DIABETES TECHNOLOGY & THERAPEUTICS
Volume 5, Number 6, 2003
© Mary Ann Liebert, Inc.
“Sweet Talk”: Text Messaging Support for Intensive
Insulin Therapy for Young People with Diabetes
VICTORIA FRANKLIN, M.R.C.P.C.H.,1 ANNALU WALLER, Ph.D.,2
CLAUDIA PAGLIARI, Ph.D.,3 and STEPHEN GREENE, F.R.C.P.C.H.1
ABSTRACT
Optimal diabetes management involves considerable behavioural modification, while nonadherence contributes significantly to poor glycaemia. Extensive research on psychological
interventions aiming to improve glycaemia suggests that current strategies are costly and timeconsuming and in our experience do not appeal to young people with Type 1 diabetes. Text
messaging has rapidly become a socially popular form of communication. It is personal, highly
transportable, and widely used, particularly in the adolescent population. However, text messaging coupled with specific behavioural health strategies has yet to be utilised effectively.
We have developed a novel support network (“Sweet Talk”), based on a unique text-messaging system designed to deliver individually targeted messages and general diabetes information. Individualised motivation strategies—based on social cognition theory, the health
belief model, and goal setting—form the theoretical basis of the message content. Intensifying insulin therapy and increasing contact with the diabetes team can improve control, but
are difficult to provide within existing resources. Our support system offers a means of contact and support between clinic visits and aims to increase adherence with intensive insulin
regimens and to improve clinical outcome.
INTRODUCTION
T
is to optimise
glycaemic control in young people to reduce the complications associated with diabetes. 1 Currently average glycaemic control in
Scotland is poor. 2 Intensive insulin therapy can
dramatically improve glycaemic control and
reduce the complications associated with diabetes. 1 In Tayside it has been established that
poor adherence with insulin regimens is common, especially in teenagers: 25% of patients
HE TARGET OF DIABETES CARE
omit up to a third of their insulin over 1 year.3
Increased support and contact may therefore
be required to sustain an improved adherence
to therapy resulting in better glycaemic control.4 However, increasing traditional contact5,6
between health care professionals and patients
within clinic settings, with additional support
groups, or remotely by telephone is time-consuming for both parties and costly and unfeasible in most health care systems. 7 In order to
successfully introduce more demanding insulin regimens, the challenge is to develop an
1 Maternal and Child Health Sciences, 2 Division of Applied Computing, and 3 Tayside Centre for General Practice,
University of Dundee, Dundee, Scotland, United Kingdom.
Portions of this work have been presented previously in abstract form at the 2002 Diabetes Technology and Therapeutics Conference in Atlanta, Georgia, and at the 2003 Diabetes UK Annual Professional Conference in Glasgow,
Scotland.
991
992
FRANKLIN ET AL.
innovative and validated intervention to optimise self-care management to reduce the mortality, morbidity, and health costs associated
with diabetes.8 In addition, this must be economical and practical within health service resources.
“Telemedicine” has been used successfully
to improve the quality of care by facilitating
contact between patient and health professional9 and improving a patient’s self-efficacy
in managing diabetes.10 An “information sharing” model of health care can be facilitated by
information technology and can empower patients by providing a flow of information that
is bidirectional, interactive, timely, and patientspecific.11 Disease specific on-line support
communities are available12 and provide a useful resource for engaging motivated people,13
but such web-based chat rooms and message
boards are reliant on users actively seeking information and contact with others. The idea of
using “push” support, where information and
support are actively sent to the user, has not
been used widely.14
Text messaging is an integral part of teenage
culture in the United Kingdom, and young people use this as a cheap, fun, and easy way to
keep in touch with their peers. Mobile phones
are personal, intimate, and constantly accessible, and their almost ubiquitous use, particularly amongst teenagers, provides a perfect
medium for delivering diabetes information
and support.
THEORETICAL BASIS OF THE
INTERVENTION
Our objective was to develop an intervention
delivered by text messaging to support young
people with diabetes between clinic visits. Providing diabetes education improves “diabetes
knowledge,” but it has been shown that this is
not translated into improved glycaemic control.15 However, this can be achieved with interventions designed to increase self-efficacy.16,17 The Sweet Talk intervention is a
multifaceted intervention based on the health
belief model 18 and social cognition theory19
and utilises a process of sequential goal setting
to increase self-efficacy for diabetes.20 These are
based on theories that health behaviour is influenced by patients understanding the severity of their disease and the benefits of changing behaviour, and that providing reminders,
feedback and support reinforces positive behaviour change. Clinic visits have been structured so that goal setting related to diabetes
self-care management is an integral component. Contact and support between clinic visits are provided by daily text messages. We
have attempted to construct personal self-management goals as a framework for the content
of the text messages.
DEVELOPING THE TEXT
MESSAGING SERVICE
The pilot text messaging service was developed in collaboration between the University
of Dundee’s Children and Adolescent Diabetes
Team and the Applied Computing Division.
The initial objective was to create a computerbased text-messaging facility that allows scheduled, patient-specific messages to be delivered
to young people with diabetes. The project followed an iterative software development cycle
of requirements gathering, prototyping, implementation, evaluation, and reporting, with particular emphasis given to user-centred design.
The user-centred design is considered to be essential if a system is to be used efficiently by
diabetes health care teams who may not have
any prior computing knowledge. The primary
aim was that the interface should be easily understood, with minimal steps needed to
achieve tasks, and that the system should be
autonomous. The project involved several interface developments throughout the cycle,
with new functionality being developed in response to the evolving needs of the project. As
the system was developed for use in a clinical
trial, it was also imperative that it could show
measurable data that can be used in statistical
analysis, and that actions could be easily
tracked and viewed from the interface. Menus
were minimised to simplify navigation around
the system. A web-based interface was chosen
because it allowed access to the system from a
variety of locations, and would be more familiar than a standard application interface for
TEXT MESSAGING SUPPORT FOR DIABETES
FIG. 1.
993
The Sweet Talk Programme web-based interface.
people with limited computer expertise (see
Fig. 1). After the initial prototype design,14
sponsorship was secured from the mobile
phone company Orange™ for SEA (a software
design company) to further develop the system
with additional features, including the ability
for patients to send text messages to the system, and incorporation of a mechanism of
biofeedback with their blood glucose results.
Pilot testing
A group of young patients with diabetes was
asked to pilot the text-messaging system before
the service was fully implemented. Suggestions
for improvement included scheduling messages for random times of the day so that they
could not be predicted, and making the service
more friendly by finishing each message with
a “smiley” ( ): These ideas were incorporated
into the system “Sweet Talk.”
THE SWEET TALK SYSTEM
Sweet Talk is currently being evaluated as a
randomised controlled trial, measuring the impact of the intervention on glycaemic control in
patients on conventional and intensive insulin
regimens compared with a control group receiving standard care. At the time of registration
to the study, basic patient demographic
details are entered into the text-messaging database, and self-management goals are identified
for each person. The messaging system then autonomously schedules daily messages selected at
random from the goal-specific message bank. In
addition, the patient receives a weekly “reminder” about their chosen goal and a motivational message written either personally or by a
member of the diabetes team to reinforce their
goals. After subsequent clinic visits goals and
motivational messages are updated.
Introducing the text-messaging system
All patients enrolling in the study received a
mobile pay-as-you-go phone. A card outlining
the facilities of the Sweet Talk system was given
to the patients assigned to the text-messaging
support group. This card reinforced that the system is not intended for emergency use. To encourage Sweet Talk to be an everyday part of life,
it also offers a reminder service for family members and friends’ birthdays. By texting in a name
and date, the system is automatically updated
and will deliver birthday reminders.
Patient profiling and message content
The database contains a bank of messages
created by the diabetes team. The messages are
994
divided according to diabetes self-management goals (blood glucose testing, insulin injections, healthy eating, and exercise). The content of each message is subdivided into type of
support offered (tips, reminders, information,
motivational messages, or questions).
Patients’ demographic details entered into
the database include age, sex, type of insulin
regimen, and diabetes clinic attended, thus allowing appropriate messages to be scheduled
according to patient profiles. Standard messages are restricted to 160 characters. “Newsletters” allow longer scheduled messages to be serialised into a set of messages.
Interactions
Patients are encouraged to use the service to
ask questions related to their diabetes care as
it has been shown that people prefer interactive exchanges of information rather than static educational information.21,22 Questions that
patients do not wish to wait until the next clinic
visit or are difficult to ask in clinic settings may
be encouraged by text messaging as this may
be less intimidating than face-to-face dialogue
with their doctor.23–25 These questions are directed to the appropriate member of the diabetes team (doctor, nurse, or dietician), and an
individual response is sent. When it is felt that
the question may be of more general interest to
the other young people, this can be sent out as
a “newsletter” to encourage reciprocity and
promote a sense of belonging to a “community” of young people with diabetes.
Patients needing information about clinic
visits or diabetes supplies are also encouraged
to contact the team by text. Like e-mail, text
messaging can provide an asynchronous form
of communication that is useful in non-urgent
situations,11 is time-saving for both health professional and patient, and reduces the “telephone tag” that frequently occurs when trying
to make contact.26
Clinic reminders
The system is used to send out a series of text
message reminders before clinic appointments,
including prompts to bring blood glucose log
books to the clinic visit.
FRANKLIN ET AL.
Incorporating biofeedback into the
text-messaging system
Motivation for self-care management can be
enhanced by biofeedback.27 Patients are therefore encouraged to send in their blood glucose
levels without any narrative text. These values
automatically update a personalised graph of
blood glucose levels on a supporting website.
When patients send in the blood glucose level
incorporated in text, this needs to be manually
entered into a “notes” box, which will then update the graph, but this requires maintenance
and has obvious time and cost implications.
Security of system
Sweet Talk is a web-based service, allowing
the diabetes team to access it from a variety of
locations. The system is password-protected
and uses session-based cookies to prevent
unauthorised access. Once the trial is successfully completed transport will be moved to
https to increase data transit security.
Safety issues
It was emphasised to young people and their
parents that Sweet Talk is not designed for use
in urgent diabetes situations, and that they
should continue to contact the local diabetes
emergency telephone support service in the
event of an emergency.
Sweet Talk system management
All databases and audit trails of interactions
within Sweet Talk are available to the research
team on a secure website (see Fig. 1). The
home page records the number of “active” patients (those who have sent messages within
the last 2 weeks). The patient page records the
number of messages sent and received by each
person. From the individual patient page, it is
possible to see all the scheduled messages
sent, messages received, and any personalised
responses.
For the purpose of the randomised controlled trial, the system is currently being run
by a single health care professional with full
privileges to work the system. It is anticipated
that in general clinical use, all members of a di-
TEXT MESSAGING SUPPORT FOR DIABETES
995
abetes team would have access to the system
to maintain contact with their patients.
2. Scottish Study Group for the Care of the Young Diabetic: Factors influencing glycemic control in young
people with type 1 diabetes in Scotland. Diabetes Care
2001;24:239–244.
3. Morris AD, Boyle DIR, McMahon AD, Greene SA,
Macdonald TM, Newton RW: Adherence to insulin
treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus. Lancet 1997;350:
1505–1510.
4. Davis KM, Heins JM, Fisher EB: Types of social support deemed important by participants in the DCCT.
Diabetes 1997;46:352.
5. Dorchy H: Dorchy’s recipes—explaining the ‘intriguing efficacy of Belgian conventional therapy.’ Diabetes Care 1994;17:458–460.
6. Mortensen HB, Villumsen J, Volund A, Petersen KE,
Nerup J: Relationship betwen insulin injection regimen and metabolic control in young Danish type 1
diabetic patients. Diabet Med 1992;9:834–839.
7. Boulton AJM: DCCT: implications for Diabetes Care
in the UK. Diabet Med 1993;10:687.
8. McKay HG, Feil EG, Glasgow RE, Brown JE: Feasibility and use of an internet support service for
diabetes self-management. Diabetes Educ 2003;24:
174–179.
9. Balas EA, Jaffrey F, Kuperman GJ, Boren SA, Brown
GD, Pinciroli F, Mitchell JA: Electronic communication with patients. Evaluation of distance medicine
technology. JAMA 1997;278:152–159.
10. Po YM: Telemedicine to improve patients’ self-efficacy in managing diabetes. J Telemed Telecare
2000;6:263–267.
11. D’Alessandro DM, Dosa NP: Empowering children
and families with information technology. Arch Pediatr Adolesc Med 2001;155:1131–1136.
12. Ferguson T: From patients to end users. BMJ
2002;324:555–556.
13. Zrebiec JF, Jacobson AM: What attracts patients with
diabetes to an internet support group? A 21 month
longitudinal website study. Diabet Med 2001;18:
154–158.
14. Gibson S: Sweet talk—intensive diabetes support using SMS scheduling [B.Sc. (Hons) thesis–unpublished]. Dundee, UK: Division of Applied Computing, University of Dundee, 2002.
15. Bloomgarden ZT, Karmally W, Metzger MJ, Brothers
M, Nechemias C, Bookman J, Faierman D, GinsbergFellner F, Rayfield E, Brown WV: Randomised, controlled trial of diabetic patient education: improved
knowledge without improved metabolic status. Diabetes Care 1987;10:263–272.
16. Grossman HY, Brink S, Hauser S: Self-efficacy in adolescent girls and boys with insulin-dependent diabetes mellitus. Diabetes Care 1987;10:324–329.
17. Howells L, Wilson AC, Skinner TC, Newton R, Morris A, Greene SA: A randomised control trial of the
effect of negotiated telephone support on glycaemic
control in young people with Type 1 diabetes. Diabet
Med 2002;19:643–648.
PROGRESS
RE-AIM (reach, efficacy, adoption, implementation, and maintenance) is a conceptual evaluation framework that evaluates the public health
impact of health promotion interventions and
their internal and external validity.28 Sweet
Talk is currently in the evaluation phase—but
a recruitment rate of 73% of the eligible clinic
population indicates high “reach” or percentage
of patients willing to participate. The Sweet
Talk system has been designed to be easily
transported and implemented in other health
care settings to support “adoption,” “implementation,” and “maintenance” by a variety of
providers for a range of users. “Efficacy” is currently being assessed in a randomised control
trial of the impact of Sweet Talk on glycaemic
control in patients on conventional and intensive insulin regimens. Secondary outcome
measures will include qualitative and quantitative assessment of the use of the Sweet Talk
text-messaging system and impact on health
service utilisation.
ACKNOWLEDGMENTS
V.F. is a Diabetes UK Paediatric Diabetes Research Fellow. The “Sweet Talk” system is
based on original work by Stuart Gibson for his
B.Sc. Applied Computing Honours Degree. We
are grateful to Orange™, which supplied the
mobile phones for the study, and SEA–Sustainable Design, which is providing ongoing
technical and developmental support. We
would also like to thank our patients for their
enthusiastic reception of the project.
REFERENCES
1. Diabetes Control and Complications Trial Research
Group: Effect of intensive diabetes treatment on the
development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications
Trial. J Pediatr 1994;125:177–188.
996
18. Rosenstock IM: Understanding and enhancing patient
compliance with diabetic regimens. Diabetes Care
1985;8:610–616.
19. Bandura A: Social cognitive theory. Ann Child Dev
1989;6:1–60.
20. Bandura A: Self-efficacy mechanism in human
agency. Am Psychologist 1982;37:122–147.
21. 5th survey on the evolution of Internet use for health
purposes. Available online at: http://www.hon.ch/
Survey/Results/Summary_oct_nov99.html. 2003.
22. GVU’s Tenth WWW User Survey Graphs. Available
online at: http://www.cc.gatech.edu/gvu/user_surveys/survey-1998-10/graphs/use/q110.htm. 2003.
23. Gustafson DH, Hawkins R, Boberg E, Pingree S, Serlin RE, Graziano F, Chan CL: Impact of a patient-centred, computer-based health information/support
system. Am J Prev Med 1999;16:1–9.
24. Pal B: Email contact between patient and doctor. BMJ
1999;318:1428.
25. Marrero DG: Computer assisted diabetes dietary
self-management counselling. Med Care 2000;38:
1059–1061.
FRANKLIN ET AL.
26. Kane B, Sands DZ: Guidelines for the clinical use of
electronic mail with patients. J Am Med Inf Assoc
1998;5:104–111.
27. Ahring KK, Ahring JPK, Joyce C, Farid NR: Telephone
modem access improves diabetes control in those
with insulin-requiring diabetes. Diabetes Care 1992;
15:971–975.
28. Hampson SE, Skinner TC, Hart J, Storey L, Gage H,
Foxcroft D, Kimber A, Cradock S, McEvilly EA: Behavioural interventions for adolescents with type 1
diabetes. Diabetes Care 2000;23:1416–1422.
Address reprint requests to:
Victoria Franklin, M.R.C.P.C.H.
Maternal and Child Health Sciences
Ninewells Hospital and Medical School
Dundee, Scotland, UK, DD1 9SY
E-mail: [email protected]
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