A web-based support for pregnant women and new mothers with type 1 diabetes mellitus in Sweden (MODIAB-Web): study protocol for a randomized controlled trial

Behavioural interventions delivered through interactive social media for health behaviour change, health outcomes, and health equity in the adult population

BACKGROUND

Social networking platforms offer a wide reach for public health interventions allowing communication with broad audiences using tools that are generally free and straightforward to use and may be combined with other components, such as public health policies. We define interactive social media as activities, practices, or behaviours among communities of people who have gathered online to interactively share information, knowledge, and opinions.

OBJECTIVES

We aimed to assess the effectiveness of interactive social media interventions, in which adults are able to communicate directly with each other, on changing health behaviours, body functions, psychological health, well-being, and adverse effects. Our secondary objective was to assess the effects of these interventions on the health of populations who experience health inequity as defined by PROGRESS-Plus. We assessed whether there is evidence about PROGRESS-Plus populations being included in studies and whether results are analysed across any of these characteristics.

SEARCH METHODS

We searched CENTRAL, CINAHL, Embase, MEDLINE (including trial registries) and PsycINFO. We used Google, Web of Science, and relevant web sites to identify additional studies and searched reference lists of included studies. We searched for published and unpublished studies from 2001 until June 1, 2020. We did not limit results by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled before-and-after (CBAs) and interrupted time series studies (ITSs). We included studies in which the intervention website, app, or social media platform described a goal of changing a health behaviour, or included a behaviour change technique. The social media intervention had to be delivered to adults via a commonly-used social media platform or one that mimicked a commonly-used platform. We included studies comparing an interactive social media intervention alone or as a component of a multi-component intervention with either a non-interactive social media control or an active but less-interactive social media comparator (e.g. a moderated versus an unmoderated discussion group). Our main outcomes were health behaviours (e.g. physical activity), body function outcomes (e.g. blood glucose), psychological health outcomes (e.g. depression), well-being, and adverse events. Our secondary outcomes were process outcomes important for behaviour change and included knowledge, attitudes, intention and motivation, perceived susceptibility, self-efficacy, and social support.

DATA COLLECTION AND ANALYSIS

We used a pre-tested data extraction form and collected data independently, in duplicate. Because we aimed to assess broad outcomes, we extracted only one outcome per main and secondary outcome categories prioritised by those that were the primary outcome as reported by the study authors, used in a sample size calculation, and patient-important.

MAIN RESULTS

We included 88 studies (871,378 participants), of which 84 were RCTs, three were CBAs and one was an ITS. The majority of the studies were conducted in the USA (54%). In total, 86% were conducted in high-income countries and the remaining 14% in upper middle-income countries. The most commonly used social media platform was Facebook (39%) with few studies utilising other platforms such as WeChat, Twitter, WhatsApp, and Google Hangouts. Many studies (48%) used web-based communities or apps that mimic functions of these well-known social media platforms. We compared studies assessing interactive social media interventions with non-interactive social media interventions, which included paper-based or in-person interventions or no intervention. We only reported the RCT results in our 'Summary of findings' table. We found a range of effects on health behaviours, such as breastfeeding, condom use, diet quality, medication adherence, medical screening and testing, physical activity, tobacco use, and vaccination. For example, these interventions may increase physical activity and medical screening tests but there was little to no effect for other health behaviours, such as improved diet or reduced tobacco use (20,139 participants in 54 RCTs). For body function outcomes, interactive social media interventions may result in small but important positive effects, such as a small but important positive effect on weight loss and a small but important reduction in resting heart rate (4521 participants in 30 RCTs). Interactive social media may improve overall well-being (standardised mean difference (SMD) 0.46, 95% confidence interval (CI) 0.14 to 0.79, moderate effect, low-certainty evidence) demonstrated by an increase of 3.77 points on a general well-being scale (from 1.15 to 6.48 points higher) where scores range from 14 to 70 (3792 participants in 16 studies). We found no difference in effect on psychological outcomes (depression and distress) representing a difference of 0.1 points on a standard scale in which scores range from 0 to 63 points (SMD -0.01, 95% CI -0.14 to 0.12, low-certainty evidence, 2070 participants in 12 RCTs). We also compared studies assessing interactive social media interventions with those with an active but less interactive social media control (11 studies). Four RCTs (1523 participants) that reported on physical activity found an improvement demonstrated by an increase of 28 minutes of moderate-to-vigorous physical activity per week (from 10 to 47 minutes more, SMD 0.35, 95% CI 0.12 to 0.59, small effect, very low-certainty evidence). Two studies found little to no difference in well-being for those in the intervention and control groups (SMD 0.02, 95% CI -0.08 to 0.13, small effect, low-certainty evidence), demonstrated by a mean change of 0.4 points on a scale with a range of 0 to 100. Adverse events related to the social media component of the interventions, such as privacy issues, were not reported in any of our included studies. We were unable to conduct planned subgroup analyses related to health equity as only four studies reported relevant data.

AUTHORS' CONCLUSIONS

This review combined data for a variety of outcomes and found that social media interventions that aim to increase physical activity may be effective and social media interventions may improve well-being. While we assessed many other outcomes, there were too few studies to compare or, where there were studies, the evidence was uncertain. None of our included studies reported adverse effects related to the social media component of the intervention. Future studies should assess adverse events related to the interactive social media component and should report on population characteristics to increase our understanding of the potential effect of these interventions on reducing health inequities.

Initial Validation of the Diabetes and Breastfeeding Management Questionnaire (DBM-Q)

Women with pre-gestational diabetes face additional challenges after birth as they struggle with breastfeeding and managing unpredictable blood glucose levels. The aim of this study is to validate the Diabetes and Breastfeeding Management Questionnaire (DBM-Q). In total, 142 mothers with type 1 diabetes mellitus answered the questionnaire, which initially consisted of 11 items. The response rate was 82.5% (n = 128) at two months, and 88.4% (n = 137) at six months postpartum. The measurement properties of the Diabetes and Breastfeeding Management Questionnaire were tested according to the Rasch measurement theory (RMT). One item showed both disordered thresholds and several model misfits and was removed. Two items showed disordered thresholds which were resolved by collapsing response categories. This resulted in a 10-item questionnaire with all the fit residuals within the range of +2.5, minor significant differential item functioning, well-targeted items and a person separation index of 0.73. Evaluating the DBM-Q according to the RMT is a strength, as it evaluates data against strict measurement criteria. This study provides an initial validation of the questionnaire. The DBM-Q shows good measurement properties for measuring diabetes and breastfeeding management postpartum in women with pre-gestational diabetes. Further studies are needed to identify cutoffs for when professional support is needed.

The Influence of Social Media on Intrapartum Decision Making: A Scoping Review

Social media has been influential in decision making regarding a number of health concerns. However, comparatively little has been examined with regard to its effects on pregnant women. The goal of this scoping review was to examine the literature and identify the role of social media in intrapartum decision making. A scoping review of the literature published between January 1990 and June 2018 was performed using PubMed, CINAHL, EMBASE, PsychINFO, Web of Science, and Cochrane databases. Of the initial 1951 records reviewed, 5 met inclusion criteria. Two of the 5 were quantitative in design, 1 was qualitative, and 2 used mixed methods. Internationally widespread, studies largely took place in developed nations including the United States, the United Kingdom, Canada, Australia, New Zealand, and Finland. Women are using the Internet, including social media, consistently as a source of pregnancy information, for example, 97% of 2400 participates in 1 exploratory study. This knowledge seeking was found to increase women's confidence and self-assurance in making decision during labor and birth. Studies identified issues surrounding women's ability to appraise available information. While it is clear that social media has an influence on women's intrapartum decision making, it is not clear exactly how. Further studies are needed to determine the content of the social media being appraised, the accuracy of the information, and the resulting decision as it affects the intrapartum experience. In addition, efforts should be made to open lines of communication between patients and care providers. This may foster a greater clinical understanding of social media consumption and its influences.

Web-Based Intervention for Women With Type 1 Diabetes in Pregnancy and Early Motherhood: Critical Analysis of Adherence to Technological Elements and Study Design

Background

Numerous Web-based interventions have been implemented to promote health and health-related behaviors in persons with chronic conditions. Using randomized controlled trials to evaluate such interventions creates a range of challenges, which in turn can influence the study outcome. Applying a critical perspective when evaluating Web-based health interventions is important.

Objective

The objective of this study was to critically analyze and discuss the challenges of conducting a Web-based health intervention as a randomized controlled trial.

Method

The MODIAB-Web study was critically examined using an exploratory case study methodology and the framework for analysis offered through the Persuasive Systems Design model. Focus was on technology, study design, and Web-based support usage, with special focus on the forum for peer support. Descriptive statistics and qualitative content analysis were used.

Results

The persuasive content and technological elements in the design of the randomized controlled trial included all four categories of the Persuasive Systems Design model, but not all design principles were implemented. The study duration was extended to a period of four and a half years. Of 81 active participants in the intervention group, a maximum of 36 women were simultaneously active. User adherence varied greatly with a median of 91 individual log-ins. The forum for peer support was used by 63 participants. Although only about one-third of the participants interacted in the forum, there was a fairly rich exchange of experiences and advice between them. Thus, adherence in terms of social interactions was negatively affected by limited active participation due to prolonged recruitment process and randomization effects. Lessons learned from this critical analysis are that technology and study design matter and might mutually influence each other. In Web-based interventions, the use of design theories enables utilization of the full potential of technology and promotes adherence. The randomization element in a randomized controlled trial design can become a barrier to achieving a critical mass of user interactions in Web-based interventions, especially when social support is included. For extended study periods, the technology used may need to be adapted in line with newly available technical options to avoid the risk of becoming outdated in the user realm, which in turn might jeopardize study validity in terms of randomized controlled trial designs.

Conclusions

On the basis of lessons learned in this randomized controlled trial, we give recommendations to consider when designing and evaluating Web-based health interventions.

Person-centred, web-based support in pregnancy and early motherhood for women with Type 1 diabetes mellitus: a randomized controlled trial

AIMS

To report results from and explore use of a multicentre, parallel-group, unblinded, randomized controlled trial testing the effectiveness in terms of well-being and diabetes management of a person-centred, web-based support programme for women with Type 1 diabetes, in pregnancy and postpartum.

METHODS

Between 2011 and 2014, 174 pregnant women with Type 1 diabetes were randomly allocated (1:1) to web-based support and standard care (intervention group, n=83), or standard care (control group, n=91). The web-based support consisted of evidence-based information; a self-care diary for monitoring of daily activities; and peer support in a discussion forum. The primary outcomes (mean difference, measured at 6 months after childbirth) were well-being and diabetes management.

RESULTS

No differences were found with regard to the primary outcome measure scores for general well-being [1.04 (95% CI -1.28 to 3.37); P=0.68] and self-efficacy of diabetes management [0.08 (95% CI -0.12 to 0.28); P= 0.75], after adjustment for baseline differences in the insulin administration method, nor with regard to the secondary outcome measures.

CONCLUSIONS

At 6 months after childbirth, the web-based support plus standard care was not superior to standard care in terms of general well-being or self-efficacy of diabetes management. This might be explained by the low number of participants who had a high activity level. Few simultaneously active participants in the web-based programme and stressors in motherhood and diabetes postpartum were the main barriers to its use. Further intervention studies that offer web-based support are needed, with lessons learned from the present study. (Clinicaltrials.gov identification number: NCT015665824).

Well-Being and Diabetes Management in Early Pregnant Women with Type 1 Diabetes Mellitus

This paper explores well-being and diabetes management in women with type 1 diabetes mellitus (DM) in early pregnancy and investigates associations among perceived well-being, diabetes management, and maternal characteristics. Questionnaires were answered by 168 Swedish women. Correlation analyses were conducted with Spearman's correlation coefficient (rs). The women reported relatively high scores of self-efficacy in diabetes management (SWE-DES-10: 3.91 (0.51)) and self-perceived health (excellent (6.5%), very good (42.3%), good (38.7%), fair (11.3%) and poor (1.2%)). Moderate scores were reported for general well-being (WBQ-12: 22.6 (5.7)) and sense of coherence (SOC-13: 68.9 (9.7), moderate/low scores for hypoglycemia fear (SWE-HFS 26.6 (11.8)) and low scores of diabetes-distress (SWE-PAID-20 27.1 (15.9)). A higher capability of self-efficacy in diabetes management showed positive correlations with self-perceived health (rs = -0.41, p < 0.0001) and well-being (rs = 0.34, p < 0.0001) as well as negative correlations with diabetes distress (rs = -0.51, p < 0.0001) and hypoglycemia worries (rs = -0.27, p = 0.0009). Women with HbA1c levels of ≤48 mmL/mol scored higher in the subscales "goal achievement" in SWE-DES (p = 0.0028) and "comprehensibility" in SOC (p = 0.016). Well-being and diabetes management could be supported by strengthening the women's capability to achieve glycemic goals and their comprehensibility in relation to the treatment. Further studies are needed to test this.

Using technology to advance type 1 diabetes care among women during the reproductive years and in pregnancy

The prevalence of diabetes is increasing globally. Technology to improve care among individuals with diabetes is constantly being developed. Women living with Type 1 Diabetes Mellitus (T1DM) have unique challenges affecting their glucose control relating to menstrual cycles, pregnancy, and menopause. The purpose of this review is to examine the literature related to the use of technology to help women with T1DM manage their diabetes during the reproductive years, pregnancy, and beyond. Continuous subcutaneous insulin infusion (CSII) therapy can provider equivalent or better glucose control when compared with multiple daily injections (MDI), with less hypoglycemia, diabetic ketoacidosis, and weight gain. The CSII therapy has features that could help improve glucose control over the menstrual cycle, menopause, and pregnancy, although the most studied of these stages is pregnancy. Continuous glucose monitoring (CGM) can be combined with any insulin delivery system (MDI or CSII) to provide data on glucose values every few minutes and show glucose trends over time. CGM introduction can highlight glucose variability for women with T1DM, may be beneficial during pregnancy, and can reduce hypoglycemia. Sensor-augmented pump therapy and hybrid artificial pancreas (closed-loop) systems are promising tools that improve outcomes among individuals with diabetes. The use of modern technology to improve glucose and metabolic control among menopausal women with diabetes has not been well studied. Internet and phone-based technologies are emerging as important tools that may help with diabetes self-care for women living with diabetes.

First nationwide web-based surveillance system for influenza-like illness in pregnant women: participation and representativeness of the French G-GrippeNet cohort

Background

Pregnancy is a risk factor for severe influenza resulting in increased risks of hospitalisation and death in mothers and their new-borns. Our objective was to assess the representativeness and participation of French women to a new web-based collaborative tool for data collection and monitoring of Influenza Like Illness (ILI) during pregnancy.

Methods

During the 2014/2015 influenza season, pregnant women living in metropolitan France were enrolled through a web platform (https://www.grippenet.fr/). Then throughout the season, participants were asked to report, on a weekly basis, if they had experienced symptoms of ILI. Representativeness was assessed by comparing the characteristics of participants to those of the French National Perinatal Survey. For each participant, the participation rate was the number of weekly questionnaires completed, divided by the length of follow-up (in weeks). Predictors of active participation (participation rate >15 %) were assessed by multivariate logistic regression.

Results

A total of 153 women were enrolled. Participants were older (mean age 34 years vs. 29 years) and more highly educated (high school level 89 % versus 52 %) than the general population of pregnant women in France, but the sample did not differ on pregnancy-related characteristics (parity, history of hospitalisation during a previous pregnancy). The median rate of participation was high (78 %, interquartile range: 34–96). Higher educational level and participation to a previous GrippeNet.fr season were associated with active participation.

Conclusion

Despite small sample size and lack of representativeness, the retention rate was high, suggesting that pregnant women are prone to adhere to a longitudinal follow-up of their health status via the Internet.