Using Motivational Text Messaging to Improve Diabetes Self-Care Among Underserved African Americans James E. Bailey, MD, MPH Center for Health System Improvement Departments of Medicine and Preventive Medicine The University of Tennessee Health Science Center, Memphis, TN
Acknowledgements To all the dedicated caregivers working day-in and day-out to help people get the primary and preventive care they need most PARTICIPATING CLINICS Methodist Medical Group Christ Community Health Services University Clinical Health Regional One Health UT Methodist Physicians Memphis Health Center FUNDING ACKNOWLEDGEMENT: This work was supported through a Patient-Centered Outcomes Research Institute (PCORI) Project Program Award (SC15-1503-28336). DISCLAIMER: All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient- Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.
Improving Self-Care Decisions of Medically Underserved African-Americans with Uncontrolled Diabetes: Effectiveness of Patient-Driven Text Messaging versus Health Coaching
Mid-South at Heart of National Epidemic of Obesity and Diabetes
Medically Underserved African-Americans Face Highest Risk Now there are more dialysis centers in Whitehaven than primary care clinics Congregational Health Network pastor • 10M African-American adults (32%) with multimorbidity 1-4 • Major barriers to needed services and self-care related to social determinants 5 • More likely to live in areas with inadequate primary care 1,6,7 • > 50% diabetes & hypertension uncontrolled 8,9 • 7 times increased risk of amputation 10 • High rates of hospitalization, complications, & death 11-13
Overall Goal: To Help Those at Highest Risk Targeting High-density African-American Communities in the U.S.
Objectives 1) To determine comparative effectiveness of: • Motivational text messaging • Motivational interviewing-based health coaching • Enhanced care 2) To identify which modalities yield greatest improvement in diabetes self-care in at-risk subpopulations
Study Design: Pragmatic randomized comparative effectiveness trial Adults > 18 with Uncontrolled Diabetes, Multiple Chronic Conditions, & Cell Phones with Texting Plan (N = 646) Enhanced Text Health Usual Care Messaging Coaching (N = 130) (N = 258) (N = 258)
Target Population — People in Health Professional Shortage Areas ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★ ★
Study Interventions 1. Enhanced Usual Care (All Participants) — Enhanced access to diabetes education and low literacy diabetes educational materials 2. Text Messaging — Motivational text messages (TM) providing information & support for diabetes self-care • TM related to patient-identified health goals, needs, and barriers to change • Intermittent TM requiring numeric responses to determine upcoming message content 3. Health Coaching — Diabetes health coaching providing information & support for diabetes self-care • Coaching related to patient-identified health goals, needs, and barriers to change • Individual motivational interviewing sessions in-person (30 -45 min.) or phone (10- 30 min.) • Typically bi-monthly sessions for first 2-3 months followed by monthly sessions for 9-10 months for 14 sessions total on average
Promising Strategies to Improve Diabetes Self-Care
Development of Culturally-Tailored Text Messaging Platform Extensive input from patients & community stakeholders: • Patient Advisory Council • Community Advisory Council • Provider Learning Collaborative • Surveys and Focus Groups
Diabetes Wellness & Prevention Coalition Patients, community members, and providers who can help the people with Steering the greatest needs help themselves Committee Patient Community Patients and Community: Advisory Advisory Council Council Providers UT Community Methodist UT Regional Health (Provider Learning Medical Methodist One Centers Collaborative) Group Physicians (FQHC) Physicians University of TN Regional One Methodist Health System: Health Science Health Le Bonheur Center Healthcare
Clinic Survey — Interest in mHealth for Diabetes Self-care 12 Cross sectional survey — comparing primary care patient experience in a medically underserved area vs. affluent suburb • 79.2% of patients in medically underserved areas extremely interested in health-related text messages (TM). Higher interest in: – 3 of 5 categories of in-person diabetes support services (p< 0.05) – 1 of 4 categories of health-related TM (p< 0.05) – 3 of 8 categories of mHealth applications (p< 0.05) • Smartphone users: – Higher interest in TM (p = 0.004) & mHealth diabetes self-care apps ( p = 0.004) • Younger patients: – More likely to have smartphone ( p < 0.006), use Internet ( p < 0.0012), use smartphone apps (p< 0.0004), & interested in using apps to manage diabetes (p< 0.004).
Initial Focus Groups: Using Text Messages to Support Self-Care 13 Perceived Barriers of Text Messaging Perceived Advantages of • Unfamiliar with Text Messaging Age and Texting Technology • Less intrusive than phone Habits • Older vs. Younger calls Generation • Avoids prolonged • Expense conversation • Safety • Convenient • Solicitation • Quicker responses • Visual Impairment Major Themes from Focus Text Message Group Characteristics Discussion • Interactivity – one way Diabetes Self Care messages Struggles • Short and to the point • Medication Reminders • Frequency – Morning and • Diet Evening • Inspirational • Instructional
Development of a Motivational Text Message Library 14
Refining the Motivational Text Message Library 14
Tailoring Motivational Text Messages 14 Humble JR et al, Journal of Telemedicine and Telecare , 2016
Preliminary Qualitative Results Patients like having a health coach – MODEL Program retention > 95% Patients report improvements in: – Diabetes self-care – Average blood sugar (A1c) – Motivation – Sense of well- being – Satisfaction with provider and overall care
Focus Groups Results: Comparison of Themes by Intervention 15 Comparison of Themes By Intervention 25 20 Number of References 15 10 5 0 Accountability Diet Incorporating Knowledge Skills for Providing and Reminders Modifications Exercise Improvement Motivation Text Message Health Coach Enhanced Care
Challenges and Insights: Use of Culturally-tailored Text Messages 1. Low-income African-American patients prefer text messages to mHealth Apps 2. Tailoring takes time and manpower 3. Cultural tailoring should target specific population segments 4. Patients want specific and actionable messages with positive tone and simple language 5. Patients appreciate culturally-tailored and relevant messages from a trusted source
Introducing Motivational Text Messaging into Routine Clinical Practice for African-American Communities 1. Demonstrate effectiveness 2. Develop and test automated text messaging (TM) tailoring system 3. Complete regional demonstration of fully automated TM tailoring system 4. Make motivational TM toolkit and automated tailoring system broadly available for adoption
Thanks to our Patient Partners Joann Hill Linda Peete Ruthie Tate Leona Marshall Sandra Williams Douglas Hall Mary Lou Gutierrez
Clinic and Health System Partners
The Team Health Coaches Research Assistants Stephen Serio Brittney Becton Jessica Shotwell Lakeithia Hawkins John Jones Blanch Thomas Valisa Harris ShaNicka Young Trisha Streater Abbie Hitchon Shannon Levitt Brenda Hinton Lindsey Swafford Kavindra Ferguson Carolyn Trimble Daphane Turner
The Team Jim Bailey, MD, MPH Ann Brown, MD Helmut Steinberg, MD Bill Breen, MBA Lauren Haley, MA Carolyn Graff, PhD Shaquita Starks, RN, PhD Jay Robinson, PsyD NIH Summer Medical Student Fellows: Alex Galloway, Ian Michalak, Nick Diloreto, Aneikan Udoko, James Susan Butterworth, PhD Satya Surbhi, PhD Betsy Tolley, PhD Justin Gatwood, PhD Sohul Shuvo, MS Humble, Kira Reich, Aubrey Flowers, Zach Pope, Sierra Gaffney, & Michelle Jones Pharmacy student: Stanley Dowell II Mace Coday, PhD Ian Brooks, PhD Cardella Leak, MPH Ankur Dashputre, MS Mary Lou Gutierrez, PhD Contact information: Jim Bailey, MD, MPH, Director, CHSI, jeb@uthsc.edu, (901) 448-2475 Cardella Leak, MPH, Research Leader, CHSI, cleak@uthsc.edu, (901) 448-4276
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