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

Abstract

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.

Effectiveness of smartphone application–based self‐management interventions in patients with type 2 diabetes: A systematic review and meta‐analysis of randomized controlled trials

“…Suboptimal self‐management behaviours have been frequently observed, especially in the young to middle‐aged population. Engaging and empowering patients in self‐management remains the most challenging issue in the continuum of diabetes care (Nelson et al, 2016, 2020). This warrants immediate attention to the development of cost‐effective and efficacious intervention to address patients’ continued needs and demands in the trajectory of diabetes management.…”

Role of Digital Engagement in Diabetes Care Beyond Measurement: Retrospective Cohort Study

“…Mobile apps have been shown to improve diabetic outcomes via education and support for adhering to evidence-based recommendations [ 13 - 16 ]. Apps for diabetes management and diabetes online communities appear to be useful tools for helping people with type 2 diabetes to control HbA 1c and are increasingly considered core intervention tools in self-management for patients with type 2 diabetes [ 17 - 19 ].…”

An Innovative, Paradigm-Shifting Lifestyle Intervention to Reduce Glucose Excursions With the Use of Continuous Glucose Monitoring to Educate, Motivate, and Activate Adults With Newly Diagnosed Type 2 Diabetes: Pilot Feasibility Study

“…After completing questionnaires, participants were mailed a CGM reader and 4.5 months of sensor supplies, (FreeStyle Libre 2 CGM system), a Fitbit Charge 3 activity monitor, and the GEM pocket guide (hard copy). This was followed by a telephone call introducing them to the CGM and activity monitor technology, inserting the CGM sensor, registering and activating the technology, and selecting seven personalized text messages, for example, “Food choices are life choices, Exercise is my friend,” which would be delivered at a time and frequency selected by the participant, to encourage GEM engagement [ 18 ]. Three days later, they received the second and final call to review the GEM pocket guide to initiate treatment.…”

“…Given that GEM has only been evaluated at the University of Virginia, we delivered GEM at diverse medical settings (external validity). Given that daily text messages have been demonstrated to improve engagement by adults with T2D [ 18 ], we employed text messaging for the first time. The primary hypotheses tested were that GEM combined with feedback from continuous glucose monitors (CGMs) and activity monitors, with automated text messages could improve metabolic control with reduced reliance on diabetes medication, while producing the secondary benefits of improved psychological function and reduced BMI.…”