mDiabetes: Using text messaging to extend diabetes self-management support outside the clinic environment

Abstract

Introduction: Globally, there is increasing prevalence of diabetes and costly long-termcomplications associated with poor glycaemic control. In New Zealand, people of ethnic minority,including Māori (indigenous), are particularly vulnerable to the development of diabetes, experiencepoorer control, and increased rates of complications. Engagement with diabetes self-managementis critical for good glycaemic control and there is a need for innovative solutions to better helppeople self-manage the condition thereby reducing the burden of diabetes as well as theassociated health disparities. There is growing evidence for the use of mobile health (mHealth) toprovide such a solution. Text messages (SMS) have the advantage of universal use, and given theubiquity of mobile phones, may be the ideal platform for the delivery of diabetes self-managementsupport to people in their day-to-day lives. The overarching aim of this thesis was to develop andevaluate an mHealth diabetes self-management support programme for adults with poorlycontrolled diabetes.Methods: A systematic review was undertaken to assess the effectiveness of SMS based diabetesself-management interventions on glycaemic control (HbA1c) in adults with poorly controlleddiabetes. A cross-sectional survey investigated the current and perceived roles of mHealth insupporting young people to manage their diabetes. Formative work, including extensiveconsultation and reviews of recommendations for self-management education, theoreticalconstructs and cultural considerations, was undertaken resulting in the development of an SMSbased self-management support programme (SMS4BG) for adults with poorly controlled diabetes.SMS4BG was designed to provide motivation and support to improve self-management behavioursand achieve better glycaemic control. The programme was personalised and tailored to individualpatient preferences, demographics, clinical characteristics, and culture. The usability andacceptability of SMS4BG was then assessed in a non-randomised pilot study before the finalintervention was finalised. Lastly, a 2-arm, parallel, randomised controlled trial (RCT) wasconducted in adults with poorly controlled diabetes to assess the effectiveness of SMS4BG.Participants were recruited from across New Zealand and randomised at a 1:1 ratio to receiveSMS4BG (intervention) in addition to usual care, or usual care alone (control). The primaryoutcome was change in HbA1c at 9 months.Results: The systematic review found that contrary to previous reviews reporting improvements inHbA1c from SMS interventions in patients with diabetes, when limited to those with poorlycontrolled diabetes, the evidence on glycaemic control was less convincing. The small number ofstudies, their heterogeneity and variable methodological quality, prevented a meta-analysis of thedata. The survey findings revealed that in young adults (aged 16-24 years; n=115) currentengagement with readily available apps for diabetes management was low (33%) but that interestin mHealth, including SMS (64%), was high. Next, the pilot study of 42 adults (aged 16-69 years)with poorly controlled diabetes established that SMS4BG was both acceptable and useful insupporting self-management. Suggestions for improvements were then incorporated into the finalSMS4BG intervention. In the RCT, 366 participants (aged 16-80 years) were randomised to theintervention (n=183) or the control (n=183) group. At 9 months, HbA1c was significantly lower in the intervention group compared with the control group (adjusted mean difference, -4.23 [95%CI,-7.30, -1.15], p=0.01). High levels of satisfaction with SMS4BG were found with 95% of participantsreporting it to be useful, 97% reporting it to be culturally appropriate, and 97% would recommend itto other people with diabetes.Discussion: The findings from this thesis show that a tailored SMS based self-managementsupport programme is acceptable and effective at improving HbA1c in adults with poorly controlleddiabetes. It shows that a single programme incorporating individual tailoring can provideintervention to a diverse population regardless of age, diabetes type, location, or culture. SMSinterventions have the potential to make culturally appropriate and personalised self-managementsupport accessible to nearly all people with diabetes regardless of location.