Using Motivational Text Messaging to Improve Diabetes Self-Care - - PowerPoint PPT Presentation

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

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.

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

University Clinical Health UT Methodist Physicians Christ Community Health Services Memphis Health Center Methodist Medical Group Regional One Health

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 Usual Care (N = 130) Text Messaging (N = 258) Health Coaching (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

Extensive input from patients & community stakeholders:

Development of Culturally-Tailored Text Messaging Platform

• Patient Advisory

Council

• Community

Advisory Council

• Provider Learning

Collaborative

• Surveys and

Focus Groups

UT Methodist Physicians

Community Health Centers (FQHC)

Patient Advisory Council

Patients and Community:

Methodist Medical Group

Steering

Committee

Community Advisory Council

UT Regional One Physicians

Methodist Le Bonheur Healthcare University of TN Health Science Center Regional One Health

Health System:

Patients, community members, and providers who can help the people with the greatest needs help themselves

Providers

(Provider Learning Collaborative)

Diabetes Wellness & Prevention Coalition

Clinic Survey—Interest in mHealth for Diabetes Self-care12

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 Advantages of Text Messaging

• Less intrusive than phone

calls

• Avoids prolonged

conversation

• Convenient
• Quicker responses

Perceived Barriers of Text Messaging

• Unfamiliar with

Technology

• Older vs. Younger

Generation

• Expense
• Safety
• Solicitation
• Visual Impairment

Text Message Characteristics

• Interactivity – one way

messages

• Short and to the point
• Frequency – Morning and

Evening

• Inspirational
• Instructional

Major Themes from Focus Group Discussion Age and Texting Habits

Diabetes Self Care Struggles

• Medication Reminders
• Diet

Development of a Motivational Text Message Library 14

Refining the Motivational Text Message Library 14

Humble JR et al, Journal of Telemedicine and Telecare, 2016

Tailoring Motivational Text Messages 14

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

• verall care

5 10 15 20 25

Accountability and Reminders Diet Modifications Incorporating Exercise Knowledge Skills for Improvement Providing Motivation

Number of References

Comparison of Themes By Intervention

Text Message Health Coach Enhanced Care

Focus Groups Results: Comparison of Themes by Intervention 15

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 Mary Lou Gutierrez Ruthie Tate Sandra Williams Douglas Hall Leona Marshall

Clinic and Health System Partners

The Team

Health Coaches Research Assistants

Brittney Becton Stephen Serio Jessica Shotwell Valisa Harris Abbie Hitchon ShaNicka Young Lakeithia Hawkins John Jones Brenda Hinton Shannon Levitt Blanch Thomas Trisha Streater Lindsey Swafford Kavindra Ferguson Carolyn Trimble Daphane Turner

NIH Summer Medical Student Fellows: Alex Galloway, Ian Michalak, Nick Diloreto, Aneikan Udoko, James Humble, Kira Reich, Aubrey Flowers, Zach Pope, Sierra Gaffney, & Michelle Jones Pharmacy student: Stanley Dowell II

Betsy Tolley, PhD Bill Breen, MBA Mace Coday, PhD Helmut Steinberg, MD Susan Butterworth, PhD Ian Brooks, PhD Mary Lou Gutierrez, PhD Justin Gatwood, PhD Ann Brown, MD Cardella Leak, MPH Satya Surbhi, PhD Sohul Shuvo, MS Lauren Haley, MA Ankur Dashputre, MS Jim Bailey, MD, MPH Jay Robinson, PsyD Carolyn Graff, PhD Shaquita Starks, RN, PhD

The Team

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

References

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10. DeVoe JE, Tillotson CJ, Wallace LS. Usual source of care as a health insurance substitute for U.S. adults with diabetes? Diabetes Care 2009;32:983-9. 11. Steiner CA, Friedman B. Hospital utilization, costs, and mortality for adults with multiple chronic conditions, Nationwide Inpatient Sample, 2009. PCD 2013;10:E62. 12. Humble JR TE, Krukowski, RA, Womack CR, Motley TS, Bailey JE. Use of and Interest in Mobile Health for Diabetes Self-Care in Vulnerable Populations. J Telemed and Telecare 2015;0:1-7. 13. Udoko AN, Bailey JE, Ransone S, et. al. Using Text Messages to Support Improved Self-Care Decisions in Medically Underserved African-Americans with Uncontrolled Diabetes: Oral presentation, Society General Internal Medicine 39th Annual Meeting, Hollywood, FL, May 13, 2016, Submitted to Cureus May 2019 14. Gatwood J, Shuvo SA, Brooks I, Smith P, Bailey JE. The Management of Diabetes in Everyday Life (MODEL) Program: Development of a Tailored Text Message Intervention to Improve Diabetes Self-Care Activities among Underserved African American Adults. Translational Behavioral Medicine, 2019 15. Scott M, Gutierrez ML, Maceri S, Riordan CJ, Bailey JE. Effectiveness of health coaching, text messaging, and patient education interventions in improving diabetes self-care: the patient perspective. Plenary session, Oral presentation, Southern Meeting of the Society of General Internal Medicine, Houston, TX, February 16, 2019.