ABSTRACT
BACKGROUND: Type 2 diabetes (T2D) is a worldwide epidemic and a leading cause of death in Mexico, with a prevalence of 15.9%, and >70% of diagnosed adults have poor glycemic control [glycated hemoglobin (HbA1c) >7.5%]. We developed a diabetes self-management education program contextualized to the study population, including dietary preferences, health literacy, and health system. OBJECTIVES: We aimed to evaluate the efficacy of a self-management + text message program (¡Sí, Yo Puedo Vivir Sano con Diabetes!) on primary (HbA1c), and secondary behavioral (self-management), clinical, and psychosocial outcomes in adults with T2D in Mexico City. METHODS: Participants were recruited at public primary healthcare centers (Seguro Popular), and randomly allocated to treatment (n = 26) or wait-list control groups (n = 21) with data collected at 3 and 6 mo. The program included 7 weekly sessions and 6 mo of daily text/picture messages. Descriptive statistics and a generalized linear mixed model with intent-to-treat analysis were calculated. RESULTS: Participants were 55.5 ± 8.8 y of age (mean ± SD), 68% female, 88.6% overweight/obese, and 57% lived in food-insecure households. Mean ± SD T2D duration was 11.9 ± 7.8 y and HbA1c was 9.2% ± 1.5%. There was 89% attendance at sessions and 6.4% attrition across both groups at 6 mo. Group-by-time effects were seen in self-monitoring of blood glucose (P < 0.01) and diabetes self-efficacy (P < 0.04); and a trend for lower HbA1c was seen in the intervention group at 6 mo (P = 0.11). Significant improvements in dietary behavior (P < 0.01) were demonstrated in the intervention group over time, but this did not reach statistical significance compared with the control group. CONCLUSIONS: The program was associated with clinically significant improvements in T2D self-management, self-efficacy, and HbA1c over time. Thus, T2D self-management skills, including diet, were improved in a vulnerable metropolitan population.This trial was registered at clinicaltrials.gov as NCT03159299.
ABSTRACT
BACKGROUND: Type 2 diabetes (T2D) is a public health pandemic disproportionately affecting low- and middle-income countries. The purpose of this formative research was to adapt evidence-based diabetes self-management education programs to the context of Seguro Popular clinics in Mexico. A theory-based mHealth (pictorial text messaging) component was developed. METHOD: Our formative research and development of the program protocol consisted of six phases: (1) interviews and focus groups with stakeholders on the challenges to T2D management, curriculum content needs, and the use of mHealth as a supplement to a DSME program; (2) review of the theoretical underpinning, curriculum, and interactive strategies of four evidence-based DSME programs and modification to meet the needs of adults with T2D and systems of care in Mexico City; (3) development of theory-based illustrated text messages; (4) evaluation of text messaging acceptability and access in adults with T2D via focus groups; (5) development of program manual; and (6) development of a training program for health care providers. RESULTS: The ¡Sí, Yo Puedo Vivir Sano Con Diabetes! included 7 group-based weekly lessons; simple, interactive content; weekly empowerment messages; video novellas; group activities; and goal setting. Adaptations to the cultural context of Mexico included content/activities on diabetes etiology (addressing cultural misconceptions), nutrition (indigenous foods and plate method), self-blood glucose monitoring, and diabetes-related stress/coping. We used the Health Action Process Approach to guide the text message development, which posits that adoption, initiation, and maintenance of health behaviors require the development of intentions, plans, coping, and self-efficacy. Our final text message bank consisted of 181 messages. There were approximately 20-30 messages for each process of behavior change (e.g., action planning, maintenance self-efficacy) and 30 messages for each content topic (e.g., eating healthy, physical activity). There were 96 messages that were illustrated. Training materials were also developed. DISCUSSION: We used a systematic approach, collaboration with stakeholders, and a well-established behavior change theory to develop an evidence-based intervention to an international context and system of care. Collectively, this process has the potential to enhance the feasibility, acceptability, and efficacy of the program.
