs. thoracolumbar), genders, and age groups. The overall preoperative IMM pain scores were found to correlate positively with the preoperative electronic medical record pain rates. Similarly, the overall preoperative IMM and electronic medical record pain scores correlated positively with the IMM-collected Neck Disability Index/Oswestry Disability Index scores. From an initial 71.2%, the response rate decreased to 54.9% for the 6-week follow-up questionnaires.

CONCLUSIONS

Our preliminary findings support the reliability of this text message-based strategy to monitor symptoms in spine surgery patients. Further studies are warranted to explore strategies to increase the response rate and expand this platform's clinical and research applicability.

Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial

BACKGROUND

Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes.

METHODS

StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals.

RESULTS

The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (- 0.08% (- 0.31 to 0.16) (IFCC - 0.82 mmol/mol (- 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was - 0.71% (- 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful.

CONCLUSIONS

Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes.

TRIAL REGISTRATION

Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.

Impact of personalized text messages from pharmacists on medication adherence in type 2 diabetes in France: A real-world, randomized, comparative study

OBJECTIVE

A real-world, randomized study assessing the impact of a new, personalized, pharmacist-led text messaging service for managing type 2 diabetes (T2D).

METHODS

Messages were tailored to patient's needs based on their disease management habits, propensity for reactance, and physical activity levels at baseline. Treatment adherence (assed using the Morisky Medication Adherence Scale, MMAS-8, questionnaire), clinical factors (body mass index and physical activity) and biological markers for T2D were compared between patients who received a text message daily for 3 months in addition to standard care (SMS group) and those who received standard care alone (control group).

RESULTS

114 pharmacies recruited 499 patients. Greater increases in global MMAS-8 scores were observed after 3 months for the SMS group than for the control group, however, this improvement was not sustained after the text messages stopped. Body mass index was found to improve with the text messaging service.

CONCLUSION

This study indicated that personalized text messages provided by community pharmacists can have an impact on adherence levels among T2D patients.

PRACTICE IMPLICATIONS

Pharmacy-led innovations, such as text messaging services, could be used to accompany patients in their treatment and to improve patient understanding of their illness between healthcare appointments.

Evaluation of an mHealth-enabled hierarchical diabetes management intervention in primary care in China (ROADMAP): A cluster randomized trial

BACKGROUND

Glycemic control remains suboptimal in developing countries due to critical system deficiencies. An innovative mobile health (mHealth)-enabled hierarchical diabetes management intervention was introduced and evaluated in China with the purpose of achieving better control of type 2 diabetes in primary care.

METHODS AND FINDINGS

A community-based cluster randomized controlled trial was conducted among registered patients with type 2 diabetes in primary care from June 2017 to July 2019. A total of 19,601 participants were recruited from 864 communities (clusters) across 25 provinces in China, and 19,546 completed baseline assessment. Moreover, 576 communities (13,037 participants) were centrally randomized to the intervention and 288 communities (6,509 participants) to usual care. The intervention was centered on a tiered care team-delivered mHealth-mediated service package, initiated by monthly blood glucose monitoring at each structured clinic visit. Capacity building and quarterly performance review strategies upheld the quality of delivered primary care. The primary outcome was control of glycated hemoglobin (HbA1c; <7.0%), assessed at baseline and 12 months. The secondary outcomes include the individual/combined control rates of blood glucose, blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C); changes in levels of HbA1c, BP, LDL-C, fasting blood glucose (FBG), and body weight; and episodes of hypoglycemia. Data were analyzed using intention-to-treat (ITT) generalized estimating equation (GEE) models, accounting for clustering and baseline values of the analyzed outcomes. After 1-year follow-up, 17,554 participants (89.8%) completed the end-of-study (EOS) assessment, with 45.1% of them from economically developed areas, 49.9% from urban areas, 60.5 (standard deviation [SD] 8.4) years of age, 41.2% male, 6.0 years of median diabetes duration, HbA1c level of 7.87% (SD 1.92%), and 37.3% with HbA1c <7.0% at baseline. Compared with usual care, the intervention led to an absolute improvement in the HbA1c control rate of 7.0% (95% confidence interval [CI] 4.0% to 10.0%) and a relative improvement of 18.6% (relative risk [RR] 1.186, 95% CI 1.105 to 1.267) and an absolute improvement in the composite ABC control (HbA1c <7.0%, BP <140/80 mm Hg, and LDL-C <2.6 mmol/L) rate of 1.9% (95% CI 0.5 to 3.5) and a relative improvement of 21.8% (RR 1.218, 95% CI 1.062 to 1.395). No difference was found on hypoglycemia episode and weight gain between groups. Study limitations include noncentralized laboratory tests except for HbA1c, and caution should be exercised when extrapolating the findings to patients not registered in primary care system.

CONCLUSIONS

The mHealth-enabled hierarchical diabetes management intervention effectively improved diabetes control in primary care and has the potential to be transferred to other chronic conditions management in similar contexts.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) IOC-17011325.

Process evaluation of a brief messaging intervention to improve diabetes treatment adherence in sub-Saharan Africa

Background

The SMS text Adherence suppoRt for people with type 2 diabetes (StAR2D) intervention is a pragmatic randomised controlled trial, testing the effectiveness of brief text messaging for improving clinical outcomes and medication adherence. The intervention did not impact glycaemic control. We conducted a pre-and post-trial process evaluation alongside the StAR2D study in Malawi and South Africa, exploring the experiences and perceptions of patient participants, to better understand potential underlying reasons for the trial outcomes.

Methods

We employed a qualitative research design, including conducting semi structured in-depth interviews and focus groups at both trial sites. Purposive sampling was used to ensure representation of a wide range of patients with type 2 diabetes with regards to age, gender, ethnicity, language, and duration of diabetes. We interviewed the same participants at baseline and at the end of the trial. We used within-case and across-case thematic analysis to identify key themes.

Results

Brief messages delivered by text were acceptable and useful for addressing informational and support needs for participants. Some participants reported behaviour changes because of the text reminders and advice on a healthy lifestyle. Both participating in the trial and the messages were experienced as a source of support, caring, and motivation. Participants’ ability to act on the messages was limited. A common theme was frustration over the lack of ability to effectively control one’s blood glucose level. They reported a range of routinised, partial diabetes care adherence behaviours, shaped by complex and interacting individual, social, and health service factors. Participant responses and intervention impact were similar across sites, despite differences in health services.

Conclusion

This process evaluation provided context and insight into the factors influencing participants’ engagement with the text messaging intervention. The complex context in which patients take their diabetes medication, may explain in part, why brief text messaging may have been insufficient to bring about changes in health outcomes. The scale of need for self-management and health service support, suggests that health system strengthening, and other forms of self-management support should accompany digital communication interventions. (Current Controlled Trials ISRCTN70768808, registered 03/08/2015.)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11552-8.

Efficacy and Safety of Text Messages Targeting Adherence to Cardiovascular Medications in Secondary Prevention: TXT2HEART Colombia Randomized Controlled Trial

Background

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality worldwide, with a prevalence of approximately 100 million patients. There is evidence that antiplatelet agents and antihypertensive medications could reduce the risk of new vascular events in this population; however, treatment adherence is very low. An SMS text messaging intervention was recently developed based on behavior change techniques to increase adherence to pharmacological treatment among patients with a history of ASCVD.

Objective

This study aims to evaluate the efficacy and safety of an SMS text messaging intervention to improve adherence to cardiovascular medications in patients with ASCVD.

Methods

A randomized controlled clinical trial for patients with a prior diagnosis of cardiovascular events, such as acute myocardial infarction, unstable angina, cerebrovascular disease, or peripheral artery disease, in one center in Colombia was conducted. Patients randomized to the intervention arm were assigned to receive SMS text messages daily for the first 4 weeks, 5 SMS text messages on week 5, 3 SMS text messages each in weeks 6 and 7, and 1 SMS text message weekly from week 8 until week 52. In contrast, patients in the control arm received a monthly SMS text message reminding them of the next study appointment and the importance of the study, requesting information about changes in their phone number, and thanking them for participating in the study. The primary endpoint was the change in low-density lipoprotein cholesterol (LDL-C) levels, whereas the secondary endpoints were the changes in thromboxane B2 levels, heart rate, systolic and diastolic blood pressure, medication adherence, cardiac and noncardiac mortality, and hospitalization. Linear regression analyses and bivariate tests were performed.

Results

Of the 930 randomized patients, 805 (86.5%) completed follow-up and were analyzed for the primary endpoint. There was no evidence that the intervention changed the primary outcome (LDL-C levels; P=.41) or any of the secondary outcomes evaluated (all P>.05). There was also no evidence that the intervention was associated with adverse events.

Conclusions

In this study, there was no evidence that a behavior modification intervention delivered by SMS text messaging improved LDL-C levels, blood pressure levels, or adherence at 12 months. More research is needed to evaluate whether different SMS text messaging strategies, including personalized messages and different timings, are effective; future studies should include mixed methods to better understand why, for whom, and in which context (eg, health system or social environment) SMS text messaging interventions work (or not) to improve adherence in patients with ASCVD.

Trial Registration

ClinicalTrials.gov NCT03098186; https://clinicaltrials.gov/ct2/show/NCT03098186

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-028017

Educating diabetic patients through an SMS intervention: a randomized controlled trial at a Brazilian public hospital

Objective

Diabetes mellitus (DM) has a high healthcare system cost worldwide. Educational strategies are important to improve self-care and control this disease. This study aimed to evaluate satisfaction and clinical efficacy of a Short Message Service (SMS) educational intervention in self-care and nutrition at a Brazilian university hospital.

Methods

We conducted a trial of educational intervention and assigned eligible patients with DM to either receive weekly educational SMS for 6 months (intervention group [IG]) or no SMS at all (control group). A satisfaction questionnaire was applied before and after the intervention in both groups. Laboratory (fasting glucose, hemoglobin [Hb] A1c, total cholesterol, triglycerides, high-density lipoprotein, and low-density lipoprotein) and clinical (blood pressure) data were also collected. Data were analyzed using nonparametric tests with the Statistical Package for the Social Sciences.

Results

We included 128 patients (64 in each group). Responses to the satisfaction questionnaire with self-care and healthcare professionals from 112 patients revealed an improvement in the perception of receiving information regarding helpful eating habits and in healthy eating behavior and an improvement in satisfaction with their diabetes care in the IG. In the post-intervention period, improved systolic blood pressure and HbA1c levels were observed in the IG as illustrated by delta % (post-intervention minus pre-intervention data divided by pre-intervention data multiplied by 100) reductions of 2.3% and 3.9%, respectively.

Conclusion

SMS intervention was useful as an educational tool for improving satisfaction and glycemic and blood pressure control of patients with DM observed at a Brazilian university hospital.

Effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management for people with type 2 diabetes. A randomized controlled trial

OBJECTIVE

Determine the effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management behaviors for Australian adults with type 2 diabetes.

METHODS

Using intention to treat analysis and generalized estimating equations, this randomized controlled trial of 395 adults determined change in HbA1c at 3 and 6 months between the intervention and control group. Secondary outcomes included change in nutrition, physical activity, blood lipid profile, body mass index, quality of life, self-efficacy, medication taking and program acceptability.

RESULTS

No significant difference was observed between the intervention or control group for HbA1c at 3 months (P = 0.23) or 6 months (P = 0.22). Significant improvements were seen in consumption of vegetables at 3 months (P < 0.001) and 6 months (P = 0.04); fruit at 3 months (P = 0.046) and discretionary sweet foods at 3 months (P = 0.02). No other significant effects seen. The intervention demonstrated high rates of acceptability (94.0%) and minimal withdrawal (1.5%).

CONCLUSIONS

DTEXT was an acceptable text message intervention that improved some nutritional behaviors in people with type 2 diabetes, but did not significantly improve HbA1c or other outcomes. Further research is required to optimize DTEXT.

PRACTICE IMPLICATIONS

DTEXT provides an acceptable, feasible form of self-management support that may complement existing diabetes care.

Understanding acceptability in the context of text messages to encourage medication adherence in people with type 2 diabetes

BACKGROUND

Acceptability is recognised as a key concept in the development of health interventions, but there has been a lack of consensus about how acceptability should be conceptualised. The theoretical framework of acceptability (TFA) provides a potential tool for understanding acceptability. It has been proposed that acceptability measured before use of an intervention (anticipated acceptability) may differ from measures taken during and after use (experienced acceptability), but thus far this distinction has not been tested for a specific intervention. This paper 1) directly compares ratings of anticipated and experienced acceptability of a text message-based intervention, 2) explores the applicability of the TFA in a technology-based intervention, and 3) uses these findings to inform suggestions for measuring acceptability over the lifespan of technology-based health interventions.

METHODS

Data were obtained from a quantitative online survey assessing anticipated acceptability of the proposed text messages (n = 59) and a 12-week proof-of-concept mixed methods study assessing experienced acceptability while receiving the text messages (n = 48). Both quantitative ratings by return text message, and qualitative data from participant interviews were collected during the proof-of-concept study.

RESULTS

The quantitative analysis showed anticipated and experienced acceptability were significantly positively correlated (r_s > .4). The qualitative analysis identified four of the seven constructs of the TFA as themes (burden, intervention coherence, affective attitude and perceived effectiveness). An additional two themes were identified as having an important impact on the TFA constructs (perceptions of appropriateness and participants' role). Three suggestions are given related to the importance of appropriateness, what may affect ratings of acceptability and what to consider when measuring acceptability.

CONCLUSIONS

The high correlation between anticipated and experienced acceptability was a surprising finding and could indicate that, in some cases, acceptability of an intervention can be gauged adequately from an anticipated acceptability study, prior to an expensive pilot or feasibility study. Directly exploring perceptions of appropriateness and understanding whether the acceptability described by participants is related to the intervention or the research - and is for themselves or others - is important in interpreting the results and using them to further develop interventions and predict future use.

The future is now: a call for action for cardiac telerehabilitation in the COVID-19 pandemic from the secondary prevention and rehabilitation section of the European Association of Preventive Cardiology

The role of comprehensive cardiac rehabilitation is well established in the secondary prevention of cardiovascular diseases such as coronary artery disease and heart failure. Numerous trials have demonstrated both the effectiveness as well as the cost-effectiveness of comprehensive cardiac rehabilitation in improving exercise capacity and quality of life, and in reducing cardiovascular mortality and morbidity. However, the current COVID-19 pandemic has led to closure of many cardiac rehabilitation centres in Europe resulting in many eligible patients unable to participate in the optimisation of secondary prevention and physical performance. This elicits an even louder call for alternatives such as cardiac telerehabilitation to maintain the delivery of the core components of cardiac rehabilitation to cardiovascular disease patients. The present call for action paper gives an update of recent cardiac telerehabilitation studies and provides a practical guide for the setup of a comprehensive cardiac telerehabilitation intervention during the COVID-19 pandemic. This set up could also be relevant to any cardiovascular disease patient not able to visit cardiac rehabilitation centres regularly after the COVID-19 pandemic ceases.

Learning from a diabetes mHealth intervention in rural Bangladesh: what worked, what did not and what next?

There is an urgent need for population-based interventions to slow the growth of the diabetes epidemic in low-and middle-income countries. We tested the effectiveness of a population-based mHealth voice messaging intervention for T2DM prevention and control in rural Bangladesh through a cluster randomised controlled trial. mHealth improved knowledge and awareness about T2DM but there was no detectable effect on T2DM occurrence. We conducted mixed-methods research to understand this result. Exposure to messages was limited by technological faults, high frequency of mobile phone number changes, message fatigue and (mis)perceptions that messages were only for those who had T2DM. Persistent social norms, habits and desires made behaviour change challenging, and participants felt they would be more motivated by group discussions than mHealth messaging alone. Engagement with mHealth messages for T2DM prevention and control can be increased by (1) sending identifiable messages from a trusted source (2) using participatory design of mHealth messages to inform modelling of behaviours and increase relevance to the general population (3) enabling interactive messaging. mHealth messaging is likely to be most successful if implemented as part of a multi-sectoral, multi-component approach to address T2DM and non-communicable disease risk factors.

The Effectiveness of Mobile Phone Messaging–Based Interventions to Promote Physical Activity in Type 2 Diabetes Mellitus: Systematic Review and Meta-analysis (Preprint).. [DOI: 10.2196/preprints.29663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

The prevalence of type 2 diabetes mellitus (T2DM) is increasing worldwide. Physical activity (PA) is an important aspect of self-care and first line management for T2DM. SMS text messaging can be used to support self-management in people with T2DM, but the effectiveness of mobile text message–based interventions in increasing PA is still unclear.

OBJECTIVE

This study aims to assess the effectiveness of mobile phone messaging on PA in people with T2DM by summarizing and pooling the findings of previous literature.

METHODS

A systematic review was conducted to accomplish this objective. Search sources included 5 bibliographic databases (MEDLINE, Cochrane Library, CINAHL, Web of Science, and Embase), the search engine <i>Google Scholar</i> (Google Inc), and backward and forward reference list checking of the included studies and relevant reviews. A total of 2 reviewers (MA and AA) independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence evaluation. The results of the included studies were synthesized narratively and statistically, as appropriate.

RESULTS

We included 3.8% (6/151) of the retrieved studies. The results of individual studies were contradictory regarding the effectiveness of mobile text messaging on PA. However, a meta-analysis of the results of 5 studies showed no statistically significant effect (<i>P</i>=.16) of text messages on PA in comparison with no intervention. A meta-analysis of the findings of 2 studies showed a nonsignificant effect (<i>P</i>=.14) of text messages on glycemic control. Of the 541 studies, 2 (0.4%) found a nonsignificant effect of text messages on anthropometric measures (weight and BMI).

CONCLUSIONS

We could not draw a definitive conclusion regarding the effectiveness of text messaging on PA, glycemic control, weight, or BMI among patients with T2MD, given the limited number of included studies and their high risk of bias. Therefore, there is a need for more high-quality primary studies.

CLINICALTRIAL

PROSPERO International Prospective Register of Systematic Reviews CRD42020156465; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=156465

Using the RE-AIM framework to evaluate internal and external validity of mobile phone-based interventions in diabetes self-management education and support

OBJECTIVE

We evaluated the extent to which studies that tested short message service (SMS)- and application (app)-based interventions for diabetes self-management education and support (DSMES) report on factors that inform both internal and external validity as measured by the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework.

MATERIALS AND METHODS

We systematically searched PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), and IEEE Xplore Digital Library for articles from January 1, 2009, to February 28, 2019. We carried out a multistage screening process followed by email communications with study authors for missing or discrepant information. Two independent coders coded eligible articles using a 23-item validated data extraction tool based on the RE-AIM framework.

RESULTS

Twenty studies (21 articles) were included in the analysis. The comprehensiveness of reporting on the RE-AIM criteria across the SMS- and app-based DSMES studies was low. With respect to internal validity, most interventions were well described and primary clinical or behavioral outcomes were measured and reported. However, gaps exist in areas of attrition, measures of potential negative outcomes, the extent to which the protocol was delivered as intended, and description on delivery agents. Likewise, we found limited information on external validity indicators across adoption, implementation, and maintenance domains.

CONCLUSIONS

Reporting gaps were found in internal validity but more so in external validity in the current SMS- and app-based DSMES literature. Because most studies in this review were efficacy studies, the generalizability of these interventions cannot be determined. Future research should adopt the RE-AIM dimensions to improve the quality of reporting and enhance the likelihood of translating research to practice.

e-Health Interventions for Community-Dwelling Type 2 Diabetes: A Scoping Review

Background: Because type 2 diabetes mellitus is a critical health problem with increasing incidence, prevalence, and complications worldwide, e-health has been widely utilized for management in type 2 diabetes. Introduction: This scoping review of meta-analyses and systematic reviews on e-health interventions aimed to examine service platforms, program types, outcomes, current status of research activities, research gaps, and the effectiveness of type 2 diabetes self-care management among community-dwelling adults. Materials and Methods: Arksey and O'Malley's method was adopted for this review. The Ovid MEDLINE and Ovid EMBASE databases were searched from inception until April 2018. Two reviewers independently screened, selected, and charted studies using a piloted charting form. Discrepancies were resolved by consensus, and results were collated, summarized, and thematically analyzed. Results: The final studies (N = 81) related to e-health interventions included systematic reviews/meta-analyses on clinical effectiveness (n = 64), usability (n = 14), and behavioral outcomes (n = 47). The commonest e-health intervention subtypes for type 2 diabetes care were patient monitoring (53/163, 32.5%), treatment adherence (50/163, 30.7%), and diabetes-related advice/education (34/163, 20.9%). Mobile devices were most often used to provide e-health services (57/142, 40.1%), followed by the internet (41/142, 28.9%). The e-health strategy that was effective in controlling blood glucose in type 2 diabetes patients was a multimodal intervention comprising treatment advice or education, treatment adherence or reminder methods, and patient monitoring. Treatment adherence or reminder methods and/or patient monitoring showed behavioral effects, but the usability of e-health interventions was controversial. Conclusions: We suggest that e-health intervention should be complex intervention including treatment advice/education, patient monitoring, and treatment adherence or reminder methods.

An Umbrella Review of Text Message Programs for Adults With Type 2 Diabetes

Purpose

The purpose of this umbrella review was to synthesize the evidence from published systematic reviews on the effectiveness of text message programs for adults with type 2 diabetes (T2DM) on glycemic management (A1C), self-management, and other clinical outcomes. The effect of directionality of the program was also explored.

Methods

A systematic search was conducted using multiple databases. Inclusion criteria were systematic review of text message programs for adults with T2DM, evaluated A1C, and English language. Quality assessment was completed using AMSTAR-2 guidelines. Data were extracted by multiple coders, and results were synthesized.

Results

The final sample included 9 systematic reviews published between 2011 and 2019, with 72 unique international studies. Text message programs focused on diabetes self-management and reducing health risks through educational and motivational content with some providing personalized feedback. A meta-analysis of program effect on A1C was conducted in 5 reviews with a pooled difference in A1C from −0.38% to −0.8%. Adults with T2DM of shorter duration and lower A1C had better treatment effects. Evidence on unidirectional versus bidirectional programs is conflicting; however, both improve outcomes. Evidence of text message programs targeting medication engagement was inconclusive. Some programs improved blood pressure, lipids, self-management, self-efficacy, and health behaviors. High satisfaction and an average of 9.6% to 18.7% attrition was reported.

Conclusions

Text messaging programs can improve T2DM outcomes, are a highly accessible mode of communication, are relatively inexpensive, and are an underutilized adjunct to clinical care.

Implementation of Technology-Delivered Diabetes Self-care Interventions in Clinical Care: a Narrative Review

PURPOSE OF REVIEW

Evidence is growing for the positive effects of technology-delivered diabetes self-care interventions on behavioral and clinical outcomes. However, our understanding of how to effectively implement these interventions into routine clinical practice is limited. This article provides an overview of the methods and results of studies examining the implementation of technology-delivered diabetes self-care interventions into clinical care. We focus specifically on patient-facing behavioral interventions delivered with technology (e.g., text messaging, apps, websites).

RECENT FINDINGS

Eleven articles were included in the review. Most studies (n = 9) examined barriers and facilitators to implementation, while about half (n = 5) integrated the intervention into clinical care and evaluated implementation and/or effectiveness. Only six studies applied a theory or framework. The most common determinants of implementation were time constraints for clinic staff, familiarity with technology, knowledge of the intervention, and perceived value. We found substantial variation in implementation outcomes, including which were reported, how they were assessed, and the results. In the four studies that evaluated effectiveness, hemoglobin A1c improved. Successful implementation of technology-delivered interventions has the potential to transform healthcare delivery and improve diabetes health on a population level. Promising strategies to address common determinants of implementation include appointing a clinic champion, developing staff training and educational materials, and adapting intervention processes to the clinic context. Future research should evaluate these implementation strategies to understand when and how they impact outcomes. Frameworks such as Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) can help ensure outcomes are systematically reported and allow for comparison across studies.