JMIR Publications

ABSTRACT

Background:

Text message-delivered interventions are a feasible and scalable approach for improving chronic disease self-management and reducing health disparities; however, information on long-term user engagement with these interventions is limited.

Objective:

We examined user engagement in a 12-month text message-delivered intervention supporting diabetes self-care, called REACH (Rapid Education/Encouragement And Communications for Health), among racially and socioeconomically diverse patients with type 2 diabetes (T2D). We explored time-trends in engagement, associations between patient characteristics and engagement, whether the addition of a human component or allowing patients to change their text frequency affected engagement, and patients’ reasons for their chosen text frequency.

Methods:

We recruited patients with T2D for a randomized trial evaluating mobile phone support relative to enhanced treatment as usual. The current analysis is limited to participants assigned to the intervention. Participants completed a survey and hemoglobin A1c (HbA1c) test and received REACH text messages including self-care promotion texts, interactive texts asking about 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, coaching stopped and participants had the option to receive fewer texts for the subsequent 6 months. We defined engagement as any response to the interactive texts. We used regression models to analyze associations with engagement and thematic analysis to understand participants’ reasons for their preferred text message frequency. We invited a subset of participants to complete a follow-up interview after participating.

Results:

Participants were, on average, 55.8 (SD=9.8) years old, 55% (137/248) female, and 52% (129/248) non-White; 41% (101/248) had a high school degree or less education, and 41% (101/248) had annual household incomes <$25,000. The median response rate to interactive texts was 91% (IQR 75-97%) over 12 months. Engagement gradually declined throughout the intervention period but remained relatively high. We did not find evidence that engagement differed by age, gender, education, income, diabetes duration, insulin status, health literacy, or numeracy. Black race, lower baseline medication adherence, and higher baseline HbA1c were each associated with lower engagement, although effects were small. Nearly half of the participants chose to continue receiving daily texts for the last 6 months of the intervention. Among the reasons for choosing fewer texts, participants said the daily texts had helped them create routines and they no longer needed them as often. Participants’ most common reason for continuing daily texts was wanting to continue experiencing benefits to their health. We found no evidence that engagement was impacted by receiving coaching, nor by participants’ chosen text frequency.

Conclusions:

Well-designed interactive text messages can engage patients in a self-care intervention for at least one year. Variation in and reasons for frequency preference suggest offering a frequency choice may be important to users’ engagement.