Feasibility and usability of a text message-based program for diabetes self-management in an urban African-American population

Meeting the Needs of Emerging Adults With Type 1 Diabetes Living in a Rural Area With Mobile Health Interventions: Focus Group Study

BACKGROUND

Emerging adults (EAs; age 18-30 years) with type 1 diabetes (T1D) have more challenges with diabetes management and glycemic control than other age groups. Living in a rural community introduces additional unique diabetes care challenges due to limited access to specialty care and ancillary support services. Yet, few interventions have been developed to improve diabetes management in rural-dwelling EAs with T1D.

OBJECTIVE

This study aimed to understand the diabetes management experiences of older adolescents and EAs (age 16-25 years) with T1D living in a rural area and to assess their perceptions of the acceptability of 4 fully automated mobile health (mHealth) interventions to support diabetes management.

METHODS

EAs were identified by clinical staff through convenience sampling. In total, 8 EAs participated in 1 focus group and 1 EA completed an individual interview; all data were collected over Zoom. Facilitators explored EAs' experiences living in a rural community with T1D and discussed EAs' impressions of, feedback on, and recommendations for improving 4 mHealth interventions to meet the specific needs of EAs with T1D living in rural communities. Discussions were transcribed and analyzed using conventional content analysis.

RESULTS

In total, 9 EAs (aged 18.8, SD 2.7 years; 5, 56% men; 8, 89% White) with a duration of diabetes of 8.6 (SD 4.3) years participated. They described experiences with diabetes stigma (attributing diabetes to poor lifestyle choices) and feelings of self-consciousness (hyperawareness) in their rural communities. They attributed these experiences to the small size of their communities ("everyone knows") and community members' lack of knowledge about diabetes (unable to differentiate between type 1 and type 2 diabetes). In contrast, EAs reported high levels of social support for diabetes and diabetes care from family, friends, and other community members, but low support for medical needs. The location of their diabetes care providers and the limited accessibility of diabetes-specific and general medical care services in their local community created a challenging medical care context. Overall, EAs found mHealth interventions appealing due to their digital delivery and highlighted features that increased accessibility (voiceovers and simple, jargon-free language), individualization (ability to tailor intervention content and delivery), and applicability to their own lives and other EAs with T1D (relatability of vignettes and other content). EAs suggestions for improving the interventions included more opportunities to tailor the interventions to their preferences (greater frequency and duration, ability to adapt content to emerging needs), increasing opportunities for peer support within the interventions (friend and significant other as identified support person, connecting with peers beyond their local community), and making the tone of intervention components more casual and engaging.

CONCLUSIONS

mHealth interventions aligned with EAs' needs and preferences are a promising strategy to support EAs in communities where social support and resources might be limited.

TRIAL REGISTRATION

N/A, not a clinical trial.

Development of a customized m-Health-based intervention to reduce loss to follow-up among patients undergoing treatment for cervical lesions at a rural referral Hospital, South Western Uganda

Background

Loss to follow-up (LTFU) in individuals undergoing cervical cancer treatment is a major challenge in many low resource settings. We describe development of a customized and tailored mHealth intervention for reducing LTFU among patients undergoing cervical cancer treatment at Mbarara Regional Referral Hospital (MRRH).

Methods

We interviewed all health care providers (HCPs) at the cervical cancer clinic of MRRH, between April and May 2023. Transcripts were subsequently derived, reviewed and coded to generate themes and categories using inductive content analytic approach. Four medical experts used this data to develop relevant SMS content, which was incorporated into an app.

Results

HCPs had owned a phone for 13.8 ≤ years, had worked at the clinic for 5 ≤ years, and used text messages regularly. Qualitative data revealed that the main challenge to re-engagement was absence of a reminder mechanism between HCPs and patients. HCPs preferred text and or audio mode of messaging to improve health care responsiveness to LTFUs, awareness, continuity of care, and health service uptake among the majority illiterate population; though with potential constraints of costs and workload. Identified key messaging content included; the importance of attending scheduled follow-ups, follow up visit date and clinic customization and tailoring the message to the intended recipient. SMS content was uploaded onto the cc-follow-up app platform and customized according to preferred language, day, frequency and time of delivery.

Conclusion

Tailoring an mHealth messaging intervention could help re-engage and reduce LTFU through improved information sharing, awareness, responsiveness, care engagement and medical compliance. A pilot study is required for our intervention in South Western Uganda.

SMS text intervention for uncontrolled hypertension among hypertensive homeless adults in shelter clinics of New York City: protocol for a pragmatic randomised trial study

INTRODUCTION

Uncontrolled hypertension (HTN) is prevalent in persons experiencing homelessness (PEH) and contributes to significant suffering and financial cost. Mobile health approaches such as short messaging service (SMS) texting have led to better control of HTN in the general population. Despite the high utilisation of mobile phones by PEH, SMS texting to support HTN control has not been evaluated among this population. We hypothesise that an SMS testing programme will enhance health communication, information management, outreach and care coordination, and provide behavioural support to address some barriers to HTN management in PEH.

METHODS AND ANALYSIS

This study will use a mixed-methods study design to address two objectives: First, it will evaluate, in a randomised controlled trial, the efficacy of a 6-month SMS texting strategy vs an attention control on blood pressure reduction and adherence to medications and clinical appointments in 120 adults PEH with uncontrolled HTN. Outcomes will be measured at 0, 2, 4 and 6 months. Second, it will assess patients' and providers' acceptability and experience of SMS texting using semistructured interviews with PEH (n=30) and providers (n=10). The study will be conducted in shelter clinics in New York City in collaboration with community organisations. The primary statistical analysis will be on an intention-to-treat basis. The trial results will be reported as comparative summary statistics (difference in response rate or means) with 95% CIs and in accordance with the Consolidated Standards of Reporting Trials (CONSORT). Interviews will be transcribed, coded and analysed using an inductive grounded theory analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board (IRB) at George Washington University. Written consent will be obtained from participants. The findings will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05187013.

Mobile phone text messaging plus motivational interviewing versus usual care: study protocol for a randomized controlled trial to evaluate effects on breastfeeding, child health, and survival outcomes, among women living with HIV (MTI-MI)

BACKGROUND

Many infants in low-resourced settings at high risk of infectious disease morbidity and death are deprived of the immunological and nutritional benefits of breast milk, through an attenuated duration of breast milk exposure. South Africa has one of the lowest exclusive breastfeeding rates in Africa, with 8% of infants under 6 months of age. We assume that breastfeeding is sustained among women living with HIV receiving weekly text messages and motivational interviewing and that this contributes to improved infant health outcomes.

OBJECTIVES

(1) To evaluate the effectiveness of a combined intervention of mobile phone text messaging and motivational interviewing in promoting (a) exclusive breastfeeding and (b) any form of breastfeeding, until 6 months of child age, compared to usual care, among mothers living with HIV. (2) To evaluate the effectiveness of a combined intervention on (a) reduction in all-cause hospitalization and mortality rates and (b) improvements in infant linear growth, compared to usual care, among HIV-exposed infants aged 0-6 months.

METHODS

We are conducting a clinical trial to determine whether text messaging plus motivational interviewing prolongs breastfeeding and improves infant health outcomes. We are recruiting 275 women living with HIV and their HIV-exposed infants at birth and randomly assign study interventions for 6 months.

STATISTICAL METHODS

Breastfeeding rates are compared between the study groups using a standard proportion test and binomial regression. Survival endpoints are presented using Kaplan-Meier survival curves and compared between the study groups using the Cox proportional-hazards regression model. The count endpoint is analysed using the Poisson random-effects model and mean cumulative function. We use mixed linear regression models to assess the evolution of infant growth over time. The maximum likelihood method will be used to handle missing data.

DISCUSSION

The study findings may facilitate decision-making on (1) whether implementation of the breastfeeding policy achieved the desired outcomes, (2) interventions needed to sustain breastfeeding, and (3) whether the interventions do have an impact on child health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05063240. Pan African Clinical Trial Registry PACTR202110870407786. Oct. 1, 2021.

The digital future of nursing: making sense of taxonomies and key concepts

Digital technology is becoming increasingly common in routine nursing practice. The adoption of digital technologies such as video calling, and other digital communication, has been hastened by the recent COVID-19 pandemic. Use of these technologies has the potential to revolutionise nursing practice, leading to potentially more accurate patient assessment, monitoring processes and improved safety in clinical areas. This article outlines key concepts related to the digitalisation of health care and the implications for nursing practice. The aim of this article is to encourage nurses to consider the implications, opportunities and challenges associated with the move towards digitalisation and advances in technology. Specifically, this means understanding key digital developments and innovations associated with healthcare provision and appreciating the implications of digitalisation for the future of nursing practice.

Evaluating the Feasibility, Acceptability, and Preliminary Efficacy of SupportMoms-Uganda, an mHealth-Based Patient-Centered Social Support Intervention to Improve the Use of Maternity Services Among Pregnant Women in Rural Southwestern Uganda: Randomized Controlled Trial

BACKGROUND

SMS text messaging and other mobile health (mHealth) interventions may improve knowledge transfer, strengthen access to social support (SS), and promote positive health behaviors among women in the perinatal period. However, few mHealth apps have been taken to scale in sub-Saharan Africa.

OBJECTIVE

We evaluated the feasibility, acceptability, and preliminary efficacy of a novel, mHealth-based, and patient-centered messaging app designed using behavioral science frameworks to promote maternity service use among pregnant women in Uganda.

METHODS

We performed a pilot randomized controlled trial between August 2020 and May 2021 at a referral hospital in Southwestern Uganda. We included 120 adult pregnant women enrolled in a 1:1:1 ratio to receive routine antenatal care (ANC; control), scheduled SMS text or audio messages from a novel messaging prototype (scheduled messaging [SM]), and SM plus SMS text messaging reminders to 2 participant-identified social supporters (SS). Participants completed face-to-face surveys at enrollment and in the postpartum period. The primary outcomes were feasibility and acceptability of the messaging prototype. Other outcomes included ANC attendance, skilled delivery, and SS. We conducted qualitative exit interviews with 15 women from each intervention arm to explore the intervention mechanisms. Quantitative and qualitative data were analyzed using STATA and NVivo, respectively.

RESULTS

More than 85% and 75% of participants received ≥85% of the intended SMS text messages or voice calls, respectively. More than 85% of the intended messages were received within 1 hour of the expected time; 18% (7/40) of women experienced network issues for both intervention groups. Over 90% (36/40) of the intervention participants found this app useful, easy to use, engaging, and compatible and strongly recommended it to others; 70% (28/40), 78% (31/40), and 98% (39/40; P=.04) of women in the control, SM, and SS arms, respectively, had a skilled delivery. Half (20/40), 83% (33/40), and all (40/40; P=.001) of the women in the control, SM, and SS arms attended ≥4 ANC visits, respectively. Women in the SS arm reported the highest support (median 3.4, IQR 2.8-3.6; P=.02); <20% (8/40; P=.002) missed any scheduled ANC visit owing to lack of transportation. Qualitative data showed that women liked the app; they were able to comprehend ANC and skilled delivery benefits and easily share and discuss tailored information with their significant others, who in turn committed to providing them the needed support to prepare and seek help.

CONCLUSIONS

We demonstrated that developing a novel patient-centered and tailored messaging app that leverages SS networks and relationships is a feasible, acceptable, and useful approach to communicate important targeted health-related information and support pregnant women in rural Southwestern Uganda to use available maternity care services. Further evaluation of maternal-fetal outcomes and integration of this intervention into routine care is needed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04313348; https://clinicaltrials.gov/ct2/show/NCT04313348.

The Use of Digital Health Interventions for Cardiometabolic Diseases Among South Asian and Black Minority Ethnic Groups: Realist Review

BACKGROUND

Digital health interventions (DHIs) for the prevention and management of cardiometabolic diseases have become increasingly common. However, there is limited evidence for the suitability of these approaches in minority ethnic populations, who are at an increased risk of these diseases.

OBJECTIVE

This study aimed to investigate the use of DHIs for cardiovascular disease and type 2 diabetes among minority ethnic populations in countries with a majority of White, English-speaking populations, focusing on people who identified as South Asian, Black, or African American.

METHODS

A realist methodology framework was followed. A literature search was conducted to develop context-mechanism-outcome configurations, including the contexts in which DHIs work for the target minority ethnic groups, mechanisms that these contexts trigger, and resulting health outcomes. After systematic searches, a qualitative analysis of the included studies was conducted using deductive and inductive coding.

RESULTS

A total of 15 studies on the uptake of DHIs for cardiovascular disease or diabetes were identified, of which 13 (87%) focused on people with an African-American background. The review found evidence supporting the use of DHIs in minority ethnic populations when specific factors are considered in implementation and design, including patients' beliefs, health needs, education and literacy levels, material circumstances, culture, social networks, and wider community and the supporting health care systems.

CONCLUSIONS

Our context-mechanism-outcome configurations provide a useful guide for the future development of DHIs targeted at South Asian and Black minority ethnic populations, with specific recommendations for improving cultural competency and promoting accessibility and inclusivity of design.

Optimizing Engagement in an mHealth Intervention for Diabetes Support During Pregnancy: the Role of Baseline Patient Health and Behavioral Characteristics

BACKGROUND

Mobile health (mHealth) technology that addresses diabetes mellitus in pregnancy has the potential to improve maternal and child health while diminishing socioeconomic and racial disparities. Little is known about health literacy, electronic health literacy, or patient characteristics that contribute to increased mHealth use. In this pilot study, we aimed to examine patient factors associated with user engagement with a novel app for diabetes support during pregnancy.

METHOD

Low-income pregnant individuals with gestational or type 2 diabetes mellitus were recruited for a 2-week usability assessment of a novel mHealth smartphone application, "SweetMama," designed to improve diabetes care. This analysis of user characteristics was a pilot assessment of data from the usability study phase. Participants completed assessments of patient health literacy, electronic health literacy, diabetes self-efficacy, and activation. User metrics (eg, sessions and total duration of use) were evaluated by participant characteristics. Descriptive analyses were conducted to assess outcomes with respect to patient's clinical history, health literacy, electronic health literacy, diabetes self-efficacy, and activation.

RESULTS

Twenty-two diverse, low-income pregnant patients with either gestational or type 2 diabetes engaged with SweetMama for 14 days. Participants with gestational diabetes had greater mean minutes of use per session and mean total duration of use than those with type 2 diabetes. Participants with greater electronic health literacy, lower patient activation, and greater self-efficacy demonstrated greater total duration of use. No user metrics differed significantly by participant general health literacy.

CONCLUSIONS

Findings of this pilot study suggest engagement with a novel mHealth app for diabetes support during pregnancy varied by baseline behavioral and clinical characteristics. Results could indicate that digital health literacy better differentiates engagement patterns than general health literacy.

Mixed methods evaluation to explore participant experiences of a pilot randomized trial to facilitate self-management of people living with stroke: Inspiring virtual enabled resources following vascular events (iVERVE)

INTRODUCTION

Despite digital health tools being popular for supporting self-management of chronic diseases, little research has been undertaken on stroke. We developed and pilot tested, using a randomized controlled design, a multicomponent digital health programme, known as Inspiring Virtual Enabled Resources following Vascular Events (iVERVE), to improve self-management after stroke. The 4-week trial incorporated facilitated person-centred goal setting, with those in the intervention group receiving electronic messages aligned to their goals, versus limited administrative messages for the control group. In this paper, we describe the participant experience of the various components involved with the iVERVE trial.

METHODS

Mixed method design: satisfaction surveys (control and intervention) and a focus group interview (purposively selected intervention participants). Experiences relating to goal setting and overall trial satisfaction were obtained from intervention and control participants, with feedback on the electronic message component from intervention participants. Inductive thematic analysis was used for interview data and open-text responses, and closed questions were summarized descriptively. Triangulation of data allowed participants' perceptions to be explored in depth.

RESULTS

Overall, 27/54 trial participants completed the survey (13 intervention: 52%; 14 control: 48%); and 5/8 invited participants in the intervention group attended the focus group. Goal setting: The approach was considered comprehensive, with the involvement of health professionals in the process helpful in developing realistic, meaningful and person-centred goals. Electronic messages (intervention): Messages were perceived as easy to understand (92%), and the frequency of receipt was considered appropriate (11/13 survey; 4/5 focus group). The content of messages was considered motivational (62%) and assisted participants to achieve their goals (77%). Some participants described the benefits of receiving messages as a 'reminder' to act. Overall trial satisfaction: Messages were acceptable for educating about stroke (77%). Having options for short message services or email to receive messages was considered important. Feedback on the length of the intervention related to specific goals, and benefits of receiving the programme earlier after stroke was expressed.

CONCLUSION

The participant experience has indicated acceptance and utility of iVERVE. Feedback from this evaluation is invaluable to inform refinements to future Phase II and III trials, and wider research in the field.

PATIENT OR PUBLIC CONTRIBUTION

Two consumer representatives sourced from the Stroke Foundation (Australia) actively contributed to the design of the iVERVE programme. In this study, participant experiences directly contributed to the further development of the iVERVE intervention and future trial design.

Development of a text message-based intervention for follow-up colposcopy among predominately underserved Black and Hispanic/Latinx women

PURPOSE

Underserved Black and Hispanic/Latinx women show low rates of follow-up care after an abnormal Pap test, despite the fact that cervical cancer is one of the few preventable cancers if detected early. However, extant literature falls short on efficacious interventions to increase follow-up for this population. A concurrent mixed methods study was completed to evaluate the acceptability of a text message-based intervention and identify perceived barriers and facilitators to follow-up after an abnormal Pap test among underserved predominantly Black and Hispanic/Latinx women.

METHODS

Patients who completed follow-up for an abnormal Pap test were recruited to complete a cross-sectional survey, qualitative interview assessing barriers and facilitators to follow-up, and text message content evaluation (N = 28). Descriptive statistics were performed to describe background variables and to evaluate the acceptability of text messages. A directed content analysis was completed for the qualitative interviews.

RESULTS

Participants expressed interest in a text message-based intervention to increase abnormal Pap test follow-up. In the qualitative interviews, low knowledge about cervical risk and negative affect toward colposcopy/test results were identified as barriers to follow-up. Facilitators of follow-up included feeling relieved after the colposcopy and adequate social support. Participants rated the text messages as understandable, personally relevant, and culturally appropriate.

CONCLUSION

The findings suggest that underserved Black and Hispanic/Latinx women experience cognitive and emotional barriers that undermine their ability to obtain follow-up care and a text message-based intervention may help women overcome these barriers. Future research should develop and evaluate text message-based interventions to enhance follow-up after an abnormal Pap test.

A Social Media-Based Diabetes Intervention for Low-Income Mandarin-Speaking Chinese Immigrants in the United States: Feasibility Study

BACKGROUND

Chinese immigrants bear a high diabetes burden and face significant barriers to accessing diabetes self-management education (DSME) and counseling programs.

OBJECTIVE

The goal of this study was to examine the feasibility and acceptability and to pilot test the potential efficacy of a social media-based DSME intervention among low-income Chinese immigrants with type 2 diabetes (T2D) in New York City.

METHODS

This was a single group pretest and posttest study in 30 Chinese immigrants with T2D. The intervention included 24 culturally and linguistically tailored DSME videos, focusing on diabetes education and behavioral counseling techniques. Over 12 weeks, participants received 2 brief videos each week via WeChat, a free social media app popular among Chinese immigrants. Primary outcomes included the feasibility and acceptability of the intervention. Feasibility was evaluated by recruitment processes, retention rates, and the video watch rate. Acceptability was assessed via a satisfaction survey at 3 months. Secondary outcomes, that is, hemoglobin A_1c (HbA_1c), self-efficacy, dietary intake, and physical activity, were measured at baseline, 3 months, and 6 months. Descriptive statistics and paired 2-sided t tests were used to summarize the baseline characteristics and changes before and after the intervention.

RESULTS

The sample population (N=30) consisted of mostly females (21/30, 70%) who were married (19/30, 63%), with limited English proficiency (30/30, 100%), and the mean age was 61 (SD 7) years. Most reported an annual household income of <US $25,000 (24/30, 80%) and a high school education or less (19/30, 63%). Thirty participants were recruited within 2 months (January and February 2020), and 97% (29/30) of the participants were retained at 6 months. A video watch rate of 92% (28/30) was achieved. The mean baseline HbA_1c level was 7.3% (SD 1.3%), and this level declined by 0.5% (95% CI -0.8% to -0.2%; P=.003) at 6 months. The mean satisfaction score was 9.9 (SD 0.6) out of 10, indicating a high level of satisfaction with the program. All strongly agreed or agreed that they preferred this video-based DSME over face-to-face visits. Compared to baseline, there were significant improvements in self-efficacy, dietary, and physical activity behaviors at 6 months.

CONCLUSIONS

This pilot study demonstrated that a social media-based DSME intervention is feasible, acceptable, and potentially efficacious in a low-income Chinese immigrant population with T2D. Future studies need to examine the efficacy in an adequately powered clinical trial.

Mobile Device Ownership, Current Use, and Interest in Mobile Health Interventions Among Low-Income Older Chinese Immigrants With Type 2 Diabetes: Cross-sectional Survey Study

Background

Chinese immigrants suffer a disproportionately high type 2 diabetes (T2D) burden and tend to have poorly controlled disease. Mobile health (mHealth) interventions have been shown to increase access to care and improve chronic disease management in minority populations. However, such interventions have not been developed for or tested in Chinese immigrants with T2D.

Objective

This study aims to examine mobile device ownership, current use, and interest in mHealth interventions among Chinese immigrants with T2D.

Methods

In a cross-sectional survey, Chinese immigrants with T2D were recruited from Chinese community centers in New York City. Sociodemographic characteristics, mobile device ownership, current use of social media software applications, current use of technology for health-related purposes, and interest in using mHealth for T2D management were assessed. Surveys were administered face-to-face by bilingual study staff in the participant’s preferred language. Descriptive statistics were used to characterize the study sample and summarize technology use.

Results

The sample (N=91) was predominantly female (n=57, 63%), married (n=68, 75%), and had a high school education or less (n=58, 64%); most participants had an annual household income of less than US $25,000 (n=63, 69%) and had limited English proficiency (n=78, 86%). The sample had a mean age of 70 (SD 11) years. Almost all (90/91, 99%) participants had a mobile device (eg, basic cell phones, smart devices), and the majority (n=83, 91%) reported owning a smart device (eg, smartphone or tablet). WeChat was the most commonly used social media platform (65/91, 71%). When asked about their top source for diabetes-related information, 63 of the 91 participants (69%) reported health care providers, followed by 13 who reported the internet (14%), and 10 who reported family, friends, and coworkers (11%). Less than one-quarter (21/91, 23%) of the sample reported using the internet to search for diabetes-related information in the past 12 months. About one-third of the sample (34/91, 37%) reported that they had watched a health-related video on their cell phone or computer in the past 12 months. The majority (69/91, 76%) of participants reported interest in receiving an mHealth intervention in the future to help with T2D management.

Conclusions

Despite high mobile device ownership, the current use of technology for health-related issues remained low in older Chinese immigrants with T2D. Given the strong interest in future mHealth interventions and high levels of social media use (eg, WeChat), future studies should consider how to leverage these existing low-cost platforms and deliver tailored mHealth interventions to this fast-growing minority group.

mHealth-Based Health Promotion Intervention to Improve Use of Maternity Care Services Among Women in Rural Southwestern Uganda: Iterative Development Study

BACKGROUND

Antenatal care (ANC) prevents perinatal morbidity and mortality, but use of these services in Uganda remains low and maternal mortality rates are among the highest in the world. There is growing evidence that mobile health (mHealth) approaches improve timely communication of health-related information and produce positive health behavior change as well as health outcomes. However, there are limited data to guide development of such interventions in settings where ANC attendance and uptake of skilled maternity care are low.

OBJECTIVE

The aim of this study is to develop a novel patient-centered mHealth intervention to encourage and support women to use maternity care services in Mbarara district, southwestern Uganda.

METHODS

Using an iterative development approach, we conducted formative stakeholder interviews with 30 women and 5 health care providers (HCPs) to identify preferred key ANC topics and characterize the preferred messaging intervention; developed content for SMS text messaging and audio messaging with the help of 4 medical experts based on the identified topics; designed an app prototype through partnership with an mHealth development company; and pilot-tested the prototype and sought user experiences and feedback to refine the intervention through 3 sets of iterative interviews, a focus group discussion, and 5 cognitive interviews. Qualitative data were coded and analyzed using NVivo (version 12.0; QSR International).

RESULTS

Of the 75 women who completed interviews during the development of the prototype, 39 (52%) had at least a primary education and 75 (100%) had access to a mobile phone. The formative interviews identified 20 preferred perinatal health topics, ranging from native medicine use to comorbid disorders and danger signs during pregnancy. In all, 6 additional topics were identified by the interviewed HCPs, including birth preparedness, skilled delivery, male partner's involvement, HCP interaction, immunization, and caring for the baby. Positive audio messaging and SMS text messaging content without authoritative tones was developed as characterized by the interviewed women. The postpilot iterative interviews and focus group discussion revealed a preference for customized messaging, reflecting an individual need to be included and connected. The women preferred short, concise, clear actionable messages that guided, supported, and motivated them to keep alert and seek professional help. Complementary weekly reminders to the women's significant others were also preferred to encourage continuity or prompt the needed social support for care seeking.

CONCLUSIONS

We used an iterative approach with diffuse stakeholders to develop a patient-centered audio messaging and SMS text messaging app designed to communicate important targeted health-related information and support rural pregnant women in southwestern Uganda. Involving both HCPs and end users in developing and formulating the mHealth intervention allowed us to tailor the intervention characteristics to the women's preferences. Future work will address the feasibility, acceptability, and effectiveness of this design approach.

Examining medication adherence and preferences for a lifestyle intervention among Black and Latinx adults with hypertension: a feasibility study

Background

Approximately 116.4 million adults in the USA have hypertension, and the rates of uncontrolled hypertension remain higher among racial and ethnic minorities. There is a need for effective interventions that promote healthy behaviors and long-term behavioral change in the management of hypertension. The primary objective of this study was to determine the feasibility of developing a lifestyle intervention that would assess hypertension management and the use of technology among Blacks and Latinx with hypertension. The secondary objective is to explore perceptions of community-based resources for hypertension and preferences for a lifestyle intervention for hypertension among Blacks and Latinx with hypertension.

Methods

In this explanatory mixed-methods study, quantitative data were collected using surveys, participants reported their use of technology and adherence to antihypertensive medication. Participants were Black and Latinx adults with hypertension living in Central Pennsylvania, USA. Qualitative data were obtained from semi-structured interviews and focus groups, and participants were asked about managing hypertension, local resources, and preferences for a behavioral intervention. Data were examined using summary statistics for quantitative data and thematic analysis for qualitative data.

Results

Black and Latinx participants (n=30) completed surveys for the quantitative study. The majority (75%) of participants self-reported being confident in managing their medication without help and remembering to take their medication as prescribed. Fewer participants (54.2%) reported using technology to help manage medication. There were 12 participants in the qualitative phase of the study. The qualitative findings indicated that participants felt confident in their ability to manage hypertension and were interested in participating in a lifestyle intervention or program based online. Some participants reported a lack of resources in their community, while others highlighted local and national resources that were helpful in managing high blood pressure.

Conclusion

This study provides important insights on barriers and facilitators for managing hypertension, current use of technology and interest in using technology to manage hypertension, and preferences for future lifestyle interventions among racial and ethnic minorities. This study also provides insights to the health needs and resources available in this community and how future behavioral interventions could be tailored to meet the needs of this community. The findings of this study will be used to inform the tailoring of future lifestyle interventions; specifically, we will include text messaging reminders for medication and to disseminate educational materials related to hypertension and provide resources to connect study participants with local and national resources.

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.

A Pharmacist and Health Coach-Delivered Mobile Health Intervention for Type 2 Diabetes: Protocol for a Randomized Controlled Crossover Study

BACKGROUND

Aggressive management of blood glucose, blood pressure, and cholesterol through medication and lifestyle adherence is necessary to minimize the adverse health outcomes of type 2 diabetes. However, numerous psychosocial and environmental barriers to adherence prevent low-income, urban, and ethnic minority populations from achieving their management goals, resulting in diabetes complications. Health coaches working with clinical pharmacists represent a promising strategy for addressing common diabetes management barriers. Mobile health (mHealth) tools may further enhance their ability to support vulnerable minority populations in diabetes management.

OBJECTIVE

The aim of this study is to evaluate the impact of an mHealth clinical pharmacist and health coach-delivered intervention on hemoglobin A1c (HbA1c, primary outcome), blood pressure, and low-density lipoprotein (secondary outcomes) in African-Americans and Latinos with poorly controlled type 2 diabetes.

METHODS

A 2-year, randomized controlled crossover study will evaluate the effectiveness of an mHealth diabetes intervention delivered by a health coach and clinical pharmacist team compared with usual care. All patients will receive 1 year of team intervention, including lifestyle and medication support delivered in the home with videoconferencing and text messages. All patients will also receive 1 year of usual care without team intervention and no home visits. The order of the conditions received will be randomized. Our recruitment goal is 220 urban African-American or Latino adults with uncontrolled type 2 diabetes (HbA1c ≥8%) receiving care from a largely minority-serving, urban academic medical center. The intervention includes the following: health coaches supporting patients through home visits, phone calls, and text messaging and clinical pharmacists supporting patients through videoconferences facilitated by health coaches. Data collection includes physiologic (HbA1c, blood pressure, weight, and lipid profile) and survey measures (medication adherence, diabetes-related behaviors, and quality of life). Data collection during the second year of study will determine the maintenance of any physiological improvement among participants receiving the intervention during the first year.

RESULTS

Participant enrollment began in March 2017. We have recruited 221 patients. Intervention delivery and data collection will continue until November 2021. The results are expected to be published by May 2022.

CONCLUSIONS

This is among the first trials to incorporate health coaches, clinical pharmacists, and mHealth technologies to increase access to diabetes support among urban African-Americans and Latinos to achieve therapeutic goals.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17170.

Integrating family and friend support, information technology, and diabetes education in community-centric diabetes self-management

OBJECTIVE

Diabetes self-management (DSM) education, social support, and information technology interventions can improve patient engagement and health. A major challenge is animating, integrating, and accessing resources in under-resourced, rural communities. Set in an island community in Hawai'i, this study piloted a program that integrated friend-and-family support, community health services, telehealth-enabled DSM education, and mobile technologies by activating the community's social capital to support the program.

MATERIALS AND METHODS

An action research approach informed the design and implementation of a community-based DSM program that included: friends and family support, telehealth classes, personalized consultations, Bluetooth-enabled blood glucose monitors, and text messaging support. Outcomes were evaluated using biometric data, surveys, interviews, and participant observations.

RESULTS

The study spanned 9 months with 7 dyads, each with 1 individual with type 2 diabetes and a friend or family member. Six of the 7 participants with diabetes experienced reduced hemoglobin A1c percentages, with 3 reducing by more than 1%. The seventh participant maintained a hemoglobin A1c level within American Diabetes Association recommended ranges. DSM knowledge and self-care behaviors improved overall. Interviews and participant observations highlighted program strengths and social challenges associated with the interpersonal relationships between the members of the dyads.

CONCLUSIONS

A community-centric diabetes program can enhance understanding of diabetes etiology, DSM activities, and communication skills for effective disease management support in under-resourced rural communities. Social capital among community members, leveraged with health information technology, can catalyze and integrate limited health system resources for DSM and social support as a cost-effective strategy to develop community-centric chronic healthcare management initiatives.

EatSmart, a Web-Based and Mobile Healthy Eating Intervention for Disadvantaged People With Type 2 Diabetes: Protocol for a Pilot Mixed Methods Intervention Study

Background

People of low socioeconomic position (SEP) are disproportionately affected by type 2 diabetes (T2D), partly due to unhealthy eating patterns that contribute to inadequate disease self-management and prognosis. Digital technologies have the potential to provide a suitable medium to facilitate diabetes education, support self-management, and address some of the barriers to healthy eating, such as lack of nutritional knowledge or shopping or cooking skills, in this target group.

Objective

This study aims to test the feasibility, appeal, and potential effectiveness of EatSmart, a 12-week, evidence-based, theoretically grounded, fully automated web-based and mobile-delivered healthy eating behavior change program to help disadvantaged people living with T2D to eat healthily on a budget and improve diabetes self-management.

Methods

EatSmart is a mixed methods (quantitative and qualitative) pre-post design pilot study. Sixty socioeconomically disadvantaged people with T2D aged 18 to 75 years will be recruited. Participants will complete self-reported baseline assessments of their basic demographic and clinical data, dietary intake, dietary self-efficacy, and barriers to healthy eating. They will be provided with login access to the EatSmart web program, which includes six progressive skill-based modules covering healthy eating planning; smart food budgeting and shopping; time-saving meal strategies, healthy cooking methods, modifying recipes; and a final reinforcement and summary module. Over the 3-month intervention, participants will also receive 3 text messages weekly, encouraging them to review goals, continue to engage with different components of the EatSmart web program, and eat healthily. Participants will undertake follow-up assessments directly following the intervention 3 months post baseline and again after a 6-month postintervention follow-up period (9 months post baseline). Feasibility will be evaluated using the number of participants recruited and retained and objective indicators of engagement with the website. Program appeal and potential effects on primary and secondary outcomes will be assessed via the same surveys used at baseline, with additional questions asking about experience with and perceptions of the program. In-depth qualitative interviews will also be conducted 6 months post intervention to provide deeper insight into experiences with EatSmart and a more comprehensive description of the program’s appeal.

Results

The EatSmart website has been developed, and all participants have viewed the modules as of May 2020. Results are expected to be submitted for publication in December 2020.

Conclusions

This study will provide data to address the currently limited evidence regarding whether disadvantaged populations with T2D may benefit from digitally delivered behavior change programs that facilitate eating healthily on a budget.

Trial Registration

Australian New Zealand Clinical Trials Registry, ACTRN12619001111167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001111167

International Registered Report Identifier (IRRID)

DERR1-10.2196/19488

Improving Diabetes Management in Emerging Adulthood: An Intervention Development Study Using the Multiphase Optimization Strategy

Background

Poor diabetes self-management in emerging adulthood (age 18-25 years) is associated with poorer diabetes health and diabetes complications. Emerging adults’ focus on individuation and independence underlies their poor diabetes outcomes, offering a lever for behavior change. Self-determination theory (SDT) suggests that interventions leveraging emerging adults’ innate developmental need for autonomy may offer a route to improving diabetes outcomes by increasing feelings of responsibility for and control over diabetes self-management activities.

Objective

This research project will use the multiphase optimization strategy to test the efficacy of three autonomy-supportive intervention components to elicit a clinically significant improvement in metabolic control, assessed by a 0.5% improvement in hemoglobin A_1c (HbA_1c), among older adolescents and emerging adults (16-25 years) with poorly controlled type 1 diabetes (T1D; HbA_1c≥9.0%).

Methods

A question prompt list (QPL) is a tool to empower patients to assume a more active role during medical visits by asking questions and stating concerns. The motivation enhancement system (MES) is a brief counseling intervention that uses motivational interviewing communication strategies to build intrinsic motivation and self-efficacy for self-management. Text message reminders to complete diabetes care tasks may increase self-efficacy for diabetes self-management. After refining these intervention components for emerging adults, we will conduct a component selection experiment using an eight-arm full factorial design: 2 (QPL yes or no)×2 (MES yes or no)×2 (Text yes or no). Participants will complete 3 study visits: baseline, treatment end at 2 months, and a follow-up at 6 months. The primary outcome is metabolic control, which will be measured via HbA_1c. Secondary outcomes include diabetes management and diabetes clinic attendance. SDT constructs of intrinsic motivation, self-efficacy, and the quality of the patient-provider relationship (ie, relatedness) are hypothesized mediators. Depression symptoms and emerging adults’ gender are hypothesized moderators. We will use the mixed-effects linear model for the analysis of variance of a factorial design to analyze continuous longitudinal experimental data; the generalized linear model will be used with categorical outcomes (eg, treatment attendance). The experiment was powered to detect the main effects of the intervention on the primary outcome.

Results

A total of 20 participants have enrolled and completed a qualitative interview after reviewing one or more intervention components. Analysis of interview data are underway, with a report of these results anticipated in the fall of 2020. The clinical trial will be launched in the fall 2020, with participants enrolled through May 2023 and data collection continuing through November 2023.

Conclusions

At the end of this experiment, we will have empirical evidence to support a large-scale, multisite effectiveness trial of an intervention package that has been optimized for older adolescents and emerging adults with poorly controlled T1D.

Trial Registration

ClinicalTrials.gov NCT04066959; https://clinicaltrials.gov/ct2/show/NCT04066959

International Registered Report Identifier (IRRID)

DERR1-10.2196/20191

Development and Evaluation of a Tailored Mobile Health Intervention to Improve Medication Adherence in Black Patients With Uncontrolled Hypertension and Type 2 Diabetes: Pilot Randomized Feasibility Trial

BACKGROUND

Research has underscored the need to develop socioculturally tailored interventions to improve adherence behaviors in minority patients with hypertension (HTN) and type 2 diabetes (T2D). Novel mobile health (mHealth) approaches are potential methods for delivering tailored interventions to minority patients with increased cardiovascular risk.

OBJECTIVE

This study aims to develop and evaluate the acceptability and preliminary efficacy of a tailored mHealth adherence intervention versus attention control (AC) on medication adherence, systolic blood pressure (SBP), diastolic blood pressure (DBP), and hemoglobin A1c (HbA1c) at 3 months in 42 Black patients with uncontrolled HTN and/or T2D who were initially nonadherent to their medications.

METHODS

This was a two-phase pilot study consisting of a formative phase and a clinical efficacy phase. The formative phase consisted of qualitative interviews with 10 members of the target patient population (7/10, 70% female; mean age 65.8 years, SD 5.6) to tailor the intervention based on the Information-Motivation-Behavioral skills model of adherence. The clinical efficacy phase consisted of a 3-month pilot randomized controlled trial to evaluate the tailored mHealth intervention versus an AC. The tablet-delivered intervention included a tailoring survey, an individualized adherence profile, and a personalized list of interactive adherence-promoting modules, whereas AC included the tailoring survey and health education videos delivered on the tablet. Acceptability was assessed through semistructured exit interviews. Medication adherence was assessed using the 8-item Morisky Medication Adherence Scale, whereas blood pressure and HbA1c were assessed using automated devices.

RESULTS

In phase 1, thematic analysis of the semistructured interviews revealed the following 5 major barriers to adherence: disruptions in daily routine, forgetfulness, concerns about adverse effects, preference for natural remedies, and burdens of medication taking. Patients recommended the inclusion of modules that address improving patient-provider communication, peer vignettes, and stress reduction strategies to facilitate adherence. A total of 42 Black patients (23/42, 55% male; mean age 57.6 years, SD 11.1) participated in the clinical efficacy pilot trial. At 3 months, both groups showed significant improvements in adherence (mean 1.35, SD 1.60; P<.001) and SBP (-4.76 mm Hg; P=.04) with no between-group differences (P=.50 and P=.10). The decreases in DBP and HbA1c over time were nonsignificant (-1.97 mm Hg; P=.20; and -0.2%; P=.45, respectively). Patients reported high acceptability of the intervention for improving their adherence.

CONCLUSIONS

This pilot study demonstrated preliminary evidence on the acceptability of a tailored mHealth adherence intervention among a sample of Black patients with uncontrolled HTN and T2D who were initially nonadherent to their medications. Future research should explore whether repeated opportunities to use the mHealth intervention would result in improvements in behavioral and clinical outcomes over time. Modifications to the intervention as a result of the pilot study should guide future efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01643473; http://clinicaltrials.gov/ct2/show/ NCT01643473.

Mobile Health in Adherence to Oral Anticancer Drugs: A Scoping Review

In oncology, adherence to oral antineoplastic medication is a key element of treatment, on which the success of any therapeutic intervention depends. Given their widespread use in clinical practice, it is important to identify tools that can facilitate the monitoring and self-management of the patient at home, to avoid the consequences of employing ineffective treatment. One of the tools available today to take action on this phenomenon is mobile health technology. The aim of this review is to describe published studies relating to the use of mobile health to promote adherence to oral antineoplastic medication. This scoping review was conducted using the framework proposed by Arksey and O'Malley, adapted according to Levac et al. Of 1320 articles identified, only seven met the eligibility criteria and therefore were included in the review. All seven articles involved the use of digital means to measure adherence to treatment, patient satisfaction, acceptability and feasibility of the digital means used, and presence of symptoms, but not the effectiveness of the digital instrument used. In conclusion, the use of digital means to assist adherence of cancer patients to oral antineoplastic medication is widely recognized, but its effectiveness in clinical practice is poorly supported by the nature of the published studies.

User Retention and Engagement With a Mobile App Intervention to Support Self-Management in Australians With Type 1 or Type 2 Diabetes (My Care Hub): Mixed Methods Study

Background

Mobile health apps are commonly used to support diabetes self-management (DSM). However, there is limited research assessing whether such apps are able to meet the basic requirements of retaining and engaging users.

Objective

This study aimed to evaluate participants’ retention and engagement with My Care Hub, a mobile app for DSM.

Methods

The study employed an explanatory mixed methods design. Participants were people with type 1 or type 2 diabetes who used the health app intervention for 3 weeks. Retention was measured by completion of the postintervention survey. Engagement was measured using system log indices and interviews. Retention and system log indices were presented using descriptive statistics. Transcripts were analyzed using content analysis to develop themes interpreted according to the behavioral intervention technology theory.

Results

Of the 50 individuals enrolled, 42 (84%) adhered to the study protocol. System usage data showed multiple and frequent interactions with the app by most of the enrolled participants (42/50, 84%). Two-thirds of participants who inputted data during the first week returned to use the app after week 1 (36/42, 85%) and week 2 (30/42, 71%) of installation. Most daily used features were tracking of blood glucose (BG; 28/42, 68%) and accessing educational information (6/42, 13%). The interview results revealed the app’s potential as a behavior change intervention tool, particularly because it eased participants’ self-care efforts and improved their engagement with DSM activities such as BG monitoring, physical exercise, and healthy eating. Participants suggested additional functionalities such as extended access to historical analytic data, automated data transmission from the BG meter, and periodic update of meals and corresponding nutrients to further enhance engagement with the app.

Conclusions

The findings of this short-term intervention study suggested acceptable levels of participant retention and engagement with My Care Hub, indicating that it may be a promising tool for extending DSM support and education beyond the confines of a physical clinic.

Using the Preparation Phase of the Multiphase Optimization Strategy to Develop a Messaging Component for Weight Loss: Formative and Pilot Research

BACKGROUND

Mobile messaging is often used in behavioral weight loss interventions, yet little is known as to the extent to which they contribute to weight loss when part of a multicomponent treatment package. The multiphase optimization strategy (MOST) is a framework that researchers can use to systematically investigate interventions that achieve desirable outcomes given specified constraints.

OBJECTIVE

This study describes the use of MOST to develop a messaging intervention as a component to test as part of a weight loss treatment package in a subsequent optimization trial.

METHODS

On the basis of our conceptual model, a text message intervention was created to support self-regulation of weight-related behaviors. We tested the messages in the ENLIGHTEN feasibility pilot study. Adults with overweight and obesity were recruited to participate in an 8-week weight loss program. Participants received a commercially available self-monitoring smartphone app, coaching calls, and text messages. The number and frequency of text messages sent were determined by individual preferences, and weight was assessed at 8 weeks.

RESULTS

Participants (n=9) in the feasibility pilot study lost 3.2% of their initial body weight over the 8-week intervention and preferred to receive 1.8 texts per day for 4.3 days per week. Researcher burden in manually sending messages was high, and the cost of receiving text messages was a concern. Therefore, a fully automated push notification system was developed to facilitate sending tailored daily messages to participants to support weight loss.

CONCLUSIONS

Following the completion of specifying the conceptual model and the feasibility pilot study, the message intervention went through a final iteration. Theory and feasibility pilot study results during the preparation phase informed critical decisions about automation, frequency, triggers, and content before inclusion as a treatment component in a factorial optimization trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01814072; https://clinicaltrials.gov/ct2/show/NCT01814072.

Identifying the barriers and perceptions of non-Hispanic black and Hispanic/Latino persons with uncontrolled type 2 diabetes for participation in a home Telemonitoring feasibility study: a quantitative analysis of those who declined participation, withdrew or were non-adherent

Objectives: Type 2 Diabetes Mellitus and its complications disproportionately affect non-Hispanic blacks and Hispanic/Latinos more than non-Hispanic whites. These disparities stem from complex interactions between biological, behavioral and socioeconomic factors. In recent years, telemedicine has been used to manage Type 2 Diabetes; however limited recruitment and retention of black and Hispanic/Latino patients into clinical trials exploring the use of telemedicine have necessitated the elucidation of their perceptions regarding participation in such trials. This study investigated patient-reported reasons for declining participation, prematurely terminating participation or demonstrating poor adherence to the study protocol in an ongoing randomized clinical trial, 'Feasibility of Telehealth Management of Diabetes Mellitus type 2 (T2DM) in Black and Hispanic Minority Patients'.Design: Semi-structured interviews comprised of open-ended questions and prompts were conducted by telephone to gauge patients' actual and perceived challenges to participating in the trial and using telemedicine to manage their diabetes. Data were collated with that of the original clinical trial and subsequently content analyzed for overarching themes and trends.Results: Eight semi-structured interviews were completed telephonically. Themes that emerged from analysis included disinterest (47%), inconvenience (33%), lack of perceived benefit (13%), lack of awareness of diabetes diagnosis (7%) and perceived lack of ability to fully participate in the study (7%).Conclusion: Adoption of telemedicine to help minority patients manage diabetes holds promise but is limited by patient factors such as disinterest, inconvenience and lack of perceived benefit. Greater awareness and understanding of these issues will be critical as we strive for greater health equity in disparity patients with uncontrolled diabetes.

Immigrant Latino parents demonstrated high interactivity with pediatric primary care text messaging intervention

BACKGROUND

The majority of Latino immigrants have been shown to have a mobile phone. Cellular phones offer a low-cost method of reaching larger populations and have the potential for increased tailoring and interactivity. This supports the development of mHealth interventions to address healthcare disparities in this population. In this study we sought to evaluate the feasibility and acceptability of interactive Spanish-language text messages sent throughout a child's first year of life in a low-income, limited-English proficient (LEP) Latino population to support families in accessing and using pediatric primary care more effectively.

METHODS

Participants (n=79) received interactive text messages over a period of 12 months as a part of a multi-modal mHealth intervention conducted at an urban academic pediatric primary care practice. Inclusion criteria were: singleton infant <2 months of age, enrollment in public health insurance, parent age >18, parent preferred healthcare language of Spanish, and at least one household cellular phone. Interactive text messages were designed to promote increased healthcare engagement and prompted participant responses through preprogramed algorithms. Text message sequences included clinic appointment reminders, support for obtaining medicine and completing referral appointments, monitoring of illness care needs and use, and parent support program reminders. Descriptive analyses were used to examine text message volume, usability, and participant response to text sequences.

RESULTS

Among participants, mean parent age was 30.1 years (SD: 6.1 years); mean years in the US was 7.5 years (SD: 5.1 years). 63.3% of parents had less than a high school education and 84.8% of parents had possible/high likelihood of limited health literacy. Participants completed the majority of sequences with appointment reminder sequences having the quickest response time. The top quartile of responders completed 88.3% of sequences; lower educational attainment was associated with lower text message sequence completion. Participants rated the program positively, especially the appointment reminders.

CONCLUSIONS

LEP Latino parents successfully engaged with interactive Spanish-language text sequences and parent acceptability was high. This study demonstrates feasibility for interventions employing this technology. Text message interventions may be a feasible approach to reduce healthcare disparities and costs for vulnerable populations.

Efficacy, acceptability and feasibility of daily text-messaging in promoting glycaemic control and other clinical outcomes in a low-resource setting of South Africa: A randomised controlled trial

South Africa is confronted with a high burden of diabetes, the majority of which are poorly controlled. The use of mHealth, specifically text messaging for fostering health, is evolving and studies on its efficacy, the majority of which were conducted in developed countries, have documented mixed findings. There is no such study done amongst patients living with diabetes in the resource-poor settings of South Africa. The aim of this study is to determine the efficacy, acceptability and feasibility of text-messaging in improving glycaemic control and other clinical outcomes among individuals living with diabetes in low-resource settings in Eastern Cape, South Africa. The study adopted a multi-centre, two-arm, parallel, randomised-controlled trial design. The study was conducted amongst patients with an uncontrolled glycaemic status. Participants were randomly assigned to the intervention (n = 108) and the control arm (n = 108). Participants in the intervention arm received daily educational text messages on diabetes for six months. Data was collected at baseline and six months post-intervention. Blood glucose, blood pressure and anthropometric measurements followed standard procedure. Mixed-model analysis was used to assess the impact of the text messages on blood glucose while linear regression was used to assess its effect on other clinical outcomes such as weight, body mass index, systolic and diastolic blood pressure. The mean age of the participants was 60.64 (SD± 11.58) years. The majority of the participants had a secondary level of education (95.3%) and earned 104.80 to 991.42 USD per month (67.7%). Both arms of the study showed improvement in their blood glucose levels, but the intervention did not have any significant effect, the mean adjusted change in blood glucose was 0.26 (-0.81 to 1.32), p = 0.634. Also, the intervention did not have any significant effect on weight, body mass index, systolic and diastolic blood pressure. Almost all participants (90.74%) were pleased with the intervention and felt it was helpful. Of those who participated in the intervention, 91% completed the follow-up after 6 months. Unidirectional text-messaging was acceptable and feasible amongst adults living with diabetes in this setting. However, its efficacy in improving glycaemic status and other clinical outcomes remains doubtful. Trial Registration: Pan African Clinical Trial Registry PACTR201810599931422.

Text Messaging and Type 1 Diabetes Management: Qualitative Study Exploring Interactions Among Patients and Health Care Professionals

BACKGROUND

The diffusion of information and communication technologies (ICTs) in type 1 diabetes (T1D) management has generated a debate on the ways in which ICTs can support the patient-provider relationship. Several studies have focused on text messages. Most of the literature proposes quantitative analysis of the impact of text messaging on the clinical conditions of patients and/or their satisfaction with the technology, while the qualitative studies have focused mainly on patients' perceptions about strengths and weaknesses of this technology.

OBJECTIVE

In contrast to past studies, we adopted a qualitative approach for the in-depth examination of patient-health care professionals' interactions in text messaging.

METHODS

The study focused on the use of the Trento Cartella Clinica del Cittadino Diabetes System (TreC-DS), a digital platform with a built-in messaging system, in two diabetes centers, integrating message analysis with interviews with patients and health care professionals. Each center focused on a specific patient profile: the first one focused on pregnant women with T1D and the second one focused on adult patients with poorly controlled diabetes.

RESULTS

The main results of the study were as follows: (1) Health care professionals and patients perceived the messaging system as useful for sharing information (ie, pregnant women for prescriptions and adults with poorly controlled diabetes for advice); (2) The content and communication styles of the two centers differed: in the case of pregnant women, interactions via text messaging were markedly prescriptive, while in the case of adult patients with poorly controlled diabetes, they were conceived as open dialogues; and (3) Conversations were initiated mainly by professionals; in the cases considered, it was mainly the diabetes center that decided whether a messaging conversation was needed.

CONCLUSIONS

The results show how the features of interactions of text messaging changed based on the patient profiles in two different centers. In addition, in both diabetes centers that were involved, the system seems to have laid a foundation for a closer relationship between patients and health care professionals.

Combining Real-Time Ratings With Qualitative Interviews to Develop a Smoking Cessation Text Messaging Program for Primary Care Patients

BACKGROUND

Text messaging (short message service, SMS) interventions show promise as a way to help cigarette smokers quit. Few studies have examined the effectiveness of text messaging (SMS) programs targeting smokers associated with primary care or hospital settings.

OBJECTIVE

This study aimed to develop a text messaging (SMS) program targeting primary care smokers.

METHODS

Adult smokers in primary care were recruited from February 2017 to April 2017. We sent patients 10 to 11 draft text messages (SMS) over 2 days and asked them to rate each message in real time. Patients were interviewed daily by telephone to discuss ratings, message preferences, and previous experiences with nicotine replacement therapy (NRT). Content analysis of interviews was directed by a step-wise text messaging (SMS) intervention development process and the Information-Motivation-Behavioral Skills model of medication adherence.

RESULTS

We sent 149 text messages (SMS) to 15 patients. They replied with ratings for 93% (139/149) of the messages: 134 (96%, 134/139) were rated as clear or useful and 5 (4%, 5/139) as unclear or not useful. Patients' preferences included the addition of graphics, electronic cigarette (e-cigarette) content, and use of first names. Regarding NRT, patients identified informational gaps around safety and effectiveness, preferred positively framed motivational messages, and needed behavioral skills to dose and dispose of NRT.

CONCLUSIONS

Patients recommended text message (SMS) personalization, inclusion of e-cigarette information and graphics, and identified barriers to NRT use. Combining real-time ratings with telephone interviews is a feasible method for incorporating primary care patients' preferences into a behavioral text messaging (SMS) program.

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.

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 text message reminders in health care services: A narrative literature review

INTRODUCTION

Despite the extensive use of mHealth behavior change interventions, questions remain about the use of technology-based reminders in delivering health care services. Text messaging, or short message service (SMS), is one reminder method that has been extensively researched. Most SMS-reminder research is distributed across a range of health care outcomes. The aim of this article is to systematically review the aggregate impact of these reminders on overall health care outcomes.

METHODS

A systematic literature review was conducted and yielded 2316 articles. Studies were included if they used SMS reminders to support patient health care outcomes. Study methodology was aligned with the PRISMA guidelines for systematic reviews.

RESULTS

Following screening, 162 articles met inclusion criteria. Of these studies, 93 investigated medical compliance reminders and 56 investigated appointment reminders. The review found that nearly all the SMS-reminder studies helped improve patient medical compliance and appointment reminders. Additionally, researchers reported numerous benefits from using SMS reminders, including ease of use, relative inexpensiveness, and rapid and automated message delivery. Minimal risks were reported and most participants found the reminders to be acceptable.

DISCUSSION

Text messages appear to be an effective reminder mechanism to promote improved patient appointment and medical compliance. Reminders should continue to be evaluated and improved to determine the most effective timing and frequency of messages for improving outcomes.

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.

HealthyhornsTXT: A Text-Messaging Program to Promote College Student Health and Wellness

Objective: Text-messaging interventions positively affect health behaviors, but their use on college campuses has been limited. Text messaging serves as a relatively affordable way to communicate with large audiences and is one of the preferred modes of communication for young adults. This study examined the feasibility and acceptability of a campus-wide, health text–messaging program. Participants: The subscriber pool consisted of approximately 6,000 undergraduate students from a large, southern university. From that pool, 1,095 participants (64% female; 41% White) completed a posttest survey. Method: Text messages covered a range of health topics and information about campus resources. Research was conducted from August through December 2015. Process data were collected throughout the semester; participants’ attitudes were assessed via an online survey at the program’s conclusion. Results: Students demonstrated engagement with the messages throughout the semester as evidenced by replies to text-back keywords and clicks on website links embedded within messages. Messages about sleep, stress management, and hydration were considered most relevant. The majority of participants (61%) reported increased awareness regarding their health. Conclusions: Text-messaging interventions are a feasible strategy to improve college student health.

SMS education for the promotion of diabetes self-management in low & middle income countries: a pilot randomized controlled trial in Egypt

Background

Due to the ubiquity of mobile phones in low and middle income countries, we aimed to examine the feasibility of SMS education among diabetic patients in Egypt, and assess the impact of educational text messages, compared to traditional paper-based methods, on glycemic control and self-management behaviors.

Methods

We conducted a 12-week randomized controlled trial at Misr University for Science & Technology hospital in Cairo-Egypt. Known as MUST diabetes awareness program, patients were included if they had diabetes, owned a mobile phone, and could read SMS messages or lived with someone that could read for them. Intervention patients received daily messages and weekly reminders addressing various diabetes care categories. We expected greater improvement in their glycemic control compared to controls who only received paper-based educational material. The primary outcome was the change in HbA1c, measured by the difference between endpoint and baseline values and by the number of patients who experienced at least 1% reduction from baseline to endpoint. Key secondary outcomes included blood glucose levels, body weight, treatment and medication adherence, self-efficacy, and diabetes knowledge. Data were analyzed using ANCOVA, chi-square, and t-tests.

Results

Thirty four intervention and 39 control patients completed the study. Over 12 weeks, 3880 messages were sent. Each intervention patient received 84 educational and 12 reminder messages plus one welcome message. Our primary outcome did not differ significantly (Δ 0.290; 95% CI -0.402 to 0.983; p = 0.406) between groups after 3 months, demonstrating a mean drop of −0.69% and −1.05% in the control and intervention group respectively. However, 16 intervention patients achieved the targeted 1% drop versus only 6 controls, suggesting clear association between study group and 1% HbA1c reductions (chi-square = 8.655; df = 1; p = 0.003). Secondary outcomes seemed in favor of intervention patients at endpoint, with considerable improvements in treatment and medication adherence, self-efficacy, and knowledge scores. Participants also indicated full satisfaction with the program.

Conclusions

SMS education is a feasible and acceptable method for improving glycemic control and self-management behaviors among Egyptian diabetics. However, whether it is more effective than traditional paper-based methods needs further investigation.

Trial registration

ClinicalTrials.govNCT02868320. Registered 9 August 2016. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4973-5) contains supplementary material, which is available to authorized users.

Text Messaging Based Obesity Prevention Program for Parents of Pre-Adolescent African American Girls

African American girls are at a greater risk of obesity than their nonminority peers. Parents have the primary control over the home environment and play an important role in the child obesity prevention. Obesity prevention programs to help parents develop an obesity-preventive home environment are needed. The purpose of this study was to collect formative research from parents of 8-10-year old African American girls about perceptions, expectations, and content for a text messaging based program. Mothers (n = 30) participated in surveys and interviews to inform message development and content. A professional expert panel (n = 10) reviewed draft text messages via a survey. All the mothers reported owning a cellphone with an unlimited texting plan, and they used their cellphones for texting (90.0%) and accessing the Internet (100.0%). The majority were interested in receiving text messages about healthy eating and physical activity (86.7%). Interviews confirmed survey findings. One hundred and seven text messages promoting an obesity-preventive home environment were developed. The expert panel and parents reported positive reactions to draft text messages. This research provides evidence that mobile health (mHealth) interventions appeal to parents of African American girls and they have ready access to the technology with which to support this approach.

A Randomized Trial of User-Controlled Text Messaging to Improve Asthma Outcomes: A Pilot Study

We enrolled 64 patients age 12 to 22 years with a diagnosis of poorly controlled persistent asthma in a 6-month longitudinal crossover study. During the 3 intervention months, participants created personalized text messages to be sent to their phones. Adherence was objectively monitored in 22 of the participants. The adolescent participants gave high ratings on the acceptability of the text messaging system. Asthma control improved from baseline to month 1 regardless of whether teens were in the texting or control group. While participants were in the texting group, their quality of life improved and worry about their asthma decreased. Receiving the text intervention resulted in an increase in adherence of 2.75% each month relative to no intervention, but the improvements were not sustained. There was modest improvement in asthma control and quality of life outcomes, as well as improved adherence during the texting intervention.

Text message reminders for improving patient appointment adherence in an office-based buprenorphine program: A feasibility study

BACKGROUND AND OBJECTIVES

Missed visits are common in office-based buprenorphine treatment (OBOT). The feasibility of text message (TM) appointment reminders among OBOT patients is unknown.

METHODS

This 6-month prospective cohort study provided TM reminders to OBOT program patients (N = 93). A feasibility survey was completed following delivery of TM reminders and at 6 months.

RESULTS

Respondents reported that the reminders should be provided to all OBOT patients (100%) and helped them to adhere to their scheduled appointment (97%). At 6 months, there were no reports of intrusion to their privacy or disruption of daily activities due to the TM reminders. Most participants reported that the TM reminders were helpful in adhering to scheduled appointments (95%), that the reminders should be offered to all clinic patients (95%), and favored receiving only TM reminders rather than telephone reminders (95%). Barriers to adhering to scheduled appointment times included transportation difficulties (34%), not being able to take time off from school or work (31%), long clinic wait-times (9%), being hospitalized or sick (8%), feeling sad or depressed (6%), and child care (6%).

CONCLUSIONS

This study demonstrated the acceptability and feasibility of TM appointment reminders in OBOT. Older age and longer duration in buprenorphine treatment did not diminish interest in receiving the TM intervention. Although OBOT patients expressed concern regarding the privacy of TM content sent from their providers, privacy issues were uncommon among this cohort. Scientific Significance Findings from this study highlighted patient barriers to adherence to scheduled appointments. These barriers included transportation difficulties (34%), not being able to take time off from school or work (31%), long clinic lines (9%), and other factors that may confound the effect of future TM appointment reminder interventions. Further research is also required to assess 1) the level of system changes required to integrate TM appointment reminder tools with already existing electronic medical records and appointment records software; 2) acceptability among clinicians and administrators; and 3) financial and resource constraints to healthcare systems. (Am J Addict 2017;26:581-586).

mHealth Application Areas and Technology Combinations*. A Comparison of Literature from High and Low/Middle Income Countries

BACKGROUND

With the continuous and enormous spread of mobile technologies, mHealth has evolved as a new subfield of eHealth. While eHealth is broadly focused on information and communication technologies, mHealth seeks to explore more into mobile devices and wireless communication. Since mobile phone penetration has exceeded other infrastructure in low and middle-income countries (LMICs), mHealth is seen as a promising component to provide pervasive and patient-centered care.

OBJECTIVES

The aim of our research work for this paper is to examine the mHealth literature to identify application areas, target diseases, and mHealth service and technology types that are most appropriate for LMICs.

METHODS

Based on the 2011 WHO mHealth report, a combination of search terms, all including the word "mHealth", was identified. A literature review was conducted by searching the PubMed and IEEE Xplore databases. Articles were included if they were published in English, covered an mHealth solution/ intervention, involved the use of a mobile communication device, and included a pilot evaluation study. Articles were excluded if they did not provide sufficient detail on the solution covered or did not focus on clinical efficacy/effectiveness. Cross-referencing was also performed on included articles.

RESULTS

842 articles were retrieved and analyzed, 255 of which met the inclusion criteria. North America had the highest number of applications (n=74) followed by Europe (n=50), Asia (n=44), Africa (n=25), and Australia (n=9). The Middle East (n=5) and South America (n=3) had the least number of studies. The majority of solutions addressed diabetes (n=51), obesity (n=25), CVDs (n=24), HIV (n=18), mental health (n=16), health behaviors (n=16), and maternal and child's health (MCH) (n=11). Fewer solutions addressed asthma (n=7), cancer (n=5), family health planning (n=5), TB (n=3), malaria (n=2), chronic obtrusive pulmonary disease (COPD) (n=2), vision care (n=2), and dermatology (n=2). Other solutions targeted stroke, dental health, hepatitis vaccination, cold and flu, ED prescribed antibiotics, iodine deficiency, and liver transplantation (n=1 each). The remainder of solutions (n=14) did not focus on a certain disease. Most applications fell in the areas of health monitoring and surveillance (n=93) and health promotion and raising awareness (n=88). Fewer solutions addressed the areas of communication and reporting (n=11), data collection (n=6), telemedicine (n=5), emergency medical care (n=3), point of care support (n=2), and decision support (n=2). The majority of solutions used SMS messaging (n=94) or mobile apps (n=71). Fewer used IVR/phone calls (n=8), mobile website/email (n=5), videoconferencing (n=2), MMS (n=2), or video (n=1) or voice messages (n=1). Studies were mostly RCTs, with the majority suffering from small sample sizes and short study durations. Problems addressed by solutions included travel distance for reporting, self-management and disease monitoring, and treatment/medication adherence.

CONCLUSIONS

SMS and app solutions are the most common forms of mHealth applications. SMS solutions are prevalent in both high and LMICs while app solutions are mostly used in high income countries. Common application areas include health promotion and raising awareness using SMS and health monitoring and surveillance using mobile apps. Remaining application areas are rarely addressed. Diabetes is the most commonly targeted medical condition, yet remains deficient in LMICs.

Interactive weekly mobile phone text messaging plus motivational interviewing in promotion of breastfeeding among women living with HIV in South Africa: study protocol for a randomized controlled trial

BACKGROUND

South Africa recently phased out access to free formula milk in the public sector in support of breastfeeding for women living with HIV. Few women living with HIV in South Africa choose breastfeeding and among those who do, many stop breastfeeding early. We sought to explore the feasibility of using mobile phone text messaging coupled with motivational interviewing to enhance adherence to breastfeeding practices.

METHODS AND DESIGN

A randomized, parallel group, single-center pilot trial. Electronic sequence generation and random allocation will be done centrally. Women of low socioeconomic status, from Cape Town, South Africa will be randomly assigned within 24 h of giving birth at a primary healthcare clinic to a structured weekly text message plus motivational interviewing and usual standard of care, using a permutation of different block sizes. Criteria for feasibility success will include: five participants recruited per week (over 12 weeks), about 75% of all eligible participants consent for study participation, complete evaluation of outcomes in at least 70% of all recruited participants, breastfeeding adherence rates of at least 70% in the intervention group, six months after delivery. Participants will be evaluated soon after giving birth and post-delivery at weeks 2, 6, 10, and 24. Primary analysis will follow the "intention-to-treat" principle. Sub-group analysis will be used to assess sub-group effects.

DISCUSSION

This pilot trial will evaluate the feasibility of conducting a larger trial on communication and support approaches to improve adherence to breastfeeding by HIV-infected women. Text messaging and motivational interviewing are simple interventions which may allow participants to access personalized adherence advice and support.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02949713 . Registered on 26 October 2016; Pan African Clinical Trial Registry PACTR201611001855404 . Registered on 8 November 2016.

Using Text Reminder to Improve Childhood Immunization Adherence in the Philippines

A comparative descriptive study was conducted to determine the effectiveness of text messages with pictures compared with plain text messages or verbal reminders in improving measles, mumps, and rubella immunization compliance in the rural areas of the Philippines. We found that text messaging with or without pictures is a feasible and useful tool in measles, mumps, rubella immunization compliance for childhood immunization. Texting with pictures (n = 23), however, was no more effective than plain text messaging (n = 19) or verbal reminder (n = 17) in improving measles, mumps, and rubella immunization compliance. Compared with parents who received verbal reminders alone, either type of text reminders was linked to parents bringing their child for measles, mumps, and rubella immunization on a timelier basis, as defined by the difference between the scheduled visit and the actual visit, although this was not statistically significant. Mobile technology that uses text reminders for immunization can potentially improve the communication process between parent, the public health nurse, and healthcare provider. Future studies can explore the application of plain text messages or text messages with pictures to improve compliance more broadly for maternal and child healthcare especially in rural areas of developing countries and may be a helpful tool for health promotion for this population.

Characteristics of online treatment seekers interested in a text messaging intervention for problem drinking: adults 51 and older versus middle-aged and younger adults

According to the Institute of Medicine, the vast older adult population is estimated to have mental health and substance use disorders at unprecedented rates and will place high demand on an unprepared healthcare system. Online and mobile health interventions, such as text messaging, could provide an alternative form of frontline intervention that could alleviate some of the burden on the healthcare system; however, it remains unknown what are characteristics of adults over 50 who might be interested in a mobile health behavioral intervention and how they may differ from their younger counterparts. To explore the characteristics of those interested in a text messaging intervention by age, we examined screening data for a randomized controlled trial testing a text messaging intervention to reduce drinking among 1,128 hazardous and problem drinkers, aged 21-30, 31-50, and 51 and older. Participants were recruited online through website advertising on alcoholscreening.org and moderationmanagement.org. Results demonstrated that over a quarter of individuals pursuing online and/or text messaging treatment were 51 and older. These participants reported heavy drinking, with significantly greater number of days drinking and binge drinking than the younger groups, but with fewer consequences. Across age groups, a vast majority of participants were female. Findings demonstrate that a group of adult heavy drinkers 51 and older already pursue online treatment and are interested in using a text messaging intervention to help them reduce drinking, suggesting an avenue to engage this population using an alternative frontline treatment.

Barriers to Remote Health Interventions for Type 2 Diabetes: A Systematic Review and Proposed Classification Scheme

Background

Diabetes self-management involves adherence to healthy daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption.

Objective

The objective of our study was to identify and classify barriers to adoption of remote health for management of type 2 diabetes.

Methods

The following 6 electronic databases were searched for articles published from 2010 to 2015: MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier). The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of 2 to review and extract data from identified papers. Information collected included study characteristics, outcomes, dropout rates, technologies used, and barriers identified.

Results

A total of 53 publications on 41 studies met the specified criteria. Lack of data accuracy due to input bias (32%, 13/41), limitations on scalability (24%, 10/41), and technology illiteracy (24%, 10/41) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations, whereas limitations on scalability were more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. In total, 40.5% (60/148) of identified barrier instances impeded patient engagement, which is manifest in the large dropout rates cited (up to 57%).

Conclusions

The barriers identified represent major challenges in the design of remote health interventions for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high dropout rates, and new interventions are needed to identify and assist those at the greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financial sustainability.

mHealth Intervention Elements and User Characteristics Determine Utility: A Mixed-Methods Analysis

BACKGROUND

Mobile health (mHealth) interventions are improving the medication adherence of adults with type 2 diabetes mellitus (T2DM), but few studies examine how users experience these interventions. Therefore, we used a mixed-methods approach to understand how T2DM users experience a text messaging and interactive voice response (IVR)-delivered medication adherence intervention called MEssaging for Diabetes (MED).

METHODS

Adults with T2DM used MED as part of a 3-month pilot study. MED sends daily tailored text messages addressing adherence barriers, daily assessment text messages asking about adherence, and weekly tailored IVR calls providing adherence feedback, encouragement, and questions to facilitate problem solving. Sixty participants completed feedback interviews. We used a mixed-methods approach to understand their experience, examining associations between participants' characteristics and their feedback.

RESULTS

Participants who completed feedback interviews were on average 50.0 ± 10.1 years old; 65% female, 62% non-white; 15% had less than a high school education, 70% had annual incomes less than $20K; and average hemoglobin A1c was 8.0% ± 1.9%. Participants rated each intervention element favorably; common reasons for MED's helpfulness included receiving novel information about diabetes medications, emotional support, and reminders to take medication. People who were younger and more recently diagnosed with T2DM had more favorable experiences using MED. In general, users valued text messages more than IVR calls.

CONCLUSIONS

Consideration of the user experience is critical for developing engaging mHealth interventions. User feedback reveals what mHealth elements have the most value and why, which users to target, and how to optimize an intervention's utility and appeal.

An exploratory study of mobile messaging preferences by age: Middle-aged and older adults compared to younger adults

INTRODUCTION

Mobile technologies, such as short message service or text messaging, can be an important way to reach individuals with medical and behavioral health problems who are homebound or geographically isolated. Optimally tailoring messages in short message service interventions according to preferences can enhance engagement and positive health outcomes; however, little is known about the messaging preferences of middle-aged and older adults.

METHODS

Utilizing secondary data, global messaging preferences were examined to inform the development of short message service interventions for adults of all ages. Two hundred and seventy-seven adults were recruited through an online labor market. They completed an online survey by evaluating message dyads in 22 content groupings. Dyads were identical in subject matter but structurally or linguistically varied. Participants selected the message in each dyad they would prefer to receive when attempting to meet a self-selected personal goal. Preferences were tested for two age groups ≤50 and 51 and older.

RESULTS

Findings reveal adults 51 and older have clear messaging preferences that differ significantly from the younger group for only two content groupings; specifically, they prefer no emoticon to a smiley face emoticon and "you" statements rather than "we" statements.

CONCLUSION

Recommendations for optimizing messaging for older adults are reviewed.

A pilot randomized trial of technology-assisted goal setting to improve physical activity among primary care patients with prediabetes

Lifestyle behavior changes can prevent progression of prediabetes to diabetes but providers often are not able to effectively counsel about preventive lifestyle changes. We developed and pilot tested the Avoiding Diabetes Thru Action Plan Targeting (ADAPT) program to enhance primary care providers' counseling about behavior change for patients with prediabetes. Primary care providers in two urban academic practices and their patients with prediabetes were recruited to participate in the ADAPT study, an unblinded randomized pragmatic trial to test the effectiveness of the ADAPT program, including a streamlined electronic medical record-based goal setting tool. Providers were randomized to intervention or control arms; eligible patients whose providers were in the intervention arm received the ADAPT program. Physical activity (the primary outcome) was measured using pedometers, and data were gathered about patients' diet, weight and glycemic control. A total of 54 patients were randomized and analyzed as part of the 6-month ADAPT study (2010-2012, New York, NY). Those in the intervention group showed an increase total daily steps compared to those in the control group (+ 1418 vs - 598, p = 0.007) at 6 months. There was also a trend towards weight loss in the intervention compared to the control group (- 1.0 lbs. vs. 3.0 lbs., p = 0.11), although no change in glycemic control. The ADAPT study is among the first to use standard electronic medical record tools to embed goal setting into realistic primary care workflows and to demonstrate a significant improvement in prediabetes patients' physical activity.

Development and Usability of REACH: A Tailored Theory-Based Text Messaging Intervention for Disadvantaged Adults With Type 2 Diabetes

BACKGROUND

Among adults with type 2 diabetes mellitus (T2DM), adherence to recommended self-care activities is suboptimal, especially among racial and ethnic minorities with low income. Self-care nonadherence is associated with having worse glycemic control and diabetes complications. Text messaging interventions are improving the self-care of adults with T2DM, but few have been tested with disadvantaged populations.

OBJECTIVE

To develop Rapid Education/Encouragement And Communications for Health (REACH), a tailored, text messaging intervention to support the self-care adherence of disadvantaged patients with T2DM, based on the Information-Motivation-Behavioral skills model. We then tested REACH's usability to make improvements before evaluating its effects.

METHODS

We developed REACH's content and functionality using an empirical and theory-based approach, findings from a previously pilot-tested intervention, and the expertise of our interdisciplinary research team. We recruited 36 adults with T2DM from Federally Qualified Health Centers to participate in 1 of 3 rounds of usability testing. For 2 weeks, participants received daily text messages assessing and promoting self-care, including tailored messages addressing users' unique barriers to adherence, and weekly text messages with adherence feedback. We analyzed quantitative and qualitative user feedback and system-collected data to improve REACH.

RESULTS

Participants were, on average, 52.4 (SD 9.5) years old, 56% (20/36) female, 63% (22/35) were a racial or ethnic minority, and 67% (22/33) had an income less than US $35,000. About half were taking insulin, and average hemoglobin A1c level was 8.2% (SD 2.2%). We identified issues (eg, user concerns with message phrasing, technical restrictions with responding to assessment messages) and made improvements between testing rounds. Overall, participants favorably rated the ease of understanding (mean 9.6, SD 0.7) and helpfulness (mean 9.3, SD 1.4) of self-care promoting text messages on a scale of 1-10, responded to 96% of assessment text messages, and rated the helpfulness of feedback text messages 8.5 (SD 2.7) on a scale of 1-10. User feedback led to refining our study enrollment process so that users understood the flexibility in message timing and that computers, not people, send the messages. Furthermore, research assistants' feedback on the enrollment process helped improve participants' engagement with study procedures.

CONCLUSIONS

Testing technology-delivered interventions with disadvantaged adults revealed preferences and concerns unique to this population. Through iterative testing and multiple data sources, we identified and responded to users' intervention preferences, technical issues, and shortcomings in our research procedures.

Patterns of User Engagement with Mobile- and Web-Delivered Self-Care Interventions for Adults with T2DM: A Review of the Literature

Technology-delivered interventions can improve the health behaviors and clinical outcomes of persons with diabetes, but only if end users engage with these interventions. To summarize the current knowledge on engagement with technology-based interventions, we conducted a review of recent mobile- and web-delivered intervention studies for adults with type 2 diabetes published from 2011 to 2015. Among 163 identified studies, 24 studies satisfied our inclusion criteria. There was substantial variation in how intervention engagement was reported across studies. Engagement rates were lower among interventions with a longer duration, and engagement decreased over time. In several studies, older age and lower health literacy were associated with less engagement, and more engagement was associated with intervention improvement in at least one outcome, including glycemic control. Future technology-based intervention studies should report on engagement, examine and report on associations between user characteristics and engagement, and aim to standardize how this is reported, particularly in longer trials.