An automated text messaging program delivering friendly reminders and health advice for patients with type 2 diabetes (T2D) sustained a high level of patient engagement over a 12-month period, and it did so among diverse patients who have not typically been well represented in studies of its type.
The research, published in Diabetes Care, was conducted by a Vanderbilt University Medical Center team that included Lyndsay Nelson, Ph.D., a research assistant professor of medicine, and Lindsay Mayberry, Ph.D., an assistant professor of medicine.
“Diabetes patients with low socioeconomic status, and patients who belong to racial or ethnic minority groups, have not been well represented in the literature on mobile health interventions, even though they may be at highest risk for nonadherence and worse outcomes,” Mayberry said.
“Diabetes patients with low socioeconomic status, and patients who belong to racial or ethnic minority groups, have not been well represented in the literature on mobile health interventions.”
Value of Continuous Texts
Most prior research into text messaging interventions for diabetes care has looked at patient engagement over a 3-month or 6-month time period. The Vanderbilt study was part of a larger randomized, controlled trial – REACH, for Rapid Education/Encouragement And Communications for Health – and expanded the analysis to a yearlong intervention with a focus on enrolling more diverse patients.
Study participants were literate, English-speaking T2D patients from community health centers and Vanderbilt primary care clinics. The average age of study participants was 56. Forty-one percent had an annual household income under $25,000. All patients had been prescribed a daily diabetes medication, for which they were responsible, and owned a mobile phone with texting capabilities.
Participants received text messages that pertained to either medication adherence or to self-care behaviors such as eating healthfully or being active. For the first six months, all participants received at least two texts daily. After six months, patients were given the choice to receive fewer texts or continue with daily texts.
Mayberry and Nelson found that the best text message content was affirming, positive and appropriate for all health literacy levels. “In the trial, we found that 44 percent of participants, or nearly half, chose to stay with the daily texts at the 6-month mark,” Nelson said. “I believe their choice to continue daily texts speaks to the quality of the texts.”
“We found that 44 percent of participants, or nearly half, chose to stay with the daily texts at the 6-month mark.”
Engaging Patients in Content Creation
The research team partnered with the local clinics to recruit patients and collect data throughout the trial. “We were present at patients’ clinics, wearing our REACH t-shirts, and working closely with their physicians and nurse practitioners,” Mayberry said. This lent their effort credibility among patient participants.
Engaging the patients themselves in the content of the texts also proved instrumental to the efforts’ success. “We designed the intervention with and for these patients,” Mayberry said. For example, as part of usability testing, patients pushed back on messages that began, “If you missed your medicine today…” or, “If you fell off your routine…” “Patients responded, ‘Don’t presume we’re not doing what we’re supposed to do,’” Mayberry said.
Reducing Barriers to Adherence
While the program significantly improved medication adherence and dietary behavior up to 12 months, “treatment effects were not significant for any outcome at 15 months,” the authors wrote. They concluded that while “REACH reduced barriers to adherence, barrier reduction did not mediate outcome improvements.”
“Addition of tailored components such as counseling with a clinical pharmacist, diabetes self-management education, or health coaching” may help to address some of these barriers, such as beliefs and behavioral skills deficits.
Looking ahead, Mayberry and Nelson plan to conduct an implementation study. “We want to see if the intervention is engaging and effective when the clinic is the one offering the program as an integrated supplement to patient care,” Nelson said. “We are hopeful that engagement will remain high.”
The two have collaborated previously to identify risk factors contributing to worse diabetes outcomes among black, non-Hispanic Americans.