Effectiveness of short message service-based intervention (SMS) on self-care in type 2 diabetes: A feasibility study

The effectiveness of telemedicine in the management of type 2 diabetes: A systematic review

Background

Type 2 diabetes, a lifestyle-related disease demanding daily self-management, is a significant health concern. In this context, the use of telemedicine as a management tool is a relatively new and promising approach. This study aims to contribute to the growing body of knowledge by identifying the effectiveness of telemedicine in managing type 2 diabetes through a systematic review approach.

Methods

Four databases were searched including PubMed, Virtual Health Library, Global Health Library, and Google Scholar on 27 July 2022. Additionally, a manual search was performed to identify any relevant articles that may have been missed. The quality of the included articles was rigorously assessed using the Study Quality Assessment Tools of the National Institute of Health.

Results

We analyzed data from 134 articles. All 134 studies were published between 2002 and 2022, including 103 controlled intervention trials, 13 cohort studies, 7 before-after (pre-post) studies with no control group, 1 initial trial, 1 case study, 1 pilot study, and 8 two-arm studies that did not report the study design. Accordingly, most studies show positive changes in glycemic index in every group using telemedicine. Overall, although the BMI and weight indices in the studies improved at the end of the course, the improvement values were considered insignificant.

Conclusion

Telemedicine may be a valuable solution for blood sugar management in patients with type 2 diabetes. However, the effectiveness of telemedicine in improving BMI and quality of life is unclear.

Efficacy of telemedicine intervention in the self-management of patients with type 2 diabetes: a systematic review and meta-analysis

Purpose

We aimed to report the latest and largest pooled analyses and evidence updates to assess the effectiveness of telemedicine interventions for self-management (DSM) in patients with type 2 diabetes mellitus (T2DM).

Methods

A systematic literature search was conducted using PubMed, Cochrane, Embase, and Web of Science in December 2023. We included randomized controlled trials (RCTs) of adults (≥18 years of age) diagnosed with T2DM where the intervention was the application of telemedicine. The Cochrane Risk of Bias Assessment was used to evaluate quality. The study's main outcome indicators were glycosylated hemoglobin (HbA1c) and diabetes self-management (DSM) capacity.

Results

A total of 17 eligible articles, comprising 20 studies and 1,456 patients (734 in the intervention group and 722 in the control group), were included in the evidence synthesis. The baseline characteristics of both groups were similar in all outcomes. Comprehensive analyses showed post-intervention decreases in HbA1c, 2-h postprandial glucose, systolic and diastolic blood pressure, increases in Diabetes Self- Care activities, DSM competencies based on dietary and medication adherence, and improvements in overall DSM scores, all of which were statistically significant. While no statistically significant differences were observed in body mass index, lipids, and other DSM dimensions. Based on subgroup analyses, app-based experimental interventions targeting under 60 years old populations in Asia and North America were found to be more effective and less heterogeneity in the short term (<6 months of intervention).

Conclusion

Telemedicine interventions may assist patients with T2DM in enhancing their DSM and improving their HbA1c levels. Clinician can use various telemedicine interventions to enhance DSM in T2DM patients, considering local circumstances.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, CRD42024508522.

The effect of nurse-led telephone-based interventions on glycosylated hemoglobin levels in people with type 2 diabetes: A meta-analysis

BACKGROUND

Telenursing interventions can contribute to achieving optimal glycemic control.

AIM

This meta-analysis aimed to determine the effect of nurse-led telephone-based interventions on glycosylated hemoglobin (HbA1c) levels in people with type 2 diabetes.

METHODS

We searched electronic databases for studies published in English up to January 2023. This study was conducted in accordance with the PRISMA 2020 checklist. The intervention effects were pooled using a random-effects model. Two authors independently assessed the risk of bias using the Cochrane Collaboration tool.

RESULTS

Eight studies involving 1179 people with type 2 diabetes were included in this study. Interventions were performed for 15-30 min and 5-16 calls. There was no evidence of a significant publication bias. The evaluation of meta-analysis data showed that nurse-led telephone-based interventions significantly reduced HbA1c levels in people with type 2 diabetes (mean difference = -0.53, 95% Confidence Interval [-0.89, -0.17], p = .003).

LINKING EVIDENCE TO ACTION

Nurse-led telephone-based interventions focused on reducing glycosylated hemoglobin levels in people with type 2 diabetes can be used as an effective intervention to achieve glycemic control. We recommend holding an average of 15-25 min interviews once or twice a week.

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.

Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with type 2 diabetes: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Digital health interventions have shown promising results for the management of type 2 diabetes, but a comparison of the effectiveness and implementation of the different modes is not currently available. Therefore, this study aimed to compare the effectiveness of SMS, smartphone application, and website-based interventions on improving glycaemia in adults with type 2 diabetes and report on their reach, uptake, and feasibility.

METHODS

In this systematic review and meta-analysis, we searched CINAHL, Cochrane Central, Embase, MEDLINE, and PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) that examined the effectiveness of digital health interventions in reducing glycated haemoglobin A1c (HbA1c) in adults with type 2 diabetes, published in English from Jan 1, 2009. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint assessed was the change in the mean (and 95% CI) plasma concentration of HbA1c at 3 months or more. Cochrane risk of bias 2 was used to assess risk of bias. Data on reach, uptake, and feasibility were summarised narratively and data on HbA1c reduction were synthesised in a meta-analysis. Grading of Recommendations, Assessment, Development, and Evaluation criteria was used to evaluate the level of evidence. The study was registered with PROSPERO, CRD42021247845.

FINDINGS

Of the 3236 records identified, 56 RCTs from 24 regions (n=11 486 participants), were included in the narrative synthesis, and 26 studies (n=4546 participants) in the meta-analysis. 20 studies used SMS as the primary mode of delivery of the digital health intervention, 25 used smartphone applications, and 11 implemented interventions via websites. Smartphone application interventions reported higher reach compared with SMS and website-based interventions, but website-based interventions reported higher uptake compared with SMS and smartphone application interventions. Effective interventions, in general, included people with greater severity of their condition at baseline (ie, higher HbA1c) and administration of a higher dose intensity of the intervention, such as more frequent use of smartphone applications. Overall, digital health intervention group participants had a -0·30 (95% CI -0·42 to -0·19) percentage point greater reduction in HbA1c, compared with control group participants. The difference in HbA1c reduction between groups was statistically significant when interventions were delivered through smartphone applications (-0·42% [-0·63 to -0·20]) and via SMS (-0·37% [-0·57 to -0·17]), but not when delivered via websites (-0·09% [-0·64 to 0·46]). Due to the considerable heterogeneity between included studies, the level of evidence was moderate overall.

INTERPRETATION

Smartphone application and SMS interventions, but not website-based interventions, were associated with better glycaemic control. However, the studies' heterogeneity should be recognised. Considering that both smartphone application and SMS interventions are effective for diabetes management, clinicians should consider factors such as reach, uptake, patient preference, and context of the intervention when deciding on the mode of delivery of the intervention. Nine in ten people worldwide own a feature phone and can receive SMS and four in five people have access to a smartphone, with numerous smartphone applications being available for diabetes management. Clinicians should familiarise themselves with this modality of programme delivery and encourage people with type 2 diabetes to use evidence-based applications for improving their self-management of diabetes. Future research needs to describe in detail the mediators and moderators of the effectiveness and implementation of SMS and smartphone application interventions, such as the optimal dose, frequency, timing, user interface, and communication mode to both further improve their effectiveness and to increase their reach, uptake, and feasibility.

FUNDING

EU's Horizon 2020 Research and Innovation Programme.

A Meta-Analysis of eHealth Interventions on Ischaemic Heart Disease Health Outcomes

Background

Electronic Health (eHealth) interventions as a secondary prevention tool to empower patients' health in decision-making and behaviour.

Objective

With the growing body of evidence supporting the use of eHealth interventions, the intention is to conduct a meta-analysis on various health outcomes of eHealth interventions among ischaemic heart disease (IHD) patients.

Methods

Based on PRISMA guidelines, eligible studies were searched through databases of Web of Science, Scopus, PubMed, EBSCOHost, and SAGE (PROSPERO registration CRD42021290091). Inclusion criteria were English language and randomised controlled trials published between 2011 to 2021 exploring health outcomes that empower IHD patients with eHealth interventions. RevMan 5.4 was utilised for meta-analysis, sensitivity analysis, and risk of bias (RoB) assessment while GRADE software for generating findings of physical health outcomes. Non-physical health outcomes were analysed using SWiM (synthesis without meta-analysis) method.

Results

This review included 10 studies, whereby, six studies with 895 participants' data were pooled for physical health outcomes. Overall, the RoB varied significantly across domains, with the majority was low risks, a substantial proportion of high risks and a sizeable proportion of unclear. With GRADE evidence of moderate to high quality, eHealth interventions improved low density lipoprotien (LDL) levels in IHD patients when compared to usual care after 12 months of interventions (SMD -0.26, 95% CI [-0.45, -0.06], I² = 0%, p = 0.01). Significance appraisal in each domain of the non-physical health outcomes found significant findings for medication adherence, physical activity and dietary behaviour, while half of the non-significant findings were found for other behavioural outcomes, psychological and quality of life.

Conclusions

Electronic Health interventions are found effective at lowering LDL cholesterol in long-term but benefits remain inconclusive for other physical and non-physical health outcomes for IHD patients. Integrating sustainable patient empowerment strategies with the advancement of eHealth interventions by utilising appropriate frameworks is recommended for future research.

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.

Clinical and patient-centered implementation outcomes of mHealth interventions for type 2 diabetes in low-and-middle income countries: a systematic review

BACKGROUND

The prevalence of Type 2 Diabetes is rising in Low- and Middle-Income Countries (LMICs), affecting all age categories and resulting in huge socioeconomic implications. Mobile health (mHealth) is a potential high-impact approach to improve clinical and patient-centered outcomes despite the barriers of cost, language, literacy, and internet connectivity. Therefore, it is valuable to examine the clinical and implementation outcomes of mHealth interventions for Type 2 Diabetes in LMICs.

METHODS

The Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines were applied in framing and reporting the review criteria. A systematic search of Cochrane Library, Web of Science, PubMed, Scopus, and Ovid databases was performed through a combination of search terms. Randomized Controlled Trials (RCTs) and cohort studies published in English between January 2010 and August 2021 were included. Risk of bias for missing results in the included studies was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2). Quantitative and qualitative methods were used to synthesize the results.

RESULTS

The search identified a total of 1161 articles. Thirty studies from 14 LMICs met the eligibility criteria. On clinical outcomes, 12 and 9 studies reported on glycated hemoglobin (HbA1c )and fasting blood glucose (FBG) respectively. Text messages was the most commonly applied mHealth approach, used in 19 out of the 30 studies. Ten out of the 12 studies (83.3%) that reported on HbA1c had a percentage difference of <0.3% between the mHealth intervention and the comparison group. Additionally, studies with longer intervention periods had higher effect size and percentage difference on HbA1c (1.52 to 2.92%). Patient-centred implementation outcomes were reported variedly, where feasibility was reported in all studies. Acceptability was reported in nine studies, appropriateness in six studies and cost in four studies. mHealth evidence reporting and assessment (mERA) guidelines were not applied in all the studies in this review.   CONCLUSION: mHealth interventions in LMICs are associated with clinically significant effectiveness on HbA1 but have low effectiveness on FBG. The application of mERA guidelines may standardize reporting of patient-centered implementation outcomes in LMICs.

TRIAL REGISTRATION

PROSPERO: Registration ID 154209.

The Effectiveness of Telemedicine Solutions for the Management of Type 2 Diabetes: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

Previous systematic reviews have aimed to clarify the effect of telemedicine on diabetes. However, such reviews often have a narrow focus, which calls for a more comprehensive systematic review within the field. Hence, the objective of the present systematic review, meta-analysis, and meta-regression is to evaluate the effectiveness of telemedicine solutions versus any comparator without the use of telemedicine on diabetes-related outcomes among adult patients with type 2 diabetes (T2D).

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We considered telemedicine randomized controlled trials (RCT) including adults (≥18 years) diagnosed with T2D. Change in glycated hemoglobin (HbA1c, %) was the primary outcome. PubMed, EMBASE, and the Cochrane Library Central Register of Controlled Trials (CENTRAL) were searched on October 14, 2020. An overall treatment effect was estimated using a meta-analysis performed on the pool of included studies based on the mean difference (MD). The revised Cochrane risk-of-bias tool was applied and the certainty of evidence was graded using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

The final sample of papers included a total of 246, of which 168 had sufficient information to calculate the effect of HbA1c%. The results favored telemedicine, with an MD of -0.415% (95% confidence interval [CI] = -0.482% to -0.348%). The heterogeneity was great (I² = 93.05%). A monitoring component gave rise to the higher effects of telemedicine.

CONCLUSIONS

In conclusion, telemedicine may serve as a valuable supplement to usual care for patients with T2D. The inclusion of a telemonitoring component seems to increase the effect of telemedicine.

Behavior change interventions in patients with type 2 diabetes: a systematic review of the effects on self-management and A1c

PURPOSE

This study aimed to identify the characteristics of interventions employed to promote behavior change in people with type 2 diabetes mellitus (T2DM) and their impact on disease self-management and glycated hemoglobin (A1c).

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to guide the protocol development for this systematic review. Randomized controlled clinical trials which compared behavior change interventions to controls in adults with T2DM and investigated disease self-management and glycated hemoglobin (A1c) measured by validated methods were eligible for this study. The risk of bias and quality of evidence was assessed respectively by Cochrane's tool and grading of recommendations, assessment, development, and evaluation (GRADE).

RESULTS

A total of 27 studies were included involving 4464 participants. Behavior change was mainly promoted by education sessions on diabetes care delivered face-to-face, monthly, or every other month, lasting more than 60 min, involving blood glucose monitoring, healthy eating, exercise, and medication. Four studies showed significant improvement in both disease self-management and A1c. The risk of bias was classified as high in most studies. A meta-analysis could not be performed for A1c and self-management due to the high differences in intervention parameters (delivery mode, number, duration, and frequency) and self-management assessments.

CONCLUSION

Low evidence of improvement in disease self-management and A1c considering only validated assessment methods were found for behavior change interventions, mainly promoted by education sessions on diabetes care. The quality of studies and probably the differences in intervention protocols contributed to this finding.

PROSPERO NUMBER

CRD42020161162.

Health education interventions to promote health literacy in adults with selected non-communicable diseases living in low-to-middle income countries: A systematic review and meta-analysis

RATIONALE, AIMS AND OBJECTIVES

Health illiteracy is an important contributor to the burden of non-communicable diseases (NCDs); in particular in settings where health illiteracy is part of a perpetuating system of risk factors. Interventions that promote health literacy may provide an important tool in the primary and secondary prevention of NCDs. The objective of this systematic review was to evaluate the effectiveness of health literacy interventions on health literacy in the management of patients with selected NCDs living in low-to-middle income countries (LMIC).

METHODS

Seven electronic databases were searched (October 29, 2020) for RCTs aimed at improving health literacy in adults with NCDs in LMICs. Eligible NCDs included those pertaining to cancer, cardiovascular disease (CVD), chronic respiratory disease (CRD) or Diabetes. Studies were included that explicitly focussed on improving health literacy, and reported comprehensive measures of health literacy, or components thereof (ie, knowledge, attitude or behaviour). Random-effect meta-analyses were conducted for continuous outcome measures (Hedges-g).

RESULTS

The completed search yielded 2573 unique results of which 53 unique studies met the inclusion criteria. Studies included patients with cancer (n = 1, 2%), CRD (n = 8, 15%), CVD (n = 11, 21%) or Diabetes (n = 33, 62%). A significant (P < .01) summary effect was found for disease knowledge (SES = 1.27 [n = 23, 95%CI = 1.05-1.49]), attitude (SES = 1.17 [n = 20, 95%CI = 0.88-1.47]), and behaviour (SES = 1.20 [n = 31, 95%CI = 0.94-1.46]).

CONCLUSIONS

These results support the conclusion that there is compelling evidence, in particular, for patients with Diabetes, that health-literacy interventions are effective in promoting disease knowledge, attitude and behaviour across four chronic conditions that drive the burden of NCDs.

Digital interventions self-management education for type 1 and 2 diabetes: A systematic review and meta-analysis

OBJECTIVE

To describe and assess digital health-led diabetes self-management education and support (DSMES) effectiveness in improving glycosylated hemoglobin, diabetes knowledge, and health-related quality of life (HrQoL) of Type 1 and 2 Diabetes in the past 10 years.

DESIGN

Systematic Review and Meta-Analysis. The protocol was registered on PROSPERO registration number CRD42019139884.

DATA SOURCES

PubMed, EMBASE, Cochrane library, Web of Science, and Scopus between January 2010 and August 2019. Study Selection and Appraisal: Randomized control trials of digital health-led DSMES for Type 1 (T1DM) or 2 (T2DM) diabetes compared to usual care were included. Outcomes were change in HbA1c, diabetes knowledge, and HrQoL. Cochrane Risk of Bias 2.0 tool was used to assess bias and GRADEpro for overall quality. The analysis involved narrative synthesis, subgroup and pooled meta-analyses.

RESULTS

From 4286 articles, 39 studies (6861 participants) were included. Mean age was 51.62 years, range (13-70). Meta-analysis revealed intervention effects on HbA1c for T2DM with difference in means (MD) from baseline -0.480% (-0.661, -0.299), I²75% (6 months), -0.457% (-0.761, -0.151), I² 81% (12 months), and for T1DM -0.41% (-1.022, 0.208) I² 83% (6 months), -0.03% (-0.210, 0.142) I² 0% (12 months). Few reported HrQoL with Hedges' g 0.183 (-0.039, 0.405), I² 0% (6 months), 0.153 (-0.060, 0.366), I² 0% (12 months) and diabetes knowledge with Hedges' g 1.003 (0.068, 1.938), I² 87% (3 months).

CONCLUSION

Digital health-led DSMES are effective in improving HbA1c and diabetes knowledge, notably for T2DM. Research shows non-significant changes in HrQoL. Intervention effect on HbA1c was more impressive if delivered through mobile apps or patient portals. Further research is needed on the impact of DSMES on these outcomes, especially for newly diagnosed diabetes patients.

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.

Effect of implementing a mobile game on improving dietary information in diabetic patients

Background: Nowadays, digital games are not just entertainment, but beside routine treatments, they are used in patient care, especially in patients with diabetes. Application of digital games in patient's education can improve self-management of diabetes. The aim of the present study was to evaluate the effect of a mobile game (Amoo) implementation on enhancing dietary information in patients with type 2 diabetes. Methods: A mobile game (called Amoo), which was developed by researchers of this study, was applied to assess the self-education of patients with diabetes. Sixty patients with type 2 diabetes participated in the study. The participants took part in a pre-intervention test to determine their dietary information. The participants were randomly divided into one of two groups, including the intervention group: played the game for 15 minutes daily for 6 weeks, and the control group: did not involve in the game. A post-intervention test was run to show a possible improvement in dietary information. Data were analyzed using paired t test and suitable non-parametric testes including Mann-Whitney and Wilcoxon signed rank tests as well as Spearman and Pearson correlation coefficients via IBM SPSS statistics version 21 (SPSS, v 21.0, IBM, Armonk, NY, USA). A P-value less than 0.05 was considered as a significant level. Results: The results indicated a statistically significant difference between the pre and post test scores in the intervention group (p<0.001). However, there was no significant difference in fasting blood sugar (p=0.125). Conclusion: The mobile game (Amoo) could enhance the knowledge of patients with type 2 diabetes about food calories and glycemic index. This means that mobile games may serve as an educational aid to these patients.

Effectiveness of eHealth Nutritional Interventions for Middle-Aged and Older Adults: Systematic Review and Meta-analysis

BACKGROUND

The risk of development of chronic diseases related to poor nutrition increases with age. In the face of an aging population, it is important for health care sectors to find solutions in delivering health services efficiently and effectively to middle-aged and older adults.

OBJECTIVE

The aim of this systematic review and meta-analysis was to consolidate the literature that reported the effectiveness of eHealth apps in delivering nutritional interventions for middle-aged and older adults.

METHODS

A literature search from five databases (PubMed, CINAHL, Cochrane, Web of Science, and Global Health) from the past 5 years was performed. Studies were selected for inclusion that used eHealth to deliver nutritional interventions to adults aged 40 years and above, and reported health and behavioral outcomes. Two independent reviewers searched for research articles and assessed the eligibility of studies to be included in the review. A third reviewer resolved disagreements on study inclusion. We also assessed the quality of the included studies using the CONSORT 2010 checklist.

RESULTS

A total of 70 studies were included for analysis. The study quality ranged from 44% to 85%. The most commonly used eHealth intervention type was mobile apps (22/70, 31%). The majority of studies (62/70, 89%) provided multicomponent health interventions, which aimed to improve nutrition and other health behaviors (eg, exercise, smoking cessation, medication adherence). Meta-analysis results indicated high and significant heterogeneity; hence, conclusions based on these results should be considered with caution. Nonetheless, the results generally showed that eHealth interventions improved anthropometric and clinical outcomes, but not behavioral outcomes such as fruit and vegetable consumption.

CONCLUSIONS

The use of eHealth apps to deliver health interventions has been increasing in recent years, and these apps have the potential to deliver health services to a larger group of people. Our findings showed that the effectiveness of eHealth apps to deliver health interventions for middle-aged to older adults was supported by the improvement of anthropometric and clinical outcomes. Future work could aim to develop research frameworks in administering eHealth interventions to address heterogeneity in this field of research.

Application of the National Institute for Health and Care Excellence Evidence Standards Framework for Digital Health Technologies in Assessing Mobile-Delivered Technologies for the Self-Management of Type 2 Diabetes Mellitus: Scoping Review

BACKGROUND

There is a growing role of digital health technologies (DHTs) in the management of chronic health conditions, specifically type 2 diabetes. It is increasingly important that health technologies meet the evidence standards for health care settings. In 2019, the National Institute for Health and Care Excellence (NICE) published the NICE Evidence Standards Framework for DHTs. This provides guidance for evaluating the effectiveness and economic value of DHTs in health care settings in the United Kingdom.

OBJECTIVE

The aim of this study is to assess whether scientific articles on DHTs for the self-management of type 2 diabetes mellitus report the evidence suggested for implementation in clinical practice, as described in the NICE Evidence Standards Framework for DHTs.

METHODS

We performed a scoping review of published articles and searched 5 databases to identify systematic reviews and primary studies of mobile device-delivered DHTs that provide self-management support for adults with type 2 diabetes mellitus. The evidence reported within articles was assessed against standards described in the NICE framework.

RESULTS

The database search yielded 715 systematic reviews, of which, 45 were relevant and together included 59 eligible primary studies. Within these, there were 39 unique technologies. Using the NICE framework, 13 technologies met best practice standards, 3 met minimum standards only, and 23 technologies did not meet minimum standards.

CONCLUSIONS

On the assessment of peer-reviewed publications, over half of the identified DHTs did not appear to meet the minimum evidence standards recommended by the NICE framework. The most common reasons for studies of DHTs not meeting these evidence standards included the absence of a comparator group, no previous justification of sample size, no measurable improvement in condition-related outcomes, and a lack of statistical data analysis. This report provides information that will enable researchers and digital health developers to address these limitations when designing, delivering, and reporting digital health technology research in the future.

Identifying features of a mobile-based application for self-care of people living with T2DM

INTRODUCTION

Diabetes self-care requires support to empower patients to improve self-monitoring and maintain the necessary self-care behaviors. We aimed to identify features of a mobile-based application as a technology-based device for self-care of people living with T2DM.

METHOD

This study was conducted in two main phases in 2020. In the first phase, a literature review study was performed to identify the data elements and technical features of the T2DM self-care application. In the second phase, using the information obtained from the review of similar articles, a questionnaire was designed to validate identified requirements. The statistical population of the present study consisted of 22 endocrinologists and metabolic specialists.

RESULTS

Identification of 55 data elements and technical features for mobile-based self-care application for people with T2DM, and according to the statistical population, 15data elements for demographic requirements, 16 data elements for clinical requirements, and 17 features for the technical capability of this app were selected.

CONCLUSION

Blood sugar monitoring, exercise, nutrition, weight monitoring, and educational capabilities were the most highlighted technical features of the T2DM self-care application. Software designers can use these requirements to design a self-care app for people with type-2 diabetes that can help manage and improve patients' health status.

Self-care, A1C and stigmatization as predictors of a negative perception of insulin among adults with type 2 diabetes: a hospital-based study in Turkey

Purpose

The purpose of this study was to investigate diabetes self-care behaviors, stigmatization and A1C as predictors of a negative perception of insulin treatment in insulin-treated type 2 diabetic patients.

Design/methodology/approach

A descriptive cross-sectional and relational design was used. The study was carried out in the Diabetes Training Centre and Endocrine and Metabolism Clinic of a university hospital in the southeast of Turkey between May and October 2017. The research sample consisted of 100 type 2 diabetic patients determined by using a convenience sampling method. An introductory information form for type 2 diabetic patients, the Insulin Treatment Appraisal Scale (ITAS), Diabetes Self-Care Activities Survey (DSCAS) and Barriers to Insulin Treatment Scale (BIT) were used to collect the research data. The data were analyzed using descriptive statistics, correlations and step wise multi-linear regression.

Findings

The number of daily insulin injections, training received about insulin and stigmatization was significant predictors of a negative perception of insulin treatment.

Originality/value

Strategies to decrease diabetic individuals' fear of stigmatization should be utilized to minimize their negative insulin treatment perception (giving diabetic individuals training about diabetes, planning public training to inform society and using mass media tools). Diabetes educators should know that diabetic individuals' perception of the severity of the illness could influence the daily number of injections applied and decrease the negative perception regarding insulin.

Telemedicine to deliver diabetes care in low- and middle-income countries: a systematic review and meta-analysis

Objective

To determine the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries.

Methods

We searched seven databases up to July 2020 for randomized controlled trials investigating the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries. We extracted data on the study characteristics, primary end-points and effect sizes of outcomes. Using random effects analyses, we ran a series of meta-analyses for both biochemical outcomes and related patient properties.

Findings

We included 31 interventions in our meta-analysis. We observed significant standardized mean differences of −0.38 for glycated haemoglobin (95% confidence interval, CI: −0.52 to −0.23; I² = 86.70%), −0.20 for fasting blood sugar (95% CI: −0.32 to −0.08; I² = 64.28%), 0.81 for adherence to treatment (95% CI: 0.19 to 1.42; I² = 93.75%), 0.55 for diabetes knowledge (95% CI: −0.10 to 1.20; I² = 92.65%) and 1.68 for self-efficacy (95% CI: 1.06 to 2.30; I² = 97.15%). We observed no significant treatment effects for other outcomes, with standardized mean differences of −0.04 for body mass index (95% CI: −0.13 to 0.05; I² = 35.94%), −0.06 for total cholesterol (95% CI: −0.16 to 0.04; I² = 59.93%) and −0.02 for triglycerides (95% CI: −0.12 to 0.09; I² = 0%). Interventions via telephone and short message service yielded the highest treatment effects compared with services based on telemetry and smartphone applications.

Conclusion

Although we determined that telemedicine is effective in improving several diabetes-related outcomes, the certainty of evidence was very low due to substantial heterogeneity and risk of bias.

The effect of diabetes education and short message service reminders on metabolic control and disease management in patients with type 2 diabetes mellitus

AIM

The aim of this study was to evaluate the effect of diabetes education and short message service reminders on metabolic control and disease management in patients with type 2 diabetes mellitus who were registered in a family health center and who were using oral antidiabetics.

METHODS

This pre-test and post-test control group interventional study was conducted between 2017 and 2019. For one-way analysis of variance, effect size=0.40, α=0.05 and 80% power for each group was considered to be appropriate for 48 participants. Considering probability of losses during the study, 101 patients with type-2 DM were selected to include in the study. At the beginning of the study of all the patients, metabolic (HbA1c, FBS, triglycerides, cholesterol, HDL, LDL), anthropometric (BMI), blood pressure (BP) and scales assessments were performed. The Follow-Up Form for Patients with Diabetes, Diabetes Self-Care Scale (DSCS) and World Health Organization (WHO) (5) Goodness Scale were used as data collection tools. In the study, the structured group-based education program consisting of five modules was given to the intervention group in two sessions. Immediately after the education program, short message reminders about diabetes management were sent twice a week for a six-month period to intervention group. During the study, each group was invited to the family health center to perform the third- and sixth-month evaluations. Data were analyzed by SPSS version 19. In the study, categorical variables were evaluated with Chi-squared test. The differences of the groups over time were evaluated using the Friedman test and binary comparisons of differences by Wilcoxon test. The changes among groups over time were evaluated by Mann-Whitney test.

RESULTS

In the evaluations for the third and sixth months, it was found that there was a statistically significant difference between the intervention and control groups in terms of HbA1c, fasting blood sugar, lipid values (except triglycerides), blood pressure, body mass index and the scales results (p<0.001).

CONCLUSION

Diabetes education and SMS reminders sent for six months were effective in improving metabolic control and disease management in patients with type 2 diabetes mellitus.

Effectiveness of short message service intervention to improve glycated hemoglobin control and medication adherence in type-2 diabetes: A meta-analysis of prospective studies

BACKGROUND

Distance education or reminder by texting short message may improve HbA1c level and medication adherence to type-2 diabetes.

METHODS

Electronic databases (PubMed, EBSCO, Elsevier, Springer, Wiley, and Cochrane) were searched systematically for published studies up to Mar 2019. SMD and 95% confidence interval (CI) were used to evaluate the intervention effect on HbA1c level and medication adherence. The heterogeneity of the study was estimated with the I2 statistic. The publication bias was described by Beggs' test, Egger's test and plot.

RESULTS

Ten studies with 380 interventions and 275 controls were included in this meta-analysis. The Hba1c overall SMD was -0.49%, 95% CI -0.75 to 0.22%, and the overall SMD was 0.96%, 95% CI 0.45-1.47 for medication adherence. The I² and P were 64.90%, 0.002 and 56.40%, 0.10 respectively for Hba1c level and medication adherence.

CONCLUSION

SMS intervention was effective for HbA1c level and medication adherence according to this study for T2DM over first 6 months.

The role of text messaging intervention in Inner Mongolia among patients with type 2 diabetes mellitus: a randomized controlled trial

Background

Short messages service (SMS) provides a practical medium for delivering content to address patients to adherence to self-management. The aim of study was to design some patient-centered health education messages, evaluate the feasibility of messages, and explore the effect of this model.

Methods

The messages were designed by a panel of experts, and SMS Quality Evaluation Questionnaire was used to evaluate their quality. A two-arm randomized controlled trial was conducted to evaluate the effectiveness of this management model. Participants were randomly divided into an intervention group (IG) who received evaluated messages and a control group (CG) who received regular education. The primary outcomes were changes in plasma glucose and control rates, and the secondary outcomes were improvements in diet control, physical activities, weight control, etc.

Results

A total of 42 messages covering five main domains: health awareness, diet control, physical activities, living habits and weight control were designed, and the average scores of the messages were 8.0 (SD 0.7), 8.5 (SD 0.6), 7.9 (SD 1.0), 8.0 (SD 0.7), and 8.4 (SD 0.9), respectively. In the SMS intervention, 171 patients with an average age of 55.1 years were involved, including 86 in the CG and 85 in the IG. At 12 months, compared with the control group (CG), the decrease of fasting plasma glucose (FPG) (1.5 vs. 0.4, P = 0.011) and control rate (49.4% vs. 33.3%, P = 0.034), the postprandial glucose (PPG) (5.8 vs. 4.2, P = 0.009) and control rate (57.8% vs. 33.7%, P = 0.002) were better in the intervention group (IG). In terms of self-management, improvements in weight control (49.3% vs. 28.2%, P = 0.031), vegetables consumption (87.3% vs. 29.0%, P < 0.001), fruits consumption (27.5% vs. 7.4%, P = 0.022), and physical activities (84.7% vs. 70.0%, P = 0.036) were better in the IG than in the CG.

Conclusions

The overall quality of the messages was high. It was effective and feasible to carry out an SMS intervention to improve the behavioral habits of patients with chronic diseases in remote and undeveloped areas.

Trial registration

Clinicaltrials.gov, ChiCTR1900023445. Registered May 28, 2019--Retrospectively registered.

Implementation barriers for mHealth for non-communicable diseases management in low and middle income countries: a scoping review and field-based views from implementers

Background: Mobile health (mHealth) has been hailed as a potential gamechanger for non-communicable disease (NCD) management, especially in low- and middle-income countries (LMIC). Individual studies illustrate barriers to implementation and scale-up, but an overview of implementation issues for NCD mHealth interventions in LMIC is lacking. This paper explores implementation issues from two perspectives: information in published papers and field-based knowledge by people working in this field. Methods: Through a scoping review publications on mHealth interventions for NCDs in LMIC were identified and assessed with the WHO mHealth Evidence Reporting and Assessment (mERA) tool. A two-stage web-based survey on implementation barriers was performed within a NCD research network and through two online platforms on mHealth targeting researchers and implementors. Results: 16 studies were included in the scoping review. Short Message Service (SMS) messaging was the main implementation tool. Most studies focused on patient-centered outcomes. Most studies did not report on process measures and on contextual conditions influencing implementation decisions. Few publications reported on implementation barriers. The websurvey included twelve projects and the responses revealed additional information, especially on practical barriers related to the patients' characteristics, low demand, technical requirements, integration with health services and with the wider context. Many interventions used low-cost software and devices with limited capacity that not allowed linkage with routine data or patient records, which incurred fragmented delivery and increased workload. Conclusion: Text messaging is a dominant mHealth tool for patient-directed of quality improvement interventions in LMIC. Publications report little on implementation barriers, while a questionnaire among implementors reveals significant barriers and strategies to address them. This information is relevant for decisions on scale-up of mHealth in the domain of NCD. Further knowledge should be gathered on implementation issues, and the conditions that allow universal coverage.

Implementation barriers for mHealth for non-communicable diseases prevention and management in low and middle income countries: a scoping review and field-based views from implementers

Background: Mobile health (mHealth) has been hailed as a potential gamechanger for non-communicable disease (NCD) management, especially in low- and middle-income countries (LMICs). Individual studies illustrate barriers to implementation and scale-up, but an overview of implementation issues for NCD mHealth interventions in LMICs is lacking. This paper explores implementation issues from two perspectives: information in published papers and field-based knowledge by people working in this field. Methods: Through a scoping review publications on mHealth interventions for NCDs in LMICs were identified and assessed with the WHO mHealth Evidence Reporting and Assessment (mERA) tool. A two-stage web-based survey on implementation barriers was performed within a NCD research network and through two online platforms on mHealth targeting researchers and implementors. Results: 18 studies were included in the scoping review. Short Message Service (SMS) messaging was the main implementation tool. Most studies focused on patient-centered outcomes. Most studies do not report on process measures and on contextual conditions influencing implementation decisions. Few publications reported on implementation barriers. The websurvey included twelve projects and the responses revealed additional information, especially on practical barriers related to the patients' characteristics, low demand, technical requirements, integration with health services and with the wider context. Many interventions used low-cost software and devices with limited capacity that not allowing linkage with routine data or patient records, which incurred fragmented delivery and increased workload. Conclusion: Text messaging is a dominant mHealth tool for patient-directed of quality improvement interventions in LMICs. Publications report little on implementation barriers, while a questionnaire among implementors reveals significant barriers and strategies to address them. This information is relevant for decisions on scale-up of mHealth in the domain of NCD. Further knowledge should be gathered on implementation issues, and the conditions that allow universal coverage.

Effect of Training through Short Message Service on Compliance and Mean Blood Pressure of Hypertensive Patients

Background:

Hypertension has been one of the early mortality and morbidity in human societies. Training and consequently compliance increase will lead to improve treatment progress and disease control. The study aimed at the effect of training through short message service (SMS) on blood pressure mean and compliance scale in hypertensive patients. Hypertension control is essential to prevent early mortality.

Methods:

This study is a randomized controlled clinical, uni-center, single-blinded. The study was managed in a health-care center subordinated to Medical University of Isfahan, Iran, in 2017. Sampling was a convenient method therefore the researchers implemented it for 188 hypertensive patients who were allocated randomly into two groups: SMS group and control group. First, all patients filled the compliance questionnaire, and their blood pressure was measured. Afterward, the intervention group would be texting daily for 1 month containing a training text. During 1 and 2 months after intervention, all patients’ blood pressure will be measured, and then the questionnaire had been filled 2 months after intervention, again.

Results:

Systolic blood pressure mean decreased from 136.23 ± 15.91 to 121.70 ± 14.43 and diastolic blood pressure mean decreased from 91.95 ± 8.24 to 86.64 ± 7.86 in the intervention group according to analysis of variance through repeated measurement and is significantly different in comparison with control group (P < 0.001). Compliance scale increased from 72.95 ± 7.65 to 85.40 ± 5.62 based on dependent t-test which was significantly different with the control group (P < 0.001).

Conclusions:

SMS training would be an effective method to control hypertension.

Self-management of non-communicable diseases in low- and middle-income countries: A scoping review

Background

The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries (LMICs). Self-management, which enables patients to better manage their health, presents a potentially-scalable means of mitigating the growing burden of NCDs in LMICs. Though the effectiveness of self-management interventions in high-income countries is well-documented, the use of these strategies in LMICs has yet to be thoroughly summarized.

Objective

The purpose of this scoping review is to summarize the nature and effectiveness of past interventions that have enabled the self-management of NCDs in LMICs.

Methods

Using the scoping review methodology proposed by Arksey and O’Malley, PubMed was searched for relevant articles published between January 2007 and December 2018. The implemented search strategy comprised three major themes: self-management, NCDs and LMICs.

Results

Thirty-six original research articles were selected for inclusion. The selected studies largely focused on the self-management of diabetes (N = 21), hypertension (N = 7) and heart failure (N = 5). Most interventions involved the use of short message service (SMS, N = 17) or phone calls (N = 12), while others incorporated educational sessions (N = 10) or the deployment of medical devices (N = 4). The interventions were generally effective and often led to improvements in physiologic indicators, patient self-care and/or patient quality of life. However, the studies emphasized results in small populations, with little indication of future scaling of the intervention. Furthermore, the results indicate a need for further research into the self-management of cardiovascular diseases, as well as for the co-management of diabetes and cardiovascular disease.

Conclusions

Self-management appears to be an effective means of improving health outcomes in LMICs. Future strategies should include patients and clinicians in all stages of design and development, allowing for a focus on long-term sustainability, scalability and interoperability of the intervention in the target setting.

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

BACKGROUND

Mobile health is the use of mobile technology in developing healthcare, with the aim of reminding and motivating patients to adopt a healthy lifestyle. We conducted a systematic review assessing the effectiveness of text-messaging interventions on HbA1c in patients with Type 2 diabetes mellitus (T2DM).

METHODS

Two authors independently searched MEDLINE, Embase, CINAHL, Cochrane Register of Randomized Control Trials and PsychInfo. The review included randomized control trials with at least 4 weeks follow up, evaluating the effect of text messaging on HbA1c, in patients with T2DM. Trials involving participants with Type 1 diabetes mellitus, pre-diabetes or gestational diabetes, or other forms of telemedicine were excluded. Studies employing bi-directional messaging were excluded.

RESULTS

208 papers were identified as meeting inclusion criteria and their abstracts reviewed. Of these, we examined the full text article of forty-four studies. Eleven randomized controlled trials were included in the final review, with a total of 1710 participants. One study focused on medication adherence only, while the remaining had educational and motivational messages. Five studies showed a significant improvement in HbA1c with the intervention. The remaining studies demonstrated a trend to improvement in HbA1c. Our meta-analysis on 9 of the 11 studies found an overall reduction in HbA1c of 0.38% (-0.53; -0.23, p-value <0.001).

CONCLUSION

Lifestyle-focused text messaging is a low cost initiative aimed at motivating patients with T2DM to adhere to a healthy lifestyle. We demonstrate that lifestyle focused text messaging is effective, with a significant improvement in HbA1c in the meta-analysis.

Perceptions and Acceptability of Text Messaging for Diabetes Care in Primary Care in Argentina: Exploratory Study

Background

Engagement in self-care behaviors that are essential to optimize diabetes care is challenging for many patients with diabetes. mHealth interventions have been shown to be effective in improving health care outcomes in diabetes. However, more research is needed on patient perceptions to support these interventions, especially in resource settings in low- and middle-income countries.

Objective

The goal of the research was to explore perceptions and acceptability of a short message service (SMS) text messaging intervention for diabetes care in underserved people with diabetes in Argentina.

Methods

A qualitative exploratory methodology was adopted as part of the evaluation of a program to strengthen diabetes services in primary care clinics located in low-resource settings. The diabetes program included a text messaging intervention for people with diabetes. A total of 24 semistructured telephone interviews were conducted with people with diabetes.

Results

Twenty-four middle-aged persons with diabetes were interviewed. Acceptability was considered adequate in terms of its actual use, frequency, and the role of texts as a reminder. We found that text messages could be a mediating device in the patient’s learning processes. Also, being exposed to the texts seemed to help bring about changes in risk perception and care practices and to function as psychosocial support. Another relevant finding was the role of text messaging as a potential facilitator in diabetes care. In this sense, we observed a strong association between receiving text messages and having a better patient-physician relationship. Additionally, social barriers that affect diabetes care such as socioeconomic and psychosocial vulnerability were identified.

Conclusions

Our findings show positive contributions of a text messaging intervention for the care of people with diabetes. We consider that an SMS strategy has potential to be replicated in other contexts. However, further studies are needed to explore its sustainability and long-term impact from the perspective of patients.

Cost-Effectiveness of a Technology-Enhanced Diabetes Care Management Program in Mexico

BACKGROUND

The prevalence of diabetes has increased substantially in Mexico over the last 40 years, leading to significant impacts on population health and the healthcare system. Technology-based solutions may improve diabetes outcomes in areas where lack of efficient transportation creates barriers to care.

OBJECTIVES

To estimate the lifetime cost-effectiveness of a technology-based diabetes care management program from the perspective of the Mexican healthcare system.

METHODS

Clinical outcomes and cost data from a 3-arm randomized clinical trial of Dulce Wireless Tijuana, a diabetes care management program incorporating short-term mobile technology, were used as inputs in a validated simulation model for type 2 diabetes. Study arms included a control group (CG), Project Dulce diabetes care management (PD), and Project Dulce with technology enhancement (PD-TE).

RESULTS

Intervention costs were $1448 for PD and $1740 for PD-TE compared with $740 for CG. Both intervention arms increased quality-adjusted life-years and costs. The incremental cost-effectiveness ratio for PD was $1635 and for PD-TE was $2220, both compared with CG. The incremental cost-effectiveness ratio for PD-TE versus PD was $4299. The results were sensitive to the time horizon. The PE and PD-TE interventions were cost-effective under time horizons of 15 to 20 years, but were not cost-effective under time horizons of 5 to 10 years.

CONCLUSIONS

Both the PD and PD-TE were highly cost-effective from a Mexican health system perspective. Considering the economic impact of the diabetes epidemic and the widespread use of cellular technology in Mexico, implementation of PD-TE is warranted.

Sociodemographic and clinical correlates of key outcomes from a Mobile Insulin Titration Intervention (MITI) for medically underserved patients

BACKGROUND

Insulin titration is typically done face-to-face with a clinician; however, this can be a burden for patients due to logistical issues associated with in-person clinical care. The Mobile Insulin Titration Intervention (MITI) used basic cell phone technology including text messages and phone calls to help patients with diabetes find their optimal basal insulin dose (OID).

OBJECTIVE

To evaluate sociodemographic and clinical correlates of reaching OID, text message response rate, and days needed to reach OID.

METHODS

Primary care providers referred patients to MITI and nurses delivered the program. Three multivariable regression models quantified relationships between various correlates and primary outcomes.

RESULTS

The sample included 113 patients from 2 ambulatory clinics, with a mean age of 50 years (SD = 10), 45% female, 79% Hispanic, 43% unemployed, and 46% uninsured. In regression models, baseline fasting blood glucose (FBG) was negatively associated with odds of reaching OID and 100% text responses, and positively associated with days to reach OID, p < .05).

CONCLUSIONS

Patients with higher baseline FBG levels were less successful across outcomes and may need additional supports in future mHealth diabetes programs.

PRACTICAL IMPLICATIONS

Basic cell phone technology can be used to adjust patients' insulin remotely, thereby reducing logistical barriers to care.

Short Message Service (SMS) e promoção do autocuidado em DM2: revisão integrativa

Resumo Objetivo: Sintetizar e analisar as evidências disponíveis na literatura científica sobre os efeitos do uso de Short Message Service (SMS) na promoção do autocuidado em diabetes mellitus tipo 2. Métodos: Foi desenvolvida uma revisão integrativa da literatura, no período de 2007 a 2017, utilizando para a busca dos estudos as seguintes bases de dados: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Scopus, Web of Science, Base de dados de enfermagem, Campus Virtual de Saúde Pública, Coleção Nacional das Fontes de Informação do Sistema Único de Saúde, Coordenadoria Regional de Saúde Sul, Índice Bibliográfico Español en Ciencias de la Salud (iBECS), Literatura Latino-Americana e do Caribe em Ciências da Saúde e PubMed. Para isso, utilizou-se descritores como: mensagem de texto, autocuidado, educação em saúde, promoção em saúde e diabetes mellitus, bem como os respectivos descritores em inglês e espanhol, e os Medical Subject Headings associados. Foi identificada uma amostra inicial de 739 artigos, dos quais 23 foram classificados como elegíveis para compor a amostra final. Resultados: Em geral, os trabalhos reportaram resultados positivos. Dentre estes, destacam-se: melhora significativa dos níveis de hemoglobina glicada, maior adesão aos medicamentos, melhora das práticas de autocuidado, aumento do conhecimento acerca do diabetes e melhor cuidado com os pés. Conclusão: Evidências científicas na literatura mostram que o uso de SMS como estratégia metodológica pode favorecer a melhora das práticas de autocuidado em diabetes tipo 2.

Effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life and clinical outcomes in patients with type 2 diabetes: A systematic review and meta-analysis

OBJECTIVES

To review the evidence and determine the effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life, glycated hemoglobin, body mass index (BMI), and blood pressure (BP) levels of adults with type 2 diabetes mellitus .

METHODS

A systematic search of five databases (PubMed, Embase, Cochrane, CINAHL and Scopus) was conducted. Studies published in English from January 2007 to January 2018 were considered. Only randomized controlled trials (RCTs) of smartphone-based self-management interventions for patients with type 2 diabetes mellitus that reported any of the study outcomes were included. Two reviewers independently screened the studies, extracted data and assessed the quality of the studies. Meta-analyses were conducted for the different study outcomes.

RESULTS

A total of 26 articles, consisting of 22 studies with 2645 participants, were included in the review. The results from meta-analysis on the studies revealed that as compared to control group, participants received smartphone-based self-management intervention had better self-efficacy with large effect size of 0.98 (P <  0.001), self-care activities with effect size of 0.90 (P <  0.001), health related quality of life with effect size of 0.26 (p=0.01), and lower glycated hemoglobin (pooled MD=-0.55; p<0.001). Subgroup analyses were also conducted for self-efficacy as significant heterogeneity was present among the studies. The effects on BMI and BP were not statistically significant.

CONCLUSIONS

Smartphone-based self-management interventions appear to have beneficial effects on self-efficacy, self-care activities and health-relevant outcomes for patients with type 2 diabetes mellitus. However, more research with good study design is needed to evaluate the effectiveness of smartphone-based self-care interventions for T2DM.

Tailored mobile text messaging interventions targeting type 2 diabetes self-management: A systematic review and a meta-analysis

OBJECTIVES

This study aimed to identify, assess and summarize available scientific evidence on tailored text messaging interventions focused on type 2 diabetes self-management. The systematic review concentrated on message design and delivery features, and tailoring strategies. The meta-analysis assessed the moderators of the effectiveness of tailored text messaging interventions.

METHODS

A comprehensive search strategy included major electronic databases, key journal searches and reference list searching for related studies. PRISMA and Cochrane Collaboration's guidelines and recommended tools for data extraction, quality appraisal and data analysis were followed. Data were extracted on participant characteristics (age, gender, ethnicity), and interventional and methodological characteristics (study design, study setting, study length, choice of modality, comparison group, message type, format, content, use of interactivity, message frequency, message timing, message delivery, tailoring strategies and theory use). Outcome measures included diet, physical activity, medication adherence and glycated hemoglobin data (HbA1C). Where possible, a random effects meta-analysis was performed to pool data on the effectiveness of the tailored text messaging interventions and moderator variables.

RESULTS

The search returned 13 eligible trials for the systematic review and 11 eligible trials for the meta-analysis. The majority of the studies were randomized controlled trials, conducted in high-income settings, used multi-modalities, and mostly delivered informative, educational messages through an automated message delivery system. Tailored text messaging interventions produced a substantial effect (g = 0.54, 95% CI = 0.08-0.99, p < 0.001) on HbA1C values for a total of 949 patients. Subgroup analyses revealed the importance of some moderators such as message delivery (Q B = 18.72, df = 1, p = 0.001), message direction (Q B = 5.26, df = 1, p = 0.022), message frequency (Q B = 18.72, df = 1, p = 0.000) and using multi-modalities (Q B = 6.18, df = 1, p = 0.013).

CONCLUSIONS

Tailored mobile text messaging interventions can improve glycemic control in type 2 diabetes patients. However, more rigorous interventions with larger samples and longer follow-ups are required to confirm these findings and explore the effects of tailored text messaging on other self-management outcomes.

Impact of Pharmacist-directed Counseling and Message Reminder Services on Medication Adherence and Clinical Outcomes in Type 2 Diabetes Mellitus

Introduction:

Medication nonadherence is the most common issue observed in the management of diabetes because of complex and lifelong therapy. The study aimed to assess the effect of pharmacist-directed counseling and daily text message reminder on medication adherence and clinical profile of patients with type II diabetes.

Materials and Methods:

This prospective, open-labeled, randomized control trial was carried out in outpatient medical department of a secondary care referral hospital. A total of 330 patients who met study criteria were enrolled and randomized into an intervention group (n = 165), received counseling and daily messages about medication intake and control group (n = 165), and usual care by physician. Medication adherence and clinical outcomes such as glycosylated hemoglobin (HbA1C), systolic blood pressure (SBP), low-density lipoprotein (LDL) cholesterol, triglyceride (TG) levels, and body mass index (BMI) were recorded at baseline and follow-up visits. Two-sample Wilcoxon rank sum test was used to compare the mean difference of medication adherence and paired t-test was used to compare clinical outcomes.

Results and Discussion:

The mean age of intervention and control groups were 57.1 ± 8.55 and 58.5 ± 8.53 years, respectively. The mean difference of medication adherence from baseline to second follow-up visit was significantly more in intervention group (12.2 ± 7.1%) compared to that in control group (0.75 ± 10.2 %) with a P < 0.001. From baseline to second follow-up visit, HbA1C (7.79 ± 0.67 to 6.91 ± 0.83 %), SBP (136.75 ± 20.09 to 126.23 ± 18.22 mm Hg), and LDL cholesterol (104.14 ± 26.23 to 98.29 ± 20.87 mg/dL) levels were significantly reduced in intervention group compared to that in control group with a P < 0.01. No significant improvement was observed in TG (169± 33.71 to 168 65 ± 33.90 mg/dL) and BMI (27.9 ± 4.21 to 27.1 ± 3.12 Kg/m²) levels from baseline to second follow-up visit.

Conclusion:

Pharmacist-directed patient counseling combined with message reminder showed a greater effect on the improvement of medication adherence and control of glycemia, blood pressure, and lipid profile in diabetes.

Using mHealth strategies in a Diabetes Management Program to improve the quality of care in Argentina: Study design and baseline data

AIM

To evaluate the one-year post effect of the implementation of a diabetes program that includes mHealth interventions on the quality of diabetic care in public primary care centers.

METHOD

It is a quasi-experimental study with outcome measurements at baseline, 6 and 12months. The program includes primary care team training, a diabetes registry with a decision support tool in an app. and text messages for patients.

RESULTS

At baseline, 947 patients were included in the registry, 62.3% women with a mean age of 53.6±11.5years and 92% with type 2 diabetes. Common comorbidities were hypertension (61.3%) and obesity (59%). Only 16.9% had one HbA1c and 48.9% a cholesterol lab in the last year, 61.9% were screened for diabetic peripheral neuropathy, and 29.0% had one eye exam in the previous year. With respect to blood sugar, lipid and blood pressure control: 44.4% of those with HbA1c measurements had levels ≥8%, total cholesterol was over 200mg/dL in 40.6% and 48.2% had uncontrolled blood pressure values.

CONCLUSION

Patients with diabetes received a low quality of care at public primary care clinics. A diabetes registry allowed us to draw an epidemiological profile of diabetic patients and determine the quality of care provided.

Increased self-care activities and glycemic control rate in relation to health education via Wechat among diabetes patients: A randomized clinical trial

BACKGROUND

Health education has been considered as the effectiveness method to increase the self-care skills of diabetes patients. However, limited studies to investigate the association of health education via Wechat platform on increased the basic self-care skills and glycemic control rate in patients with type 2 diabetes.

METHODS

A total number of 120 type 2 diabetes patients were randomized into intervention (health education by Wechat platform plus usual care) and the control group (usual care). Biochemical parameters including fasting plasma glucose (FPG), 2-hour plasma glucose (2hPG), glycosylated hemoglobin A1c (HbA1c) were measured among the 2 groups at baseline 6-month and 12-month. Diabetes Management Self-Efficacy (SE) Scale was completed at baseline 6-month and 12-month.

RESULTS

Significant difference of HbA1c concentration and SE were found between intervention and control groups at 6-month and 12-month (P <.05). The effect of groups and health education duration times was found on reduced HbA1c concentration and increased the total score of SE (P <.05). No significant difference of FPG and 2hPG concentrations were found between intervention and control groups at 6 months and 12 months (P >.05).

CONCLUSION

Health education of diabetic individuals via Wechat platform in conjunction with conventional diabetes treatment could improve glycemic control and positively influence other aspects of diabetes self-care skills.

The State of Digital Interventions for Demand Generation in Low- and Middle-Income Countries: Considerations, Emerging Approaches, and Research Gaps

The recent introduction of digital health into generating demand for health commodities and services has provided practitioners with an expanded universe of potential tools to strengthen demand and ensure service delivery receipt. However, considerable gaps remain in our understanding of which interventions are effective, which characteristics mediate their benefit for different target populations and health domains, and what is necessary to ensure effective deployment. This paper first provides an overview of the types of digital health interventions for demand generation, including untargeted client communication, client-to-client communication, on-demand information services, personal health tracking, client financial transactions, and targeted client communication. It then provides a general overview of 118 studies published between January 1, 2010, and October 3, 2017, that used digital interventions to generate demand for health interventions. The majority (61%) of these studies used targeted client communication to provide health education or reminders to improve treatment adherence, and the most frequently (27%) studied health condition was HIV/AIDS. Intervention characteristics that have been found to have some effect on gains in demand generation include modality, directionality, tailoring, phrasing, and schedule. The paper also explores new emergent digital approaches that expand the potential effect of traditional demand generation in terms of personalization of content and services, continuity of care, and accountability tracking. Applying existing frameworks for monitoring and evaluation and reporting, research on emerging approaches will need to consider not only their feasibility but also their effectiveness in achieving demand generation outcomes. We propose a research agenda to help guide the field of digital demand generation studies and programs within a broader health systems strengthening agenda, including establishing and documenting the influence of intervention characteristics within different populations and health domains and examining the long-term effects and cost-effectiveness of digital demand generation interventions, as well as equity in access to such interventions.

Exploring app features with outcomes in mHealth studies involving chronic respiratory diseases, diabetes, and hypertension: a targeted exploration of the literature

Objectives

Limited data are available on the correlation of mHealth features and statistically significant outcomes. We sought to identify and analyze: types and categories of features; frequency and number of features; and relationship of statistically significant outcomes by type, frequency, and number of features.

Materials and Methods

This search included primary articles focused on app-based interventions in managing chronic respiratory diseases, diabetes, and hypertension. The initial search yielded 3622 studies with 70 studies meeting the inclusion criteria. We used thematic analysis to identify 9 features within the studies.

Results

Employing existing terminology, we classified the 9 features as passive or interactive. Passive features included: 1) one-way communication; 2) mobile diary; 3) Bluetooth technology; and 4) reminders. Interactive features included: 1) interactive prompts; 2) upload of biometric measurements; 3) action treatment plan/personalized health goals; 4) 2-way communication; and 5) clinical decision support system.

Discussion

Each feature was included in only one-third of the studies with a mean of 2.6 mHealth features per study. Studies with statistically significant outcomes used a higher combination of passive and interactive features (69%). In contrast, studies without statistically significant outcomes exclusively used a higher frequency of passive features (46%). Inclusion of behavior change features (ie, plan/goals and mobile diary) were correlated with a higher incident of statistically significant outcomes (100%, 77%).

Conclusion

This exploration is the first step in identifying how types and categories of features impact outcomes. While the findings are inconclusive due to lack of homogeneity, this provides a foundation for future feature analysis.

Text Messaging to Improve Disease Management in Patients With Painful Diabetic Peripheral Neuropathy

Purpose The purpose of the study was to determine the impact of educational text messages on diabetes self-management activities and outcomes in patients with painful diabetic peripheral neuropathy (pDPN). Methods Patients with pDPN identified from a large integrated health system who agreed to participate were randomized to 6 months of usual care (UC) or UC plus twice-daily diabetes self-management text messages (UC+TxtM). Outcomes included the Pain Numerical Rating Scale, Summary of Diabetes Self-Care Activities (SDSCA), questions on diabetes health beliefs, and glycated hemoglobin (A1C). Changes from baseline were evaluated at 6 months and compared between groups. Results Demographic characteristics were balanced between groups (N = 62; 53% female, mean age = 63 years, 94% type 2 diabetes), as were baseline measures. After 6 months, pain decreased with UC+TxtM from 6.3 to 5.5 and with UC from 6.5 to 6.0, with no difference between groups. UC+TxtM but not UC was associated with significant improvements from baseline on all SDSCA subscales. On diabetes health beliefs, UC+TxtM patients reported significantly increased benefits and reduced barriers and susceptibility relative to UC at 6 months. A1C declined in both groups, but neither change was significant relative to baseline. Conclusions Patients with pDPN who receive twice-daily text messages regarding diabetes management reported reduced pain relative to baseline, although this change was not significant compared with usual care. In addition, text messaging was associated with increased self-management activities and improved diabetes health beliefs and total self-care. These results warrant further investigation.

Optimal Glycated Hemoglobin Cutoff Point for Diagnosis of Type 2 Diabetes in Iranian Adults

OBJECTIVES

The aim of this study was to evaluate the capability of glycated hemoglobin (A1C) levels to be a tool for identifying Iranian adults with diabetes and prediabetes.

METHODS

In a cross-sectional population-based study, 1,813 adults, men and women 35 to 75 years of age and without a history of diabetes and hemoglobinopathies, were included. Fasting blood glucose and A1C levels were obtained. According to the criteria of the American Diabetes Association, participants were categorized into 3 groups: newly diagnosed diabetes, prediabetes and healthy subjects. The optimal cutoff point for A1C in diabetes and prediabetes diagnosis was determined by studying the sensitivity and specificity of different cutoff points for A1C, while using different levels of fasting blood glucose as the gold standard.

RESULTS

Participants with newly diagnosed diabetes were significantly older than subjects with prediabetes and healthy subjects (mean [± SD] 47.3±12.9, 44.6±13.0 and 39.2±14.1 years, respectively) and also had higher body mass indexes. As expected, the levels of fasting blood glucose (8.79±2.24, 6.01±0.38 and 4.97±0.4 mmol/L) and A1C (6.55±1.4%, 5.61±0.61% and 5.28±0.59%) were significantly different in the groups (p<0.001). The optimal cutoff point for A1C to predict prediabetes was 5.5% (sensitivity of 60.5% and specificity of 63.1%) and for diabetes was 5.9% (sensitivity of 66.7% and specificity of 81.2%). ADA cutoff points for prediabetes and diabetes detection yielded a sensitivity of 45.2% and 39.8%, respectively.

CONCLUSIONS

The findings suggest the necessity of determining the A1C cutoffs for detecting diabetes or prediabetes in each region's population. They also suggest that the combination of these A1C cutoffs with fasting blood glucose levels are required to determine diabetes and prediabetes more accurately.

A peer support intervention in improving glycemic control in patients with type 2 diabetes

OBJECTIVE

This study aims to assess the effectiveness of a peer support intervention, in which patients with T2DM were provided ongoing self-management support by trained peers with diabetes directed at improving self-care behaviors, self-efficacy and life quality.

METHODS

In this randomized controlled trial, 200 patients referred to a diabetes specialty clinic were allocated to peer support or control group. Participants in both groups received usual education by diabetes educators. Intervention participants worked with the trained volunteer peers who encouraged participants to engage in daily self-management and to discuss and share their experiences and challenges of diabetes management. The primary outcomes were HbA1c, BMI, self-care behaviors, self-efficacy and life quality RESULTS: After 6 months, patients in the peer support group experienced a significant decline in mean A1c value (P=0.045). Also, mean diabetes self-management scores, mean self-efficacy scores and mean quality of life scores significantly improved in peer support group compared to control group (P values <0.001).

CONCLUSION

Peer support activities can be successfully applied in diabetes self-management, especially in areas with a shortage of professionals and economic resources.

PRACTICE IMPLICATIONS

Peer support strategies should be integrated into our healthcare system to meet minimum needs of people with T2DM in Iran.

Effect of Telephone Follow-up by Nurses on Self-care in Children with Diabetes

Background

Diabetes is a serious chronic disease during childhood. Because of the chronic nature of the disease, self-care is necessary. Education alone is not effective in providing care. Misunderstanding by the patients regarding diabetes during the training programs render telephone follow-up after training essential.

Materials and Methods

This quasi-experimental study with two groups (experimental and control) was conducted in two phases in 2014. The study population consisted of 70 children of 10-18 years of age with type I diabetes (35 patients in the experimental group and 35 in the control group). The participants were randomly selected from the patients referring to the Sedigheh Tahereh Diabetic Research and Treatment Center in Isfahan, Iran. Data were collected using a researcher-made questionnaire on self-care and a glycosylated hemoglobin recording form. The experimental group received 12 weeks of telephone follow-up training by the center, whereas the control group received no follow-up.

Results

The results showed that, after intervention, the total mean score of self-care in all aspects of diabetes care for children was significantly higher in the experimental group (p < 0.001). In addition, a statistically significant difference was observed between the experimental and control groups in terms of mean glycosylated hemoglobin after the intervention (p = 0.030).

Conclusions

It can be concluded that telephone follow-up by a nurse can improve total self-care and glycosylated hemoglobin in patients with type I diabetes.

Technology Interventions to Manage Food Intake: Where Are We Now?

PURPOSE OF REVIEW

This review describes the state-of-the-art for dietary assessment using smartphone apps and digital technology and provides an update on the efficacy of technology-mediated interventions for dietary change.

RECENT FINDINGS

Technology has progressed from apps requiring entry of foods consumed, to digital imaging to provide food intake data. However, these methods rely on patients being active in data collection. The automated estimation of the volume and composition of every meal consumed globally is years away. The use of text messaging, apps, social media, and combinations of these for interventions is growing and proving effective for type 2 diabetes mellitus (T2DM). Effectiveness of text messaging for obesity management is improving and multicomponent interventions show promise. A stand-alone app is less likely to produce positive outcomes and social media is relatively unexplored. A concentrated effort will be needed to progress digital dietary assessment. Researcher-designed technology programs are producing positive outcomes for T2DM but further research is needed in the area of weight management.

mHealth Interventions to Counter Noncommunicable Diseases in Developing Countries: Still an Uncertain Promise

mHealth constitutes a promise for health care delivery in low- and middle-income countries (LMICs) where health care systems are unprepared to combat the threat of noncommunicable diseases (NCDs). This article assesses the impact of mHealth on NCD outcomes in LMICs. A systematic review identified controlled studies evaluating mHealth interventions that addressed NCDs in LMICs. From the 1274 abstracts retrieved, 108 articles were selected for full text review and 20 randomized controlled trials were included from 14 LMICs. One-way SMS was the most commonly used mobile function to deliver reminders, health education, and information. mHealth interventions in LMICs have positive but modest effects on chronic disease outcomes.