The effectiveness of text message-based self-management interventions for poorly-controlled diabetes: A systematic review

The impact of using reinforcement learning to personalize communication on medication adherence: findings from the REINFORCE trial

Text messaging can promote healthy behaviors, like adherence to medication, yet its effectiveness remains modest, in part because message content is rarely personalized. Reinforcement learning has been used in consumer technology to personalize content but with limited application in healthcare. We tested a reinforcement learning program that identifies individual responsiveness ("adherence") to text message content and personalizes messaging accordingly. We randomized 60 individuals with diabetes and glycated hemoglobin A1c [HbA1c] ≥ 7.5% to reinforcement learning intervention or control (no messages). Both arms received electronic pill bottles to measure adherence. The intervention improved absolute adjusted adherence by 13.6% (95%CI: 1.7%-27.1%) versus control and was more effective in patients with HbA1c 7.5- < 9.0% (36.6%, 95%CI: 25.1%-48.2%, interaction p < 0.001). We also explored whether individual patient characteristics were associated with differential response to tested behavioral factors and unique clusters of responsiveness. Reinforcement learning may be a promising approach to improve adherence and personalize communication at scale.

Digitally Delivered Interventions to Improve Nutrition Behaviors Among Resource-Poor and Ethnic Minority Groups With Type 2 Diabetes: Systematic Review

BACKGROUND

Resource-poor individuals, such as those with a low income, are disproportionately affected by diabetes and unhealthy eating patterns that contribute to poor disease self-management and prognosis. Digitally delivered interventions have the potential to address some of the barriers to healthy eating experienced by this group. However, little is known about their effectiveness in disadvantaged populations.

OBJECTIVE

This systematic review is conducted to assess the effectiveness of digitally delivered interventions in improving nutritional behaviors and nutrition-related health outcomes among disadvantaged people with type 2 diabetes (T2D).

METHODS

MEDLINE complete, Global Health, Embase, CINAHL complete, Informit Health, IEEE Xplore, and Applied Science and Technology Source databases were searched for studies published between 1990 and 2022 on digitally delivered nutrition interventions for disadvantaged people with T2D. Two reviewers independently assessed the studies for eligibility and determined the study quality using the Cochrane Risk-of-Bias Assessment Tool. The Behavioral Change Technique Taxonomy V1 was used to identify behavior change techniques used in the design of interventions.

RESULTS

Of the 2434 identified records, 10 (0.4%), comprising 947 participants, met the eligibility criteria and were included in the review. A total of 2 digital platforms, web and messaging services (eg, SMS text messaging interventions or multimedia messaging service), were used to deliver interventions. Substantial improvements in dietary behaviors were reported in 5 (50%) of the 10 studies, representing improvements in healthier food choices or increases in dietary knowledge and skills or self-efficacy. Of the 10 studies, 7 (70%) examined changes in blood glucose levels, of which 4 (57%) out of 7 achieved significant decreases in hemoglobin A1C levels ranging from 0.3% to 1.8%. The most frequently identified behavior change techniques across all studies were instruction on how to perform the behavior, information about health consequences, and social support.

CONCLUSIONS

This review provided some support for the efficacy of digitally delivered interventions in improving healthy eating behaviors in disadvantaged people with T2D, an essential dietary prerequisite for changes in clinical metabolic parameters. Further research is needed into how disadvantaged people with T2D may benefit more from digital approaches and to identify the specific features of effective digital interventions for supporting healthy behaviors among disadvantaged populations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020149844; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149844.

The effect of personalized intelligent digital systems for self-care training on type II diabetes: a systematic review and meta-analysis of clinical trials

AIMS

Type 2 diabetes (T2D) is rising worldwide. Self-care prevents diabetic complications. Lack of knowledge is one reason patients fail at self-care. Intelligent digital health (IDH) solutions have a promising role in training self-care behaviors based on patients' needs. This study reviews the effects of RCTs offering individualized self-care training systems for T2D patients.

METHODS

PubMed, Web of Science, Scopus, Cochrane Library, and Science Direct databases were searched. The included RCTs provided data-driven, individualized self-care training advice for T2D patients. Due to the repeated studies measurements, an all-time-points meta-analysis was conducted to analyze the trends over time. The revised Cochrane risk-of-bias tool (RoB 2.0) was used for quality assessment.

RESULTS

In total, 22 trials met the inclusion criteria, and 19 studies with 3071 participants were included in the meta-analysis. IDH interventions led to a significant reduction of HbA1c level in the intervention group at short-term (in the third month: SMD = - 0.224 with 95% CI - 0.319 to - 0.129, p value < 0.0; in the sixth month: SMD = - 0.548 with 95% CI - 0.860 to - 0.237, p value < 0.05). The difference in HbA1c reduction between groups varied based on patients' age and technological forms of IDH services delivery. The descriptive results confirmed the impact of M-Health technologies in improving HbA1c levels.

CONCLUSIONS

IDH systems had significant and small effects on HbA1c reduction in T2D patients. IDH interventions' impact needs long-term RCTs. This review will help diabetic clinicians, self-care training system developers, and researchers interested in using IDH solutions to empower T2D patients.

An Adaptive, Algorithm-based Text Message Intervention to Promote Health Behavior Adherence in Type 2 Diabetes: Treatment Development and Proof-of-Concept Trial

BACKGROUND

Most individuals with type 2 diabetes (T2D) struggle to adhere to one or more health behaviors. Text message interventions (TMIs) have the potential to improve adherence but have had mixed effects on diet and activity in T2D. We developed an eight-week, adaptive, algorithm-driven TMI to promote physical activity, diet, self-care, and well-being. Then, in a single-arm trial, we assessed its feasibility, acceptability, and preliminary efficacy in 15 individuals with T2D and suboptimal adherence.

METHODS

Participants received daily text messages and were asked to rate the utility of each message (0=not helpful, 10=very helpful). These ratings were used by an algorithm to select subsequent messages based on each participant's prior ratings. We assessed intervention feasibility by rates of message transmission/response and acceptability through ratings of message utility and burden. Finally, we examined pre-post changes in diabetes self-care, diet, physical activity, and psychological outcomes and calculated effect sizes (Cohen's d).

RESULTS

All text messages were delivered, and participants provided ratings for 79% of messages, above our a priori thresholds for feasibility. Participants rated the individual messages and overall TMI as subjectively useful (utility: 8.1 [SD=2.1] and 7.8 [SD=2.0], respectively) and not burdensome (burden: 0.8 [SD=1.8]). The intervention led to significant, medium- to large-sized improvements in self-care (d=0.77), diet (d=0.99), and activity (d=0.61) but minimal change in psychological outcomes.

CONCLUSIONS

The TMI was feasible and well-accepted, and it led to promising improvements in adherence-related outcomes. These findings should be confirmed in a larger randomized controlled trial.

The Use of Mobile Health Interventions for Outcomes among Middle-Aged and Elderly Patients with Prediabetes: A Systematic Review

BACKGROUND

There are currently limited systematic reviews of mobile health interventions for middle-aged and elderly patients with prediabetes from trial studies. This review aimed to gather and analyze information from experimental studies investigating the efficacy of mobile health usability for outcomes among middle-aged and elderly patients with prediabetes.

METHODS

We conducted a literature search in five databases: Clinicaltrials.gov, the International Clinical Trials Registry Platform (ICTRP), PubMed, ProQuest, and EBSCO, with a date range of January 2007 to July 2022 written in English, following a registered protocol on PROSPERO (CRD42022354351). The quality and possibility of bias were assessed using the Jadad score. The data extraction and analysis were conducted in a methodical manner.

RESULTS

A total of 25 studies were included in the qualitative synthesis, with 19 studies using randomized trial designs and 6 studies with non-randomized designs. The study outcomes were the incidence of diabetes mellitus, anthropometric measures, laboratory examinations, measures of physical activity, and dietary behavior. During long-term follow-up, there was no significant difference between mobile health interventions and controls in reducing the incidence of type 2 diabetes. The findings of the studies for weight change, ≥3% and ≥5% weight loss, body mass index, and waist circumference changes were inconsistent. The efficacy of mobile health as an intervention for physical activity and dietary changes was lacking in conclusion. Most studies found that mobile health lacks sufficient evidence to change hbA1c. According to most of these studies, there was no significant difference in blood lipid level reduction.

CONCLUSIONS

The use of mobile health was not sufficiently proven to be effective for middle-aged and elderly patients with prediabetes.

REinforcement learning to improve non-adherence for diabetes treatments by Optimising Response and Customising Engagement (REINFORCE): study protocol of a pragmatic randomised trial

INTRODUCTION

Achieving optimal diabetes control requires several daily self-management behaviours, especially adherence to medication. Evidence supports the use of text messages to support adherence, but there remains much opportunity to improve their effectiveness. One key limitation is that message content has been generic. By contrast, reinforcement learning is a machine learning method that can be used to identify individuals' patterns of responsiveness by observing their response to cues and then optimising them accordingly. Despite its demonstrated benefits outside of healthcare, its application to tailoring communication for patients has received limited attention. The objective of this trial is to test the impact of a reinforcement learning-based text messaging programme on adherence to medication for patients with type 2 diabetes.

METHODS AND ANALYSIS

In the REinforcement learning to Improve Non-adherence For diabetes treatments by Optimising Response and Customising Engagement (REINFORCE) trial, we are randomising 60 patients with suboptimal diabetes control treated with oral diabetes medications to receive a reinforcement learning intervention or control. Subjects in both arms will receive electronic pill bottles to use, and those in the intervention arm will receive up to daily text messages. The messages will be individually adapted using a reinforcement learning prediction algorithm based on daily adherence measurements from the pill bottles. The trial's primary outcome is average adherence to medication over the 6-month follow-up period. Secondary outcomes include diabetes control, measured by glycated haemoglobin A1c, and self-reported adherence. In sum, the REINFORCE trial will evaluate the effect of personalising the framing of text messages for patients to support medication adherence and provide insight into how this could be adapted at scale to improve other self-management interventions.

ETHICS AND DISSEMINATION

This study was approved by the Mass General Brigham Institutional Review Board (IRB) (USA). Findings will be disseminated through peer-reviewed journals, clinicaltrials.gov reporting and conferences.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT04473326).

Preferences for mHealth Technology and Text Messaging Communication in Patients With Type 2 Diabetes: Qualitative Interview Study

Background

Individuals with diabetes need regular support to help them manage their diabetes on their own, ideally delivered via mechanisms that they already use, such as their mobile phones. One reason for the modest effectiveness of prior technology-based interventions may be that the patient perspective has been insufficiently incorporated.

Objective

This study aims to understand patients’ preferences for mobile health (mHealth) technology and how that technology can be integrated into patients’ routines, especially with regard to medication use.

Methods

We conducted semistructured qualitative individual interviews with patients with type 2 diabetes from an urban health care system to elicit and explore their perspectives on diabetes medication–taking behaviors, daily patterns of using mobile technology, use of mHealth technology for diabetes care, acceptability of text messages to support medication adherence, and preferred framing of information within text messages to support diabetes care. The interviews were digitally recorded and transcribed. The data were analyzed using codes developed by the study team to generate themes, with representative quotations selected as illustrations.

Results

We conducted interviews with 20 participants, of whom 12 (60%) were female and 9 (45%) were White; in addition, the participants’ mean glycated hemoglobin A_1c control was 7.8 (SD 1.1). Overall, 5 key themes were identified: patients try to incorporate cues into their routines to help them with consistent medication taking; many patients leverage some form of technology as a cue to support adherence to medication taking and diabetes self-management behaviors; patients value simplicity and integration of technology solutions used for diabetes care, managing medications, and communicating with health care providers; some patients express reluctance to rely on mobile technology for these diabetes care behaviors; and patients believe they prefer positively framed communication, but communication preferences are highly individualized.

Conclusions

The participants expressed some hesitation about using mobile technology in supporting diabetes self-management but have largely incorporated it or are open to incorporating it as a cue to make medication taking more automatic and less burdensome. When using technology to support diabetes self-management, participants exhibited individualized preferences, but overall, they preferred simple and positively framed communication. mHealth interventions may be improved by focusing on integrating them easily into daily routines and increasing the customization of content.

The Use of Mobile Messaging for Telecommunications with Patients in Ophthalmology: A Systematic Review

Background: Communication and concordance between patients and providers are crucial for improved outcomes and disease prevention. Mobile health strategies have been shown to improve patient accessibility and convenience. Mobile messaging is one strategy that has demonstrated varying degrees of effectiveness in patient care. The aim of this review is to investigate methods, outcomes, and conclusions of studies that have assessed mobile messaging interventions in ophthalmology. Methods: A qualitative systematic review of PubMed, Scopus, Web of Science, and Embase databases was conducted to identify studies that investigated the implementation and efficacy of mobile messaging services in ophthalmology practice. Included articles were categorized based on study content: appointment attendance, patient preference and willingness, education, concordance, and other clinical outcomes. Three tools were used to assess for potential bias. Results: Out of a total of 3,655 unique titles retrieved, 15 articles were included in the final qualitative synthesis after abstract and full-text screening. Included studies were published between 2008 and 2020 from seven different countries and across various contexts. All but one study found that the use of mobile messaging in ophthalmology care led to improved process measures or patient outcomes. Evidence for a positive effect was the strongest for appointment follow-up. Survey and feedback data suggest that patients, more so younger patients, are open to mobile message interventions. Conclusion: Mobile messaging interventions can play a role in improving appointment attendance, patient education, and patient practices for ophthalmology patients. Further study is necessary to determine the effectiveness of this tool across various groups and settings.

Text message reminders for adolescents with poorly controlled type 1 diabetes: A randomized controlled trial

Background

Among adolescents with type 1 diabetes, some experience great difficulties with treatment adherence, putting them at high risk of complications. We assessed the effect of text messaging (Short Messaging Service [SMS]) on glycemic control.

Methods

A two-arm open label randomized controlled trial enrolled adolescents with type 1 diabetes aged 12–21 years with baseline HbA1c ≥ 69 mmol/mol (8.5%). The intervention group received daily SMS reminders at self-selected times about insulin injections while the control group received standard of care. The patients allocated to the control group were not aware of the intervention.

Results

92 patients were randomized, 45 in the SMS arm and 47 in the control arm. After 6 months, median HbA1c level was significantly lower in the intervention arm: 73 mmol/mol (8.8%) in the SMS arm and 83 mmol/mol (9.7%) in the control arm in the intent-to-treat analysis (P = 0.03) but no longer in the per protocol analysis (P = 0.65). When we consider the proportions of patients whose HbA1c level decreased by at least 1% between baseline and 6 months, we find a significant difference among patients whose baseline HbA1c was ≥ 80 mmol/mol (9.5%) (n = 56): 60% in the SMS arm and 30.6% in the control arm had lowered their HbA1c level (P = 0.03) in the intent-to-treat analysis but not in the per-protocol analysis (P = 0.50). Patients in the SMS arm reported high satisfaction with the intervention.

Conclusions

While there is a trend to lower HbA1c in the intervention group, no firm conclusions can yet be drawn. Further studies are needed to address methodological issues as we believe these interventions can support behavior change among adolescents with poorly controlled type 1 diabetes. ClinicalTrials.gov identifier: NCT02230137.

Impact of Non-Tailored One-Way Automated Short Messaging Service (OASMS) on Glycemic Control in Type 2 Diabetes: A Retrospective Feasibility Study

Short message service (SMS) is easily accessible and potentially an ideal platform for delivering patient-targeted messages. However, an effective SMS dosing strategy is not well established. Our purpose was to evaluate the impact of diabetes self-care promoting messages via non-tailored one-way automated SMS (OASMS) on glycemic control in type 2 diabetes (T2DM). The change in hemoglobin A1c (HbA1c) was compared between patients who received the service and those who did not. This retrospective quasi-experimental pre-post feasibility study was conducted at an academic medical center endocrinology clinic. English-speaking adults (≥18 years) with uncontrolled T2DM (HbA1c ≥ 8%) were included. A total of 69 patients (intervention n = 34; control n = 35) met the inclusion criteria. The mean (±SD) baseline HbA1c values were 10.2% (±1.9%) and 9.9% (±1.7%) in the intervention and control arms, respectively. Median follow-up was 3.3 months (IQR = 3-4.2). An ANCOVA model adjusted for baseline HbA1c and age showed an estimated HbA1c reduction difference of -0.97% (95% CI, -1.73 to -0.20%, p = 0.014), favoring the intervention arm. Inverse propensity score weighting confirmed the ANCOVA results. Our study suggests that adding diabetes self-care promoting messages via non-tailored OASMS to usual care improves glycemic control in poorly controlled T2DM. Larger and longer studies are needed to evaluate different features of the non-tailored OASMS strategy.

Use of Brief Messages Based on Behavior Change Techniques to Encourage Medication Adherence in People With Type 2 Diabetes: Developmental Studies

BACKGROUND

Brief messages are a promising way to improve adherence to medication for people with type 2 diabetes. However, it is often unclear how messages have been developed and their precise content, making it difficult to ascertain why certain messages are successful and some are not.

OBJECTIVE

The goal of the research was to develop messages that have proven fidelity to specified evidence-derived behavior change techniques (BCTs) and are acceptable to people with type 2 diabetes.

METHODS

Four studies were conducted: (1) a workshop (n=21) where behavioral change researchers and health care professionals developed messages based on specific BCTs or beliefs or concerns related to taking medication, (2) a focus group study with people with type 2 diabetes (n=23) to assess acceptability of the approach, (3) a survey to ascertain the acceptability of a subset of messages to people with type 2 diabetes (n=61) and, (4) a survey with behavior change researchers to assess the fidelity of a subset of messages to their intended BCT (n=18).

RESULTS

In study 1, 371 messages based on 38 BCTs and beliefs/concerns were developed. Workshop participants rated BCTs to be relevant to medication adherence (mean 7.12/10 [SD 1.55]) and messages to have good fidelity (mean 7.42/10 [SD 1.19]). In study 2, the approach of providing medication adherence support through text messages was found to be acceptable. In study 3, mean acceptability of all BCTs was found to be above the midpoint (mean 3.49/5 [SD 0.26]). In study 4, mean fidelity for all BCTs was found to be above the midpoint (mean 7.61/10 [SD 1.38]).

CONCLUSIONS

A library of brief messages acceptable to people with type 2 diabetes and representative of specific evidence-derived BCTs was developed. This approach allowed brief messages to be developed with known content that can be used to test theory.

Effectiveness of Mobile Health Interventions on Diabetes and Obesity Treatment and Management: Systematic Review of Systematic Reviews

BACKGROUND

Diabetes and obesity have become epidemics and costly chronic diseases. The impact of mobile health (mHealth) interventions on diabetes and obesity management is promising; however, studies showed varied results in the efficacy of mHealth interventions.

OBJECTIVE

This review aimed to evaluate the effectiveness of mHealth interventions for diabetes and obesity treatment and management on the basis of evidence reported in reviews and meta-analyses and to provide recommendations for future interventions and research.

METHODS

We systematically searched the PubMed, IEEE Xplore Digital Library, and Cochrane databases for systematic reviews published between January 1, 2005, and October 1, 2019. We analyzed 17 reviews, which assessed 55,604 original intervention studies, that met the inclusion criteria. Of those, 6 reviews were included in our meta-analysis.

RESULTS

The reviews primarily focused on the use of mobile apps and text messaging and the self-monitoring and management function of mHealth programs in patients with diabetes and obesity. All reviews examined changes in biomarkers, and some reviews assessed treatment adherence (n=7) and health behaviors (n=9). Although the effectiveness of mHealth interventions varied widely by study, all reviews concluded that mHealth was a feasible option and had the potential for improving patient health when compared with standard care, especially for glycemic control (-0.3% to -0.5% greater reduction in hemoglobin A1c) and weight reduction (-1.0 kg to -2.4 kg body weight). Overall, the existing 6 meta-analysis studies showed pooled favorable effects of these mHealth interventions (-0.79, 95% CI -1.17 to -0.42; I2=90.5).

CONCLUSIONS

mHealth interventions are promising, but there is limited evidence about their effectiveness in glycemic control and weight reduction. Future research to develop evidence-based mHealth strategies should use valid measures and rigorous study designs. To enhance the effectiveness of mHealth interventions, future studies are warranted for the optimal formats and the frequency of contacting patients, better tailoring of messages, and enhancing usability, which places a greater emphasis on maintaining effectiveness over time.

Long-term follow-up of a randomized controlled trial of a text-message diabetes self-management support programme, SMS4BG

AIMS

To determine the long-term effectiveness of an individually tailored text-message diabetes self-management support programme, SMS4BG, on glycaemic control at 2 years in adults with diabetes with an HbA_1c concentration > 64 mmol/mol (8%).

METHODS

We conducted a 2-year follow-up of a two-arm, parallel, randomized controlled trial across health services in New Zealand. Participants were English-speaking adults with type 1 or 2 diabetes and with an HbA_1c >64 mmol/mol (8%). In the main trial participants randomized to the intervention group (N=183) received up to 9 months of an automated tailored text-message programme in addition to usual care. Participants in the control group (N=183) received usual care for 9 months. In this follow-up study, 293 (80%) of 366 randomized participants in the main trial were included. The primary outcome measure was change in glycaemic control (HbA_1c ) from baseline to 2 years. Mixed-effect models were used to compare the group differences at 3, 6, 9 and 24 months, adjusted for baseline HbA_1c and stratification factors (health district category, diabetes type and ethnicity).

RESULTS

The decrease in HbA_1c at 2 years was significantly greater in the intervention group [mean (sd) -10 (18) mmol/mol or -0.9 (1.6)%] compared with the control group [mean (sd) -1 (20) mmol/mol or -0.1 (1.8)%], with an adjusted mean difference of -9 mmol/mol (95% CI -14, -5) or -0.8% (95% CI -1.2, -0.4; P<0.0001).

CONCLUSIONS

Improvements in glycaemic control resulting from a text-message diabetes self-management support programme were sustained at 2 years after randomization. These findings support the implementation of SMS4BG in current practice.

The use of text messaging for improving adherence to anti-diabetic regimen and glycaemic control in low-resource settings of South Africa: A study protocol for a randomised controlled trial

Background

Despite the various innovations and treatment modalities, diabetes treatment outcomes remain sub-optimal globally and in South Africa. This places significant strain on the healthcare system. Text messaging is a cost-effective measure for promoting health. Yet, its effectiveness in improving diabetes treatment outcomes has not been documented in South Africa, especially in the resource-restrained settings. This study aims as determining the effectiveness, feasibility and acceptability of text messaging in improving diabetes outcomes in low-resource settings of the Eastern Cape Province of South Africa.

Methods and analysis

This is a multi-centre, two-arm, parallel, randomised controlled trial which will compare the use of text messaging in addition to diabetes standard care to standard care alone in promoting diabetes outcomes for six months. The study will be conducted at six primary healthcare centres in two selected districts in Eastern Cape, South Africa. The study requires 216 participants if an attrition rate of 20% is anticipated. Data will be collected at baseline and six months. Randomisation will follow baseline data collection using simple randomisation, with an allocation ratio of 1:1, after removing any identifying information. The primary outcome measure is a change in mean morning random blood sugar. Secondary outcomes include change in diabetes knowledge, medication adherence, self-management, health-related quality of life, mean blood pressure, weight and clinic attendance. Data will be obtained through self-reporting using validated measures, review of clinical records and objective measurements. Data collection and measurements will follow standard procedure. Data analysis will be based on the principle of Intention-to-treat.

Trial registration

This trial was registered in the Pan African Clinical Trial Registry, trial number: PACTR201810599931422.

Assessment of Rwandan diabetic patients' needs and expectations to develop their first diabetes self-management smartphone application (Kir'App)

BACKGROUND

Knowledge of and coping with diabetes is still poor in some communities in Rwanda. While smartphone applications (or apps) have demonstrated improving diabetes self-care, there is no current study on the use of smartphones in the self-management of diabetes in Rwanda.

METHODS

The main objective of this study was to assess the needs and expectations of Rwandan diabetic patients for mobile-health-supported diabetes self-management in order to develop a patient-centred smartphone application (Kir'App).

RESULTS

Convenience sampling was used to recruit study participants at the Rwanda Diabetes Association. Twenty-one patients participated in semi-structured, in-depth, face-to-face interviews. Thematic analysis was performed using Mayring's method of qualitative content analysis.

CONCLUSIONS

The study included 21 participants with either type 1 (female = 5, male = 6) or type 2 (female = 6, male = 4) diabetes. Participants' age ranged from 18 to 69 years with a mean age of 35 and 29 years, respectively. Eight main themes were identified. These were (a) diabetes education and desired information provision; (b) lack of diabetes knowledge and awareness; (c) need for information in crisis situations; (d) required monitoring and reminder functions; (e) information on nutrition and alcohol consumption; (f) information on physical activity; (g) coping with burden of disease, through social support and network; (h) app features. This study provides recommendations that will be used to design the features of the first Rwandan diabetes self-management smartphone application (Kir'App). The future impact of the application on the Rwandan diabetic patients' self-management capacity and quality of life will be evaluated afterwards.

Artificial Intelligence for Participatory Health: Applications, Impact, and Future Implications

Objective : Artificial intelligence (AI) provides people and professionals working in the field of participatory health informatics an opportunity to derive robust insights from a variety of online sources. The objective of this paper is to identify current state of the art and application areas of AI in the context of participatory health.

Methods : A search was conducted across seven databases (PubMed, Embase, CINAHL, PsychInfo, ACM Digital Library, IEEExplore, and SCOPUS), covering articles published since 2013. Additionally, clinical trials involving AI in participatory health contexts registered at clinicaltrials.gov were collected and analyzed.

Results : Twenty-two articles and 12 trials were selected for review. The most common application of AI in participatory health was the secondary analysis of social media data: self-reported data including patient experiences with healthcare facilities, reports of adverse drug reactions, safety and efficacy concerns about over-the-counter medications, and other perspectives on medications. Other application areas included determining which online forum threads required moderator assistance, identifying users who were likely to drop out from a forum, extracting terms used in an online forum to learn its vocabulary, highlighting contextual information that is missing from online questions and answers, and paraphrasing technical medical terms for consumers.

Conclusions : While AI for supporting participatory health is still in its infancy, there are a number of important research priorities that should be considered for the advancement of the field. Further research evaluating the impact of AI in participatory health informatics on the psychosocial wellbeing of individuals would help in facilitating the wider acceptance of AI into the healthcare ecosystem.

DTEXT - text messaging intervention to improve outcomes of people with type 2 diabetes: protocol for randomised controlled trial and cost-effectiveness analysis

BACKGROUND

Diabetes prevalence is rapidly increasing, with type 2 diabetes predicted to be the leading contributor of non-communicable disease in Australia by 2020. It is anticipated that rates of type 2 diabetes will continue to increase if factors such as overweight and obesity, low physical activity and poor nutrition are not addressed. The majority of Australians with type 2 diabetes do not meet the guidelines for optimal diabetes management, and access to diabetes education is limited. This highlights the need for new interventions that can reduce existing barriers to diabetes education, attain greater population reach and support self-management strategies for people with type 2 diabetes. Mobile phone text messages have shown promising results as an intervention for people with chronic disease. They have the ability to achieve high levels of engagement and broad population reach, whilst requiring minimal resources. There is however, no evidence on the effect of text messaging to improve the health of people with type 2 diabetes in Australia.

METHODS/DESIGN

This randomised controlled trial aims to investigate if a 6 month text message intervention (DTEXT) can lead to improvements in glycated haemoglobin (HbA1c) and diabetes self-management among Australian residents in New South Wales (NSW) with type 2 diabetes. Community dwelling adults (n = 340) will be recruited with the primary outcome being change in HbA1c at 6 months. Secondary outcomes include behaviour change for diabetes self-management, self-efficacy, quality of life and intervention acceptability. An economic evaluation will be conducted using a funder plus patient perspective.

DISCUSSION

This study will provide evidence on the effectiveness and cost effectiveness of a text message intervention to reduce HbA1c and enhance self-management of type 2 diabetes in the Australian population. If successful, this intervention could be used as a model to complement and extend existing diabetes care in the Australian health care system.

TRIAL REGISTRATION

The study has been registered with the Australian New Zealand Clinical Trials Registry, Trial ID: ACTRN12617000416392 . Registered: 23 March 2017.

Social Media in Primary Care

Social media has become a standard part of the day for the majority of people in the United States, and reciprocally has become an effective platform and tool for patient engagement within health care. This review provides context for its place in patient education, communication, and treatment, combined with a review of general operational and ethical principles for social media platforms within a primary care practice.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What do people with type 2 diabetes want from a brief messaging system to support medication adherence?

BACKGROUND

Many people with type 2 diabetes do not take their treatment as prescribed. Brief messages to support medication use could reach large numbers of people at a very low cost per person, but current interventions using brief messages rarely adequately describe the content of the messages, nor base these messages on explicit behavior change principles. This study reports the views of people with type 2 diabetes concerning the acceptability of 1) a messaging system and 2) proposed messages based on behavior change techniques (BCTs) and beliefs and concerns around taking medication.

METHODS

The proposed system and brief messages were discussed in focus groups of people with type 2 diabetes recruited through general practices in England. Transcripts were analyzed thematically.

PARTICIPANTS

Twenty-three participants took part in one of five focus group discussions. All participants were over 18 years, were taking tablet medication for their diabetes, and had access to a mobile phone. Key exclusion criteria were recent hospitalization for hyper- or hypoglycemia or diagnosis with a terminal illness.

RESULTS

Four themes were identified as relating to the acceptability of the messaging system: "opportunities and limitations of technology", "us and them (who is the system for?)", "responsibility for adherence", and "diabetes management beyond medication". Participants recognized the benefit of using technology. Those with high confidence in their ability to adhere were keen to make a distinction between themselves and those who did not adhere; participants were more comfortable taking responsibility for medication than diet and exercise. Acceptability of the messages hinged on avoiding "preaching to the converted".

CONCLUSIONS

These findings show that brief messaging could be acceptable to the target population for a range of diabetes-related behaviors but highlight the need for such a system to be perceived as personally relevant. Acceptable messages would need to maintain novelty for the target population.

Strengthening Delivery of Health Services Using Digital Devices

BACKGROUND

Delivery of high-quality efficient health services is a cornerstone of the global agenda to achieve universal health coverage. According to the World Health Organization, health service delivery is considered good when equitable access to a comprehensive range of high-quality health services is ensured within an integrated and person-centered continuum of care. However, good health service delivery can be challenging in low-resource settings. In this review, we summarize and discuss key advances in health service delivery, particularly in the context of using digital health strategies for mitigating human resource constraints.

METHODS

The review updates the foundational systematic review conducted by Agarwal et al. in 2015. We used PubMed, EMBASE, and CINAHL to find relevant English-language peer-reviewed articles published 2018. Our search strategy for MEDLINE was based on MeSH (medical subject headings) terms and text words of key articles that we identified a priori. Our search identified 92 articles. After screening, we selected 24 articles for abstract review, of which only 6 met the eligibility criteria and were ultimately included in this review.

RESULTS

Despite encouraging advances in the evidence base on digital strategies for health service delivery, the current body of evidence is still quite limited in 3 main areas: the effectiveness of interventions on health outcomes, improvement in health system efficiencies for service delivery, and the human capacity required to implement and support digital health strategies at scale. Two particular areas, digital health-enhanced referral coordination and mobile clinical decision support systems, demonstrate considerable potential to improve the quality and comprehensiveness of care received by patients, but they require a greater level of standardization and an expanded scope of health worker engagement across the health system in order to scale them up effectively.

CONCLUSIONS

Additional research is urgently needed to inform the effectiveness of interventions on health outcomes, improvement in health system efficiencies, and cost-effectiveness of service delivery. In particular, more documentation and research on ways to standardize and engage health workers in digital referral and clinical decision support systems can provide the foundation needed to scale these promising approaches in low- and middle-income settings.

Diabetes Care in the Digital Era: a Synoptic Overview

PURPOSE OF REVIEW

Diabetes care is undergoing a remarkable transformation by the advancements in information and communications technology (ICT). The aim of this review is to provide a general overview of various ICT-based interventions for diabetes care, challenges of their adoption, and consider future directions.

RECENT FINDINGS

A number of systematic reviews have examined studies on various aspects of telemedicine and eHealth for diabetes care, but they are generally focused on one specific type of technology application for diabetes care. A wide range of solutions from manual or automated telephone calls, short message services, websites, mobile health apps, remote monitoring devices, and sophisticated artificial intelligence systems has been studied in different settings and scopes with mixed results. However, despite the promising results of research studies, such innovative solutions are not widely adopted by health systems worldwide. Lack of supportive policy and legislation, unsustainable reimbursement, inefficient business models, and concerns regarding the security and privacy of health data are among the most problematic barriers.