The Management of Diabetes in Everyday Life Program

Background and Significance: There is a critical need to determine the comparative effectiveness of text messaging (TM) and health coaching (HC) among African-Americans with uncontrolled diabetes and multiple chronic conditions living in medically underserved areas (MUA) and to identify which modality yields greater improvement in diabetes self-care at-risk urban and rural subpopulations. Although numerous recent studies demonstrate the effectiveness of either TM or HC in improving diabetes and other chronic disease self-care behaviors, and to the knowledge of the investigators no information is available regarding comparative effectiveness of these modalities in urban and rural subgroups. Prevalence of diabetes, related comorbidities, poverty, obesity, food insecurity, and tobacco use is higher in rural areas as compared with urban. Moreover, rural areas struggle to address these needs because of lower access to transportation, primary care, specialty care, diabetes education, and mental health resources. However, urban living has its own unique set of problems-including increased stress and fear for one's physical safety-that may impact the comparative effectiveness of HC and TM. Although there are HC studies that show effectiveness in interventions either in rural or urban areas, there are no HC studies of which the investigators are aware that specifically examine the differences in U.S. rural and urban participants in regards to engagement rates and clinical outcomes from a health coaching intervention. Similarly, telemedicine and mobile health approaches have been particularly advocated for rural populations yet little evidence supports their comparative benefit. The lack of comparative effectiveness of text messaging and health coaching for diabetes self-care in vulnerable urban and rural subgroups represents a critical gap in research that the study is designed to directly address. The study will compare both strategies with enhanced usual care (EC) with diabetes educational materials.

Study Aims: As a result, this research will use a pragmatic randomized trial to determine the comparative effectiveness of patient-driven TM versus HC versus EC for African-American adults with uncontrolled diabetes and multiple chronic conditions in MUA with an emphasis on identifying and quantifying important interactions between key baseline characteristics and treatment arm. Specific aims include: Aim 1-Quantify the effectiveness of TM, HC, and EC in improving the primary outcome measures (diabetes self-care activities related to general diet, exercise and medication adherence); Aim 2-Determine the contributions of six key, baseline patient characteristics: 1) urban vs. rural residence, 2) health literacy, 3) medical complexity, 4) social complexity, 5) smart vs. cell phone ownership, and 6) age, to the comparative effectiveness of TM, HC, and EC; and Aim 3-Quantify the effectiveness of TM, HC, and EC in improving secondary outcomes of average blood sugar, quality of life, and primary care engagement. The long-term objectives are to disseminate and foster implementation of the results of this research in MUA nationwide to improve critical self-care supports in primary care for our most vulnerable populations.

Overall study design: Pragmatic randomized clinical trial.

Main components of the intervention and comparator(s): The study will test two critical strategies for patient engagement that may lead to substantive improvements in the quality of care and outcomes most important to vulnerable patients with diabetes: 1) patient-driven TM, and 2) patient-driven HC. The two parallel primary care-based and patient-driven study interventions (i.e. TM and HC) have been designed to provide approximately the same content, but with two alternative delivery mechanisms. TM will incorporate supportive cognitive behavioral strategies to encourage improved diabetes self-care decisions and will be tailored based on participant demographics, health literacy, preferences, treatment self-regulation, perceived competency and reported barriers to self-care. Motivational interviewing focused HC will aim to meet with participants for individual HC sessions bi-monthly the first 2 months (Intensive Phase-4 sessions following randomization) followed by monthly for remaining 8 months (12 sessions total) to provide support regarding diet/weight loss, physical activity, and medication adherence tailored according to patient-identified health goals. Both strategies will be compared with EC with diabetes educational materials.

Study population: For the main comparative effectiveness analysis (Aim 1) the total sample size (after dropouts) is N=800 with 40% randomized to the TM arm (N1=320), 40% to the HC arm (N2=320), and 20% to the EC arm (N3 = 160). Participants include African-American adults, ages 35-75, with uncontrolled diabetes and multiple chronic conditions, living in medically underserved communities in the MidSouth who have a cell phone or smart phone with texting capability and complete a two-week run-in period demonstrating responsiveness to TM.

Primary/secondary outcomes: The primary outcome measures assessing effectiveness include: three (out of six total) subscales of the revised Summary of Diabetes Self-Care Activities questionnaire assessing general diet, exercise, and medication adherence. Secondary outcomes include: diabetes-specific quality of life using the Diabetes-39, primary care engagement using National Health Interview Survey questions regarding delayed needed care, and average blood sugar (A1c) obtained from medical records and reported in the DWPC-R.

Analytic methods: For Aim 1, in the context of repeated measures ANOVA, using t-tests within arm to detect change from baseline to 12-months (Follow-up 3), power exceeds 0.9 for all primary outcomes. For Aim 2, six analyses will assess heterogeneity of treatment effects by evaluating the interaction of each key, dichotomized, baseline characteristic with treatment arm, estimating means and standard errors of six subclasses, and within each characteristic (e.g. low or high health literacy) testing for differences between TM and HC, TM and EC, and HC and TM. Analyses for Aim 3 will be conducted as described above for Aim 1.