Development of a diabetes self-management + mHealth program: tailoring the intervention for a pilot study in a low-income setting in Mexico

Abstract

Background: Type 2 diabetes (T2D) is a public health pandemic disproportionately affecting low-and middleincome countries. The purpose of this formative research was to adapt evidence-based diabetes self-management education programs to the context of Seguro Popular clinics in Mexico. A theory-based mHealth (pictorial text messaging) component was developed. Method: Our formative research and development of the program protocol consisted of six phases: (1) interviews and focus groups with stakeholders on the challenges to T2D management, curriculum content needs, and the use of mHealth as a supplement to a DSME program; (2) review of the theoretical underpinning, curriculum, and interactive strategies of four evidence-based DSME programs and modification to meet the needs of adults with T2D and systems of care in Mexico City; (3) development of theory-based illustrated text messages; (4) evaluation of text messaging acceptability and access in adults with T2D via focus groups; (5) development of program manual; and (6) development of a training program for health care providers.Results: The ¡Sí, Yo Puedo Vivir Sano Con Diabetes! included 7 group-based weekly lessons; simple, interactive content; weekly empowerment messages; video novellas; group activities; and goal setting. Adaptations to the cultural context of Mexico included content/activities on diabetes etiology (addressing cultural misconceptions), nutrition (indigenous foods and plate method), self-blood glucose monitoring, and diabetes-related stress/coping. We used the Health Action Process Approach to guide the text message development, which posits that adoption, initiation, and maintenance of health behaviors require the development of intentions, plans, coping, and selfefficacy. Our final text message bank consisted of 181 messages. There were approximately 20-30 messages for each process of behavior change (e.g., action planning, maintenance self-efficacy) and 30 messages for each content topic (e.g., eating healthy, physical activity). There were 96 messages that were illustrated. Training materials were also developed. Discussion:We used a systematic approach, collaboration with stakeholders, and a well-established behavior change theory to develop an evidence-based intervention to an international context and system of care. Collectively, this process has the potential to enhance the feasibility, acceptability, and efficacy of the program.

The Impact of the Covid-19 Pandemic on the Well-Being and Diabetes Management of Adolescents With Type 1 Diabetes and Their Caregivers: A Scoping Review

“…Nonetheless, the authors themselves stated that there is no evidence to prove the efficacy of this digital intervention on adolescents' improved glycemic levels (30). Still, the literature shows that most eHealth interventions are predominantly oriented towards adults with diabetes, and they are mainly pilot or proof-of-concept studies (36)(37)(38).…”

The Barriers and Facilitators of eHealth-Based Lifestyle Intervention Programs for People With a Low Socioeconomic Status: Scoping Review

“…Several RCTs and observational studies evaluated eHealth interventions on health outcomes (eg, BMI, blood pressure, and hemoglobin A 1c ) [ 30 , 34 , 35 - 37 , 40 , 43 , 45 , 47 , 48 , 53 , 78 ], nutrition-related behavior outcomes [ 32 , 38 , 39 , 79 , 80 ], physical activity–related outcomes, smoking-related outcomes [ 23 , 31 , 46 , 51 , 81 , 82 ], usage outcomes [ 33 , 49 , 54 ], and reach [ 44 ], as well as feasibility and acceptability outcomes [ 47 , 80 ] ( Multimedia Appendix 3 ). Design studies examined recruitment [ 57 ], usability, feasibility [ 57 - 65 ], development, or acceptability of eHealth interventions [ 58 - 60 , 64 , 65 , 67 , 68 , 70 ]. The interventions were aimed at weight loss (n=9), physical activity (n=9), healthy eating (n=11), smoking (n=13), and alcohol use (n=2), and 17 interventions focused on multiple behaviors.…”

“…In the various stages of the development and evaluation of the intervention (ie, problem definition, development, and implementation for the study) [ 48 , 50 , 59 , 60 , 64 , 66 , 69 , 70 , 84 ], several studies involved stakeholders, which included family members, experts, key informants [ 50 , 61 , 69 , 75 , 84 , 86 ], health professionals, and end users [ 48 , 54 , 64 - 66 , 68 - 70 , 73 , 75 , 83 ]. However, some studies provided little information on the identification of stakeholders and did not clarify the level of involvement of stakeholders and end users [ 37 , 44 , 50 , 56 , 66 , 70 , 78 , 79 , 81 , 83 , 87 ]. The studies used multiple methods, such as interviews, focus groups, and user testing [ 50 , 54 , 57 , 64 - 70 , 73 , 75 , 83 ], to gain insights from end users and stakeholders.…”

Efficacy of eHealth Interventions for Adults with Diabetes: A Systematic Review and Meta-Analysis

“…The latter is a construct that encompasses several interrelated psychosocial dimensions, namely diabetes distress, distress (subsuming depression, anxiety, and stress symptoms referred to life at large) and mental well-being (encompassing quality of life, positive attitudes, and positive relationships) [6]. These findings give rise to reflections on the importance of developing and delivering eHealth interventions suitable to provide psychosocial support to people with DM, using an RCT design to test their effectiveness; indeed, most research on eHealth interventions developed to provide psychosocial support consists of pilot or proof-of-concept studies [47][48][49].…”

“…Therefore, the current meta-analysis could not assess the differences between eHealth interventions aimed at fostering psychosocial vs. medical support. Additionally, most studies currently available in the literature that have integrated the psychosocial factors within the digital health solutions are mostly pilot or proof-of-concept studies [47][48][49], thus not feasible for rigorous systematic reviews and meta-analyses. Therefore, future studies should move towards RCT designs to prove the effectiveness of eHealth interventions while also taking into account the bidirectionality between psychosocial and medical factors.…”