Effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management for people with type 2 diabetes. A randomized controlled trial

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Highlights

  • DTEXT is the largest Australian RCT for type 2 diabetes text message health interventions

  • Text message interventions are highly accepted amongst people with type 2 diabetes

  • A type 2 diabetes text message intervention can improve some nutritional outcomes

  • DTEXT offers feasible self-management support to complement existing diabetes care

Abstract

Objective

Determine the effectiveness and acceptability of a text message intervention (DTEXT) on HbA1c and self-management behaviors for Australian adults with type 2 diabetes.

Methods

Using intention to treat analysis and generalized estimating equations, this randomized controlled trial of 395 adults determined change in HbA1c at 3 and 6 months between the intervention and control group. Secondary outcomes included change in nutrition, physical activity, blood lipid profile, body mass index, quality of life, self-efficacy, medication taking and program acceptability.

Results

No significant difference was observed between the intervention or control group for HbA1c at 3 months (P = 0.23) or 6 months (P = 0.22). Significant improvements were seen in consumption of vegetables at 3 months (P < 0.001) and 6 months (P = 0.04); fruit at 3 months (P = 0.046) and discretionary sweet foods at 3 months (P = 0.02). No other significant effects seen. The intervention demonstrated high rates of acceptability (94.0%) and minimal withdrawal (1.5%).

Conclusions

DTEXT was an acceptable text message intervention that improved some nutritional behaviors in people with type 2 diabetes, but did not significantly improve HbA1c or other outcomes. Further research is required to optimize DTEXT.

Practice implications

DTEXT provides an acceptable, feasible form of self-management support that may complement existing diabetes care.

Introduction

In Australia, diabetes is one of the fastest growing chronic diseases, with prevalence increasing threefold since 1990 [1]. It is the 7th leading cause of death in Australia [1], one of the largest contributors to preventable hospitalizations [2], and contributes $14.6 billion annually in direct and indirect costs [3]. Type 2 diabetes accounts for 85% of diabetes, with around 1.1 million (5%) Australians currently diagnosed with the disease, and half a million undiagnosed cases [4]. Driving the development and progression of type 2 diabetes are increasing rates of overweight and obesity, largely attributed to modifiable lifestyle factors such as poor diet and physical inactivity [5]. Type 2 diabetes can result in microvascular and macrovascular complications, and premature mortality [6], leading to a decreased quality of life and increased burden of the disease for the individual and the health system [3,4]. Diabetes education and self-management have been shown to improve glycemic control and health outcomes for people with type 2 diabetes [7,8], however in Australia, programs are often underfunded [8] with low attendance [9,10], and self-management behaviors are often not followed [11]. An important need therefore exists for the Australian health system to develop new models of diabetes care that improve outcomes in a financially sustainable way [12].

Lifestyle interventions delivered via mobile phone text message interventions have been shown to benefit a range of chronic conditions and health behaviors [13]. Automated and unidirectional text message interventions for people with type 2 diabetes have demonstrated the potential for scalability to a population level, without requiring large amounts of funding or clinical information [14]. However evidence on the optimal characteristics of text message interventions to improve the health and self-management of people with type 2 diabetes is limited and inconclusive [[14], [15], [16]]. Our study aimed to determine the effectiveness and acceptability of a six-month mobile phone text message intervention (DTEXT) on HbA1c and self-management behaviors for Australian adults with type 2 diabetes and HbA1c ≥7.0% (53 mmol/mol).

Section snippets

Study design

This study was a pragmatic randomized controlled trial (RCT) with two parallel arms. The intervention arm received usual care and the text message intervention (DTEXT). The control arm received usual care only. Usual care consisted of routine care by the participants’ treating physician and associated health professionals. Ethical approval was obtained from the University of Wollongong & Illawarra Shoalhaven Local Health District Human Research Ethics Committee (Health and Medical) (2016/343)

Results

A total of 1231 people expressed interest in the study and were assessed for eligibility. The majority of people were excluded due to good control of their diabetes, with HbA1c <7.0% (53 mmol/L). Randomization of 395 people resulted in 197 participants in the intervention group and 198 participants in the control group. Data collection occurred between May 2017 and March 2019. There was minimal withdrawal and loss to follow up for both groups, with 95% of participants completing the study (Fig.

Discussion

Our study suggests that a 6 month diabetes self-management support program delivered via mobile phone text messages can lead to small improvements in some nutritional outcomes, but does not have a statistically significant effect on improving HbA1c, BMI, blood lipids or other diabetes self-management behaviors. Overall however, the intervention did show small positive trends for improvement across most outcomes, and was highly accepted by participants, suggesting that a text message support

Funding

This work was supported by the New South Wales Ministry of Health Translational Research Grants Scheme (Grant ID: 23, Round 1, 2016). The funding body had no role in the study design, collection, analysis, interpretation of data, writing or submission of this manuscript for publication.

CRediT authorship contribution statement

Karen Waller: Conceptualization, Methodology, Software, Formal analysis, Investigation, Resources, Data curation, Visualization, Writing - original draft, Project administration. Susan Furber: Conceptualization, Methodology, Resources, Investigation, Project administration, Writing - review & editing, Supervision. Adrian Bauman: Conceptualization, Methodology, Writing - review & editing, Supervision. Margaret Allman-Farinelli: Methodology, Writing - review & editing, Supervision. Paul van den

Declaration of Competing Interest

None

Acknowledgements

The authors thank Vanessa Jackson, Tania Starr, Charlotte Slater and Nicole Elliott from the Health Promotion Service, Illawarra Shoalhaven Local Health District (ISLHD), for their communication, marketing and administrative support; Darren Mayne from the Public Health Unit, ISLHD, for his support with interpreting the analysis; and the NSW Health IT department for their assistance in setting up the automated text message system.

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