Abstract
BackgroundText 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.ObjectiveThe 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.MethodsWe 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.ResultsThe 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.ConclusionsWell-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.
Highlights
BackgroundFor many patients with chronic conditions, including type 2 diabetes (T2D), consistent, daily self-care is critical to avoid adverse health outcomes
Black race and worse baseline medication adherence and hemoglobin A1c (HbA1c) were each associated with lower engagement, the effects were small
8 participants were not included in these analyses due to early withdrawal (n=5), a technical error resulting in text messages not being sent (n=2), or opting out of text messages during the first 30 days (n=1)
Summary
For many patients with chronic conditions, including type 2 diabetes (T2D), consistent, daily self-care (eg, taking medications, eating healthy, and exercising) is critical to avoid adverse health outcomes. Patients with T2D face many barriers to self-care, including a lack of diabetes-related education and information, social barriers (eg, lack of motivation and caregiver stress), and difficulties with finances and transportation [1]. Evidence is growing for the efficacy of text message–delivered interventions to improve self-care for T2D and other chronic conditions [11,12,13]; there is a paucity of research examining how users engage with these interventions, in the long term [14,15]. Text message–delivered interventions are a feasible and scalable approach for improving chronic disease self-care and reducing health disparities; information on long-term user engagement with these interventions is limited
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