Implementation of a Text Messaging Intervention to Patients on Warfarin Therapy in Brazilian Primary Care Units: A Quasi-Experimental Study

Background: Warfarin remains the most affordable oral anticoagulant in many countries. However, it may have serious side effects, and the success of the therapy depends on the patient's understanding of the medication and their adherence to treatment. The use of short messages services (SMS) is a strategy that can be used to educate patients, but there are no studies evaluating this intervention in patients taking warfarin. Therefore, our aim was to report the implementation of a text-messaging intervention to primary care patients taking warfarin in a middle-sized Brazilian city. Methods: A bank of 79 SMS was drafted and validated by an expert panel. During six months, three times a week, patients received messages about anticoagulation with warfarin. At baseline and after three months, we assessed their knowledge and adherence with validated instruments. At the end of the follow-up, participants answered a satisfaction questionnaire. Subsequently, a scale-up phase was conducted, with another round of the intervention including 82 participants (29 from the first phase and 53 newly recruited). Seven months after the end of the scale-up, we interviewed the patients for their insights about the long-term effects of this program. All patients signed informed consent. The study was approved by the Research and Ethics committee of the Universidade Federal de Minas Gerais. Results: In the pilot, 33 (89.2%) patients completed the follow-up. Among the participants who answered the satisfaction questionnaire, 86.2% considered that the intervention motivated a healthy lifestyle and improved their understanding of warfarin therapy. All patients were willing to continue receiving the messages. Adherence measured by the Measure of Adherence to Treatment (MAT) test was high in the pre-intervention assessment and remained high (96.7% vs. 93.3%; p=1.0000). There was a trend to improve knowledge of warfarin therapy measured by the Oral Anticoagulation Knowledge (OAK) test (6.5% to 25.6% of correct answers, p = 0.0703). In the scale-up, 23 patients were interviewed. The main long-term knowledge reported was dietary information. Nine patients received the messages but did not remember their content.Conclusion: The intervention was well-accepted and had a positive impact on patient’s knowledge about oral anticoagulation therapy. The scale-up assessment reinforced the need to constantly monitor digital interventions.

Effectiveness of a customised mobile phone text messaging intervention supported by data from activity monitors for improving lifestyle factors related to the risk of type 2 diabetes among women after gestational diabetes: protocol for a multicentre randomised controlled trial (SMART MUMS with smart phones 2)

IntroductionGestational diabetes (GDM) contributes substantially to the population burden of type 2 diabetes (T2DM), with a high long-term risk of developing T2DM. This study will assess whether a structured lifestyle modification programme for women immediately after a GDM pregnancy, delivered via customised text messages and further individualised using data from activity monitors, improves T2DM risk factors, namely weight, physical activity (PA) and diet.Methods and analysisThis multicentre randomised controlled trial will recruit 180 women with GDM attending Westmead, Campbelltown or Blacktown hospital services in Western Sydney. They will be randomised (1:1) on delivery to usual care with activity monitor (active control) or usual care plus activity monitor and customised education, motivation and support delivered via text messaging (intervention). The intervention will be customised based on breastfeeding status, and messages including their step count achievements to encourage PA. Messages on PA and healthy eating will encourage good lifestyle habits. The primary outcome of the study is healthy lifestyle composed of weight, dietary and PA outcomes, to be evaluated at 6 months. The secondary objectives include the primary objective components, body mass index, breastfeeding duration and frequency, postnatal depression, utilisation of the activity monitor, adherence to obtaining an oral glucose tolerance test post partum and the incidence of dysglycaemia at 12 months. Relative risks and their 95% CIs will be presented for the primary objective and the appropriate regression analysis, adjusting for the baseline outcome results, will be done for each outcome.Ethics and disseminationEthics approval has been received from the Western Sydney Local Health District Human Research Ethics Committee (2019/ETH13240). All patients will provide written informed consent. Study results will be disseminated via the usual channels including peer-reviewed publications and presentations at national and international conferences.Trial registration numberACTRN12620000615987; Pre-results.

Text Messages and Financial Incentives for Physical Activity: Insights from Virtual Group Interviews of Adolescents with Prediabetes and Type 2 Diabetes (Preprint)

BACKGROUND Despite recommendations that physical activity be a major component of treatment for adolescents with obesity and prediabetes or type 2 diabetes, physical activity is especially low in this population. OBJECTIVE To obtain end-user feedback on text message content and to assess acceptability of a planned text messaging intervention with financial incentives to motivate youth with prediabetes or type 2 diabetes to increase physical activity METHODS Adolescents with overweight or obesity and prediabetes or type 2 diabetes who attended a large academic pediatric endocrinology clinic were recruited to participate in group interviews (2-4/group) via videoconferencing. Participants were asked to share their thoughts about use of text messages and financial incentives to remind and motivate individuals like themselves to be more physically active. They rated and provided feedback on specific messages to be used in a clinical trial. To explore attitudes about the use of financial incentives for physical activity, participants were asked about their personal experience with rewards to motivate behavior change, as well as their anticipated reactions to rewards provided for goal attainment (gain-framing) versus provided and then taken away if a goal was not met (loss-framing). Interviews were conducted by two trained facilitators and an observer/recorder. Content analysis was used to explore themes. RESULTS Focus groups were completed in 20 participants (11 female; 15 type 2 diabetes/5 prediabetes) of mean age 15 years (range 12-18) and body mass index range of 32-52 kg/m2 (>95th percentile for age/sex). The majority were Non-Hispanic Black (70%), and 2 were Hispanic (10%). Fifty-three percent (n=8) of participants with type 2 diabetes were prescribed insulin. All agreed that text messages would serve as good reminders to be physically active, and there was strong consensus about the need for short messages. Favorable content included references to what they will likely to be doing when the messages are sent (e.g., homework, watching television), as well as messages that were encouraging or informative. Specific physical activity suggestions were rated favorably, but participants differed in the perceived utility of including links to exercise videos. Attitudes about financial incentives varied, with approximately half reporting that loss-framed incentives could be highly motivating in order to avoid the frustration of loss. CONCLUSIONS Adolescents with obesity and diabetes or prediabetes endorsed support for text messages that are short, encouraging, and informative for physical activity promotion. Participants were familiar with the concept of rewards for behavior change, but only half expected that loss-framed incentives would be motivating. A text messaging intervention employing financial incentives to motivate youth with prediabetes or type 2 diabetes to be more physically active is theoretically acceptable, but the impact on actual activity level in this population requires prospective evaluation in a clinical trial.