Process evaluation of Dulce Digital-Me: an adaptive mobile health (mHealth) intervention for underserved Hispanics with diabetes

Digital Health Technology Use Among Spanish Speakers in the US: A Scoping Review

Importance

Digital health technologies include patient portals, telehealth, mobile health, and web-based resources; they have the potential to expand health care access, increase quality of care, and improve health outcomes. An emerging literature describes factors associated with disparities between Spanish and English speakers with the use of digital health tools and documents.

Objective

To characterize barriers and facilitators and to inform hypothesis-generating questions and intervention planning associated with digital health technology use among Spanish-speaking populations in the US.

Evidence Review

Between January 2023 and April 2024, PubMed, Scopus, Web of Science, and Google Scholar were searched for publications between January 2013 and April 2024. Systematic reviews, protocols, editorials, abstracts, unpublished literature, non-peer-reviewed literature, and non-US-based and non-English studies were excluded. The Covidence platform was used to avoid duplicate records, and an abstract and full-text screening were then conducted for exclusions. Unstructured text in the final dataset was thematically analyzed.

Findings

Of 688 publications searched, 192 were excluded as duplications, 277 were excluded from abstract screenings, and 113 were excluded from full-text screenings. Among the 106 included studies (68% of which were published between 2019 and 2024), 73 (69%) used quantitative methods, 15 (14%) used qualitative methods, and 18 (17%) used applied mixed methods. The primary technologies studied were characterized as portal (21% [n = 22]), telehealth (42% [n = 45]), mobile health (16% [n = 17]), web-based resources (9% [n = 10]), and mixed (studies reporting >1 technology; 11% [n = 12]). Compared with English speakers, studies revealed consistently lower portal account activation, portal use, telehealth adoption, and online resource use among Spanish speakers. Barriers to use across all technologies included limited access to technology and Wi-Fi, low literacy, and limited digital literacy. Barriers to portal and telehealth use included lack of awareness of digital tools, limited patient-facing instructions in Spanish, and interpreter-related challenges. Facilitators cited across multiple technologies included use of text messaging and social media interventions, interventions involving care partners and/or interpreters, and culturally and linguistically tailored Spanish materials.

Conclusions and Relevance

The results of this scoping review suggest that Spanish-speaking persons in the US faced technology, language, and literacy-related barriers to digital technology use. Embracing support for care partners, facilitating text message or social media-oriented workflows, and ensuring that materials are linguistically and culturally tailored represent approaches for health systems, electronic health record vendors, and community health organizations to mitigate these disparities.

Digital health equity frameworks and key concepts: a scoping review

OBJECTIVES

Digital health equity, the opportunity for all to engage with digital health tools to support good health outcomes, is an emerging priority across the world. The field of digital health equity would benefit from a comprehensive and systematic understanding of digital health, digital equity, and health equity, with a focus on real-world applications. We conducted a scoping review to identify and describe published frameworks and concepts relevant to digital health equity interventions.

MATERIALS AND METHODS

We conducted a scoping review of published peer-reviewed literature guided by the PRISMA Extension for Scoping Reviews. We searched 5 databases for frameworks related to or applied to digital health or equity interventions. Using deductive and inductive approaches, we analyzed frameworks and concepts based on the socio-ecological model.

RESULTS

Of the 910 publications initially identified, we included 44 (4.8%) publications in our review that described 42 frameworks that sought to explain the ecosystem of digital and/or health equity, but none were comprehensive. From the frameworks we identified 243 concepts grouped into 43 categories including characteristics of individuals, communities, and organizations; societal context; perceived value of the intervention by and impacts on individuals, community members, and the organization; partnerships; and access to digital health services, in-person services, digital services, and data and information, among others.

DISCUSSION

We suggest a consolidated definition of digital health equity, highlight illustrative frameworks, and suggest concepts that may be needed to enhance digital health equity intervention development and evaluation.

CONCLUSION

The expanded understanding of frameworks and relevant concepts resulting from this study may inform communities and stakeholders who seek to achieve digital inclusion and digital health equity.

Dulce Digital-Me: results of a randomized comparative trial of static versus adaptive digital interventions for Latine adults with diabetes

OBJECTIVE

To compare the effectiveness of a static, text-based diabetes education and support intervention (Dulce Digital, DD) versus a dynamic approach with personalized feedback and goal setting (Dulce Digital-Me, DD-Me) in improving diabetes outcomes.

DESIGN AND METHODS

Comparative effectiveness trial in 310 Latine adults with poorly managed type 2 diabetes in a Federally Qualified Health Center in Southern California, randomized to DD, DD-Me-Auto (algorithm-driven text-based personalized feedback), or DD-Me-Tel (coach delivered personalized feedback). Changes in HbA1c (primary outcome), low-density lipoprotein-cholesterol, systolic blood pressure, and patient-reported outcomes were examined across 6 and 12 months, with the primary comparison being DD versus DD-Me (combined automated and telephonic).

RESULTS

Participants were 52.1 (±10.2) years old, 69.7% female, with HbA1c 9.3% (±1.6) at baseline. Across groups, there was a statistically significant improvement in HbA1c at 6 months (mean∆ per month = -0.17, 95% CI -0.20, -0.14; P < .001) and 12 months (mean∆ per month = -0.07, 95% CI -0.09, -0.05; P < .001). However, there were no time-by-group interaction effects indicating group differences in clinical outcomes across 6 or 12 months. The DD-Me groups showed greater improvements across time than the DD group for diabetes self-management behaviors.

CONCLUSIONS

Static and adaptive digital interventions for Latine adults with type 2 diabetes had similar and clinically significant effects on HbA1c across 12 months. Simple digital approaches can be integrated within primary care-based chronic care models to reduce diabetes disparities.

CLINICALTRIALS.GOV REGISTRATION

NCT03130699, Initial Release 04/24/2017, https://clinicaltrials.gov/ct2/show/NCT03130699?term=NCT03130699&draw=2&rank=1.

Culturally Congruent Latino-Adapted Telemonitoring of Underrepresented Adults With Type 2 Diabetes: The CULTURA-DM2 Trial

This study reports on the development and testing of a comprehensive diabetes telemonitoring program tailored to meet the needs of underserved Hispanic/Latino patients with diabetes. Individuals participating in the culturally tailored program had significantly better 6-month outcomes than those receiving comprehensive outpatient management for A1C, blood pressure, and diabetes self-efficacy, with no differences between groups in quality of life, medication adherence, emotional functioning, patient activation, or unscheduled physician visits. These findings suggest that culturally congruent diabetes telemonitoring may be effective for this underserved population.

Outcomes of the Dulce Digital-COVID Aware (DD-CA) discharge texting platform for US/Mexico border Hispanic individuals with diabetes

BACKGROUND

Hispanic individuals have higher type 2 diabetes (T2D) prevalence, poorer outcomes, and are disproportionately affected by COVID-19. Culturally-tailored, diabetes educational text messaging has previously improved HbA1c in this population.

METHODS

During the pandemic, hospitalized Hispanic adults with T2D (N = 172) were randomized to receive Dulce Digital-COVID Aware ("DD-CA") texting platform upon discharge plus diabetes transition service (DTS) or DTS alone. DD-CA includes diabetes educational messaging with additional COVID-safe messaging (e.g., promoting masking; social distancing; vaccination).

FINDINGS

Among adults with poorly-controlled diabetes (Mean HbA1c = 9.6 ± 2.2 %), DD-CA did not reduce 30- or 90-day readmissions compared to standard care (28 % vs 15 %, p = .06; 37 % vs 35 %, p = .9, respectively). However, the improvement in HbA1c was larger among those in the DD-CA compared to DTS at 3 months (n = 56; -2.69 % vs. -1.45 %, p = .0496) with reduced effect at 6 months (n = 64; -2.03 % vs -0.91 %, p = .07). Low follow-up completion rates and the addition of covariates (to control for baseline group differences that existed despite randomization) impacted statistical power.

INTERPRETATION

During the pandemic, DD-CA offered an alternative digital approach to diabetes and COVID education and support for a high-risk Hispanic population and achieved trends toward improvement in glycemic control despite relatively low engagement and not reducing hospital readmissions.