ORLANDO, Fla. — Personalized text message interventions that incorporate the use of emojis and memes are more likely to engage adolescents with type 1 diabetes than automated messages, particularly for those who struggle with low diabetes self-management, according to a speaker here.
Few pediatric patients meet the recommendations for glycemic control, and adolescents and emerging adults are at high risk for elevated HbA1c and repeated episodes of diabetic ketoacidosis, David V. Wagner, PhD, assistant professor of pediatrics at Oregon Health and Science University School of Medicine, said at the American Diabetes Association Scientific Sessions. Most available behavioral interventions for this population, he said, have several limitations: they tend to be office-based and are relatively infrequent, especially in an age of near-constant communication. Interventions that incorporate text messages are a proven way to engage teens in their diabetes management and even improve outcomes, although texting, too, has its challenges, he said.
“You can’t wave a magic wand to engage teens with type 1 diabetes,” Wagner said during his presentation. “There are no short cuts. This is not an easy thing to do, and it will take effort.”
Typical interventions, Wagner said, lack the immediacy that text messaging provides. Texting also tends to be feasible for providers, and many teens report preferring text messages vs. other interventions, he said.
“If we really want to change behavior, we want to frequently respond to it, and respond quickly,” Wagner said. “If you think about it, text allows us to frequently and immediately reinforce diabetes adherence.”
Making it personal
Evidence on the efficiency of texting interventions, however, is mixed. Wagner cited a recent review that suggested teens who already struggle with low self-management and high HbA1c tend to benefit less from text-based interventions. Additionally, youth already struggling are also least likely to share information you may use in a text-based intervention, he said.
But personalized text messages, in combination with in-person initiatives, may improve outcomes in adolescents with type 1 diabetes.
As part of the Novel Interventions in Children’s Healthcare (NICH) program at Oregon Health and Science University, personalized text messaging — never automated or written in advance — is used to increase contact with patients and families and reinforce diabetes management and build rapport, according to Wagner, who is also a NICH clinical supervisor. The texts often include emojis or memes, and providers are encouraged to ask teens nondiabetes-related questions about their lives.
In an analysis of the NICH initiative published in the May 2017 issue of the Journal of Diabetes Science & Technology, Wagner and colleagues found that fewer than half of the text messages sent to patients and their caregivers in the program were identified as being related to diabetes, and more than 95% of diabetes-related texts were identified as adherence-related. Participants in the NICH program also demonstrated a decrease in HbA1c values and DKA-related hospital visits while involved in the program.
Wagner also said that, through experience, providers quickly learned that including emojis and memes in texts, in addition to asking nondiabetes-related questions, increased the response rate from teens.
“The more reinforcing texts per patient, the greater decreases in HbA1c were observed,” Wagner said. “Use of emojis and memes was associated with texting back more frequently.”
Wagner noted that one can’t infer causality from the findings, adding that it is possible that participants who are already doing well are the ones most likely to text a provider back. But the findings suggest that the level and type of engagement matters, he said.
“As part of our model, we should be in frequent contact with patients,” Wagner said. “We should treat people with type 1 as people first, and as individuals with type 1 diabetes second.”
Providers engaging in a text message intervention with teens should determine what their philosophy will be, Wagner said. Is it your job to engage adolescents, or is it their job to come to you?
Providers must also confront a host of other related issues that come with such an intervention, including provider burnout when texting outside of traditional business hours, issues of confidentiality and privacy, a possible loss of consistency or control that comes with sending personalized messages, and unintended consequences. Wagner spoke of one teen who accidentally sent a sext message to a provider.
Wagner said it is important to take a hard look at texting intervention programs for adolescents and evaluate how they are working. Many programs are available that use some form of automated or predetermined text message delivery — and many are good —but they may not be the best for the most vulnerable patients with type 1 diabetes, he said.
“We need to think about ways to increase our patients’ access to us and interact with them more frequently, and think about all the different systems in which they are embedded and treat them as people first and individuals with diabetes second,” Wagner said.
For some providers engaging in a text message intervention, that could also mean taking a critical look at the type of messages sent to teens and the questions providers are asking them.
“The biggest message is to reinforce that they are doing well as much as you can, in ways that actually resonate with the way that they see the world,” Wagner said. – by Regina Schaffer
Wagner DV, et al. Texting teens to improve management and reduce diabetic ketoacidosis. Presented at: American Diabetes Association 78th Scientific Sessions; June 22-26, 2018; Orlando, Fla.
Disclosure: Wagner reports no relevant financial disclosures.