Acceptability and feasibility of FAMS-T1D mHealth intervention to optimize self- and social regulation for emerging adults with type 1 diabetes

BACKGROUND

Among emerging adults with type 1 diabetes (T1D), self-regulation and social regulation skills can help avoid high A1c and diabetes distress. FAMS (Family/friend Activation to Motivate Self-care) is mobile phone-delivered intervention that supports development of these skills and is efficacious among adults with type 2 diabetes. However, the acceptability and feasibility of the FAMS intervention among emerging adults with T1D are unknown.

METHODS

Therefore, we adapted FAMS for in a new disease context and developmental stage and then conducted a 3-month mixed-methods pre-post pilot study. Participants were emerging adults with T1D and a friend/family member enrolled as a support person (optional). Feasibility/acceptability outcomes and associated progression thresholds were recruitment (≥ 70% eligible emerging adults), retention (≥ 85%), intervention engagement (≥ 70%), and satisfaction (≥ 70%). We also collected qualitative feedback to determine if the intervention addressed relevant needs and explored changes in outcomes of interest (family/friend involvement, self-efficacy, self-management, distress, A1c).

RESULTS

Recruitment rates indicate recruitment of emerging adults with T1D (n = 30) and their support persons (n = 20) is feasible - 79% of emerging adults who screened as eligible enrolled and 70% of enrolled emerging adults invited a support person. Emerging adults completed 98% of coaching sessions, and response rates to automated text messages were median 85% IQR [68%, 90%]. Changes in selected measures for outcomes of interest were in expected directions suggesting sensitivity to changes occasioned by the intervention in a future evaluative trial. Emerging adults said FAMS-T1D helped with setting realistic goals, motivated them to prioritize diabetes goals, and increased support, indicating acceptability of the intervention in this new disease and developmental context.

CONCLUSIONS

Findings suggest potential for FAMS-T1D to engage emerging adults and their support persons and feasibility for an evaluative trial examining effects on self-regulation (self-efficacy, self-management), social regulation (family/friend involvement), and outcomes (diabetes distress, A1c).

TRIAL REGISTRATION

We did not register this study on ClinicalTrials.gov because the purpose of the study was to assess the feasibility and acceptability of the intervention and study procedures and measures in preparation for a future trial. The purpose of that future trial will be to evaluate the effect of the intervention on health-related biomedical and behavioral outcomes, and that trial will be registered accordingly.

Goal change and goal achievement for emerging adults across the pilot FAMS-T1D intervention for type 1 diabetes

Objective

Interventions for emerging adults (EAs) with type 1 diabetes (T1D) focus on goal setting, but little is known about how goal achievement relates to intervention outcomes. We examined how goals change, how goal achievement relates to diabetes outcomes, and identified barriers and facilitators to goal achievement.

Method

EAs with T1D (N=29, M age=21.6 years, 57% female) were coached monthly to set a behavioral goal across a 3-month feasibility trial. Coaching notes were qualitatively coded regarding type, complexity, and changes in goals. Goal achievement was measured via daily responses to texts. HbA1c, self-efficacy, diabetes distress, and self-care were assessed pre- and post-intervention.

Results

EAs frequently set food goals (79%) in combination with other goals. EAs overwhelmingly changed their goals (90%), with most increasing goal complexity. Goal achievement was high (79% of days) and not affected by goal change or goal complexity. Goal achievement was associated with increases in self-efficacy and self-care across time. Qualitative themes revealed that aspects of self-regulation and social-regulation were important for goal achievement.

Conclusion

Meeting daily diabetes goals may enhance self-efficacy and self-care for diabetes.

Practice Implications

Assisting EAs to reduce self-regulation challenges and enhance social support for goals may lead to better diabetes outcomes.

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.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

AIMS

Family/friend Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS' effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT.

METHODS

Persons with diabetes (PWDs) were randomized to FAMS or control with their support person (family/friend, optional). FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period.

RESULTS

PWDs (N = 329) were 52 % male, 39 % reported minoritized race or ethnicity, with mean HbA1c 8.6 ± 1.7 %. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64 %; 95 % CI [-1.22 %, -0.05 %]), but overall mean effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27 %; 95 % CI [-0.49 %, -0.09 %]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19 %; 95 % CI [-0.40 %, -0.01 %]).

CONCLUSIONS

Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

Acceptability and Feasibility of FAMS-T1D mHealth intervention to optimize self- & social regulation for emerging adults with type 1 diabetes

Background

Among emerging adults with type 1 diabetes (T1D), self-regulation and social regulation skills can help avoid high A1c and diabetes distress. FAMS (Family/friend Activation to Motivate Self-care) is mobile phone-delivered intervention that supports development of these skills and is efficacious among adults with type 2 diabetes. However, the acceptability and feasibility of the FAMS intervention among emerging adults with T1D is unknown.

Methods

Therefore, we adapted FAMS for in a new disease context and developmental stage then conducted a 3-month mixed-methods pre-post pilot study. Participants were emerging adults with T1D and a friend/family member enrolled as a support person (optional). Feasibility/acceptability outcomes and associated progression thresholds were recruitment (≥ 70% eligible emerging adults), retention (≥ 85%), intervention engagement (≥ 70%) and satisfaction (≥ 70%). We also collected qualitative feedback to determine if the intervention addressed relevant needs and explored changes in outcomes of interest (family/friend involvement, self-efficacy, self-management, distress, A1c).

Results

Recruitment rates indicate recruitment of emerging adults with T1D and their support persons is feasible - 79% of emerging adults who screened as eligible enrolled and 70% of enrolled emerging adults invited a support person. Emerging adults completed 98% of coaching sessions, and response rates to automated text messages were median 85% IQR [68%, 90%]. Changes in selected measures for outcomes of interest were in expected directions suggesting sensitivity to changes occasioned by the intervention in a future evaluative trial. Emerging adults said FAMS-T1D helped with setting realistic goals, motivated them to prioritize diabetes goals, and increased support, indicating acceptability of the intervention in this new disease and developmental context.

Conclusions

Findings suggest potential for FAMS-T1D to engage emerging adults and their support persons and feasibility for evaluation of effects on hypothesized intervention targets and outcomes in a subsequent evaluative trial.

Trial Registration

We did not register this study on clinicaltrials.gov because the purpose of the study was to assess the feasibility and acceptability of the intervention and study procedures and measures in preparation for a future trial. The purpose of that future trial will be to evaluate the effect of the intervention on health-related biomedical and behavioral outcomes and that trial will be registered accordingly.

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.

Well-being outcomes of a family-focused intervention for persons with type 2 diabetes and support persons: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

AIMS

Type 2 diabetes self-management occurs within social contexts. We sought to test the effects of Family/friend Activation to Motivate Self-care (FAMS), a self-care support intervention delivered via mobile phones, on psychosocial outcomes for persons with diabetes (PWDs) and their support persons.

METHODS

PWDs had the option to enroll with a friend/family member as a support person in a 15-month RCT to evaluate FAMS versus enhanced usual care. FAMS included 9 months of monthly phone coaching and text message support for PWDs, and text message support for enrolled support persons.

RESULTS

PWDs (N = 329) were 52% male and 39% reported minoritized race or ethnicity ; 50% enrolled with elevated diabetes distress. Support persons (N = 294) were 26% male and 33% reported minoritized race or ethnicity. FAMS improved PWDs' diabetes distress (d = -0.19) and global well-being (d = 0.21) during the intervention, with patterns of larger effects among minoritized groups. Post-intervention (9-month) and sustained (15-month) improvements were driven by changes in PWDs' self-efficacy, self-care behaviors, and autonomy support. Among support persons, FAMS improved helpful involvement without increasing burden or harmful involvement.

CONCLUSIONS

FAMS improved PWDs' psychosocial well-being, with post-intervention and sustained improvements driven by improved self-efficacy, self-care, and autonomy support. Support persons increased helpful involvement without adverse effects.

Prerandomization withdrawals from a Type 2 diabetes self-care support intervention trial are associated with lack of available support person coparticipant

OBJECTIVES

Dyadic interventions, involving two persons with a preexisting close relationship, offer the opportunity to activate support persons (SPs) to improve health for adults with chronic conditions. Requiring SP coparticipation can challenge recruitment and bias samples; however, the associations between voluntary SP coparticipation and recruitment outcomes across patient characteristics are unknown.

METHODS

The Family/Friend Activation to Motivate Self-care 2.0 randomized controlled trial (RCT) enrolled adults with Type 2 diabetes (T2D) from an academic health system. Participants were asked-but not required-to invite an SP to coenroll. Using data from the electronic health record we sought to describe RCT enrollment in the setting of voluntary SP coparticipation.

RESULTS

In a diverse sample of adults with (T2D) (48% female, 44% minoritized race/ethnicity), most participants (91%) invited SPs and (89%) enrolled with SPs. However, prerandomization withdrawal was significantly higher among participants who did not have consenting SPs than those who did. Females were less likely to invite SPs than males and more Black PWD were prerandomization withdrawals than randomized.

DISCUSSION

Voluntary SP coenrollment may benefit recruitment for dyadic sampling; however, more research is needed to understand if these methods systematically bias sampling and to prevent these unintended biases.

Well-being outcomes of a family-focused intervention for persons with type 2 diabetes and support persons: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

Aims

Type 2 diabetes self-management occurs within social contexts. We sought to test the effects of Family/friends Activation to Motivate Self-care (FAMS), a self-care support intervention delivered via mobile phones, on psychosocial outcomes for persons with diabetes (PWDs) and their support persons.

Methods

PWDs had the option to enroll with a friend/family member as a support person in a 15-month RCT to evaluate FAMS versus enhanced usual care. FAMS included 9-months of monthly phone coaching and text message support for PWDs, and text message support for enrolled support persons.

Results

PWDs (N=329) were 52% male and 39% from minoritized racial or ethnic groups; 50% enrolled with elevated diabetes distress. Support persons (N=294) were 26% male and 33% minoritized racial or ethnic groups. FAMS improved PWDs' diabetes distress ( d =-0.19) and global well-being ( d =0.21) during the intervention, with patterns of larger effects among minoritized groups. Post-intervention and sustained (15-month) improvements were driven by changes in PWDs' self-efficacy, self-care behaviors, and autonomy support. Among support persons, FAMS improved helpful involvement without increasing burden or harmful involvement.

Conclusions

FAMS improved PWDs' psychosocial well-being, with post-intervention and sustained improvements driven by improved self-efficacy, self-care, and autonomy support. Support persons increased helpful involvement without adverse effects.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

Aims

Family/friends Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT.

Methods

Persons with diabetes (PWDs) and their support persons (family/friend, optional) were randomized to FAMS or control. FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period.

Results

PWDs (N=329) were 52% male, 39% from minoritized racial or ethnic groups, with mean HbA1c 8.6±1.7%. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64%; 95% CI [-1.22%, -0.05%]), but overall effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27%; 95% CI [-0.49%, -0.09%]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19%; 95% CI [-0.40%, -0.01%]).

Conclusions

Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

Optimizing adaptive stepped-care interventions to change adults' health behaviors: A systematic review

Chronic diseases are ubiquitous and costly in American populations. Interventions targeting health behavior change to manage chronic diseases are needed, but previous efforts have fallen short of producing meaningful change on average. Adaptive stepped-care interventions, that tailor treatment based on the needs of the individual over time, are a promising new area in health behavior change. We therefore conducted a systematic review of tests of adaptive stepped-care interventions targeting health behavior changes for adults with chronic diseases. We identified 9 completed studies and 13 research protocols testing adaptive stepped-care interventions for health behavior change. The most common health behaviors targeted were substance use, weight management, and smoking cessation. All identified studies test intermediary tailoring for treatment non-responders via sequential multiple assignment randomized trials (SMARTs) or singly randomized trials (SRTs); none test baseline tailoring. From completed studies, there were few differences between embedded adaptive interventions and minimal differences between those classified as treatment responders and non-responders. In conclusion, updates to this work will be needed as protocols identified here publish results. Future research could explore baseline tailoring variables, apply methods to additional health behaviors and target populations, test tapering interventions for treatment responders, and consider adults' context when adapting interventions.

Rates and Correlates of Uptake of Continuous Glucose Monitors Among Adults with Type 2 Diabetes in Primary Care and Endocrinology Settings

BACKGROUND

Clinical trials indicate continuous glucose monitor (CGM) use may benefit adults with type 2 diabetes, but CGM rates and correlates in real-world care settings are unknown.

OBJECTIVE

We sought to ascertain prevalence and correlates of CGM use and to examine rates of new CGM prescriptions across clinic types and medication regimens.

DESIGN

Retrospective cohort using electronic health records in a large academic medical center in the Southeastern US.

PARTICIPANTS

Adults with type 2 diabetes and a primary care or endocrinology visit during 2021.

MAIN MEASURES

Age, gender, race, ethnicity, insurance, clinic type, insulin regimen, hemoglobin A1c values, CGM prescriptions, and prescribing clinic type.

KEY RESULTS

Among 30,585 adults with type 2 diabetes, 13% had used a CGM. CGM users were younger and more had private health insurance (p < .05) as compared to non-users; 72% of CGM users had an intensive insulin regimen, but 12% were not taking insulin. CGM users had higher hemoglobin A1c values (both most recent and most proximal to the first CGM prescription) than non-users. CGM users were more likely to receive endocrinology care than non-users, but 23% had only primary care visits in 2021. For each month in 2021, a mean of 90.5 (SD 12.5) people started using CGM. From 2020 to 2021, monthly rates of CGM prescriptions to new users grew 36% overall, but 125% in primary care. Most starting CGM in endocrinology had an intensive insulin regimen (82% vs. 49% starting in primary care), whereas 28% starting CGM in primary care were not using insulin (vs. 5% in endocrinology).

CONCLUSION

CGM uptake for type 2 diabetes is increasing rapidly, with most growth in primary care. These trends present opportunities for healthcare system adaptations to support CGM use and related workflows in primary care to support growth in uptake.

Family involvement and diabetes distress across dyads for adults with type 2 diabetes

OBJECTIVE

Family/friend involvement and diabetes distress are associated with outcomes for persons with type 2 diabetes (PWDs), but little is known about how they relate to each other. We aim to (1) describe associations between PWD and support person (SP) distress; (2) describe associations between involvement and diabetes distress for PWDs, for SPs, and across the dyad; and (3) explore whether associations differ by PWD-SP cohabitation.

METHODS

PWDs and SPs co-enrolled in a study evaluating the effects of a self-care support intervention and completed self-report measures at baseline.

RESULTS

PWDs and SPs (N = 297 dyads) were, on average, in their mid-50s and around one-third identified as racial or ethnic minorities. The association between PWD and SP diabetes distress was small (Spearman's ρ = 0.25, p < 0.01). For PWDs, experienced harmful involvement from family/friends was associated with more diabetes distress (standardized β = 0.23, p < 0.001) independent of helpful involvement in adjusted models. Separately, SPs' self-reported harmful involvement was associated with their own diabetes distress (standardized β = 0.35, p < 0.001) and with PWDs' diabetes distress (standardized β = 0.25, p = 0.002), independent of SPs' self-reported helpful involvement.

CONCLUSION AND PRACTICE IMPLICATIONS

Findings suggest dyadic interventions may need to address both SP harmful involvement and SP diabetes distress, in addition to PWD distress.

Empowering patients to address diabetes care gaps: formative usability testing of a novel patient portal intervention

Objective

The aim of this study was to design and assess the formative usability of a novel patient portal intervention designed to empower patients with diabetes to initiate orders for diabetes-related monitoring and preventive services.

Materials and Methods

We used a user-centered Design Sprint methodology to create our intervention prototype and assess its usability with 3 rounds of iterative testing. Participants (5/round) were presented with the prototype and asked to perform common, standardized tasks using think-aloud procedures. A facilitator rated task performance using a scale: (1) completed with ease, (2) completed with difficulty, and (3) failed. Participants completed the System Usability Scale (SUS) scored 0-worst to 100-best. All testing occurred remotely via Zoom.

Results

We identified 3 main categories of usability issues: distrust about the automated system, content concerns, and layout difficulties. Changes included improving clarity about the ordering process and simplifying language; however, design constraints inherent to the electronic health record system limited our ability to respond to all usability issues (eg, could not modify fixed elements in layout). Percent of tasks completed with ease across each round were 67%, 60%, and 80%, respectively. Average SUS scores were 87, 74, and 93, respectively. Across rounds, participants found the intervention valuable and appreciated the concept of patient-initiated ordering.

Conclusions

Through iterative user-centered design and testing, we improved the usability of the patient portal intervention. A tool that empowers patients to initiate orders for disease-specific services as part of their existing patient portal account has potential to enhance the completion of recommended health services and improve clinical outcomes.

The growing gap: A study of sleep, encoding, and consolidation of new words in chronic traumatic brain injury

Word learning is an iterative and dynamic process supported by multiple neural and cognitive systems. Converging evidence from behavioral, cellular, and systems neuroscience highlights sleep as an important support for memory and word learning over time. In many lab-based word learning experiments, participants encode and subsequently retrieve newly learned words in a single session. These designs are inadequate to capture the full dynamic word learning process, making them less ecologically valid. Single timepoint studies also limit investigation of the role of behavioral and lifestyle factors, like sleep, in supporting word learning over time. Adults with a history of traumatic brain injury (TBI), who commonly exhibit deficits in the memory systems that support word learning and report concomitant sleep disturbance, provide a unique opportunity to examine the link between memory, sleep, and word learning. Here we examined word learning over time and the influence of sleep on short- and long-term word recall in 50 adults with chronic moderate-severe TBI and 50 demographically matched neurotypical peers. We used a randomized within-participant crossover design to assess immediate encoding of new words and the consolidation of those words over time across intervals that did or did not involve sleep. Participants completed this study over the course of two weeks in their own homes to capture the iterative, dynamic process of real-world word learning. We also measured sleep in free living conditions using actigraphy throughout the experiment. Participants with TBI exhibited a word learning deficit that began at encoding and persisted across time. Critically, this deficit grew over the course of the week. The performance gap between groups was larger at the 1-week post-test than the immediate post-test, suggesting deficits in both encoding and consolidation of new words in individuals with TBI. Participants with and without TBI remembered more words when they slept after learning. Ecologically valid research designs that examine the relationship between memory, sleep, and word learning over time promise to advance mechanistic accounts of word learning and improve the long-term retention of new words in individuals with and without brain injury.

Correction: Development of a Tailored Mobile Phone-Based Intervention to Facilitate Parent-Child Communication and Build Human Papillomavirus Vaccine Confidence: Formative Qualitative Study

[This corrects the article DOI: 10.2196/43041.].

Development of a Tailored Mobile Phone-Based Intervention to Facilitate Parent-Child Communication and Build Human Papillomavirus Vaccine Confidence: Formative Qualitative Study

BACKGROUND

Human papillomavirus (HPV) vaccine hesitancy is on the rise, and provider communication is a first-line strategy to address parental concerns. The use of the presumptive approach and motivational interviewing by providers may not be enough to influence parental decision-making owing to the providers' limited time, self-efficacy, and skills to implement these strategies. Interventions to enhance provider communication and build parental HPV vaccine confidence have been undertested. Delivering tailored patient education to parents via mobile phones before they visit the health care provider may address time constraints during clinic visits and positively affect vaccine uptake.

OBJECTIVE

This study aimed to describe the development and evaluate the acceptability of a mobile phone-based, family-focused intervention guided by theory to address concerns of HPV vaccine-hesitant parents before the clinic visit, as well as explore intervention use to facilitate parent-child communication.

METHODS

The health belief model and theory of reasoned action guided intervention content development. A multilevel stakeholder engagement process was used to iteratively develop the HPVVaxFacts intervention, including a community advisory board review, a review by an advisory panel comprising HPV vaccine-hesitant parents, a health communications expert review, semistructured qualitative interviews with HPV vaccine-hesitant parents (n=31) and providers (n=15), and a content expert review. Inductive thematic analysis was used to identify themes in the interview data.

RESULTS

The qualitative interviews yielded 4 themes: overall views toward mobile device use for health information, acceptability of HPVVaxFacts, facilitators of HPVVaxFacts use, and barriers to HPVVaxFacts use. In parent interviews after reviewing HPVVaxFacts prototypes, almost all parents (29/31, 94%) stated they intended to have their child vaccinated. Most of the parents stated that they liked the added adolescents' corner to engage in optional parent-child communication (ie, choice to share and discuss information with their child; 27/31, 87%) and shared decision-making in some cases (8/31, 26%). After incorporating all input, the final intervention consisted of a 10-item survey to identify the top 3 concerns of parents, followed by tailored education that was mapped to each of the following concerns: evidential messages, images or graphics to enhance comprehension and address low literacy, links to credible websites, a provider video, suggested questions to ask their child's physician, and an optional adolescents' corner to educate the patient and support parent-child communication.

CONCLUSIONS

The multilevel stakeholder-engaged process used to iteratively develop this novel intervention for HPV vaccine-hesitant families can be used as a model to develop future mobile health interventions. This intervention is currently being pilot-tested in preparation for a randomized controlled trial aiming to increase HPV vaccination among adolescent children of vaccine-hesitant parents in a clinic setting. Future research can adapt HPVVaxFacts for other vaccines and use in other settings (eg, health departments and pharmacies).

The Role of Habit Formation and Automaticity in Diabetes Self-Management: Current Evidence and Future Applications

PURPOSE OF REVIEW

Diabetes is a chronic condition that requires consistent self-management for optimal health outcomes. People with diabetes are prone to burnout, cognitive burden, and sub-optimal performance of self-management tasks. Interventions that focus on habit formation have the potential to increase engagement by facilitating automaticity of self-management task performance. The purpose of this review is to (1) clarify the conceptualizations of habit formation and behavioral automaticity in the context of health behavior interventions, (2) review the evidence of habit in relation to behaviors relevant to diabetes self-management, and (3) discuss opportunities for incorporating habit formation and automaticity into diabetes self-management interventions.

RECENT FINDINGS

Modern habit research describes a habit as a behavior that results over time from an automatic mental process. Automatic behaviors are experienced as cue-dependent, goal-independent, unconscious, and efficient. Habit formation requires context-dependent repetition to form cue-behavior associations. Results of diabetes habit studies are mixed. Observational studies have shown positive associations between habit strength and target self-management behaviors such as taking medication and monitoring blood glucose, as well as glycemic outcomes such as HbA1c. However, intervention studies conducted in similar populations have not demonstrated a significant benefit of habit-forming interventions compared to controls, possibly due to varying techniques used to promote habit formation. Automaticity of self-management behaviors has the potential to minimize the burden associated with performance of self-management tasks and ultimately improve outcomes for people with diabetes. Future studies should focus on refining interventions focused on context-dependent repetition to promote habit formation and better measurement of habit automaticity in diabetes self-management.

Association of Perceived Health Competence With Cardiac Rehabilitation Initiation

PURPOSE

Cardiac rehabilitation (CR), a program of supervised exercise and cardiovascular risk management, is widely underutilized. Psychological factors such as perceived health competence, or belief in one's ability to achieve health-related goals, may play a role in CR initiation. The aim of this study was to evaluate the association of perceived health competence with CR initiation among patients hospitalized for acute coronary syndrome (ACS) after adjusting for demographic, clinical, and psychosocial characteristics.

METHODS

The Vanderbilt Inpatient Cohort Study (VICS) characterized the effect of psychosocial characteristics on post-discharge outcomes in ACS inpatients hospitalized from 2011 to 2015. The primary outcome for this analysis was participation in an outpatient CR program. The primary predictor was the two-item Perceived Health Competence Scale (PHCS-2), which yields a score from 2 to 10 (higher scores indicate greater perceived health competence). Multiple logistic regression was used to evaluate the relationship between the PHCS-2 and CR initiation.

RESULTS

A total of 1809 VICS participants (median age: 61 yr, 39% female) with ACS were studied, of whom 294 (16%) initiated CR. The PHCS-2 was associated with a higher odds of CR initiation (OR = 1.15/point increase: 95% CI, 1.06-1.26, P = .001) after adjusting for covariates. Participants with comorbid heart failure had a lower odds of CR initiation (OR = 0.31: 95% CI, 0.16-0.60, P < .001) as did current smokers (OR = 0.64: 95% CI, 0.43-0.96, P = .030).

CONCLUSION

Perceived health competence is associated with outpatient CR initiation in patients hospitalized with ACS. Interventions designed to support perceived health competence may be useful for improving CR participation.

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.

Mediators, Moderators, and Covariates: Matching Analysis Approach for Improved Precision in Cognitive-Communication Rehabilitation Research

PURPOSE

The dual goals of this tutorial are (a) to increase awareness and use of mediation and moderation models in cognitive-communication rehabilitation research by describing options, benefits, and attainable analytic approaches for researchers with limited resources and sample sizes and (b) to describe how these findings may be interpreted for clinicians consuming research to inform clinical care.

METHOD

We highlight key insights from the social sciences literature pointing to the risks of common approaches to linear modeling, which may slow progress in clinical-translational research and reduce the clinical utility of our work. We discuss the potential of mediation and moderation analyses to reduce the research-to-practice gap and describe how researchers may begin to implement these models, even in smaller sample sizes. We discuss how these preliminary analyses can help focus resources for larger trials to fully encapsulate the heterogeneity of individuals with cognitive-communication disorders.

RESULTS

In rehabilitation research, we study groups, but we use the findings from those studies to treat individuals. The most functional clinical research is about more than establishing only whether a given effect exists for an "average person" in the group of interest. It is critical to understand the active ingredients and mechanisms of action by which a given treatment works (mediation) and to know which circumstances, contexts, or individual characteristics might make that treatment most beneficial (moderation).

CONCLUSIONS

Increased adoption of mediation and moderation approaches, executed in appropriate steps, could accelerate progress in cognitive-communication rehabilitation research and lead to the development of targeted treatments that work for more clients. In a field that has made limited progress in developing successful interventions for the last several decades, it is critical that we harness new approaches to advance clinical-translational research results for complex, heterogeneous groups with cognitive-communication disorders.

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.

Effectiveness-implementation trial comparing a family model of diabetes self-management education and support with a standard model

BACKGROUND

Diabetes self-management education and support (DSMES) is an effective approach for improving diabetes self-care behaviors to achieve improved glycemic management and other health outcomes. Engaging family members may improve outcomes, both for the person with diabetes (PWD) and for the family members. However, family models of DSMES have been inconsistently defined and delivered. We operationalize Family-DSMES to be generalizable and replicable, detail our protocol for a comparative effectiveness trial comparing Standard-DSMES with Family-DSMES on outcomes for PWDs and family members, and detail our mixed-methods implementation evaluation plan.

METHODS

We will examine Family-DSMES relative to Standard-DSMES using a Hybrid Type 1 effectiveness-implementation design. Participants are ≥18 years old with type 2 diabetes mellitus and hemoglobin A1c ≥7.0%, recruited from rural and urban primary care clinics that are part of an academic medical center. Each participant invites a family member. Dyads are randomly assigned to Family- or Standard-DSMES, delivered in a small-group format via telehealth. Data are collected at baseline, immediately post-intervention, and 6-, 12-, and 18-months post-intervention. Outcomes include PWDs' hemoglobin A1c (primary), other biometric, behavioral, and psychosocial outcomes (secondary), and family members' diabetes-related distress, involvement in the PWD's diabetes management, self-efficacy for providing support, and biometric outcomes (exploratory). Our mixed-methods implementation evaluation will include process data collected during the trial and stakeholder interviews guided by the Consolidated Framework for Implementation Research.

CONCLUSION

Results will fill knowledge gaps about which type of DSMES may be most effective and guide Family-DSMES implementation efforts.

REGISTRATION

The trial is pre-registered at clinicaltrials.gov (#NCT04334109).

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 ).

Family resilience and childhood obesity among children exposed to adverse childhood experiences in a national survey

OBJECTIVE

Adverse childhood experiences (ACEs) contribute to poor overall health among children with obesity. This study evaluated how one potential protective factor-family resilience-affects the association between ACEs and childhood obesity.

METHODS

This analysis was a secondary analysis of the 2016-2018 National Survey of Children's Health (NSCH), a repeated cross-sectional survey based on parent report. Nine ACEs were queried. Family resilience was assessed with four items (potential range 0-12). The primary outcome was child weight status. Multivariable ordinal logistic regression was used, adjusting for potential confounders and the interaction between ACEs and family resilience.

RESULTS

For 49,365 children ages 10-17, the median number of ACEs was 1 (IQR 0, 2), the median family resilience score was 10 (IQR 8,12), 15.3% of children had overweight, and 15.4% of children had obesity. Among the 51.3% of children who experienced one or more ACEs, higher family resilience scores attenuated the odds of being in a higher weight category. This pattern was not observed in children with zero ACEs.

CONCLUSIONS

In the 2016-2018 NSCH, children ages 10-17 who were exposed to ACEs had higher rates of overweight and obesity, the odds of which may be reduced when children also have higher family resilience.

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.

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.

Development of a Typology of Diabetes-Specific Family Functioning Among Adults With Type 2

BACKGROUND

Family members' responses to adults' diabetes and efforts to manage it vary widely. Multiple aspects of diabetes-specific family functioning have been identified as important for self-management and psychosocial well-being in theoretical (i.e., theories of social support and collaborative coping) and observational literature.

PURPOSE

Develop a typological framework of diabetes-specific family functioning and examine cross-sectional associations between type and diabetes outcomes.

METHODS

We used electronic health record (EHR) data to identify a cohort of 5,545 adults receiving outpatient care for type 2 diabetes and invited them to complete a survey assessing 10 dimensions of diabetes-specific family functioning. We used k-means cluster analysis to identify types. After type assignment, we used EHR data for the full cohort to generate sampling weights to correct for imbalance between participants and non-participants. We used weighted data to examine unadjusted associations between participant characteristics and type, and in regression models to examine associations between type and diabetes outcomes. Regression models were adjusted for sociodemographics, diabetes duration, and insulin status.

RESULTS

We identified and named four types: Collaborative and Helpful (33.8%), Satisfied with Low Involvement (22.2%), Want More Involvement (29.6%), and Critically Involved (14.5%; reflecting the highest levels of criticism and harmful involvement). Across these types, hemoglobin A1c, diabetes distress, depressive symptoms, diabetes medication adherence, and diabetes self-efficacy worsened. After covariate adjustment, type remained independently associated with each diabetes outcome (all p's < .05).

CONCLUSIONS

The typology extends theories of family support in diabetes and applications of the typology may lead to breakthroughs in intervention design, tailoring, and evaluation.

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.

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.

Depressed Mood, Perceived Health Competence and Health Behaviors: aCross-Sectional Mediation Study in Outpatients with Coronary Heart Disease

BACKGROUND

Identifying potential mechanisms that link depressed mood with worse health behaviors is important given the prevalence of depressed mood in patients with coronary heart disease (CHD) and its relationship with subsequent mortality. Perceived health competence is an individual's confidence in his/her ability to successfully engineer solutions to achieve health goals and may explain how depressed mood affects multiple health behaviors.

OBJECTIVE

Examine whether or not perceived health competence mediates the relationship between depressed mood and worse health behaviors.

DESIGN

A cross-sectional study conducted by the Patient-Centered Outcomes Research Institute-funded Mid-South Clinical Data Research Network between August 2014 and September 2015. Bootstrapped mediation was used.

PARTICIPANTS

Patients with coronary heart disease (n = 2334).

MAIN MEASURES

Two items assessing perceived health competence, a single item assessing depressed mood, and a Health Behaviors Index including: the International Physical Activity Questionnaire (IPAQ); select items from the National Adult Tobacco Survey and the Alcohol Use Disorder Inventory Test; and single items assessing diet and medication adherence.

KEY RESULTS

Depressed mood was associated with lower perceived health competence (a = - 0.21, p < .001) and lower perceived health competence was associated with worse performance on a Health Behaviors Index(b = 0.18, p < .001). Perceived health competence mediated the influence of depressed mood on health behaviors (ab = - 0.04, 95% CI = - 0.05 to - 0.03). The ratio of the indirect effect to the total effect was used as a measure of effect size (P_M = 0.26, 95% CI: 0.18 to 0.39).

CONCLUSIONS

Depressed mood is associated with worse health behaviors directly and indirectly via lower perceived health competence. Interventions to increase perceived health competence may lessen the deleterious impact of depressed mood on health behaviors and cardiovascular outcomes.

Health Literacy and 1-Year Mortality: Mechanisms of Association in Adults Hospitalized for Cardiovascular Disease

OBJECTIVE

To test theorized patient-level mediators in the causal pathway between health literacy (HL) and 1-year mortality in adults with cardiovascular disease (CVD).

PATIENTS AND METHODS

A total of 3000 adults treated at Vanderbilt University Hospital from October 11, 2011, through December 18, 2015, for acute coronary syndrome or acute decompensated heart failure (ADHF) participated in the Vanderbilt Inpatient Cohort Study. Participants completed a bedside-administered survey and consented to health record review and longitudinal follow-up. Multivariable mediation models examined the direct and indirect effects of HL (a latent variable with 4 indicators) with 1-year mortality after discharge (dichotomous). Hypothesized mediators included social support, health competence, health behavior, comorbidity index, type of CVD diagnosis, and previous-year hospitalizations.

RESULTS

Of the 2977 patients discharged from the hospital (60% male; mean age, 61 years; 83% non-Hispanic white, 37% admitted for ADHF), 17% to 23% had inadequate HL depending on the measure, and 10% (n=304) died within 1 year. The total effect of lower HL on 1-year mortality (adjusted odds ratio [AOR]=1.31; 95% CI, 1.01-1.69) was decomposed into an indirect effect (AOR=1.50; 95% CI, 1.35-1.67) via the mediators and a nonsignificant direct effect (AOR=0.87; 95% CI, 0.66-1.14). Each SD decrease in HL was associated with an absolute 3.2 percentage point increase in the probability of 1-year mortality via mediators admitted for ADHF, comorbidities, health behavior, health competence, and previous-year hospitalizations (listed by contribution to indirect effect).

CONCLUSION

Patient-level factors link low HL and mortality. Health competence and health behavior are modifiable mediators that could be targeted by interventions post hospitalization for CVD.

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.

Relation of Perceived Health Competence to Physical Activity in Patients With Coronary Heart Disease

Physical inactivity is highly associated with mortality, especially in patients with coronary heart disease. We evaluated the effect of perceived health competence, a patient's belief in his or her ability to achieve health-related goals, on cumulative physical activity levels in the Mid-South Coronary Heart Disease Cohort Study. The Mid-South Coronary Heart Disease Cohort Study consists of 2,587 outpatients (32% were female) with coronary heart disease at an academic medical center network in the United States. Cumulative physical activity was quantified in metabolic equivalent (MET)-minutes per week with the International Physical Activity Questionnaire. We investigated associations between the 2-item Perceived Health Competence Scale (PHCS-2) and MET-minutes/week after adjusting for co-morbidities and psychosocial factors with linear regression. Nearly half of participants (47%) exhibited low physical activity levels (<600 MET-minutes/week). Perceived health competence was highly associated with physical activity after multivariable adjustment. A nonlinear relation was observed, with the strongest effect on physical activity occurring at lower levels of perceived health competence. There was effect modification by gender (p = 0.03 for interaction). The relation between perceived health competence and physical activity was stronger in women compared with men; an increase in the PHCS-2 from 3 to 4 was associated with a 73% increase in MET-minutes/week in women (95% confidence interval 43% to 109%, p <0.0001) compared with a 53% increase in men (95% confidence interval 27% to 84%, p <0.0001). In conclusion, low perceived health competence was strongly associated with less physical activity in patients with coronary heart disease and may represent a potential target for behavioral interventions.

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

Background

Nonadherence to self-care is common among patients with type 2 diabetes (T2D) and often leads to severe complications. Moreover, patients with T2D who have low socioeconomic status and are racial/ethnic minorities disproportionately experience barriers to adherence and poor outcomes. Basic phone technology (text messages and phone calls) provides a practical medium for delivering content to address patients’ barriers to adherence; however, trials are needed to explore long-term and sustainable effects of mobile phone interventions among diverse patients.

Objective

The aim of this study is to evaluate the effects of mobile phone–based diabetes support interventions on self-care and hemoglobin A_1c (HbA_1c) among adults with T2D using a 3-arm, 15-month randomized controlled trial with a Type 1 hybrid effectiveness-implementation approach. The intervention arms are (1) Rapid Encouragement/Education And Communications for Health (REACH) and (2) REACH + Family-focused Add-on for Motivating Self-care (FAMS).

Methods

We recruited primary care patients with T2D (N=512) from Federally Qualified Health Centers and an academic medical center, prioritizing recruitment of publicly insured and minority patients from the latter. Eligible patients were prescribed daily diabetes medication and owned a cell phone with text messaging capability. We excluded patients whose most recent HbA_1c result within 12 months was <6.8% to support detection of intervention effects on HbA_1c. Participants were randomly assigned to REACH only, REACH + FAMS, or the control condition. REACH provides text messages tailored to address patient-specific barriers to medication adherence based on the Information-Motivation-Behavioral skills model, whereas FAMS provides monthly phone coaching with related text message content focused on family and friend barriers to diet and exercise adherence. We collect HbA_1c and self-reported survey data at baseline and at 3, 6, and 12 months, and again at 15 months to assess sustained changes. We will use generalized estimating equation models to test the effects of REACH (either intervention arm) on HbA_1c relative to the control group, the potential additive effects of FAMS, and effects of either intervention on adherence to self-care behaviors and diabetes self-efficacy.

Results

The trial is ongoing; recruitment closed December 2017. We plan to perform analyses on 6-month outcomes for FAMS in July 2018, and project to have 15-month data for REACH analyses in April 2019.

Conclusions

Our study will be one of the first to evaluate a long-term, theory-based text messaging intervention to promote self-care adherence among racially/ethnically and socioeconomically diverse adults with T2D. Moreover, our study will assess the feasibility of a family-focused intervention delivered via mobile phones and compare the effects of text messaging alone versus text messaging plus phone coaching. Findings will advance our understanding of how interventions delivered by phone can benefit diverse patients with chronic conditions.

Trial Registration

ClinicalTrials.gov NCT02409329; https://clinicaltrials.gov/ct2/show/NCT02409329 (Archived by WebCite at http://www.webcitation.org/6yHkg9SSl); NCT02481596; https://clinicaltrials.gov/ct2/show/NCT02481596 (Archived by WebCite at http://www.webcitation.org/6yHkj9XD4)

The MEssaging for Diabetes Intervention Reduced Barriers to Medication Adherence Among Low-Income, Diverse Adults With Type 2

BACKGROUND

Nonadherence to diabetes medication is prevalent and costly. MEssaging for Diabetes (MED), a mobile health (mHealth) intervention, identified and addressed user-specific barriers to medication adherence. We assessed whether MED reduced users' targeted barriers and if barrier reductions were associated with within-participant improvements in adherence or glycemic control (HbA1c).

METHODS

Adults (N = 80) with type 2 diabetes completed self-report measures identifying barriers to adherence at baseline and monthly for 3 months. At each assessment, 17 barriers were assessed and ranked for each user. Each subsequent month, users received daily text messages addressing their 3 highest ranked barriers. Targeted barriers were different for each participant and could change monthly. Paired t-tests assessed within-participant improvement in targeted barriers each month, and nested regression models assessed if changes in a participant's barrier scores were associated with improvements in adherence and HbA1c.

RESULTS

Participants were 69% non-white and 82% had incomes <$25K. Average HbA1c was 8.2 ± 2.0%. Assessment completion rates were 100% at baseline, 59% at 1 month, 30% at 2 months, and 65% at 3 months. The most commonly reported barriers were the cost of medications (76%), believing medications are harmful (58%), and lacking information about medications (53%). Participants' barrier scores improved each month and barrier improvement predicted adherence assessed via nightly adherence assessment text messages ( P < .001). Among participants who completed assessments each month, barrier improvement in months 2 and 3 ( P < .05) predicted HbA1c improvement.

CONCLUSIONS

Iterative, individual tailoring may overcome users' barriers to adherence. Attrition is a challenge for mHealth interventions among low-income patients.

Development and Usability of REACH: A Tailored Theory-Based Text Messaging Intervention for Disadvantaged Adults With Type 2 Diabetes

Background

Among adults with type 2 diabetes mellitus (T2DM), adherence to recommended self-care activities is suboptimal, especially among racial and ethnic minorities with low income. Self-care nonadherence is associated with having worse glycemic control and diabetes complications. Text messaging interventions are improving the self-care of adults with T2DM, but few have been tested with disadvantaged populations.

Objective

To develop Rapid Education/Encouragement And Communications for Health (REACH), a tailored, text messaging intervention to support the self-care adherence of disadvantaged patients with T2DM, based on the Information-Motivation-Behavioral skills model. We then tested REACH’s usability to make improvements before evaluating its effects.

Methods

We developed REACH’s content and functionality using an empirical and theory-based approach, findings from a previously pilot-tested intervention, and the expertise of our interdisciplinary research team. We recruited 36 adults with T2DM from Federally Qualified Health Centers to participate in 1 of 3 rounds of usability testing. For 2 weeks, participants received daily text messages assessing and promoting self-care, including tailored messages addressing users’ unique barriers to adherence, and weekly text messages with adherence feedback. We analyzed quantitative and qualitative user feedback and system-collected data to improve REACH.

Results

Participants were, on average, 52.4 (SD 9.5) years old, 56% (20/36) female, 63% (22/35) were a racial or ethnic minority, and 67% (22/33) had an income less than US $35,000. About half were taking insulin, and average hemoglobin A_1c level was 8.2% (SD 2.2%). We identified issues (eg, user concerns with message phrasing, technical restrictions with responding to assessment messages) and made improvements between testing rounds. Overall, participants favorably rated the ease of understanding (mean 9.6, SD 0.7) and helpfulness (mean 9.3, SD 1.4) of self-care promoting text messages on a scale of 1-10, responded to 96% of assessment text messages, and rated the helpfulness of feedback text messages 8.5 (SD 2.7) on a scale of 1-10. User feedback led to refining our study enrollment process so that users understood the flexibility in message timing and that computers, not people, send the messages. Furthermore, research assistants’ feedback on the enrollment process helped improve participants’ engagement with study procedures.

Conclusions

Testing technology-delivered interventions with disadvantaged adults revealed preferences and concerns unique to this population. Through iterative testing and multiple data sources, we identified and responded to users’ intervention preferences, technical issues, and shortcomings in our research procedures.

The Hidden Work of Exiting Homelessness: Challenges of Housing Service Use and Strategies of Service Recipients

This study explored the experiences of parents attempting to re-attain housing after a shelter stay. Eighty parents participated in semistructured face-to-face interviews approximately six months after being recruited from shelters in four states across the U.S. Qualitative analyses identified common challenges of service use, strategies of service recipients, and characteristics of positive and negative service experiences. Challenges of service use included "catch-22s" resulting from incongruity between service policies/procedures and participants' contexts and/or requirements of other services, confusion and uncertainty resulting from absent or insufficient communication about services, and long waitlists. Participants demonstrated persistence and determination, networked with service providers, and activated formal resources. Positive service experiences were tailored to families' needs and marked by clear and consistent communication between providers and with service recipients. Findings suggest effective health communication tactics should be applied to housing services. Providers should collaborate to ensure service attainment does not impede other pathways to stability.

Medication adherence may be more important than other behaviours for optimizing glycaemic control among low-income adults

WHAT IS KNOWN

Patients with type 2 diabetes mellitus (T2DM) are required to perform multiple self-care behaviours to achieve and maintain optimal glycaemic control (HbA1c), which prevents complications and premature mortality. Patients with T2DM and low socioeconomic status (SES) are more likely to have suboptimal HbA1c, often due to being less adherent to recommended self-care activities than their higher-SES counterparts.

OBJECTIVE

Although studies support performing certain diabetes self-care behaviours for optimizing glycaemic control, there is limited research on the relative importance of each behaviour for this purpose. Identifying what behaviours are most important for HbA1c among low-SES patients with T2DM would be particularly useful for informing policy and intervention efforts for this high-risk group.

METHODS

In a cross-sectional study of 314 adults with T2DM and low SES, we used the Summary of Diabetes Self-Care Activities to assess self-care behaviours and multivariate models to test which behaviours were associated with lower HbA1c.

RESULTS AND DISCUSSION

Only medication adherence was significantly associated with lower HbA1c after adjusting for the other self-care behaviours (β = -0·14, P = 0·028) and further adjusting for demographic and diabetes characteristics (β = -0·16, P = 0·024).

WHAT IS NEW

Medication adherence may be the most important self-care behaviour for glycaemic control among adults with T2DM and low SES.

CONCLUSION

Focused efforts to improve medication adherence among low-SES patient populations may improve glycaemic control.

Families experiencing housing instability: the effects of housing programs on family routines and rituals

Maintenance of family processes can protect parents, children, and families from the detrimental effects of extreme stressors, such as homelessness. When families cannot maintain routines and rituals, the stressors of poverty and homelessness can be compounded for both caregivers and children. However, characteristics of living situations common among families experiencing homelessness present barriers to the maintenance of family routines and rituals. We analyzed 80 in-depth interviews with parents who were experiencing or had recently experienced an instance of homelessness. We compared their assessments of challenges to family schedules, routines, and rituals across various living situations, including shelter, transitional housing programs, doubled-up (i.e., living temporarily with family or friends), and independent housing. Rules common across shelters and transitional housing programs impeded family processes, and parents felt surveilled and threatened with child protective service involvement in these settings. In doubled-up living situations, parents reported adapting their routines to those of the household and having parenting interrupted by opinions of friends and family members. Families used several strategies to maintain family routines and rituals in these living situations and ensure consistency and stability for their children during an otherwise unstable time.