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

Adapting a Text Messaging Intervention to Improve Diabetes Medication Adherence in a Spanish-Speaking Population: Qualitative Study

Background

Latino adults with type 2 diabetes (T2D) have higher rates of diabetes medication nonadherence than non-Hispanic White adults. REACH (Rapid Encouragement/Education And Communications for Health) is a text message platform based on the information-motivation-behavioral skills model that addresses barriers to adherence and was shown to improve adherence and glycated hemoglobin (HbA1c) levels, but it is only available in English.

Objective

This study aimed to report the multiphase, stakeholder-driven adaptation of the REACH barriers to diabetes medication adherence content to a Latino population (REACH-Español).

Methods

This was a qualitative study using focus groups. We identified potentially eligible patients (≥18 y old, Latino ethnicity, Spanish-language preference, and T2D diagnosis) using a Mass General Brigham Hospital query. Eligible patients were invited to participate in a focus group conducted in Spanish between April 13 and November 9, 2023. A total of 5 focus groups were conducted. Focus groups 1-3 centered on ranking 40 barriers to diabetes medication adherence (derived from REACH and the extant literature), whereas focus groups 4-5 centered on translation and cultural modifications of the original SMS text message content associated with each of the REACH barriers. Barriers were mapped onto information-motivation-behavioral constructs. We used descriptive statistics to summarize participant characteristics. Focus groups were audio-recorded, professionally transcribed, and analyzed with thematic content analysis using NVivo (Lumivero).

Results

In total, 22 participants attended the focus groups. The mean (SD) age was 63.2 (11) years, 55% (n=10/22) were female, and the mean HbA1c level was 8.5%. All participants were born in Latin America or the Caribbean and spoke Spanish as their preferred language, and 54.5% (12/22) had completed middle-school education or less. Among the top 10 ranked barriers, 50% (n=5) corresponded to information, 20% (n=2) to social motivation, 20% (n=2) to behavioral skills, and 10% (n=1) to personal motivation. Personal motivation barriers (medication burden and fear of side effects) and behavioral skills (forgetting to take medication) emerged as important themes in the focus groups.

Conclusions

A stakeholder-driven approach to intervention adaptation identified and prioritized relevant barriers to diabetes medication adherence among Latino adults with T2D and facilitated the adaptation of the REACH platform to a Spanish-speaking population.

mHealth Social Support Versus Standard Support for Diabetes Management in Safety-Net Emergency Department Patients: Randomized Phase-III Trial

BACKGROUND

Mobile health (mHealth) is a low-cost method to improve health for patients with diabetes seeking care in safety-net emergency departments, resulting in improved medication adherence and self-management. Additions of social support to mHealth interventions could further enhance diabetes self-management by increasing the gains and the postintervention maintenance.

OBJECTIVE

We assessed outcomes of an unblinded, parallel, equal-allocation randomized phase-III trial that tested a social support mHealth intervention to improve emergency department patients' diabetes self-management.

METHODS

Patients with glycated hemoglobin (HbA1c) levels of ≥8.5% mg/dL and a text-capable phone were recruited during their emergency department visit for any reason (diabetes related or not) at a US public hospital along with a friend or family member as a supporter. Patients received 6 months of the Trial to Examine Text Messaging in Emergency Department Patients With Diabetes self-management mHealth program. Supporters were randomized to receive either (1) an mHealth social support program (Family and Friends Network Support)-daily SMS text messages guiding supporters to provide diabetes-related social support-or (2) a non-mHealth social support program as an active control-pamphlet-augmented social support with Family and Friends Network Support content. Point-of-care HbA1c level, self-reported diabetes self-care activities, medication adherence, and safety events were collected. Mixed-effects linear regression models analyzed group differences at the end of the intervention (6 months) and the postintervention phase (12 months) for HbA1c level and behavioral outcomes.

RESULTS

A total of 166 patients were randomized. In total, 8.4% (n=14) reported type 1 diabetes, 66.9% (n=111) reported type 2 diabetes, and 24.7% (n=41) did not know their diabetes type; 50% (n=83) reported using insulin for diabetes management. Trial follow-up was completed with 58.4% (n=97) of the patients at 6 months and 63.9% (n=106) of the patients at 12 months. Both groups showed significant HbA1c level improvements (combined group change=1.36%, SD 2.42% mg/dL; 95% CI 0.87-1.83; P<.001), with no group difference (group mean difference=0.14%, SD 4.88% mg/dL; 95% CI -1.11 to 0.83; P=.87) at 6 months. At 12 months, both groups maintained their improved HbA1c levels, with a combined mean change from 6 months of 0.06% (SD 1.89% mg/dL; 95% CI -0.34 to 0.47; P=.76) and no clinically meaningful difference between groups. No differences were observed in safety events. In subgroup analyses, patients recently diagnosed with diabetes in the mHealth social support group improved their glycemic control compared to the standard social support group (between-group difference of 1.96%, SD 9.59% mg/dL; 95% CI -3.81 to -0.125; P=.04).

CONCLUSIONS

A 6-month change in HbA1c level did not differ by mode of social support in persons using an existing patient-focused mHealth diabetes self-management program, but both groups improved in self-management and glycemic control. Newly diagnosed patients with diabetes benefited most from mHealth-augmented social support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03178773; https://clinicaltrials.gov/study/NCT03178773.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.cct.2019.03.003.

Technological interventions to address cardiovascular health disparities impacting racial minorities: Opportunities and challenges

Racial minority groups suffer from higher rates of cardiovascular disease CVD and related conditions relative to White Americans due to multiple factors, including on average lower income, hazardous neighborhoods, and reduced access to healthcare. Digital health (mHealth) technologies, such as mobile apps and wearable devices, are an increasingly utilized method of health management that provide a promising option for patients to track and manage aspects of their health in ways that can be integrated into daily life and shared amongst community members. However, challenges facing the widespread adoption of these technologies in underrepresented groups include limited digital health literacy, lack of cultural tailoring, and distrust of healthcare resources. To promote the adoption of mHealth in these communities, policy changes that establish community partnership at all levels of mHealth development, improve digital health literacy, and increase access to mHealth can be enacted.

Assessing the Effectiveness of Digital Health Behavior Strategies on Type 2 Diabetes Management: Systematic Review and Network Meta-Analysis

BACKGROUND

Various mobile technologies and digital health interventions (DHIs) have been developed for type 2 diabetes mellitus (T2DM) management. Strategies are crucial for ensuring the effectiveness of DHIs. However, there is currently a lack of categorization and summarization of the strategies used in DHIs for T2DM.

OBJECTIVE

This study aims to (1) identify and categorize the strategies used in DHIs for T2DM management; (2) assess the effectiveness of these DHI strategies; and (3) compare and rank the efficacy of different strategy combinations on glycated hemoglobin A1c (HbA1c) levels, fasting blood glucose (FBG) levels, BMI, and weight loss.

METHODS

Relevant randomized controlled trials (RCTs) were extracted from PubMed, Web of Science, and Scopus databases. Three rounds of screening and selection were conducted. The strategies were identified and categorized based on the principles of behavior change techniques and behavior strategies. The synthesis framework for the assessment of health IT was used to structure the evaluation of the DHI strategies qualitatively. A network meta-analysis was performed to compare the efficacy of different strategy combinations. The data quality was assessed using the Cochrane Risk of Bias tool.

RESULTS

A total of 52 RCTs were included, identifying 63 strategies categorized into 19 strategy themes. The most commonly used strategies were guide, monitor, management, and engagement. Most studies reported positive or mixed outcomes for most indicators based on the synthesis framework for the assessment of health IT. Research involving a medium or high number of strategies was found to be more effective than research involving a low number of strategies. Of 52 RCTs, 27 (52%) were included in the network meta-analysis. The strategy combination of communication, engagement, guide, and management was most effective in reducing HbA1c levels (mean difference [MD] -1.04, 95% CI -1.55 to -0.54), while the strategy combination of guide, management, and monitor was effective in reducing FBG levels (MD -0.96, 95% CI -1.86 to -0.06). The strategy combination of communication, engagement, goal setting, management, and support was most effective for BMI (MD -2.30, 95% CI -3.16 to -1.44) and weight management (MD -6.50, 95% CI -8.82 to -4.18).

CONCLUSIONS

Several DHI strategy combinations were effective in reducing HbA1c levels, FBG levels, BMI, and weight in T2DM management. Health care professionals should be encouraged to apply these promising strategy combinations in DHIs during clinical care. Future research should further explore and optimize the design and implementation of strategies.

TRIAL REGISTRATION

PROSPERO CRD42024544629; https://tinyurl.com/3zp2znxt.

The value of diabetes technology enabled coaching (DTEC) to support remission evaluation of medical interventions in T2D: Patient and health coach perspectives

The multicomponent Remission Evaluation of Medical Interventions in T2D (REMIT) program has shown reduction of hazard of diabetes relapse by 34-43%, but could benefit from improved ability to scale, spread, and sustain it. This study explored, at the conceptualization phase, patient and health coach perspectives on the acceptability, adoption, feasibility, and appropriateness of a digital REMIT adaptation (diabetes technology enabled coaching (DTEC)). Twelve semi-structured interviews were conducted with patients (n = 6) and health coaches (n = 6) to explore their experiences with the REMIT study, opportunities for virtualisation, and a cognitive walkthrough of solution concepts. Transcripts were analyzed both inductively and deductively to allow for organic themes to emerge and to position these themes around the constructs of acceptability, adoption, feasibility, and appropriateness while allowing new codes to emerge for discussion. Participants saw value in DTEC as: an opportunity to facilitate and extend REMIT support; a convenient, efficient, and scalable concept (acceptability); having potential to motivate through connecting behaviours to outcomes (adoption); an opportunity for lower-effort demands for sustained use (feasibility). Participants also highlighted important considerations to ensure DTEC could provide compassionate insights and support automated data entry (appropriateness). Several considerations regarding equitable access were raised and warrant further consideration including: provision of technology, training to support technology literacy, and the opportunity for DTEC to support and improve health literacy. As such, DTEC may act as a moderator that can enhance or diminish access which affects who can benefit. Provided equity considerations are addressed, DTEC has the potential to address previous shortcomings of the conventional REMIT program.

Impact of a Text Messaging Intervention as an In-Between Support to Diabetes Group Visits in Federally Qualified Health Centers: Cluster Randomized Controlled Study

Background

In the United States, 1 in 11 people receive primary care from a federally qualified health center (FQHC). Text messaging interventions (TMIs) are accessible ways to deliver health information, engage patients, and improve health outcomes in the health center setting.

Objective

We aimed to evaluate the impact of a TMI implemented with a group visit (GV) intervention among patients with type 2 diabetes mellitus (T2DM) at FQHCs on patient-reported outcomes and clinical outcomes based on patient TMI engagement.

Methods

A TMI was implemented for 11 health centers participating in a cluster randomized study of diabetes GVs in Midwestern FQHCs targeting adults with T2DM. FQHC patients participated in 6 monthly GVs either in person or online and a concurrent 25-week TMI. Outcome measures included clinical markers such as glycated hemoglobin A1c and patient-reported diabetes distress, diabetes self-care, diabetes self-efficacy, diabetes care knowledge, diabetes quality of life, diabetes social support, and TMI use and satisfaction. TMI response rate was calculated as responses to an SMS text message requesting a response divided by total messages requesting a response sent. Patients were grouped as high responders if their response rate was greater than or equal to the median response rate and low responders if their response rate was below the median. We conducted linear mixed models to compare high and low responders and within a group, adjusting for age, gender, GV attendance, and depression/anxiety at baseline.

Results

In total, 101 of 124 GV patients (81.5%) enrolled in the TMI. The average age of the population in the TMI was 53 years. Of the 101 respondents, 61 (60%) were racial or ethnic minorities, while 42 of 82 respondents (51%) had a high school diploma/General Education Development or less, and 56 of 80 respondents (71%) reported an annual income less than US $30,000. In addition, 70 of 81 respondents (86%) owned a smartphone and 74 of 80 respondents (93%) had an unlimited texting plan. The median response rate was 41% and the mean response rate was 41.6%. Adjusted models showed significantly improved diabetes knowledge (P<.001), foot care (P<.001), and exercise (P=.002) in high responders (n=34) compared to low responders (n=23) at 6 months. No group difference was found in glycated hemoglobin A1c. Within high responders, diabetes distress (P=.001), social support (P<.001), quality of life (P<.001), diabetes knowledge (P<.001), foot care (P<.001), and diet (P=.003) improved from baseline to 6 months. Low responders only improved in diabetes quality of life (P=.003) from baseline to 6 months.

Conclusions

In a FQHC safety net population participating in a combined TMI and GV intervention, our study showed improved diabetes distress, social support, knowledge, self-care, self-efficacy, and quality of life among patients highly engaged in the SMS text messaging program.

Reach and Engagement With Population Health Management Interventions to Address COVID-19 Among Safety-Net Health Care Systems

Interventions designed to address COVID-19 needed to be rapidly scaled up to the population level, and to address health equity by reaching historically marginalized populations most affected by the pandemic (e.g., racial/ethnic minorities and rural and low socioeconomic status populations). From February 2021 to June 2022, SCALE-UP Utah used text messaging interventions to reach 107 846 patients from 28 clinics within seven safety-net health care systems. Interventions provided informational and motivational messaging regarding COVID-19 testing and vaccination, and were developed using extensive community partner input. (Am J Public Health. 2024;114(11):1207-1211. https://doi.org/10.2105/AJPH.2024.307770).

Implementing mobile text messaging on glycemic control in patients with diabetes mellitus

BACKGROUND

Uncontrolled blood glucose may lead to serious complications in patients with type two diabetes mellitus (T2DM). Patients may not have the support, motivation, or encouragement to adhere to the lifestyle changes necessary to control their T2DM.

LOCAL PROBLEM

More than 75% of the primary care clinic's patients are diagnosed with T2DM, with most patients at the practice site having an average hemoglobin A1c (HbA1c) level of 8.5%. The primary care clinic did not use text messaging to disseminate diabetes self-management education and support (DSMES) as outlined in Standard 4 of the American Diabetic Association's (ADA) clinical practice guideline.

METHODS

This evidence-based quality improvement project was conducted in a rural outpatient primary care clinic to determine whether implementing the ADA's 2022 National Standards for DSMES using text messaging would affect HbA1C levels among adult patients with T2DM.

INTERVENTIONS

Patients were sent weekly text messages over a 12-week period. Text messages contained information promoting self-care, tips about healthy diet, exercise reminders, instructions about proper blood glucose monitoring, and reminders about medication adherence.

RESULTS

A total of 160 patients were included. A paired-sample t -test showed a reduction in HbA1c levels after the intervention from baseline (M = 7.53, SD = 1.72) to postimplementation (M = 6.91, SD = 0.89), t (159) = 11.88, p = .001.

CONCLUSION

Based on the results, implementing the ADA's National Standards for DSMES Standard 4 may affect HbA1c levels in this population.

User Engagement With mHealth Interventions to Promote Treatment Adherence and Self-Management in People With Chronic Health Conditions: Systematic Review

BACKGROUND

There are numerous mobile health (mHealth) interventions for treatment adherence and self-management; yet, little is known about user engagement or interaction with these technologies.

OBJECTIVE

This systematic review aimed to answer the following questions: (1) How is user engagement defined and measured in studies of mHealth interventions to promote adherence to prescribed medical or health regimens or self-management among people living with a health condition? (2) To what degree are patients engaging with these mHealth interventions? (3) What is the association between user engagement with mHealth interventions and adherence or self-management outcomes? (4) How often is user engagement a research end point?

METHODS

Scientific database (Ovid MEDLINE, Embase, Web of Science, PsycINFO, and CINAHL) search results (2016-2021) were screened for inclusion and exclusion criteria. Data were extracted in a standardized electronic form. No risk-of-bias assessment was conducted because this review aimed to characterize user engagement measurement rather than certainty in primary study results. The results were synthesized descriptively and thematically.

RESULTS

A total of 292 studies were included for data extraction. The median number of participants per study was 77 (IQR 34-164). Most of the mHealth interventions were evaluated in nonrandomized studies (157/292, 53.8%), involved people with diabetes (51/292, 17.5%), targeted medication adherence (98/292, 33.6%), and comprised apps (220/292, 75.3%). The principal findings were as follows: (1) >60 unique terms were used to define user engagement; "use" (102/292, 34.9%) and "engagement" (94/292, 32.2%) were the most common; (2) a total of 11 distinct user engagement measurement approaches were identified; the use of objective user log-in data from an app or web portal (160/292, 54.8%) was the most common; (3) although engagement was inconsistently evaluated, most of the studies (99/195, 50.8%) reported >1 level of engagement due to the use of multiple measurement methods or analyses, decreased engagement across time (76/99, 77%), and results and conclusions suggesting that higher engagement was associated with positive adherence or self-management (60/103, 58.3%); and (4) user engagement was a research end point in only 19.2% (56/292) of the studies.

CONCLUSIONS

The results revealed major limitations in the literature reviewed, including significant variability in how user engagement is defined, a tendency to rely on user log-in data over other measurements, and critical gaps in how user engagement is evaluated (infrequently evaluated over time or in relation to adherence or self-management outcomes and rarely considered a research end point). Recommendations are outlined in response to our findings with the goal of improving research rigor in this area.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022289693; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022289693.

Time for a Reframe: Shifting Focus From Continuous Glucose Monitor Uptake to Sustainable Use to Optimize Outcomes

Continuous glucose monitors (CGMs) improve glycemic outcomes and quality of life for many people with diabetes. Research and clinical practice efforts have focused on CGM initiation and uptake. There is limited understanding of how to sustain CGM use to realize these benefits and limited consideration for different reasons/goals for CGM use. Therefore, we apply the Information-Motivation-Behavioral Skills (IMB) model as an organizing framework to advance understanding of CGM use as a complex, ongoing self-management behavior. We present a person-centered, dynamic perspective with the central thesis that IMB predictors of optimal CGM use vary based on the CGM use goal of the person with diabetes. This reframe emphasizes the importance of identifying and articulating each person's goal for CGM use to inform education and support.

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.

Systematic Review Examining the Behavior Change Techniques in Medication Adherence Intervention Studies Among People With Type 2 Diabetes

BACKGROUND

Although previous systematic reviews have studied medication adherence interventions among people with Type 2 diabetes (PwT2D), no intervention has been found to improve medication adherence consistently. Furthermore, inconsistent and poor reporting of intervention description has made understanding, replication, and evaluation of intervention challenging.

PURPOSE

We aimed to identify the behavior change techniques (BCTs) and characteristics of successful medication adherence interventions among PwT2D.

METHODS

A systematic search was conducted on Medline, Embase, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus. Studies were included if they were randomized controlled trials with BCT-codable interventions designed to influence adherence to anti-diabetic medication for PwT2D aged 18 years old and above and have medication adherence measure as an outcome.

RESULTS

Fifty-five studies were included. Successful interventions tend to target medication adherence only, involve pharmacists as the interventionist, contain "Credible source" (BCT 9.1), "Instruction on how to perform the behaviour" (BCT 4.1), "Social support (practical)" (BCT 3.2), "Action planning" (BCT 1.4), and/ or "Information about health consequences" (BCT 5.1). Very few interventions described its context, used theory, examined adherence outcomes during the follow-up period after an intervention has ended, or were tailored to address specific barriers of medication adherence.

CONCLUSION

We identified specific BCTs and characteristics that are commonly reported in successful medication adherence interventions, which can facilitate the development of future interventions. Our review highlighted the need to consider and clearly describe different dimensions of context, theory, fidelity, and tailoring in an intervention.

The impact of using reinforcement learning to personalize communication on medication adherence: findings from the REINFORCE trial

Text messaging can promote healthy behaviors, like adherence to medication, yet its effectiveness remains modest, in part because message content is rarely personalized. Reinforcement learning has been used in consumer technology to personalize content but with limited application in healthcare. We tested a reinforcement learning program that identifies individual responsiveness ("adherence") to text message content and personalizes messaging accordingly. We randomized 60 individuals with diabetes and glycated hemoglobin A1c [HbA1c] ≥ 7.5% to reinforcement learning intervention or control (no messages). Both arms received electronic pill bottles to measure adherence. The intervention improved absolute adjusted adherence by 13.6% (95%CI: 1.7%-27.1%) versus control and was more effective in patients with HbA1c 7.5- < 9.0% (36.6%, 95%CI: 25.1%-48.2%, interaction p < 0.001). We also explored whether individual patient characteristics were associated with differential response to tested behavioral factors and unique clusters of responsiveness. Reinforcement learning may be a promising approach to improve adherence and personalize communication at scale.

Digitally Delivered Interventions to Improve Nutrition Behaviors Among Resource-Poor and Ethnic Minority Groups With Type 2 Diabetes: Systematic Review

BACKGROUND

Resource-poor individuals, such as those with a low income, are disproportionately affected by diabetes and unhealthy eating patterns that contribute to poor disease self-management and prognosis. Digitally delivered interventions have the potential to address some of the barriers to healthy eating experienced by this group. However, little is known about their effectiveness in disadvantaged populations.

OBJECTIVE

This systematic review is conducted to assess the effectiveness of digitally delivered interventions in improving nutritional behaviors and nutrition-related health outcomes among disadvantaged people with type 2 diabetes (T2D).

METHODS

MEDLINE complete, Global Health, Embase, CINAHL complete, Informit Health, IEEE Xplore, and Applied Science and Technology Source databases were searched for studies published between 1990 and 2022 on digitally delivered nutrition interventions for disadvantaged people with T2D. Two reviewers independently assessed the studies for eligibility and determined the study quality using the Cochrane Risk-of-Bias Assessment Tool. The Behavioral Change Technique Taxonomy V1 was used to identify behavior change techniques used in the design of interventions.

RESULTS

Of the 2434 identified records, 10 (0.4%), comprising 947 participants, met the eligibility criteria and were included in the review. A total of 2 digital platforms, web and messaging services (eg, SMS text messaging interventions or multimedia messaging service), were used to deliver interventions. Substantial improvements in dietary behaviors were reported in 5 (50%) of the 10 studies, representing improvements in healthier food choices or increases in dietary knowledge and skills or self-efficacy. Of the 10 studies, 7 (70%) examined changes in blood glucose levels, of which 4 (57%) out of 7 achieved significant decreases in hemoglobin A1C levels ranging from 0.3% to 1.8%. The most frequently identified behavior change techniques across all studies were instruction on how to perform the behavior, information about health consequences, and social support.

CONCLUSIONS

This review provided some support for the efficacy of digitally delivered interventions in improving healthy eating behaviors in disadvantaged people with T2D, an essential dietary prerequisite for changes in clinical metabolic parameters. Further research is needed into how disadvantaged people with T2D may benefit more from digital approaches and to identify the specific features of effective digital interventions for supporting healthy behaviors among disadvantaged populations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020149844; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149844.

Global stress and daily general and type 1 diabetes stressors and links to daily affect and diabetes outcomes during emerging adulthood

We examined how global stress and general stressors of daily life relate to emotional well-being and type 1 diabetes (T1D) outcomes and amplify the effects of diabetes stressors in emerging adults. Two-hundred and seven 18-19-year-olds with T1D (duration 8.47 years) completed the Perceived Stress Scale (global stress) and a daily diary assessing daily diabetes and general stressors, positive and negative affect, self-care behaviors, and blood glucose (BG). Multi-level analyses indicated that global stress and within-person daily general and diabetes stressors were associated with more negative and less positive affect. In addition, general stress (between-person) was associated with more negative affect. Global stress amplified the association between daily diabetes stressors and negative affect, with greater affect reactivity to stress for those experiencing higher global stress. Global stress and both within- and between-person diabetes stressors were associated with lower self-care and higher BG. Emerging adults' general stressors in their daily lives relate to poorer well-being beyond the experience of diabetes stressors.

The Goldilocks Dilemma on Balancing User Response and Reflection in mHealth Interventions: Observational Study

Background

Mobile health (mHealth) has the potential to radically improve health behaviors and quality of life; however, there are still key gaps in understanding how to optimize mHealth engagement. Most engagement research reports only on system use without consideration of whether the user is reflecting on the content cognitively. Although interactions with mHealth are critical, cognitive investment may also be important for meaningful behavior change. Notably, content that is designed to request too much reflection could result in users' disengagement. Understanding how to strike the balance between response burden and reflection burden has critical implications for achieving effective engagement to impact intended outcomes.

Objective

In this observational study, we sought to understand the interplay between response burden and reflection burden and how they impact mHealth engagement. Specifically, we explored how varying the response and reflection burdens of mHealth content would impact users' text message response rates in an mHealth intervention.

Methods

We recruited support persons of people with diabetes for a randomized controlled trial that evaluated an mHealth intervention for diabetes management. Support person participants assigned to the intervention (n=148) completed a survey and received text messages for 9 months. During the 2-year randomized controlled trial, we sent 4 versions of a weekly, two-way text message that varied in both reflection burden (level of cognitive reflection requested relative to that of other messages) and response burden (level of information requested for the response relative to that of other messages). We quantified engagement by using participant-level response rates. We compared the odds of responding to each text and used Poisson regression to estimate associations between participant characteristics and response rates.

Results

The texts requesting the most reflection had the lowest response rates regardless of response burden (high reflection and low response burdens: median 10%, IQR 0%-40%; high reflection and high response burdens: median 23%, IQR 0%-51%). The response rate was highest for the text requesting the least reflection (low reflection and low response burdens: median 90%, IQR 61%-100%) yet still relatively high for the text requesting medium reflection (medium reflection and low response burdens: median 75%, IQR 38%-96%). Lower odds of responding were associated with higher reflection burden (P<.001). Younger participants and participants who had a lower socioeconomic status had lower response rates to texts with more reflection burden, relative to those of their counterparts (all P values were <.05).

Conclusions

As reflection burden increased, engagement decreased, and we found more disparities in engagement across participants' characteristics. Content encouraging moderate levels of reflection may be ideal for achieving both cognitive investment and system use. Our findings provide insights into mHealth design and the optimization of both engagement and effectiveness.

Telehealth Technologies in Diabetes Self-management and Education

BACKGROUND

The coronavirus pandemic of 2019 (COVID-19) forced worldwide recognition and implementation of telehealth as a means of providing continuity of care by varied health care institutions. Diabetes is a global health threat with rates that continue to accelerate, thereby causing an increased need for clinicians to provide diabetes care and education to keep up with demand. Utilizing technology to provide education via phone/smartphone, video/audio, web, text message, mobile apps, or a combination of these methods can help improve patient access and clinical outcomes, cut costs, and close gaps in care.

METHODS

While numerous publications have summarized the various tools and technologies available for capturing remote clinical data and their relevance to diabetes care and self-management, this review focuses on self-educational telehealth tools available for diabetes self-management, their advantages and disadvantages, and factors that need to be considered prior to implementation. Recent relevant studies indexed by PubMed were included.

RESULTS

The widespread use and popularity of phones/smartphones, tablets, computers, and the Internet by patients of all age groups, cultures, socioeconomic and geographic areas allow for increased outreach, flexibility, and engagement with diabetes education, either in combination or as an adjunct to traditional in-person visits. Demonstrated benefits of using health technologies for diabetes self-management education include improved lifestyle habits, reduced hemoglobin A1C levels, decreased health care costs, and better medication adherence. Potential drawbacks include lack of regulation, need for staff training on methodologies used, the requirement for patients to be tech savvy, privacy concerns, lag time with technology updates/glitches, and the need for more long-term research data on efficacy.

CONCLUSIONS

Telehealth technologies for diabetes self-education improve overall clinical outcomes and have come a long way. With increasing numbers of patients with diabetes, it is expected that more optimal and user-friendly methodologies will be developed to fully engage and help patients communicate with their physicians.

The effect of personalized intelligent digital systems for self-care training on type II diabetes: a systematic review and meta-analysis of clinical trials

AIMS

Type 2 diabetes (T2D) is rising worldwide. Self-care prevents diabetic complications. Lack of knowledge is one reason patients fail at self-care. Intelligent digital health (IDH) solutions have a promising role in training self-care behaviors based on patients' needs. This study reviews the effects of RCTs offering individualized self-care training systems for T2D patients.

METHODS

PubMed, Web of Science, Scopus, Cochrane Library, and Science Direct databases were searched. The included RCTs provided data-driven, individualized self-care training advice for T2D patients. Due to the repeated studies measurements, an all-time-points meta-analysis was conducted to analyze the trends over time. The revised Cochrane risk-of-bias tool (RoB 2.0) was used for quality assessment.

RESULTS

In total, 22 trials met the inclusion criteria, and 19 studies with 3071 participants were included in the meta-analysis. IDH interventions led to a significant reduction of HbA1c level in the intervention group at short-term (in the third month: SMD = - 0.224 with 95% CI - 0.319 to - 0.129, p value < 0.0; in the sixth month: SMD = - 0.548 with 95% CI - 0.860 to - 0.237, p value < 0.05). The difference in HbA1c reduction between groups varied based on patients' age and technological forms of IDH services delivery. The descriptive results confirmed the impact of M-Health technologies in improving HbA1c levels.

CONCLUSIONS

IDH systems had significant and small effects on HbA1c reduction in T2D patients. IDH interventions' impact needs long-term RCTs. This review will help diabetic clinicians, self-care training system developers, and researchers interested in using IDH solutions to empower T2D patients.

Family Typology for Adults With Type 2 Diabetes: Longitudinal Stability and Validity for Diabetes Management and Well-being

OBJECTIVE

We validated longitudinally a typology of diabetes-specific family functioning (named Collaborative and Helpful, Satisfied with Low Involvement, Want More Involvement, and Critically Involved) in adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We conducted k-means cluster analyses with nine dimensions to determine if the typology replicated in a diverse sample and if type assignment was robust to variations in sampling and included dimensions. In a subsample with repeated assessments over 9 months, we examined the stability and validity of the typology. We also applied a multinomial logistic regression approach to make the typology usable at the individual level, like a diagnostic tool.

RESULTS

Participants (N = 717) were 51% male, more than one-third reported minority race or ethnicity, mean age was 57 years, and mean hemoglobin A1c (HbA1c) was 7.9% (63 mmol/mol; 8.7% [72 mmol/mol] for the longitudinal subsample). The typology was replicated with respect to the number of types and dimension patterns. Type assignment was robust to sampling variations (97% consistent across simulations). Type had an average 52% stability over time within participants; instability was not explained by measurement error. Over 9 months, type was independently associated with HbA1c, diabetes self-efficacy, diabetes medication adherence, diabetes distress, and depressive symptoms (all P < 0.05).

CONCLUSIONS

The typology of diabetes-specific family functioning was replicated, and longitudinal analyses suggest type is more of a dynamic state than a stable trait. However, type varies with diabetes self-management and well-being over time as a consistent independent indicator of outcomes. The typology is ready to be applied to further precision medicine approaches to behavioral and psychosocial diabetes research and care.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

Mobile Health Intervention in Patients With Type 2 Diabetes: A Randomized Clinical Trial

Importance

Clinical pharmacists and health coaches using mobile health (mHealth) tools, such as telehealth and text messaging, may improve blood glucose levels in African American and Latinx populations with type 2 diabetes.

Objective

To determine whether clinical pharmacists and health coaches using mHealth tools can improve hemoglobin A1c (HbA1c) levels.

Design, Setting, and Participants

This randomized clinical trial included 221 African American or Latinx patients with type 2 diabetes and elevated HbA1c (≥8%) from an academic medical center in Chicago. Adult patients aged 21 to 75 years were enrolled and randomized from March 23, 2017, through January 8, 2020. Patients randomized to the intervention group received mHealth diabetes support for 1 year followed by monitored usual diabetes care during a second year (follow-up duration, 24 months). Those randomized to the waiting list control group received usual diabetes care for 1 year followed by the mHealth diabetes intervention during a second year.

Interventions

The mHealth diabetes intervention included remote support (eg, review of glucose levels and medication intensification) from clinical pharmacists via a video telehealth platform. Health coach activities (eg, addressing barriers to medication use and assisting pharmacists in medication reconciliation and telehealth) occurred in person at participant homes and via phone calls and text messaging. Usual diabetes care comprised routine health care from patients' primary care physicians, including medication reconciliation and adjustment.

Main Outcomes and Measures

Outcomes included HbA1c (primary outcome), blood pressure, cholesterol, body mass index, health-related quality of life, diabetes distress, diabetes self-efficacy, depressive symptoms, social support, medication-taking behavior, and diabetes self-care measured every 6 months.

Results

Among the 221 participants (mean [SD] age, 55.2 [9.5] years; 154 women [69.7%], 148 African American adults [67.0%], and 73 Latinx adults [33.0%]), the baseline mean (SD) HbA1c level was 9.23% (1.53%). Over the initial 12 months, HbA1c improved by a mean of -0.79 percentage points in the intervention group compared with -0.24 percentage points in the waiting list control group (treatment effect, -0.62; 95% CI, -1.04 to -0.19; P = .005). Over the subsequent 12 months, a significant change in HbA1c was observed in the waiting list control group after they received the same intervention (mean change, -0.57 percentage points; P = .002), while the intervention group maintained benefit (mean change, 0.17 percentage points; P = .35). No between-group differences were found in adjusted models for secondary outcomes.

Conclusions and Relevance

In this randomized clinical trial, HbA1c levels improved among African American and Latinx adults with type 2 diabetes. These findings suggest that a clinical pharmacist and health coach-delivered mobile health intervention can improve blood glucose levels in African American and Latinx populations and may help reduce racial and ethnic disparities.

Trial Registration

ClinicalTrials.gov Identifier: NCT02990299.

Effect of Mobile Phone Text Messaging Self-Management Support for Patients With Diabetes or Coronary Heart Disease in a Chronic Disease Management Program (SupportMe) on Blood Pressure: Pragmatic Randomized Controlled Trial

BACKGROUND

Maintaining engagement and support for patients with chronic diseases is challenging. SMS text messaging programs have complemented patient care in a variety of situations. However, such programs have not been widely translated into routine care.

OBJECTIVE

We aimed to examine the implementation and utility of a customized SMS text message-based support program for patients with type 2 diabetes (T2D), coronary heart disease, or both within a chronic disease integrated care program.

METHODS

We conducted a 6-month pragmatic parallel-group, single-blind randomized controlled trial that recruited people with T2D or coronary heart disease. Intervention participants received 4 semipersonalized SMS text messages per week providing self-management support to supplement standard care. Preprogrammed algorithms customized content based on participant characteristics, and the messages were sent at random times of the day and in random order by a fully automated SMS text messaging engine. Control participants received standard care and only administrative SMS text messages. The primary outcome was systolic blood pressure. Evaluations were conducted face to face whenever possible by researchers blinded to randomization. Participants with T2D were evaluated for glycated hemoglobin level. Participant-reported experience measures were evaluated using questionnaires and focus groups and summarized using proportions and thematic analysis.

RESULTS

A total of 902 participants were randomized (n=448, 49.7% to the intervention group and n=454, 50.3% to the control group). Primary outcome data were available for 89.5% (807/902) of the participants. At 6 months, there was no difference in systolic blood pressure between the intervention and control arms (adjusted mean difference=0.9 mm Hg, 95% CI -1.1 to 2.1; P=.38). Of 642 participants with T2D, there was no difference in glycated hemoglobin (adjusted mean difference=0.1%, 95% CI -0.1% to 0.3%; P=.35). Self-reported medication adherence was better in the intervention group (relative risk=0.82, 95% CI 0.68-1.00; P=.045). Participants reported that the SMS text messages were useful (298/344, 86.6%) and easily understood (336/344, 97.7%) and motivated change (217/344, 63.1%). The lack of bidirectional messaging was identified as a barrier.

CONCLUSIONS

The intervention did not improve blood pressure in this cohort, possibly because of high clinician commitment to improved routine patient care as part of the chronic disease management program as well as favorable baseline metrics. There was high program engagement, acceptability, and perceived value. Feasibility as part of an integrated care program was demonstrated. SMS text messaging programs may supplement chronic disease management and support self-care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616001689460; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371769&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2018-025923.

Adherence therapy for adults with type 2 diabetes: a feasibility study of a randomized controlled trial

BACKGROUND

Adherence Therapy is a candidate intervention to promote consistent medication taking in people with type 2 diabetes. The aim of this study was to establish the feasibility of conducting a randomized controlled trial of adherence therapy in people with type 2 diabetes who were non-adherent with medication.

METHODS

The design is an open-label, single-center, randomized controlled feasibility trial. Participants were randomly allocated to receive either eight sessions of telephone-delivered adherence therapy or treatment as usual. Recruitment occurred during the COVID-19 pandemic. Outcome measures-adherence, beliefs about medication, and average blood glucose (sugar) levels (HbA1c)-were administered at baseline and after 8 weeks (TAU group) or at the completion of the treatment (AT group). Feasibility outcomes included the number of people approached to participate in the trial and the numbers that consented, completed study measures, finished treatment with adherence therapy, and dropped out of the trial. Fieldwork for this trial was conducted in the National Guard Hospital, a tertiary care provider, in the Kingdom of Saudi Arabia.

RESULTS

Seventy-eight people were screened, of which 47 met eligibility criteria and were invited to take part in the trial. Thirty-four people were excluded for various reasons. The remaining thirteen who consented to participate were enrolled in the trial and were randomized (AT, n = 7) (TAU, n = 6). Five (71%) of the seven participants in the adherence therapy arm completed treatment. Baseline measures were completed by all participants. Week 8 (post-treatment) measures were completed by eight (62%) participants. Dropout may have been linked to a poor understanding of what was involved in taking part in the trial.

CONCLUSIONS

It may be feasible to conduct a full RCT of adherence therapy, but careful consideration should be given to developing effective recruitment strategies, consent procedures, rigorous field testing, and clear support materials.

TRIAL REGISTRATION

The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12619000827134, on the 7th of June 2019.

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 ).

A New Taxonomy for Technology-Enabled Diabetes Self-Management Interventions: Results of an Umbrella Review

BACKGROUND

A 2017 umbrella review defined the technology-enabled self-management (TES) feedback loop associated with a significant reduction in A1C. The purpose of this 2021 review was to develop a taxonomy of intervention attributes in technology-enabled interventions; review recent, high-quality systematic reviews and meta-analyses to determine if the TES framework was described and if elements contribute to improved diabetes outcomes; and to identify gaps in the literature.

METHODS

We identified key technology attributes needed to describe the active ingredients of TES interventions. We searched multiple databases for English language reviews published between April 2017 and April 2020, focused on PwD (population) receiving diabetes care and education (intervention) using technology-enabled self-management (comparator) in a randomized controlled trial, that impact glycemic, behavioral/psychosocial, and other diabetes self-management outcomes. AMSTAR-2 guidelines were used to assess 50 studies for methodological quality including risk of bias.

RESULTS

The TES Taxonomy was developed to standardize the description of technology-enabled interventions; and ensure research uses the taxonomy for replication and evaluation. Of the 26 included reviews, most evaluated smartphones, mobile applications, texting, internet, and telehealth. Twenty-one meta-analyses with the TES feedback loop significantly lowered A1C.

CONCLUSIONS

Technology-enabled diabetes self-management interventions continue to be associated with improved clinical outcomes. The ongoing rapid adoption and engagement of technology makes it important to focus on uniform measures for behavioral/psychosocial outcomes to highlight healthy coping. Using the TES Taxonomy as a standard approach to describe technology-enabled interventions will support understanding of the impact technology has on diabetes outcomes.

Personalized Digital Health Communications to Increase COVID-19 Vaccination in Underserved Populations: A Double Diamond Approach to Behavioral Design

The COVID-19 pandemic exacerbated pre-existing health disparities. People of historically underserved communities, including racial and ethnic minority groups and people with lower incomes and educational attainments, experienced disproportionate premature mortality, access to healthcare, and vaccination acceptance and adoption. At the same time, the pandemic increased reliance on digital devices, offering a unique opportunity to leverage digital communication channels to address health inequities, particularly related to COVID-19 vaccination. We offer a real-world, systematic approach to designing personalized behavior change email and text messaging interventions that address individual barriers with evidence-based behavioral science inclusive of underserved populations. Integrating design processes such as the Double Diamond model with evidence-based behavioral science intervention development offers a unique opportunity to create equitable interventions. Further, leveraging behavior change artificial intelligence (AI) capabilities allows for both personalizing and automating that personalization to address barriers to COVID-19 vaccination at scale. The result is an intervention whose broad component library meets the needs of a diverse population and whose technology can deliver the right components for each individual.

Celebrity Endorsements, Whitening products and Consumer Purchase Intentions: A Review of Literature

PURPOSE

The purpose of this study was to examine how much celebrity endorsement stimulates skin colour racism in the cosmetics industry.

DESIGN /METHODOLOGY/APPROACH

The data were collected from google scholar and web of science published articles, and researchers had chosen forty-five research articles. Some of the research articles used a quantitative research approach while others had used qualitative research approach. And for the current study, content analysis has been used.

FINDINGS

The study finds that celebrity endorsement does influence and promote racism, implying that when celebrities promote fairness products, people perceive themselves inferior due to darker skin tone that gives birth to the notion of racism. Brand Image intervenes in the relationship between Celebrity Endorsement and Racism, and also, intervenes in the relationship between Celebrity Endorsement and Purchase Intention.

LIMITATIONS

This study is only limited to google scholar and web of science directory. Only forty-five articles were taken from 2001 to the 2021 year. Real examples were taken from all over the world, but especially from the Less Developed countries like Pakistan and India due to to the huge population, rising income and surging cosmetics industry. Hence the findings of this study cannot be generalized to the Technologically Advanced Countries.

IMPLICATIONS

It is obvious that firms design advertisement campaigns that can get consumers' attention. For this purpose, they engage celebrities to evoke more interest and awareness as well as perception. The study will help the management of different brands to understand that how they can improve their advertisements in a way that does not promote racism. And the celebrities, signing contracts with brands that promote racism, will keep in mind the negative influence these endorsements have on society while companies will make sure that they are also not promoting racism by making such promotional campaigns.

Feasibility and Short-Term Effects of a Multi-Component Emergency Department Blood Pressure Intervention: A Pilot Randomized Trial

Background

Emergency department (ED) visits can be opportunities to address uncontrolled hypertension. We sought to compare short‐term blood pressure measures between the Vanderbilt Emergency Room Bundle (VERB) intervention and usual care plus education.

Methods and Results

We conducted a randomized trial of 206 adult patients with hypertension and elevated systolic blood pressure (SBP) presenting to 2 urban emergency departments in Tennessee, USA. The VERB intervention included educational materials, a brief motivational interview, pillbox, primary care engagement letter, pharmacy resources, and 45 days of informational and reminder text messages. The education arm received a hypertension pamphlet. After 78 participants were enrolled, text messages requested confirmation of receipt. The primary clinical outcome was 30‐day SBP. The median 30‐day SBP was 122 and 126 mm Hg in the VERB and education arms, respectively. We estimated the mean 30‐day SBP to be 3.98 mm Hg lower in the VERB arm (95% CI, −2.44 to 10.4; P=0.22). Among participants enrolled after text messages were adapted, the respective median SBPs were 121 and 130 mm Hg, and we estimated the mean 30‐day SBP to be 8.57 mm Hg lower in the VERB arm (95% CI, 0.98‒16.2; P=0.027). In this subgroup, the median response rate to VERB text messages was 56% (interquartile range, [26%‒80%]).

Conclusions

This pilot study demonstrated feasibility and found an improvement in SBP for the subgroup for whom interactive messages were featured. Future studies should evaluate the role of interactive text messaging as part of a comprehensive emergency department intervention to improve blood pressure control.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02672787.

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.

Telehealth Interventions to Improve Diabetes Management Among Black and Hispanic Patients: a Systematic Review and Meta-Analysis

BACKGROUND

Previous systematic reviews have found that telehealth is an effective strategy for implementing interventions to improve glycemic control and other clinical outcomes for diabetes patients. However, these reviews have not meaningfully focused on Black and Hispanic patients-partly because of the lack of adequate representation of people from racial and ethnic minority groups in clinical trials. It is unclear whether telehealth interventions are effective at improving glycemic control among Black and Hispanic patients given the disproportionate number of barriers they face accessing health care.

OBJECTIVES

A systematic review and meta-analysis of randomized control trials that used telehealth interventions for improving glycemic control among Black and Hispanic diabetes patients.

METHODS

We reviewed PubMed, Embase, Web of Science, CINAHL, PsycINFO, and clinicalTrials.gov from inception to March 2021. We used a narrative summary approach to describe key study characteristics and graded the quality of studies using two reviewers. The pooled net change in HbA1c values was estimated across studies using a random-effects model.

RESULTS

We identified 10 studies that met our inclusion and exclusion criteria. Nine studies were included in the meta-analysis. Only one study was rated as having low bias. Telehealth interventions were primarily delivered by telephone calls, text messages, web-based portals, and virtual visits. Most interventions involved delivering diabetes self-management education. Telehealth intervention pooled across studies with a mix of Black and Hispanic participants (> 50% sample) was associated with a - 0.465 ([CI: - 0.648 to - 0.282], p = 0.000) reduction in HbA1c.

CONCLUSIONS

Our findings suggest telehealth interventions are effective at improving glycemic control among Black and Hispanic diabetes patients.

The Cochlear Implant Use Questionnaire: Assessing Habits and Barriers to Use

OBJECTIVE

The objective was to design a questionnaire to identify daily cochlear implant (CI) use habits and barriers to daily CI use and to administer this questionnaire to adult CI users. We hypothesized that recipients who reported a greater number of barriers to daily CI use would show lower daily CI use.

STUDY DESIGN

Questionnaire.

SETTING

Academic medical center.

PATIENTS

Hundred adult CI recipients.

MAIN OUTCOME MEASURES

Questionnaire responses and amount of CI use per day as measured from the CI software.

RESULTS

The cochlear implant use questionnaire (CIUQ) was created and responses were obtained from 100 participants. The CIUQ yielded an average overall score of 23 (range, 3-54) out of 100; responses were variable, and CI recipients experienced different barriers to using their CI processor. The CIUQ overall score was significantly correlated with recipients' daily CI use (h/d) (rs = -0.561, p < 0.0001, 95% confidence interval [-0.694, -0.391]), which provides evidence of construct validity. Responses were immediately useful for identifying and overcoming barriers to consistent CI use with our study participants.

CONCLUSIONS

Increasing evidence suggests that daily CI use is correlated with speech recognition outcomes. To optimize outcomes, clinicians should consider implementing this questionnaire to identify and overcome barriers to consistent, full-time CI processor use.

Estimating the impact of engagement with digital health interventions on patient outcomes in randomized trials

OBJECTIVE

Guidance is needed on studying engagement and treatment effects in digital health interventions, including levels required for benefit. We evaluated multiple analytic approaches for understanding the association between engagement and clinical outcomes.

MATERIALS AND METHODS

We defined engagement as intervention participants' response rate to interactive text messages, and considered moderation, standard regression, mediation, and a modified instrumental variable (IV) analysis to investigate the relationship between engagement and clinical outcomes. We applied each approach to two randomized controlled trials featuring text message content in the intervention: REACH (Rapid Encouragement/Education and Communications for Health), which targeted diabetes, and VERB (Vanderbilt Emergency Room Bundle), which targeted hypertension.

RESULTS

In REACH, the treatment effect on hemoglobin A1c was estimated to be -0.73% (95% CI: [-1.29, -0.21]; P = 0.008), and in VERB, the treatment effect on systolic blood pressure was estimated to be -10.1 mmHg (95% CI: [-17.7, -2.8]; P = 0.007). Only the IV analyses suggested an effect of engagement on outcomes; the difference in treatment effects between engagers and non-engagers was -0.29% to -0.51% in the REACH study and -1.08 to -3.25 mmHg in the VERB study.

DISCUSSION

Standard regression and mediation have less power than a modified IV analysis, but the IV approach requires specification of assumptions. This is the first review of the strengths and limitations of various approaches to evaluating the impact of engagement on outcomes.

CONCLUSIONS

Understanding the role of engagement in digital health interventions can help reveal when and how these interventions achieve desired outcomes.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

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.

Effectiveness of a customised mobile phone text messaging intervention supported by data from activity monitors for improving lifestyle factors related to the risk of type 2 diabetes among women after gestational diabetes: protocol for a multicentre randomised controlled trial (SMART MUMS with smart phones 2)

INTRODUCTION

Gestational diabetes (GDM) contributes substantially to the population burden of type 2 diabetes (T2DM), with a high long-term risk of developing T2DM. This study will assess whether a structured lifestyle modification programme for women immediately after a GDM pregnancy, delivered via customised text messages and further individualised using data from activity monitors, improves T2DM risk factors, namely weight, physical activity (PA) and diet.

METHODS AND ANALYSIS

This multicentre randomised controlled trial will recruit 180 women with GDM attending Westmead, Campbelltown or Blacktown hospital services in Western Sydney. They will be randomised (1:1) on delivery to usual care with activity monitor (active control) or usual care plus activity monitor and customised education, motivation and support delivered via text messaging (intervention). The intervention will be customised based on breastfeeding status, and messages including their step count achievements to encourage PA. Messages on PA and healthy eating will encourage good lifestyle habits. The primary outcome of the study is healthy lifestyle composed of weight, dietary and PA outcomes, to be evaluated at 6 months. The secondary objectives include the primary objective components, body mass index, breastfeeding duration and frequency, postnatal depression, utilisation of the activity monitor, adherence to obtaining an oral glucose tolerance test post partum and the incidence of dysglycaemia at 12 months. Relative risks and their 95% CIs will be presented for the primary objective and the appropriate regression analysis, adjusting for the baseline outcome results, will be done for each outcome.

ETHICS AND DISSEMINATION

Ethics approval has been received from the Western Sydney Local Health District Human Research Ethics Committee (2019/ETH13240). All patients will provide written informed consent. Study results will be disseminated via the usual channels including peer-reviewed publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12620000615987; Pre-results.

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.