Mobile Phone Support for Diabetes Self-Care Among Diverse Adults: Protocol for a Three-Arm Randomized Controlled Trial

The use of implementation science theoretical approaches in hybrid effectiveness-implementation type 1 randomised trials of healthcare interventions: A scoping review

BACKGROUND

Hybrid type 1 effectiveness-implementation randomised controlled trials (RCTs) aim to accelerate the translation of proven clinical interventions into routine care by concurrently investigating the effectiveness of clinical interventions and the context for real-world implementation. Hybrid type 1 RCTs can make use of implementation science theoretical approaches (i.e., theories, models, and frameworks) to understand barriers and facilitators to sustainable implementation of clinical interventions; however, the extent to which these approaches have been used in hybrid type 1 RCTs has not been systematically investigated. This scoping review aimed to investigate the extent to which implementation science theoretical approaches have been used in hybrid type 1 RCTs of healthcare interventions and describe which approaches have been reported and how they have been used.

METHODS

The review was conducted in accordance with the pre-registered protocol ( https://doi.org/10.17605/OSF.IO/CJ8A7 ). Searches of six electronic databases were conducted for published hybrid type 1 RCTs evaluating any clinical intervention in any healthcare setting. The included trials were full-text, peer-reviewed primary research articles written in English, and reporting the findings of hybrid type 1 RCTs of healthcare interventions. Non-English language reports, reviews, protocols without a linked trial results report, methodological papers, opinion pieces, commentaries, books/book chapters, dissertations, and conference abstracts were excluded. Two reviewers independently selected studies, extracted data, and assessed use of theoretical approach/es.

RESULTS

We identified 8,878 citations, screened 673 full-text records, and included 37 trials. Most trials were conducted in North America (68%), investigating clinical interventions for mental health problems (32%) in adults (43%). Twenty-eight (76%) trials cited use of at least one theoretical approach. The most common was the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework (43%). Theoretical approaches were most often applied (62%) to justify the implementation study design, guide selection of study materials or analyse implementation outcomes.

CONCLUSION

The majority of published hybrid type 1 effectiveness-implementation RCTs of healthcare interventions report using at least one theoretical approach to explore the context for implementation. Use of implementation science theories, models, and/or frameworks to understand the barriers and facilitators to implementation and sustainability of proven clinical interventions is likely to accelerate future translation of evidence-based practices into routine care and thus optimise patient outcomes.

Engagement in Hypertension and Diabetes Clinical Trials at Federally Qualified Health Centers: A Systematic Review

Importance

Federally qualified community health centers (FQHCs) are potential partners in the quest to increase diversity in clinical trials. Despite this opportunity, there is limited knowledge about FQHC engagement in clinical trials.

Objective

To assess levels of FQHC engagement in hypertension and type 2 diabetes (T2D) clinical trials and identify FQHC characteristics associated with engagement in the US.

Evidence Review

Six literature databases were searched for protocols and reports of clinical trials addressing hypertension or T2D among adults at FQHCs in the US, published between January 1, 2013, and November 6, 2023. Guided by a framework on community-engaged research, 4 levels of FQHC engagement in clinical trials were defined, ranging from level 1 (FQHC informed) to level 4 (FQHC driven). An ordinal regression analysis was conducted to investigate the association between FQHC organizational and patient demographic characteristics and levels of engagement in hypertension and T2D clinical trials using the publicly available data from Uniform Data System (UDS) for all identifiable FQHCs.

Findings

The initial literature search identified 4552 articles. Following deduplication, title and abstract screening, full-text review, data extraction, and matching with available information in UDS, a total of 33 clinical trials were included. Together, these clinical trials engaged 67 FQHCs. In most cases, FQHC engagement occurred at level 1 (15 clinical trials engaging 19 FQHCs) or level 2 (8 clinical trials engaging 38 FQHCs). A higher ratio of full-time equivalent physicians to patients was associated with 54% (odds ratio [OR], 1.54; 95% CI, 1.06-2.23) higher odds of having a higher level of FQHC engagement in hypertension and T2D clinical trials. A higher ratio of full-time community and patient education specialists to patients was associated with 41% (OR, 1.41; 95% CI, 1.03-1.94) higher odds of having a higher level of FQHC engagement in hypertension and T2D clinical trials.

Conclusions and Relevance

In this systematic review of FQHC engagement in clinical trials, lower levels of engagement in hypertension and T2D clinical trials were found. Further research is required to identify clinical trial design and implementation strategies that promote FQHC participation in clinical trials and research capacity building.

Sequential monitoring using the Second Generation P-Value with Type I error controlled by monitoring frequency

The Second Generation P-Value (SGPV) measures the overlap between an estimated interval and a composite hypothesis of parameter values. We develop a sequential monitoring scheme of the SGPV (SeqSGPV) to connect study design intentions with end-of-study inference anchored on scientific relevance. We build upon Freedman's "Region of Equivalence" (ROE) in specifying scientifically meaningful hypotheses called Pre-specified Regions Indicating Scientific Merit (PRISM). We compare PRISM monitoring versus monitoring alternative ROE specifications. Error rates are controlled through the PRISM's indifference zone around the point null and monitoring frequency strategies. Because the former is fixed due to scientific relevance, the latter is a targettable means for designing studies with desirable operating characters. An affirmation step to stopping rules improves frequency properties including the error rate, the risk of reversing conclusions under delayed outcomes, and bias.

Older Chinese and Filipino American Immigrants with Type 2 Diabetes and their Adult Child: A Qualitative Dyadic Exploration of Family Support

Type 2 Diabetes (T2D) among older Asian American immigrants (AA) is a growing concern. Asian Americans represent 9% of diagnosed diabetes. Very little is known on how older Asian American immigrants with T2D navigate diabetes management, in particular the role of family support. This qualitative study examines Chinese and Filipino Americans, the two largest Asian subgroups in the US (4.2 million, and 3.6 million, respectively), and family support dynamics among adult children and their parents diagnosed with T2D. Ten dyads (n = 20) made up of adult children and aging parents participated in in-depth and dyadic interviews. Results indicate that family support occurs in a trajectory of stages. The following thematic patterns emerged in these dyads around support: independence, transitions, partnership, and stepping in. The findings point to various supportive stages that Asian American adult children and aging parents with T2D experience and the importance of developing supportive interventions for both adult children and aging parents at these various stages.

Disparities in mobile phone use among adults with type 2 diabetes participating in clinical trials 2017-2021

Despite smartphone ownership becoming ubiquitous, it is unclear whether and where disparities persist in experience using health apps. In 2 diverse samples of adults with type 2 diabetes collected 2017-2018 and 2020-2021, we examined adjusted disparities in smartphone ownership and health app use by age, gender, race, education, annual household income, health insurance status, health literacy, and hemoglobin A1c. In the earlier sample (N = 422), 87% owned a smartphone and 49% of those had ever used a health app. Participants with lower income or limited health literacy had ≥50% lower odds of owning a smartphone. Comparatively, in the later sample (N = 330), almost all participants (98%) owned a smartphone and 70% of those had ever used a health app; however, disparities in health app use closely mirrored disparities in smartphone ownership from 2017 to 2018. Our findings suggest device ownership is necessary but insufficient for assuming people will use apps to support their health.

Feasibility of a Reinforcement Learning-Enabled Digital Health Intervention to Promote Mammograms: Retrospective, Single-Arm, Observational Study

BACKGROUND

Preventive screenings such as mammograms promote health and detect disease. However, mammogram attendance lags clinical guidelines, with roughly one-quarter of women not completing their recommended mammograms. A scalable digital health intervention leveraging behavioral science and reinforcement learning and delivered via email was implemented in a US health system to promote uptake of recommended mammograms among patients who were 1 or more years overdue for the screening (ie, 2 or more years from last mammogram).

OBJECTIVE

The aim of this study was to establish the feasibility of a reinforcement learning-enabled mammography digital health intervention delivered via email. The research aims included understanding the intervention's reach and ability to elicit behavioral outcomes of scheduling and attending mammograms, as well as understanding reach and behavioral outcomes for women of different ages, races, educational attainment levels, and household incomes.

METHODS

The digital health intervention was implemented in a large Catholic health system in the Midwestern United States and targeted the system's existing patients who had not received a recommended mammogram in 2 or more years. From August 2020 to July 2022, 139,164 eligible women received behavioral science-based email messages assembled and delivered by a reinforcement learning model to encourage clinically recommended mammograms. Target outcome behaviors included scheduling and ultimately attending the mammogram appointment.

RESULTS

In total, 139,164 women received at least one intervention email during the study period, and 81.52% engaged with at least one email. Deliverability of emails exceeded 98%. Among message recipients, 24.99% scheduled mammograms and 22.02% attended mammograms (88.08% attendance rate among women who scheduled appointments). Results indicate no practical differences in the frequency at which people engage with the intervention or take action following a message based on their age, race, educational attainment, or household income, suggesting the intervention may equitably drive mammography across diverse populations.

CONCLUSIONS

The reinforcement learning-enabled email intervention is feasible to implement in a health system to engage patients who are overdue for their mammograms to schedule and attend a recommended screening. In this feasibility study, the intervention was associated with scheduling and attending mammograms for patients who were significantly overdue for recommended screening. Moreover, the intervention showed proportionate reach across demographic subpopulations. This suggests that the intervention may be effective at engaging patients of many different backgrounds who are overdue for screening. Future research will establish the effectiveness of this type of intervention compared to typical health system outreach to patients who have not had recommended screenings as well as identify ways to enhance its reach and impact.

Exploring determinants and strategies for implementing self-management support text messaging interventions in safety net clinics

Background

Text message-delivered interventions for chronic disease self-management have potential to reduce health disparities, yet limited research has explored implementing these interventions into clinical care. We partnered with safety net clinics to evaluate a texting intervention for type 2 diabetes called REACH (Rapid Encouragement/Education And Communications for Health) in a randomized controlled trial. Following evaluation, we explored potential implementation determinants and recommended implementation strategies.

Methods

We interviewed clinic staff (n = 14) and a subset of intervention participants (n = 36) to ask about REACH's implementation potential. Using the Consolidated Framework for Implementation Research (CFIR) as an organizing framework, we coded transcripts and used thematic analysis to derive implementation barriers and facilitators. We integrated the CFIR-ERIC (Expert Recommendations for Implementing Change) Matching Tool, interview feedback, and the literature to recommend implementation strategies.

Results

Implementation facilitators included low complexity, strong evidence and quality, available clinic resources, the need for a program to support diabetes self-management, and strong fit between REACH and both the clinics' existing workflows and patients' needs and resources. The barriers included REACH only being available in English, a lack of interoperability with electronic health record systems, patients' concerns about diabetes stigma, limited funding, and high staff turnover. Categories of recommended implementation strategies included training and education, offering flexibility and adaptation, evaluating key processes, and securing funding.

Conclusion

Text message-delivered interventions have strong potential for integration in low-resource settings as a supplement to care. Pursuing implementation can ensure patients benefit from these innovations and help close the research to practice gap.

Rationale, design, and recruitment outcomes for the Family/Friend Activation to Motivate Self-care (FAMS) 2.0 randomized controlled trial among adults with type 2 diabetes and their support persons

BACKGROUND

Self-care behaviors help reduce hemoglobin A1c (HbA1c) and prevent or delay type 2 diabetes (T2D) complications. Individualized interventions that support goal setting and self-monitoring improve self-care and HbA1c in the short-term; engaging family and friends may enhance and/or sustain effects. Family/Friend Activation to Motivate Self-care (FAMS) is a mobile phone-delivered intervention (i.e., phone coaching and text message support) based on Family Systems Theory which was successfully piloted among diverse adults with T2D.

METHODS

We made improvements to FAMS and conducted iterative usability testing to finalize FAMS 2.0 before evaluation in a randomized controlled trial (RCT). Adult persons with diabetes (PWDs) who enrolled were asked to invite a support person (friend or family member) to participate alongside them. For the RCT, dyads were randomly assigned to FAMS 2.0 or enhanced treatment as usual (control) for the first 9 months of the 15-month trial. Outcomes include PWDs' HbA1c and psychosocial well-being (including diabetes distress) and support persons' own diabetes distress and support burden.

RESULTS

We recruited RCT participants from April 2020 through October 2021 (N = 338 PWDs with T2D; 89% [n = 300] with a support person). PWDs were 52% male, 62% non-Hispanic White, aged 56.9 ± 11.0 years with HbA1c 8.7% ± 1.7% at enrollment; 73% cohabitated with their enrolled support person. Data collection is ongoing through January 2023.

CONCLUSION

Findings will inform the utility of engaging family/friends in self-care behaviors for both PWD and support person outcomes. Using widely available mobile phone technology, FAMS 2.0, if successful, has potential for scalability.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04347291 posted April 15, 2020.

Dyadic digital health interventions: Their rationale and implementation

While most psychosocial and behavioral digital health interventions have been designed to be consumed by an individual, intervening at the level of a dyad - two interdependent individuals - can more comprehensively address the needs of both individuals and their relationship. The clinical utility of the dyadic digital health intervention approach, as well as the practical implementation of this design, will be demonstrated via three examples: eSCCIP, FAMS, and OurRelationship.

Exploring mHealth potential to improve kidney function: secondary analysis of a randomized trial of diabetes self-care in diverse adults

BACKGROUND

Many individuals living with chronic kidney disease (CKD) have comorbid Type 2 diabetes (T2D). We sought to explore if efficacious interventions that improve glycemic control may also have potential to reduce CKD progression.

METHODS

REACH is a text message-delivered self-management support intervention, which focused on medication adherence, diet, and exercise that significantly improved glycemic control in N = 506 patients with T2D. Using data from the trial, we characterized kidney health in the full sample and explored the intervention's effect on change in estimated glomerular filtration rate (eGFR) at 12 months in a subsample of N=271 patients with eGFR data.

RESULTS

In a diverse sample with respect to race/ethnicity and socioeconomic status, 37.2% had presence of mild or heavy proteinuria and/or an eGFR < 60 mL/min/1.73 m2. There was a trending interaction effect between intervention and presence of proteinuria at baseline (b = 6.016, p = .099) such that patients with proteinuria at baseline who received REACH had less worsening of eGFR.

CONCLUSIONS

Future research should examine whether diabetes directed self-management support reduces CKD progression in ethnically diverse individuals with albuminuria. In highly comorbid populations, such as T2D and CKD, text-based support can be further tailored according to individuals' multimorbid disease self-management needs and is readily scalable for individuals with limited resources.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov ( NCT02409329 ).

Changes in family involvement occasioned by FAMS mobile health intervention mediate changes in glycemic control over 12 months

Mobile phone-delivered interventions have proven effective in improving glycemic control (HbA1c) in the short term among adults with type 2 diabetes (T2D). Family systems theory suggests engaging family/friend in adults' diabetes self-care may enhance or sustain improvements. In secondary analysis from a randomized controlled trial (N = 506), we examined intervention effects on HbA1c via change in diabetes-specific helpful and harmful family/friend involvement. We compared a text messaging intervention that did not target family/friend involvement (REACH), REACH plus family-focused intervention components targeting helpful and harmful family/friend involvement (REACH + FAMS), and a control condition. Over 6 months, both intervention groups experienced improvement in HbA1c relative to control, but at 12 months neither did. However, REACH + FAMS showed an indirect effect on HbA1c via change in helpful family/friend involvement at both 6 and 12 months while REACH effects were not mediated by family/friend involvement. Consistent with family systems theory, improvements in HbA1c mediated by improved family/friend involvement were sustained.

Adults with type 2 diabetes benefit from self-management support intervention regardless of depressive symptoms

AIMS

Elevated depressive symptoms are common among adults with type 2 diabetes (T2D). In a secondary analysis from an RCT of a diabetes self-management support intervention that did not target depressive symptoms, we sought to determine if depressive symptoms were reduced by the intervention (i.e., depressive symptoms an outcome) or, alternatively, if intervention effects on hemoglobin A1c were lesser among persons with clinically elevated depressive symptoms (i.e., depressive symptoms an effect modifier).

METHODS

We evaluated a text messaging intervention, REACH, in a diverse (half non-white, half underinsured) sample of N = 506 adults with T2D. Participants completed the Patient Health Questionnaire-8 (PHQ) and A1c tests at baseline and 6 months. We conducted a factor analysis to identify somatic- and cognitive-affective symptoms on the PHQ. We tested our hypotheses with regression models, using interaction terms and subgroup analyses.

RESULTS

REACH improved depressive symptoms among participants with lower baseline A1c (<8.5%; β = -0.133, p = .007; cognitive β = -0.107, p = .038; somatic β = -0.131, p = .014) but not among participants with higher baseline A1c (≥8.5%; β = 0.040, p = .468). Baseline depressive symptoms did not modify the effect on A1c.

CONCLUSIONS

We found support for the hypothesis that depressive symptoms - both somatic- and cognitive-affective - may be an outcome, rather than an effect modifier, of effective diabetes self-management support interventions.

Analysis of Continuous Nursing Intervention on Aplastic Anemia Patients Based on the "Information-Motivation-Behavioral Skills Model"

Objective

To explore the effect of continuous nursing care based on the “information-motivation-behavioral skills model” (IMB) in the intervention of patients with aplastic anemia.

Methods

A total of 90 patients with aplastic anemia who were admitted to our hospital from June 2019 to January 2021 were included in the study. The patients were divided into an observation group and a control group according to the random number table, with 45 patients in each group. The control group received routine nursing care, while the observation group received continuous nursing care based on IMB on the basis of the control group. Patients were followed up for 3 months, and their health knowledge was assessed with our self-made health knowledge rating scale. Patients' medication compliance was assessed using the Morisky medication compliance questionnaire. The self-care ability was assessed with the self-made self-care ability scale in our hospital. The comprehensive quality of life assessment questionnaire (GQOLI-74) was used to assess the quality of life of patients. A self-prepared nursing satisfaction questionnaire was used to score patients' nursing satisfaction. The total effective rate of nursing was evaluated.

Results

The awareness scores of basic disease knowledge, medication knowledge, and daily self-care knowledge in the observation group were higher than those in the control group (P < 0.05). The scores of medication compliance in the observation group were higher than those in the control group (P < 0.05). The self-care abilities such as healthy diet, psychological adjustment, self-care skills, oral care, and perianal care in the observation group were higher than those in the control group (P < 0.05). The quality of life scores of patients in the two groups in the 3 months of nursing were higher than those when they were discharged from hospital (P < 0.05). The GQOLI-74 score of 3 months' nursing care in the observation group was higher than that in the control group (P < 0.05). The nursing satisfaction degree of the observation group (97.78%) was higher than that of the control group (82.23%) (P < 0.05). The total effective rate of nursing care in the observation group (97.78%) was higher than that in the control group (77.78%) (P < 0.05).

Conclusion

IMB-based continuous nursing care can significantly increase the awareness of health knowledge in patients with aplastic anemia, effectively improve medication compliance, significantly enhance self-care ability, and thus, improve the quality of life.

Evaluation of the My Diabetes Care Patient Portal Intervention: Protocol for a Pilot Randomized Controlled Trial

Background

My Diabetes Care (MDC) is a multi-faceted intervention embedded within an established patient portal, My Health at Vanderbilt. MDC is designed to help patients better understand their diabetes health data and support self-care. MDC uses infographics to visualize and summarize patients’ diabetes health data, incorporates motivational strategies, provides literacy-level appropriate educational resources, and links to a diabetes online patient support community and diabetes news feeds.

Objective

This study aims to evaluate the effects of MDC on patient activation in adult patients with type 2 diabetes mellitus. Moreover, we plan to assess secondary outcomes, including system use and usability, and the effects of MDC on cognitive and behavioral outcomes (eg, self-care and self-efficacy).

Methods

We are conducting a 6-month, 2-arm, parallel-design, pragmatic pilot randomized controlled trial of the effect of MDC on patient activation. Adult patients with type 2 diabetes mellitus are recruited from primary care clinics affiliated with Vanderbilt University Medical Center. Participants are eligible for the study if they are currently being treated with at least one diabetes medication, are able to speak and read in English, are 21 years or older, and have an existing My Health at Vanderbilt account and reliable access to a desktop or laptop computer with internet access. We exclude patients living in long-term care facilities, patients with known cognitive deficits or severe visual impairment, and patients currently participating in any other diabetes-related research study. Participants are randomly assigned to MDC or usual care. We collect self-reported survey data, including the Patient Activation Measure (R) at baseline, 3 months, and 6 months. We will use mixed-effects regression models to estimate potentially time-varying intervention effects while adjusting for the baseline measure of the outcome. The mixed-effects model will use fixed effects for patient-level characteristics and random effects for health care provider variables (eg, primary care physicians).

Results

This study is ongoing. Recruitment was closed in May 2020; 270 patients were randomized. Of those randomized, most (214/267, 80.1%) were non-Hispanic White, and 13.1% (35/267) were non-Hispanic Black, 43.7% (118/270) reported being 65 years or older, and 33.6% (90/268) reported limited health literacy. We obtained at least 95.6% (258/270) completion among participants through the 3-month follow-up assessment.

Conclusions

This randomized controlled trial will be one of the first to evaluate a patient-facing diabetes digital health intervention delivered via a patient portal. By embedding MDC into Epic’s MyChart platform with more than 127 million patient records, our intervention is directly integrated into routine care, highly scalable, and sustainable. Our findings and evolving patient portal functionality will inform the continued development of MDC to best meet users’ needs and a larger trial focused on the impact of MDC on clinical end points.

Trial Registration

ClinicalTrials.gov NCT03947333; https://clinicaltrials.gov/ct2/show/NCT03947333

International Registered Report Identifier (IRRID)

DERR1-10.2196/25955

Retaining diverse adults with diabetes in a long-term trial: Strategies, successes, and lessons learned

Background Retention can be difficult in longitudinal trials, especially among minoritized groups and individuals with low socioeconomic status (SES) who may experience more barriers to research participation. Organized retention strategies may help; however, limited research has reported on this in detail. Methods We employed several strategies throughout a 15-month randomized controlled trial to encourage retention among a diverse sample of adults with type 2 diabetes. Participants were randomized to receive mobile health support for diabetes self-care for 12 months or an attention control. Participants completed assessments at 3, 6, 12, and 15 months post-baseline. We used three main categories of retention strategies: flexibility in participation (e.g., multiple methods for data collection), communication (e.g., tracking contacts), and community building (e.g., study branding, newsletters). We monitored participants' use of strategies and examined associations between participant characteristics and retention. Results Retention remained high (≥90%) at each follow-up assessment. Participants used various methods for survey completion: online (34%), in-person (31%), and mail (30%). Most (73%) used a mail-in A1c kit at least once. Multiple completion methods were important for retaining minoritized and lower SES participants who completed assessments in-person more frequently. Communication also facilitated retention; 39% of participants used a study Helpline and tracking systems helped maintain contact. Conclusions Retaining disadvantaged patients in clinical trials is necessary so findings generalize to and can benefit these populations. Retention strategies that reduce barriers to participation and engage participants and community partners can be successful. Future studies should assess the impact of retention strategies.

Text messaging to engage friends/family in diabetes self-management support: acceptability and potential to address disparities

OBJECTIVE

Explore acceptability of engaging family/friends in patients' type 2 diabetes (T2D) self-management using text messaging.

MATERIALS AND METHODS

Participants (N = 123) recruited from primary care clinics for a larger trial evaluating mobile phone support for T2D completed self-report measures and a hemoglobin A1c test and then had the option to invite an adult support person to receive text messages. We examined characteristics and reasons of participants who did/did not invite a support person, responses to the invitation, and feedback from patients and support persons.

RESULTS

Participants were 55.9 ± 10.1 years old, 55% female, 53% minority, and 54% disadvantaged (low income, less than high school degree/GED, uninsured, and/or homeless). Participants who invited a support person (48%) were slightly younger, more likely to be partnered, and reported more depressive symptoms and more emergency department visits in the year prior to study enrollment as compared to participants who did not (all p <.05). Participants' reasons for inviting a support person included needing help and seeing benefits of engaging others, while reasons for not inviting a support person included concerns about being a "burden" and support person's ability or desire to text. Support persons reported the texts increased awareness, created dialogue, and improved their own health behaviors.

DISCUSSION

Patients inviting a support person had higher need and thus may stand to benefit most. Most support persons were open to engagement via text messages.

CONCLUSION

Across race and socioeconomic status, text messaging may engage support persons to increase health-related support-particularly for patients with higher levels of need.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02409329.

Effects of a Tailored Text Messaging Intervention Among Diverse Adults With Type 2 Diabetes: Evidence From the 15-Month REACH Randomized Controlled Trial

OBJECTIVE

Text messaging interventions have high potential for scalability and for reductions in health disparities. However, more rigorous, long-term trials are needed. We examined the long-term efficacy and mechanisms of a tailored text messaging intervention.

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes participated in a parallel-groups, 15-month randomized controlled trial and were assigned to receive Rapid Education/Encouragement and Communications for Health (REACH) for 12 months or control. REACH included interactive texts and tailored texts addressing medication adherence and nontailored texts supporting other self-care behaviors. Outcomes included hemoglobin A1c (HbA1c), diabetes medication adherence, self-care, and self-efficacy.

RESULTS

Participants (N = 506) were approximately half racial/ethnic minorities, and half were underinsured, had annual household incomes <$35,000, and had a high school education or less; 11% were homeless. Average baseline HbA1c was 8.6% ± 1.8%; 70.0 ± 19.7 mmol/mol) with n = 219 having HbA1c ≥8.5% (69 mmol/mol). Half were prescribed insulin. Retention was over 90%. Median response rate to interactive texts was 91% (interquartile range 75%, 97%). The treatment effect on HbA1c at 6 months (-0.31%; 95% CI -0.61%, -0.02%) was greater among those with baseline HbA1c ≥8.5% (-0.74%; 95% CI -1.26%, -0.23%), and there was no evidence of effect modification by race/ethnicity or socioeconomic disadvantage. REACH improved medication adherence and diet through 12 months and self-efficacy through 6 months. Treatment effects were not significant for any outcome at 15 months. REACH reduced barriers to adherence, but barrier reduction did not mediate outcome improvements.

CONCLUSIONS

REACH engaged at-risk patients in diabetes self-management and improved short-term HbA1c. More than texts alone may be needed to sustain the effects.

Mixed-Methods Randomized Evaluation of FAMS: A Mobile Phone-Delivered Intervention to Improve Family/Friend Involvement in Adults' Type 2 Diabetes Self-Care

BACKGROUND

Family and friends have both helpful and harmful effects on adults' diabetes self-management. Family-focused Add-on to Motivate Self-care (FAMS) is a mobile phone-delivered intervention designed to improve family/friend involvement, self-efficacy, and self-care via monthly phone coaching, texts tailored to goals, and the option to invite a support person to receive texts.

PURPOSE

We sought to evaluate how FAMS was received by a diverse group of adults with Type 2 diabetes and if FAMS improved diabetes-specific family/friend involvement (increased helpful and reduced harmful), diabetes self-efficacy, and self-care (diet and physical activity). We also assessed if improvements in family/friend involvement mediated improvements in self-efficacy and self-care.

METHODS

Participants were prospectively assigned to enhanced treatment as usual (control), an individualized text messaging intervention alone, or the individualized text messaging intervention plus FAMS for 6 months. Participants completed surveys at baseline, 3 and 6 months, and postintervention interviews. Between-group and multiple mediator analyses followed intention-to-treat principles.

RESULTS

Retention, engagement, and fidelity were high. FAMS was well received and helped participants realize the value of involving family/friends in their care. Relative to control, FAMS participants had improved family/friend involvement, self-efficacy, and diet (but not physical activity) at 3 and 6 months (all ps < .05). Improvements in family/friend involvement mediated effects on self-efficacy and diet for FAMS participants but not for the individualized intervention group.

CONCLUSIONS

The promise of effectively engaging patients' family and friends lies in sustained long-term behavior change. This work represents a first step toward this goal by demonstrating how content targeting helpful and harmful family/friend involvement can drive short-term effects.

TRIAL REGISTRATION NUMBER

NCT02481596.

User Engagement Among Diverse Adults in a 12-Month Text Message-Delivered Diabetes Support Intervention: Results from a Randomized Controlled Trial

Background

Text message–delivered interventions are a feasible and scalable approach for improving chronic disease self-care and reducing health disparities; however, information on long-term user engagement with these interventions is limited.

Objective

The aim of this study is to examine user engagement in a 12-month text message–delivered intervention supporting diabetes self-care, called REACH (Rapid Education/Encouragement And Communications for Health), among racially and socioeconomically diverse patients with type 2 diabetes (T2D). We explored time trends in engagement, associations between patient characteristics and engagement, and whether the addition of a human component or allowing patients to change their text frequency affected engagement. Qualitative data informed patients’ subjective experience of their engagement.

Methods

We recruited patients with T2D for a randomized trial evaluating mobile phone support relative to enhanced treatment as usual. This analysis was limited to participants assigned to the intervention. Participants completed a survey and hemoglobin A1c (HbA1c) test and received REACH text messages, including self-care promotion texts, interactive texts asking about medication adherence, and adherence feedback texts. For the first 6 months, texts were sent daily, and half of the participants also received monthly phone coaching. After 6 months, coaching stopped, and participants had the option to receive fewer texts for the subsequent 6 months. We defined engagement via responses to the interactive texts and responses to a follow-up interview. We used regression models to analyze associations with response rate and thematic and structural analysis to understand participants’ reasons for responding to the texts and their preferred text frequency.

Results

The participants were, on average, aged 55.8 (SD 9.8) years, 55.2% (137/248) female, and 52.0% (129/248) non-White; 40.7% (101/248) had ≤ a high school education, and 40.7% (101/248) had an annual household income <US $25,000. The median response rate to interactive texts was 91% (IQR 75%-97%) over 12 months. Engagement gradually declined throughout the intervention but remained high. Engagement did not differ by age, gender, education, income, diabetes duration, insulin status, health literacy, or numeracy. Black race and worse baseline medication adherence and HbA1c were each associated with lower engagement, although the effects were small. Nearly half of the participants chose to continue receiving daily texts for the last 6 months of the intervention. Participants who continued daily text messages said they wanted to continue experiencing benefits to their health, whereas those who chose fewer texts said that the daily texts had helped them create routines and they no longer needed them as often. Engagement was not impacted by receiving coaching or by participants’ chosen text frequency.

Conclusions

Well-designed interactive text messages can engage diverse patients in a self-care intervention for at least 1 year. Variation in and reasons for frequency preference suggest that offering a frequency choice may be important to users’ engagement.

mHealth Apps as Effective Persuasive Health Technology: Contextualizing the "Necessary" Functionalities

Persuasive health technology (PHT) is any technology purposely designed to influence, reinforce, change, or shape health-related attitudes or behaviors. Behavioral interventions can be developed for the purpose of maintaining or improving a person's health status. Delivering behavioral interventions via PHTs is a promising approach for encouraging healthy behaviors among individuals and populations. Important attributes of all PHTs include their functionalities. A functionality refers to any useful features, functions, capabilities, or technologies associated with computer hardware or software. Creating effective PHTs requires a deliberate selection of appropriate functionalities for supporting specific behavioral interventions. The number and types of functionalities necessary to create an effective PHT will be specific to the context of each project, influenced by project objectives, stakeholder goals, behavioral interventions, and a variety of real-world constraints. Selecting appropriate functionalities can be challenging. Fortunately, there are frameworks and models developed specifically for guiding the design of PHTs. The Persuasive Systems Design model describes 4 categories, and 28 design principles for creating effective persuasive interventions. These same design principles could also be useful for guiding the selection of appropriate functionalities.

The Effect of Information-Motivation-Behavioral Skills on Breastfeeding Success: A Hypothetical Model

Introduction: Although breastfeeding is a common practice in Turkey, there are problems with exclusive breastfeeding for the first 6 months of life or sustaining breastfeeding. The purpose of this study was to determine the variables that affect breastfeeding success of Turkish women by creating a hypothetical model based on the information-motivation-behavioral skills model. Methodology: This cross-sectional study was conducted with 229 women who gave birth at a public hospital. Data were collected using a questionnaire and through observation. Structural equation model was used for data analyses. Results: Information was found to directly affect behavioral skills and indirectly affect self-management behaviors and breastfeeding success (p < .05). The motivation was found to affect self-management behaviors directly (p < .05). Behavioral skills were found to directly affect self-management behaviors and indirectly affect breastfeeding success (p < .05). Discussion: The results can be used to develop culturally congruent nursing interventions and improve breastfeeding success.

Condom use to enhance regression of cervical intraepithelial neoplasia: study protocol for a randomized controlled trial

Background

Condom use can reduce the risk of infection by human papillomavirus (HPV). Furthermore, it has been suggested that condom use can increase the regression rate of cervical lesions. In Denmark, women with cervical intraepithelial neoplasia grade 2 (CIN2) and a future wish to conceive are not treated immediately but are followed up by a gynecologist about 6 months later. The aim of this project was to determine if advising women to have their male partners to use a condom during sexual intercourse in the follow-up period can increase the regression rate of CIN2.

Methods/design

This is a randomized clinical trial of women with CIN2. The intervention group was advised to use condoms between the date of diagnosis and the date of their follow-up visit. The control group received standard care. Cervical samples were tested for HPV. The primary endpoint will be the intention-to-treat analysis with the relative rate of CIN2 regression between the intervention group and the control group. Regression is defined as <CIN2 at the follow-up visit. In addition, a per-protocol analysis of the regression rate in women adhering to condom use compared with the control group will be performed. The secondary endpoint will be the HPV-clearance rate in the condom group.

Discussion

If condom use for 6 months can enhance the regression of cervical lesions, then more women can be spared conization. This is an efficient treatment of cervical lesions but is associated with an increased risk of preterm delivery.

Trial registration

ClinicalTrials.gov, NCT02907333. Registered on 14 September 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3564-4) contains supplementary material, which is available to authorized users.

Beyond Race Disparities: Accounting for Socioeconomic Status in Diabetes Self-Care

INTRODUCTION

Among patients with type 2 diabetes, racial disparities are prevalent across a variety of outcomes; however, inconsistent disparities in determinants of outcomes warrants exploring the impact of other, related factors. This study sought to examine whether disparities in health literacy, numeracy, self-care behaviors, and HbA1c persisted between non-Hispanic blacks and non-Hispanic whites after applying a robust adjustment for socioeconomic status (SES).

METHODS

From 2016 to 2018, adult patients with type 2 diabetes (N=444) were recruited from primary care clinics. Participants self-reported demographics; indicators of SES (i.e., income, education, health insurance, housing status, and financial strain); subjective health literacy and numeracy; and self-care behaviors. Participants also completed an HbA1c test. In 2018, differences were examined between non-Hispanic blacks and non-Hispanic whites in health literacy, numeracy, self-care, and HbA1c, first unadjusted and then adjusted using propensity score weighting.

RESULTS

In unadjusted analyses, compared with non-Hispanic whites, non-Hispanic blacks had lower health literacy (p=0.039) and numeracy (p<0.001); less medication adherence (p=0.009); use of information for dietary decisions (p=0.013); and problem eating behaviors (p<0.001; i.e., non-Hispanic blacks reported fewer problems); and higher HbA1c levels (p=0.005). After adjusting for all SES indicators, only the reverse disparity in problem eating behaviors (p=0.016) and the disparity in HbA1c (p=0.011) remained.

CONCLUSIONS

Findings highlight the importance of considering SES when examining disparities in health-related skills and behaviors. Moving beyond education and income to inclusion of more comprehensive markers of SES can improve understanding of how SES may contribute to disparities and the ability to appropriately target factors leading to inequality.

Assessing helpful and harmful family and friend involvement in adults' type 2 diabetes self-management

OBJECTIVE

Develop and evaluate a measure assessing helpful and harmful family/friends' involvement in adults' type 2 diabetes (T2D) self-management.

METHODS

Prior mixed-methods research, cognitive interviews, and expert input informed measure development. We administered the measure in two studies (N = 392 and N = 512) to evaluate its factor structure, internal consistency reliability, test-retest reliability, and construct, criterion and predictive validity.

RESULTS

Analyses supported a two-factor solution: helpful and harmful involvement with internal consistency reliability α = .86 and .72, respectively. Three-month test-retest reliability was rho = 0.64 for helpful and rho = 0.61 for harmful (both p < 0.001). Over 90% reported at least one instance of family/friend involvement in the past month. Associations with other measures of diabetes involvement were as anticipated (all p < .01). Helpful and harmful involvement were independently associated with diabetes self-efficacy, diet, blood glucose testing and medication adherence cross-sectionally [βs 0.13-0.39 helpful, -0.12--0.33 harmful; all p < .05]. Harmful involvement independently predicted worse HbA1c (β = 0.08), and worsening HbA1c over three months (β = 0.12, both p < 0.05).

CONCLUSION

The Family and Friend Involvement in Adults' Diabetes (FIAD) is a reliable and valid measure assessing family/friend involvement in adults' T2D.

PRACTICE IMPLICATIONS

FIAD use can inform interventions to improve social contexts in which adults manage diabetes.

Improving the assessment of medication adherence: Challenges and considerations with a focus on low-resource settings

Improving patient survival and quality of life in chronic diseases requires prolonged and often lifelong medication intake. Less than half of patients with chronic diseases globally are adherent to their prescribed medications which preclude the full benefit of treatment, worsens therapeutic outcomes, accelerates disease progression, and causes enormous economic losses. The accurate assessment of medication adherence is pivotal for both researchers and clinicians. Medication adherence can be assessed through both direct and indirect measures. Indirect measures include both subjective (self-report measures such as questionnaire and interview) and objective (pill count and secondary database analysis) measures and constitute the mainstay of assessing medication adherence. However, the lack of an inexpensive, ubiquitous, universal gold standard for assessment of medication adherence emphasizes the need to utilize a combination of measures to differentiate adherent and nonadherent patients. The global heterogeneity in health systems precludes the development of a universal guideline for evaluating medication adherence. Methods based on the secondary database analysis are mostly ineffectual in low-resource settings lacking electronic pharmacy and insurance databases and allowing refills without updated, valid prescriptions from private pharmacies. This significantly restricts the choices for assessing adherence until digitization of medical data takes root in much of the developing world. Nevertheless, there is ample scope for improving self-report measures of adherence. Effective interview techniques, especially accounting for suboptimal patient health literacy, validation of adherence questionnaires, and avoiding conceptual fallacies in reporting adherence can improve the assessment of medication adherence and promote understanding of its causal factors.

Assessing barriers to diabetes medication adherence using the Information-Motivation-Behavioral skills model

AIMS

Medication nonadherence is a prevalent and costly problem among patients with type 2 diabetes. Applications of theory can inform and improve adherence promotion interventions. We used a new assessment based on the Information-Motivation-Behavioral skills (IMB) model of adherence to assess patient-reported barriers and test the theoretical model.

METHODS

Participants (N = 237) completed a card sorting task to identify barriers to adherence, a survey, and a hemoglobin A1c (HbA1c) test. We identified the most commonly reported adherence barriers and examined associations between patient characteristics and barriers mapped onto each of the IMB constructs. We used structural equation modeling to test the IMB model and determine if barriers as reported on this measure predict patients' self-reported diabetes medication adherence and, in turn, HbA1c levels.

RESULTS

The most frequently reported barriers were forgetting doses, thinking brand name medicine works better than generic medicine, not seeing immediate benefit, and feeling burned out with taking diabetes medicine. Younger age and lower health literacy were associated with higher barrier scores for all IMB model constructs. Information and social motivation barriers affected adherence via behavioral skills barriers (indirect effects -0.19, CI [-0.33, -0.09] and -0.24, CI [-0.37, -0.14], respectively). The IMB barrier constructs explained 44% of the variance in diabetes medication adherence which, in turn, was significantly associated with and explained 8% of the variance in HbA1c (both p < .001).

CONCLUSIONS

Results suggest this assessment task can identify patient-specific barriers to diabetes medication adherence. Interventions targeting patient-specific barriers using this assessment could improve adherence and HbA1c.