TY - JOUR
AU - Bailey,, James
AB - Abstract Tailoring health-related materials is an effective mechanism to encourage behavior change; however, little research has described processes and critical characteristics for effective tailoring in underserved populations. The purpose of this study is to describe a process using input from content experts and lay patient advisors to tailor text messages focused on improving self-care behaviors of African-American adults with diabetes and identify characteristics of messages perceived to be most effective. An initial library of tailorable messages was created using theory-based approaches, expert opinion, and publicly available materials. A study-specific advisory council representing the program’s intended population provided sequential individual and focus group review of a sample of draft messages focused on medication use, healthy eating, and physical activity. Messages were reviewed for content, tone, and applicability to African-American adults with diabetes from underserved communities. Based on this feedback, messages were revised and a final library of tailorable messages was constructed for use in a text messaging intervention. The initial library had over 5,000 tailorable messages. Participants preferred messages that included: (1) encouraging statements without condescension; (2) short sentences in lay language; (3) specific, actionable instructions; and (4) content relatable to daily activities of living. When possible, messages with similar themes should be repeated over short periods of time to improve the odds of material being absorbed and action being taken. Input from patient participants and advisors is essential for designing deeply tailored messages that honor the preferences, values, and norms of the population under study and promote health behavior change. Trial Registration NCT02957513 Implications Practice: Direct patient feedback on expert-developed text messages is a replicable and effective process for adapting the content and tone of tailored messages to specific patient populations. Policy: Health systems seeking to leverage the power of text messaging to engage patients with diabetes should first consider cultural aspects and vernacular used by their patients in order to improve the odds of message elaboration and subsequent action. Research: Future work should consider how a library of tailorable messages could be expanded to further incorporate population-specific factors that may impede or assist with self-care activities, such as social determinants of health, and mechanisms to automate the message delivery and adjustment process. INTRODUCTION Effective management of diabetes requires patients to incorporate multiple self-care activities into their daily routines. Considering this complex nature of diabetes care, it may not be surprising that adherence to medication and lifestyle modification remains a significant problem among patients with diabetes mellitus. In this population, medication adherence ranges from 31% to 98%, while estimates of those maintaining recommended levels of physical activity range from 10% to 80% [1–3]. Further, significantly fewer patients with diabetes or prediabetes are physically active compared with the general population [4–6]. In response to the high prevalence of nonadherence with lifestyle and medication recommendations among patients with type 2 diabetes, numerous studies have investigated how interventions can encourage healthy behaviors in order to improve clinical outcomes. However, these efforts to support patients in improving their diabetes self-care have shown varied effect among patients with diabetes [7]. Many self-care interventions have used targeted messaging (whereby each member of a particular patient population receives the same type of message), but individually tailored messages offer more promise for changing behavior. By tailoring messages for behavioral interventions, researchers may highlight condition- and treatment-specific influences that are most personally relevant to each recipient with a clear, personalized goal in mind. In tailoring, standardized and psychometrically sound measures are gathered to assess individual characteristics relevant to a behavior. These characteristics are then strategically placed into a message to influence behavior using a piece of communication appearing to be relevant only to the recipient—a practice built out of information processing theory [8]. Consequently, tailored health communication is thought to improve the odds of capturing users’ attention through individualization, increasing the likelihood that the message will be more thoughtfully considered and, ultimately, have a greater impact on health behavior. This level of communication is particularly relevant to patients with diabetes as reflected in the individualized, patient-centered approaches advocated by the recently released National Standards for Diabetes Self-Management Education and Support, which specifically call attention to the need for tailored education once a treatment plan is initiated [9]. Given the ubiquity of mobile phones in the United States, diabetes self-care interventions are increasingly turning to mobile health approaches for delivering key health messages to vulnerable populations. According to the most recent report by the Pew Research Center, 95% of American adults now own a mobile phone and, as of 2011, nearly three-quarters (73%) of this population actively sends and receives text messages [10, 11]. Considering its widespread use, text messaging is increasingly utilized in healthcare settings in the hopes of improving health outcomes. However, only a few studies have investigated the combined effect of text messaging and tailoring on self-care behavior change, and even fewer have provided robust details on methods taken to develop tailorable materials for mobile delivery [12–15]. Specific to diabetes, Gatwood et al. [16] described how a step-wise tailoring process can be followed to create tailored messages for mobile phone delivery to address diabetes-related medication adherence. Similarly, Nelson et al. [17] described a process by which patient-derived barriers could be sourced to address unique challenges experienced by individuals under the Information–Motivation–Behavioral skills model. However, these studies, along with reviews of patient engagement in technology-driven self-care interventions for adults with type 2 diabetes, suggest that more work needs to be done in this area in order to improve the impact of behavior change programs that leverage mobile health techniques [18, 19]. Improving the effectiveness of mobile health diabetes self-care interventions will require addressing several shortfalls observed in previous programs and studies. First, a limitation of many diabetes-specific interventions delivered by mobile phone has been the short duration of the trial, the lengths of which are often 6 months or shorter [20]. However, pooled evidence across conditions suggests that improved results are more likely if the intervention lasts at least 6 months, suggesting the need for longer intervention periods [21]. Additionally, the complexity of these interventions varies widely in both their interactive nature and the extent to which the host of self-care activities required of patients with diabetes are addressed [20]. Consequently, intervention quality may be improved if additional steps are taken to improve patient-centeredness by being responsive to individual needs and goals, some of which may change over time, and the extent to which patient input is acted upon using mobile messaging. Finally, assessment of text message quality has uncovered discrepancies between researcher-derived message content and its acceptability by targeted populations, and such differences have the potential to significantly deteriorate the program’s impact [21]. Considering that culturally sensitive message content has demonstrated positive impact in certain populations with diabetes, it would seem beneficial to mobile-delivered interventions to ensure that message content and tone match vernacular, cultural-specific challenges, and health literacy of its target population [22, 23]. This paper describes an approach to developing theory-based tailored messages designed for mobile phone delivery using both expert and patient input to develop effective messages specific to an underserved, minority population. These messages were drafted to support the Patient-Centered Outcomes Research Institute-funded Management Of Diabetes in Everyday Life (MODEL) program, which is a year-long intervention comparing the effectiveness of multiple approaches to behavior change among adults with diabetes and multiple chronic conditions. In addition to serving as the foundation of the MODEL program text messaging intervention, the methods described herein can assist future studies in tailoring text messages based on population- and disease-specific needs to improve health behaviors and clinical outcomes. MATERIALS AND METHODS Management of Diabetes in Everyday Life Program The MODEL program is an ongoing randomized, controlled trial based in Memphis, TN comparing three approaches for improving self-care activities in African-American adults with diabetes and comorbid chronic disease. Participants are being drawn from multiple primary care clinics operating in medically underserved areas of West Tennessee and North Mississippi. Under study is the comparative effectiveness of three interventions focused on diabetes management: (1) enhanced diabetes care (usual care plus educational materials); (2) live diabetes health coaching; and (3) tailored text messages. Participants in all three study arms are given educational materials, but enhanced care is considered the control group for the study. Eligible subjects are African Americans living in medically underserved areas who have uncontrolled diabetes (hemoglobin A1C of ≥ 8.0%), at least one other comorbid, chronic condition, are 18 years of age or older, and have mobile phones with text messaging capability. Once enrolled, subjects are followed for 1 year and evaluated for changes in several outcomes: diabetes self-care activities (diet, exercise, and medication adherence), hemoglobin A1C levels, quality of life, and primary care engagement. Recruitment for the study began in November of 2016 and will continue until the intended number of subjects within each cohort (400 in each of health coaching and text messaging, and 200 in enhanced care) is reached. Study procedures were reviewed and approved by the University of Tennessee Health Science Center Institutional Review Board (clinical trials.gov identifier: NCT02957513). A hallmark of the MODEL program is its incorporation of patient oversight and input on all stages of the research through the Diabetes, Wellness, and Prevention Coalition Patient Advisory Council, a committee comprising local patients representing the intervention’s target population. Members were recruited from urban areas within the study’s operating region and asked to provide personal insight and community perspective on the content across all three arms of the study. In doing so, study content could be crafted to better meet the needs of the target population and be crafted in a culturally sensitive manner. Patient Advisory Council members who contributed insight to the study are considered part of the research team; therefore, to maintain the study’s integrity and avoid potential bias, they were not allowed to participate in the study. This committee meets on a monthly basis to discuss study-dictated topics, and members receive a meal and nominal compensation from MODEL resources. The Patient Advisory Council provided critical input on draft text messages to assist in making text messages more patient-centered. Initial message drafting The messaging library and algorithm for the MODEL program is an extension of methods employed by Gatwood et al. [16] in a study involving adults with uncontrolled diabetes that focused solely on improving diabetes-related medication adherence. They used Kreuter’s five-step process of tailored material development—adjusted for mobile text message delivery—by measuring a participant’s status on a theory-driven, identified problem area [24]. Their method incorporated constructs of Self-Determination Theory and the Health Belief Model to build the initial text message stems based on Likert-scaled responses. In addition, the method incorporated patient-reported medication regimens to include medication-specific guidance. Finally, personal patient characteristics were added to the message to improve the perception of individualization. Based on the results of the prior Gatwood et al. study, concepts of Self-Determination Theory were employed by the current study as a mechanism to focus content on the intrinsic and extrinsic motivations of each subject with the intent of gradually shifting patients to being more intrinsically motivated, thus improving the odds of long-standing behavior change [25, 26]. Consequently, the current intervention uses the Treatment Self-Regulation Questionnaire and Perceived Competence Scale to gauge patient motivation and then develop theoretical construct-based tailorable messages based on survey-derived values [27–29]. Similarly, medication-specific information was derived from prescribing information and the published literature, summarizing data at the class level for FDA-approved antidiabetic medications. However, the MODEL program aims to improve multiple self-care activities; therefore, the text messages developed for the current study focus used additional sources of information and theoretical constructs to derive message content focusing on the expanded target areas: medication adherence, physical activity, and healthy eating. These foci were chosen to mirror the content and goals discussed during one-on-one live diabetes health coaching sessions, which is a comparator cohort in the MODEL program. To facilitate the need for expanded content, additional validated instruments and sources of information were added to the patient survey. These included the Diabetes-39 quality of life instrument and the Adherence to Refills and Medications Scale, which allowed the team to assess multiple influencers on patients’ functioning and adherence to recommended self-care activities so that additional items could be scaled for tailored message creation as previously done [30, 31]. Similar to completed work that informed the MODEL program’s library, the content and focus of these survey items were used to provide verbiage for message stems that were then combined with subject characteristics to create a tailored message [16]. For example, a survey item inquiring about the impact of “money matters” on diabetes-related quality of life would then incorporate language in the message stem that recognized the relative effect of finances on the subject’s current state. The specific language would reflect the severity of the item’s factor on quality of life based on the Likert-scaled response provided by the subject (during the program); consequently, up to three variants (e.g., high, medium, low) of each message based on a validated survey item were created. Additionally, information published online by the American Diabetes Association was used as source material on recommended dietary and physical activity practices for adults with diabetes [32]. Messages focused on healthy eating included nutrition facts, guidance for grocery shopping and storage tips, ways to control calorie or sugar intake, healthy cooking tips, composition of a balanced meal, and the importance of healthy eating. Physical activity messages focused on the benefits of exercise, how to be active through regular, daily activities of living, encouraging incremental changes in activity, specific activity recommendations, and simple reminders of daily activity goals. Messages promoting medication adherence had four themes: effectiveness, safety/side effects, mechanism of action, and miscellaneous information. To more broadly focus on medications commonly used by patients with diabetes, information on antihypertensive and lipid-lowering drugs were also sourced and used in message content, when appropriate. A category of “other” messages was also included, which focused on topics of diabetes-related care beyond the three major foci and were drafted using information provided by the American Diabetes Association. Examples of topics in this category of messages included immunizations, management of common comorbid chronic diseases (e.g., hypertension, high cholesterol), managing stress, and regular blood sugar testing. Initial message stems contained general information regarding diabetes self-management built around each of the three focus areas and were devoid of any participant-specific information. Each message was limited to a defined character length to allow for future tailoring where participant-specific information such as names or greetings could be added; some messages were gender- or age-specific allowing for deeper tailoring. The message stems were constructed in three different ways to match the frames: message content and tone either (1) simply conveyed information related to diabetes self-care (educational); (2) aimed to motivate adherence to the three focus areas (motivational); or (3) focused participants on achieving self-care goals (goal setting). For the goal-setting frame, messages that had a secondary focus (i.e., one of the two focus areas not selected in a given quarter of the program) were written in a manner to reinforce how the impact of the primary goal could be bolstered by responding to the message’s content. For example, in cases when a patient chose to focus on healthy eating in a calendar quarter of the program, goal-setting framed messages written to address medication use or physical activity were drafted to indicate how medication adherence or exercising supplement the efforts provided by working toward a healthy eating goal. Messages were also drafted in each of the three frames that focused on other self-management behaviors outside the primary foci offered to each subject (e.g., immunizations, managing comorbid chronic conditions, testing blood sugar). Message adjustment Two focus group sessions were held during regular Patient Advisory Council meetings to gather feedback on the extent to which the initial message library’s content and tone met the target population’s unique ethnic, geographic, and vernacular needs. Each session was led by either a study co-investigator or research assistants who provided the meeting attendees with a randomly chosen set of draft messages from each of the focus areas and message frames. Participants were asked to review each message and indicate how well each message resonated with them, what they liked and disliked, the likelihood of them acting on the message after reading it, and what changes they would make, if any. In total, participants reviewed 95 sample messages from the study’s initial library (59 in the first session and 36 in the second session). Following an individual assessment of each message, a group discussion was facilitated to gain deeper insight from the members exchanging their views on each item. Written comments were collected from all participants and research assistants took notes on the discussions to summarize how Patient Advisory Council members felt about each message. After each session, a MODEL program co-investigator reviewed all comments and applied the suggested changes, if needed, to all focus areas and frames. Investigators then assessed comments to extract common themes and summarize the insight gained from the Patient Advisory Council members for future consideration. Message tailoring The MODEL tailored text messaging intervention incorporates advanced patient-centered approaches to more holistically address the needs, challenges, and goals of its target population over the course of the yearlong program. At baseline, 3 months, and 6 months and then every 3 months, patients express preferences within three message-related categories: focus, frame, and frequency. First, mirroring the methods of the health coaching active intervention arm, patients decide which self-care activity will be the focus for the quarter (adjustable each program quarter as outlined in what follows): healthy eating, physical activity, or medication adherence. Second, patients select how their messages are framed in terms of content and tone: purely educational, motivational, or focused on a particular goal. Although patients select a particular focus and frame, they receive messages from all foci and frames at least once throughout the course of each study quarter. Finally, patients have three options for frequency of message delivery: twice daily, once a day, or once every other day. Also, they can specify the time of day to receive each text. At baseline, all of these options are presented to each participant in the survey instrument completed in person; however, at the end of each study quarter, patients express preferences by text message using bi-directional messaging in response to multiple-choice questions. Their responses at baseline, 3 months, and 6 months dictate the message algorithm for the subsequent 3 months of the intervention. This algorithm was a simple randomization of message order by focus (e.g., medication adherence, physical activity, diet) to appropriately distribute the foci and frames throughout each quarter and to limit back-to-back messages of the same focus area. The order of messages in the algorithm was determined prior to the study and was the same for all subjects throughout the program. Responses at month 6 carry over for the subsequent 6 months. In addition to quarterly message adjustments based on patient-expressed preferences, the algorithms can be adjusted more frequently in response to self-reported behavior corresponding to diet, exercise, and medication use items from the Summary of Diabetes Self-Care Activities measure [33]. For the start of each study quarter, the messaging library is configured to deliver 50% of all messages in the patient’s preferred focus and frame, which alternates between foci and frame to avoid the same type of message being sent on subsequent days. At the end of each month, patients receive a text message to determine whether they have improved their self-care behavior. If the patient has regressed or failed to improve, the proportion of messages is increased from 50% to 60% and then to 70% if no progress was realized in the following month. Figure 1 depicts the flow of information involved in the study that created, delivered, and adjusted the messages. Fig 1 Open in new tabDownload slide | Message tailoring, delivery, and adjustment scheme. Fig 1 Open in new tabDownload slide | Message tailoring, delivery, and adjustment scheme. Analysis At the conclusion of the focus groups, two study team members independently reviewed the comments made by the subjects to determine emerging themes of the sessions. The themes were then discussed until consensus was reached on the overarching categories of comments that best characterized the feedback and insight provided. RESULTS Message library To address the MODEL program planned recruitment and interventional needs, a library of nearly 5,100 messages was constructed (Table 1 describes the breakdown of messages by focus and frame). The majority of messages drafted (61.1%) were medication-specific, which is merely a reflection of the need for numerous drug class-specific messages to be written within the context of medication use and in reinforcing the effects of either diet or exercise when those latter categories were the primary foci (i.e., messages focusing on medication use [the message’s focus] supporting the effects of diet [the patient’s primary focus for the quarter]). For such purposes, only minimal changes were necessary (i.e., changing the goal referenced by the message), but the number of messages listed references the unique messages created. Relatively more messages were created for the motivational and goal-setting frames as these generally used theory-driven content and were, therefore, scaled based on the participant’s survey response (during the active intervention); consequently, each message required up to three different potential messages. Conversely, the educational messages were, for the most part, single items and not intended to be responsive to scaled items- those based on self-reported medication adherence were the exception. Table 1 | Text messaging library contents Message focus . Message frame, N (%) . . . Total . . Educational . Motivational . Goal settingb . . Medication 814 (26.1) 324 (10.4) 1,975 (63.4) 3,113 Healthy eating 133 (17.5) 229 (30.1) 398 (52.4) 760 Physical activity 125 (15.5) 262 (32.5) 419 (52.0) 806 Other topicsa 102 (24.3) 158 (37.7) 159 (37.9) 419 Total 1,174 973 2,951 5,098 Message focus . Message frame, N (%) . . . Total . . Educational . Motivational . Goal settingb . . Medication 814 (26.1) 324 (10.4) 1,975 (63.4) 3,113 Healthy eating 133 (17.5) 229 (30.1) 398 (52.4) 760 Physical activity 125 (15.5) 262 (32.5) 419 (52.0) 806 Other topicsa 102 (24.3) 158 (37.7) 159 (37.9) 419 Total 1,174 973 2,951 5,098 Proportions (%) listed are those for each focus. aTopics included checking sugar levels, management of comorbidities, habit-forming behaviors, upcoming physician visits, or general well-being. bIncludes messages intended for use for categories when not the primary focus. Open in new tab Table 1 | Text messaging library contents Message focus . Message frame, N (%) . . . Total . . Educational . Motivational . Goal settingb . . Medication 814 (26.1) 324 (10.4) 1,975 (63.4) 3,113 Healthy eating 133 (17.5) 229 (30.1) 398 (52.4) 760 Physical activity 125 (15.5) 262 (32.5) 419 (52.0) 806 Other topicsa 102 (24.3) 158 (37.7) 159 (37.9) 419 Total 1,174 973 2,951 5,098 Message focus . Message frame, N (%) . . . Total . . Educational . Motivational . Goal settingb . . Medication 814 (26.1) 324 (10.4) 1,975 (63.4) 3,113 Healthy eating 133 (17.5) 229 (30.1) 398 (52.4) 760 Physical activity 125 (15.5) 262 (32.5) 419 (52.0) 806 Other topicsa 102 (24.3) 158 (37.7) 159 (37.9) 419 Total 1,174 973 2,951 5,098 Proportions (%) listed are those for each focus. aTopics included checking sugar levels, management of comorbidities, habit-forming behaviors, upcoming physician visits, or general well-being. bIncludes messages intended for use for categories when not the primary focus. Open in new tab Focus group insight Following completion of the initial message library, two focus groups were held with members of the Patient Advisory Council. During both sessions, all foci were discussed; however, in the first session only educational messages were presented to participants while the second session involved motivational and goal-setting messages. Additionally, messages requiring a response by text from the subject were reviewed to determine the extent to which the requested action could be easily interpreted and correctly addressed. Each session lasted approximately 2 hr and involved 16 participants (mean age 60.8, range 45–70) representative of the MODEL program’s target population, with some overlap of the same people in each session: two males and seven females in session one, and one male and six females in session two. Feedback from the participants on the content and tone of the messages reviewed generally fell into four categories: (1) conveying a positive tone; (2) using simple language; (3) providing a specific action; and (4) focusing on relatable, everyday activities (Table 2). Specifically, participants responded negatively to statements that reminded them of the challenges or barriers they face in managing diabetes, particularly those that alluded to any shame or failure as part of the message’s tone (e.g., “it’s easy to get irritated by needing to check your blood sugar,” “hurting your quality of life”). Instead, their preference was for motivational messages to begin with encouragement, such as having a “positive” or “winning” attitude, which could then be followed by something educational or actionable. Similarly, they preferred messages that suggested doing something positive, such as eating healthy foods, rather than reminding them not to eat unhealthy items. Table 2 | Characteristics of effective diabetes self-care text messages Theme . Defining characteristic . Examples . . . . Original . Suggested . Positive tone Cushion message with an initial encouraging statement “Even if you wouldn’t feel ashamed about not working out…” “Believing in the power of exercising is a winning attitude…” Simple language Use shorter phrasing and mostly lay language “glucose” “hypoglycemia” “sugar” “low blood sugar” Provide a recommended action Give a specific activity that will assist in achieving a defined health goal “Make sure to have a grocery list full of healthy foods before your next shopping trip” “Check for sugar content in the ingredients list while you shop” Everyday activity Provide examples that have a relatable context or that can be easily visualized “Aim to consume 25 grams of fiber today” “Eat half of a banana” Theme . Defining characteristic . Examples . . . . Original . Suggested . Positive tone Cushion message with an initial encouraging statement “Even if you wouldn’t feel ashamed about not working out…” “Believing in the power of exercising is a winning attitude…” Simple language Use shorter phrasing and mostly lay language “glucose” “hypoglycemia” “sugar” “low blood sugar” Provide a recommended action Give a specific activity that will assist in achieving a defined health goal “Make sure to have a grocery list full of healthy foods before your next shopping trip” “Check for sugar content in the ingredients list while you shop” Everyday activity Provide examples that have a relatable context or that can be easily visualized “Aim to consume 25 grams of fiber today” “Eat half of a banana” Open in new tab Table 2 | Characteristics of effective diabetes self-care text messages Theme . Defining characteristic . Examples . . . . Original . Suggested . Positive tone Cushion message with an initial encouraging statement “Even if you wouldn’t feel ashamed about not working out…” “Believing in the power of exercising is a winning attitude…” Simple language Use shorter phrasing and mostly lay language “glucose” “hypoglycemia” “sugar” “low blood sugar” Provide a recommended action Give a specific activity that will assist in achieving a defined health goal “Make sure to have a grocery list full of healthy foods before your next shopping trip” “Check for sugar content in the ingredients list while you shop” Everyday activity Provide examples that have a relatable context or that can be easily visualized “Aim to consume 25 grams of fiber today” “Eat half of a banana” Theme . Defining characteristic . Examples . . . . Original . Suggested . Positive tone Cushion message with an initial encouraging statement “Even if you wouldn’t feel ashamed about not working out…” “Believing in the power of exercising is a winning attitude…” Simple language Use shorter phrasing and mostly lay language “glucose” “hypoglycemia” “sugar” “low blood sugar” Provide a recommended action Give a specific activity that will assist in achieving a defined health goal “Make sure to have a grocery list full of healthy foods before your next shopping trip” “Check for sugar content in the ingredients list while you shop” Everyday activity Provide examples that have a relatable context or that can be easily visualized “Aim to consume 25 grams of fiber today” “Eat half of a banana” Open in new tab Secondly, while participants indicated they could interpret some clinical information, such as hemoglobin A1C, they suggested that nonclinical terminology be used, whenever possible. For instance, they recommended replacing “carbohydrate” or “glucose” with “sugar,” and changing “quality of life” to “the way you live.” Moreover, they conveyed that specific terms used by their community were more likely to resonate with the target audience and that many messages were missing culturally specific language that better represented how they would communicate with each other. Specifically, “sugar” could also be used in general reference to “diabetes” (e.g., “in order to better manage your sugar” instead of “…manage your diabetes”). Similarly, respondents indicated that African Americans with diabetes were more likely to understand “food from the walls” instead of “most fresh food is found in the outer ring of the grocery store.” High praise was given for messages that were conveyed in a condensed phrase (e.g., “for diabetes, feeling is believing”) where the point was delivered as succinctly as possible. Additionally, participants advised that messages provide as much specific direction as possible when suggesting a particular action. For instance, when suggesting an increase in physical activity, participants felt that phrases like “try walking 500 more steps today” would be more likely to motivate change. Similarly, using the statement, “taking your metformin as directed by your doctor will help lower your blood sugar by 1 point or more,” would be more influential as it provides a specific action and ties it to a likely benefit. Furthermore, participants praised messages that suggested or encouraged incremental change or smaller steps that could be taken to reach behavioral goals. Moreover, they said references to specific activities should also be connected to something relatable rather than using a clinical or scientific term. For example, instead of indicating a measured amount of certain foods that should be consumed, such as grams or ounces, participants suggested providing references that could be easily visualized, such as a whole piece of fruit or an amount the size of the palm of their hand. General suggestions to the overarching message development and delivery methods were also provided. Participants indicated that a clear connection between topics over a defined time period would be preferred and more likely to lead to long-term adoption of the target behavior. For instance, tying together healthy eating-focused messages where the focus was on carbohydrate consumption during a given week was suggested as a mechanism by which recipients could more deeply understand the importance of monitoring how much sugar could be healthfully consumed. Additionally, when referencing data behind healthy eating or particular medications, the use of local opinions (e.g., area physicians) was suggested in lieu of messages referring to national experts or associations. DISCUSSION Thanks in part to technological advancements, the tailoring of health-related material to drive behavior change is a growing area of research with potential to affect chronic disease self-management. Facilitating this process is the rising availability of mobile phone platforms that can deliver individualized material using text messaging, the most widely used application inherent to mobile devices [34]. While the combined mechanism of tailored content and text messaging holds great promise for behavior change interventions, key limitations to this approach have been identified and likely contributed to the moderate effects that have been realized to date. These factors include relatively small sample sizes, limited follow-up, statically tailored material, and the sustainability of the realized changes [35, 36]. Moreover, the extent to which these programs could be cost-effectively sustained by systems has been limited, which calls into question how larger populations could benefit from the benefits of tailored programming [35, 36]. Additionally, the extent to which content is truly tailored to the individual has been questioned, specifically as it relates to cultural appropriateness and the extent to which language used reflects the local vernacular and preferences [37, 38]. The importance of sensitivity to sociocultural reasons for medication nonadherence or deviations from recommended diabetes management strategies is one that has been raised by other investigators focused on illness representation and perception of medications [39, 40]. The MODEL program was designed to overcome these shortfalls and test the effectiveness of tailored text messages in a manner that is dynamic and culturally sensitive. Moreover, as a comparative effectiveness program aimed at providing guidance to other health systems, the algorithms used, library constructed, and attempts at automating some processes intended to demonstrate how a diabetes-related text message program could operate in areas of the country servicing the needs of underserved populations. In doing so, the resources created and tested by this program would provide guidance to similar health systems on adoption and sustainability of supportive text messaging systems that could assist providers in supporting patients with limited healthcare resources. To more appropriately and effectively address the needs of African-American adults with diabetes, a library of messages was developed using traditional methods that expanded tailoring by asking for input from groups of participants representative of the target population, similar to methods employed by Nelson et al. [17] but expanded to focus on self-care activities beyond medication use. Feedback suggested that effective messages for African-American adults with uncontrolled diabetes and multiple chronic conditions should be: (1) positive in tone; (2) use simple language common to the target population; (3) provide a specific, recommended action; and (4) use everyday context to drive particular behaviors. Study methods are easily reproducible for future studies or health system interventions seeking to target specific patient populations with diabetes. Further, our blueprint can be adapted with relatively limited resources to develop messages for patients with other conditions or socioeconomic backgrounds. Qualitative analyses of patients’ perceptions and acceptance of these messages are planned as part of the MODEL program outcomes. Limitations Several limitations should be considered when interpreting these findings. First, a relatively small group of individuals provided feedback on the draft messages. Consequently, their impressions may not completely reflect the opinions or needs of our target population nor others wishing to replicate message development in a similar fashion. Importantly, this group was chosen from among the program’s target population and each member was longitudinally involved with the development of the interventions, making them aware of both the needs of their peers and the limitations of the program. However, a larger collection of representative patients may have added increased value to the interpretations collected. Secondly, a relatively small subset of draft messages was reviewed in each session. Even though these were intended to represent the content and tone of the larger library as a whole, it is likely that the intervention, and the insight reported herein, could have benefitted from multiple rounds of feedback from the Patient Advisory Council. Finally, while focus groups are commonly used mechanisms to extract qualitative feedback from subjects, the interpretation of each message may have been influenced by the group and social dynamics of each session and may not reflect how each person would have felt after receiving each message individually. Future studies seeking to adjust messages in a similar manner may benefit from participant feedback recorded immediately following receipt of a message during a pilot or test phase in order to capture more real-world context of how the content and tone were received. CONCLUSIONS As part of a large, randomized controlled behavioral health intervention, we outline the means by which tailored messages can be adjusted to better suit the needs of a target population. Results suggest that significant editing of expertly drafted, theory-based behavior-change messages may be necessary to better match the preferred verbiage and tone of study participants. Future studies can consider replicating this approach to improve the development of their message libraries to specific user preferences that are culturally relevant. Themes extracted from our sample of participants can guide the tailoring of mobile messages to African Americans with diabetes. Acknowledgments The study team wishes to thank the valuable input of the Diabetes, Wellness, and Prevention Coalition Patient Advisory Council whose guidance helped shape the intervention and the messages described by this paper. In addition, the team appreciates the assistance of Jacob Crossfield during the focus group sessions and in the message development process. This work was supported through a Patient-Centered Outcomes Research Institute (PCORI) Project Program Award (SC15-1503–28336; PI: J.B.). Compliance with Ethical Standards Conflict of Interest: None declared. Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. 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TI - The Management of Diabetes in Everyday Life (MODEL) program: development of a tailored text message intervention to improve diabetes self-care activities among underserved African-American adults
JF - Translational Behavioral Medicine
DO - 10.1093/tbm/ibz024
DA - 2020-02-03
UR - https://www.deepdyve.com/lp/oxford-university-press/the-management-of-diabetes-in-everyday-life-model-program-development-Vh3HBpCw1k
SP - 204
VL - 10
IS - 1
DP - DeepDyve
ER -