Going Mobile With Diabetes Support: A Randomized Study of a Text Message–Based Personalized Behavioral Intervention for Type 2 Diabetes Self-Care

Abstract

Objective. Patients with type 2 diabetes often fail to achieve self-management goals. This study tested the impact on glycemic control of a two-way text messaging program that provided behavioral coaching, education, and testing reminders to enrolled individuals with type 2 diabetes in the context of a clinic-based quality improvement initiative. The secondary aim examined patient interaction and satisfaction with the program.Methods. Ninety-three adult patients with poorly controlled type 2 diabetes (A1C >8%) were recruited from 18 primary care clinics in three counties for a 6-month study. Patients were randomized by a computer to one of two arms. Patients in both groups continued with their usual care; patients assigned to the intervention arm also received from one to seven diabetes-related text messages per day depending on the choices they made at enrollment. At 90 and 180 days, A1C data were obtained from the electronic health record and analyzed to determine changes from baseline for both groups. An exit survey was used to assess satisfaction. Enrollment behavior and interaction data were pulled from a Web-based administrative portal maintained by the technology vendor.Results. Patients used the program in a variety of ways. Twenty-nine percent of program users demonstrated frequent engagement (texting responses at least three times per week) for a period of ≥90 days. Survey results indicate very high satisfaction with the program. Both groups’ average A1C decreased from baseline, possibly reflecting a broader quality improvement effort underway in participating clinics. At 90 and 180 days, there was no statistically significant difference between the intervention and control groups in terms of change in A1C (P >0.05).Conclusions. This study demonstrated a practical approach to implementing and monitoring a mobile health intervention for self-management support across a wide range of independent clinic practices.

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

“…For example, Katz et al’s [25] 12-month intervention reported the average number of blood glucose uploads during the first and last 10 weeks of the study period, but not the full 12 months. When detailed engagement information was included, studies reported on users’ median time to respond to a text message [22, 26] and the number of users who met a minimum level of engagement (e.g., users who completed at least nine of 12 IVR calls, users who sent responses at least 3 times per week) [14, 28, 31]. Lastly, several studies categorized users by their level of engagement [21, 25, 29].…”

“…Alternatively, for those reporting higher engagement rates (80% and 84%), the intervention length was one [22] and three months [13], respectively. In four studies [14, 21, 23, 28], authors reported the number of users who did not engage at all or did so very minimally; rates ranged from 5.8% to 24%. In the six studies reporting changes in engagement, engagement decreased in two studies [13, 25], remained relatively stable in three studies [24, 26, 30], and varied by the individual user in one study [29].…”

“…Schubart et al’s 2011 [12] review of web-delivered self-care interventions found differences in how studies report on user engagement (e.g., frequency of website visits, number of users logging in at least once, and pages viewed). Such reporting differences are also common among mobile-delivered interventions (e.g., text message response rate [13], number of users who responded to text messages at least three times per week [14]).…”

Text message behavioral interventions: from here to where?

“…Almost universally, published reviews have found that SMS can have a small, positive effect on health behaviors, but numerous limitations preclude definitive judgment about effectiveness. SMS behavioral interventions supporting disease self-management showed no effect on diabetes [15*] and hypertension [16*] outcomes. SMS behavioral intervention focused on improving medication adherence showed no improved adherence or health outcomes to antiretroviral therapy for HIV [17*] or naltrexone for alcohol use disorder [18*], but did show improved adherence for anti-platelet therapy in heart disease [19] and intra-nasal corticosteroids for allergic rhinitis [20].…”

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

“…To date, the majority of studies examining diabetes users' opinions of mHealth interventions have assessed helpfulness and satisfaction quantitatively with close-ended self-report scales. 14,15 Although some studies have collected qualitative feedback, study samples have been small 8,11,16 or based on a short intervention duration (i.e., 2-4 weeks). 7,17 Therefore, we conducted interviews using both quantitative and qualitative questions to understand T2DM users' experiences with and opinions of a 3-month text messaging and interactive voice response (IVR) intervention called MEssaging for Diabetes (MED).…”