Effect of mobile phone short text messages on glycaemic control in children with type 1 diabetes

Introduction

In diabetes, optimum care and management involves considerable behavioural modification, and non-adherence to therapy contributes significantly to poor glycaemic control. ¹ Research on psychological interventions to improve glycaemia suggests that current strategies are costly and time-consuming, especially in young children and adolescents with type 1 diabetes.^2,3 Mobile phone text messaging has rapidly become a popular form of communication. It is widely used, particularly in the Western countries.^4–7 However, text messaging coupled with specific behavioural health strategies has yet to be utilized effectively in developing countries for diabetes work. Several papers have shown that the mobile phone can offer a means of contact and support for patients between clinic visits, and may increase adherence with insulin therapy and improve clinical outcomes.^8–10 The aim of the present study was to test the feasibility of a telemedical educational support programme using the mobile phone short message service (SMS) and to evaluate its effect on glycaemic control in children with type 1 diabetes.

Methods

The study was a prospective experimental trial lasting for six months. Children with type 1 diabetes were invited to participate. The selection criteria were: children above the age of four years and a diabetes duration of more than one year to avoid the possibility of a “honeymoon period” and endogenous insulin secretion. Before the trial began, the children were followed at the Pediatric Diabetes Clinic of the Security Forces Hospital in Riyadh for at least six months. The study was approved by the appropriate ethics committee.

Results

A total of 200 children were invited to participate in the study and all agreed. The mean age of the children was 11.0 years (SD 5.5). During the study, approximately 30,000 information messages were sent. The average number was 6 information messages per patient per week (range 5–7). In addition, a total of 2800 interactive messages were sent. At the parents' request, 43 MMS messages were sent. Two hundred phone calls were made to ensure that the parents had received the messages during the trial. Insulin doses adjustment was discussed in 82 of these 200 calls.

One month prior to the trial, the mean fasting blood glucose level of the children was 150.4 mg/dl. After the trial, the mean fasting blood glucose level was 132.7 mg/dl. This change was significant (P < 0.001). There were similar significant changes in the other variables measured, see Table 1. The parents assessed the quality of the SMS messages as good, with a mean score of 8.2 out 10.

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Table 1.

Outcome variables before and after the trial (n = 200).

	Pre-trial		Post-trial		P-value
	Mean	SD	Mean	SD
Fasting blood glucose level (mg/dl)	150	67	133	67	<0.0001
Post prandial blood glucose level (mg/dl)	191	79	181	67	<0.0001
Frequency of simple hypoglycaemic attacks (/week)	0.8	1.2	0.6	0.9	<0.0001
Frequency of hyperglycaemic attacks (/week)	2.7	1.2	2.1	1.5	<0.0001
HbA1c (%)	10.0	2.0	9.5	1.8	<0.0001
Frequency of missing insulin injections (/week)	0.3	0.4	0	0	<0.0001
Frequency of blood glucose monitoring (/day)	1.9	1.1	3.2	1.0	<0.0001
Frequency of hospital episodes* (/month)	0.4	0.5	0	0	<0.0001
Parent's knowledge test score	14.7	4.4	17.0	3.0	<0.0001

Discussion

Diabetes management can be difficult for children and adolescents. Several diabetes guidelines recommend offering young children intensive insulin therapy, in conjunction with emotional and behavioural support. ¹¹ However, increasing the frequency of clinic visits is costly and impractical, especially in countries with a high prevalence of diabetes.

Information and communication technologies (ICT) have considerable potential to help patients with chronic and long-term diseases. Young people with diabetes have reported using ICT to improve their knowledge and support their needs. ¹² Text messaging via mobile phones is widely used among teenagers and children in many parts of the world for non-health purposes.^2,3

A meta-analysis conducted by Liu and Ogwu ¹³ examined the effectiveness of mobile phone technology in diabetes care. Fifteen English-language articles were reviewed. Studies that used mobile phone interventions and reported changes in diet, physical activity and blood glucose and /or HbA_1c levels were retrieved. Sample sizes ranged from 12 to 130 participants, and the subjects were aged 8 to 70 years old. Overall, significant improvements were observed in blood glucose and/or HbA_1c concentration, adherence to medication, healthy lifestyle and self-efficacy. Five studies examined patients with type 1 diabetes and two included patients with both type 1 diabetes and type 2 diabetes. Only one study ² included children (92 in total). Twelve of 15 trials, which had serum HbA_1c measures, showed an average 0.39% HbA_1c reduction. In our trial which included 200 children and adolescents, HbA_1c improved significantly by 0.5% and fasting and post prandial blood glucose levels improved by 12% and 5% respectively. The studies reviewed took place in several countries including the US and Europe. Our study is probably the first to be conducted in the Arab Gulf region where diabetes prevalence is very high.

Holtz et al. ¹⁴ conducted a systematic review and identified 21 articles. Subjects with type 1 diabetes were enrolled exclusively in over half of the studies. Seventy-one percent of the studies used a study-specific application, which had supplementary features in addition to text messaging. The outcomes varied considerably across studies, but some positive trends were noted, such as improved self-efficacy, HbA_1c and self management behaviours. In our cohort, the SMS service was associated with positive changes in child and adolescent behaviour. The frequency of missing insulin injections reduced to zero, with a substantial decrease in the number of severe and simple hypoglycaemic attacks. Franklin et al. ³ designed a text-messaging support system (called Sweet Talk) to enhance self-efficacy, facilitate uptake of intensive insulin therapy and improve glycaemic control in paediatric patients with type 1 diabetes. Although HbA_1c did not improve, 82% of the children felt that Sweet Talk had improved their diabetes self management and 90% wanted to continue receiving messages. In addition, a trial on mobile phone text messaging was conducted for 8 months and included 23 patients with diabetes. The results suggest that SMS may provide a simple, fast and efficient adjunct to the management of diabetes especially in elderly people and teenagers, who have difficulty in controlling their diabetes. ¹⁵

Hanauer et al. tested the effect of electronic reminding messages on 40 adolescents with type 1 diabetes, reminding them to check their blood glucose levels via mobile phone text messaging or email. They showed that mobile phone text messaging is a viable and acceptable method of promoting blood glucose monitoring. ¹⁶ In our study, the frequency of blood glucose monitoring improved by more than 10%. Wangberg and colleagues tested the feasibility of using the mobile phone short message service for reaching people with diabetes information. Eleven Norwegian children with type 1 diabetes received SMS messages for 11 weeks. Parents were positive about the system and reported that the messages were helpful to facilitate communication with their adolescent children. ¹⁷ Frøisland et al. tested the effect of mobile phone applications which enabled children to communicate with the treating team by sending SMS messages, and a picture-based diabetes diary including photographs of eaten food and blood glucose readings. Although HbA_1c and participants' theoretical knowledge were not significantly different before and after the intervention, visualization of these data in diabetes self-care was found to be an important educational tool. ¹⁸ Educational achievement and knowledge were also tested in our patients and the scoring on the written questionnaire showed an increase of more than 15%.