Consistent daily self-care practices in type 2 diabetes, such as adhering to medication regimens, eating healthy, and exercising, are critically important to ensuring patients avoid adverse health outcomes. However, these individuals often face many barriers to optimal self-care, including a lack of diabetes-related education and information, social barriers, and difficulties with finances and transportation. Racial and ethnic minorities and those with low socioeconomic status tend to experience even more barriers to optimal self-care practices.

Text message-delivered interventions have been explored as a potential approach to extending self-care support for patient groups who are hardest to reach and most vulnerable. “As more mobile health interventions are developed and deployed, it’s critical to determine if these interventions engage patients and to see who is most likely to engage and for how long,” says Lyndsay A. Nelson, PhD. “We need to understand the extent to which patients will use these interventions and if certain types of people are more or less willing to use them. Implementing technology interventions that only some patients use may actually worsen health disparities.”

Assessing Engagement

For a study published in JMIR mHealth and uHealth, Dr. Nelson, Lindsay S. Mayberry, PhD, MS, and colleagues examined user engagement in a 12-month text message-delivered intervention supporting diabetes self-care, called REACH (Rapid Education/Encouragement And Communications for Health), in a diverse group of patients with type 2 diabetes. Participants completed surveys and A1C tests and received REACH text messages, including self-care promotion texts, interactive texts regarding 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, the coaching was stopped, and participants had the option to receive fewer texts for the subsequent 6 months. The authors defined engagement using responses to the interactive texts. They analyzed 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. A subset of participants also completed a follow-up interview after they finished their participation.

Overarching Themes

“Our research showed that the median response rate to the interactive texts was 91% over 12 months and response rates remained high over 12 months,” says Dr. Mayberry. “This is a much higher response rate than what we have seen with other technology-delivered interventions, like apps and websites, even in short-term evaluations. Engagement was high across participants of different races and ages as well as various levels of education, income, health literacy, and numeracy.” Engagement gradually declined over time but remained high, with the predicted response rate never dipping below 70% (Figure).

The study team also assessed patterns of engagement when patients with type 2 diabetes were given the option to receive fewer texts. “When given the option to receive fewer texts after the first 6 months, nearly half of the participants—44%—chose to continue receiving daily texts,” says Dr. Nelson. Participants who continued daily text messages reported wanting to continue experiencing benefits to their health, whereas those who chose fewer texts said the daily texts helped them create routines and they no longer needed them as often. The researchers did not see differences in engagement based on receipt of phone coaching or the selected text message frequency.

Important Implications

“Our findings indicate that well-designed text messaging interventions can engage traditionally hard-to-reach patients over the long term,” says Dr. Mayberry. “Programs that support adherence through interactive text messages may engage a diverse group of patients in their self-care between clinic visits. Participants in our study reported increased adherence and feeling accountable as a result of receiving these types of messages.”

Dr. Nelson and Dr. Mayberry recommend more studies provide robust reporting on long-term engagement with mobile health interventions. As a next step to the current study, plans are underway to evaluate how engagement with REACH impacts outcomes, including A1C and medication adherence. “Efficacy results from the REACH study will be published soon,” says Dr. Nelson. “We plan to work with community health centers to implement this intervention and see if engagement remains high when the texting program is delivered as a supplement to care.”