Alexandra Greene

Patients’ Engagement With “Sweet Talk” – A Text Messaging Support System for Young People With Diabetes

Background Guidelines for optimizing type 1 diabetes in young people advocate intensive insulin therapy coupled with personal support from the health care team. “Sweet Talk” is a novel intervention designed to support patients between clinic visits using text messages sent to a mobile phone. Scheduled messages are tailored to patient profiles and diabetes self-management goals, and generic messages include topical “newsletters” and anonymized tips from other participants. The system also allows patients to submit data and questions to the diabetes care team. Objectives The aim was to explore how patients with type 1 diabetes interact with the Sweet Talk system in order to understand its utility to this user group. Methods Subjects were 64 young people with diabetes who were participating in the intervention arms of a randomized controlled trial. All text messages submitted to Sweet Talk during a 12-month period were recorded. Messaging patterns and content were analyzed using mixed quantitative and qualitative methods. Results Patients submitted 1180 messages during the observation period (mean 18.4, median 6). Messaging frequency ranged widely between participants (0-240) with a subset of 5 high users contributing 52% of the total. Patients’ clinical and sociodemographic characteristics were not associated with total messaging frequency, although girls sent significantly more messages unrelated to diabetes than did boys (P = .002). The content of patients’ messages fell into 8 main categories: blood glucose readings, diabetes questions, diabetes information, personal health administration, social messages, technical messages, message errors, and message responses. Unprompted submission of blood glucose values was the most frequent incoming message type (35% of total). Responses to requests for personal experiences and tips generated 40% of all the incoming messages, while topical news items also generated good responses. Patients also used the service to ask questions, submit information about their self-management, and order supplies. No patients nominated supporters to receive text messages about their self-management goals. Another option that was not used was the birthday reminder service. Conclusions Automated, scheduled text messaging successfully engaged young people with diabetes. While the system was primarily designed to provide “push” support to patients, submission of clinical data and queries illustrates that it was seen as a trusted medium for communicating with care providers. Responses to the newsletters and submission of personal experiences and tips for circulation to other participants also illustrate the potential value of such interventions for establishing a sense of community. Although participants submitted relatively few messages, positive responses to the system suggest that most derived passive support from reading the messages. The Sweet Talk system could be readily adapted to suit other chronic disease models and age groups, and the results of this study may help to inform the design of future text message support interventions.

Performance Assessment and Wicked Problems: The Case of Health Inequalities:

This article considers the background to one of the projects in the UK Economic and Social Research Councils Public Services Programme: a major; three-year investigation of how health inequalities are being framed for intervention at a local level in post-devolution England, Scotland and Wales. A particular interest is in the difference that performance assessment makes as it engages to a greater or lesser extent with health inequalities.

Do managed clinical networks improve quality of diabetes care? Evidence from a retrospective mixed methods evaluation

Problem: System-wide improvement of chronic disease care is challenging because it requires collaboration and communication across organisational and professional boundaries. Managed clinical networks are one potential solution, but there is little evidence of their effectiveness. Design and setting: Retrospective, mixed-methods evaluation of the form and impact of quality improvement in the Tayside Diabetes Managed Clinical Network (MCN) 1998–2005. Strategies for change: Progressive implementation of multiple quality improvement strategies predominately directed at individuals and clinical teams (guideline development and dissemination, education, clinical audit, encouragement of multidisciplinary team working, task redesign). Information technology played an important role in supporting QI activity, but participants identified it as facilitative rather than delivering QI by itself. More important was achieving widespread clinical engagement through persuasion and appeal to shared professional values by clinical leaders. Effects of change: Simple process measures such as glycated haemoglobin measurement rapidly improved. More complex process measures such as eye screening improved more slowly, and were more dependent on redesign of the care pathway. Improvement was greater for type 2 than type 1 diabetes. Significant shifts of care for type 2 diabetes into primary care were achieved, but were harder to achieve without additional resources. Lessons learnt: Delivering better care to whole populations across organisational and professional boundaries required sustained work over long periods, and at all levels of the system of care. Past network focus on clinical collaboration has been effective at improving clinical process and outcome, and the network is now prioritising work with managers and patients to support future redesign.

What healthcare professionals can do: a view from young people with diabetes

A major part of the DAWN program is to provide support for diabetes healthcare professionals across the world to adopt patient-centered treatment strategies. A key outcome of DAWN Youth at the national level is to facilitate training programs, new insights, practical tools, and strategies that health professionals can use to support young people’s physical and psychosocial self-management of their diabetes. To date, related research has tended to focus on the problems associated with young people’s poor management of diabetes and the challenges faced by health professionals delivering services for them. Less well explored are insights and guidance directly from young people themselves to inform clinical practice and outcomes. This paper reports on the accounts of young people with diabetes describing their insights, and illustrates their views on the strategies that health professionals may use to support patient-centered care. In line with the key goal of the DAWN Youth program, the paper considers the involvement of young people in the planning of their own care, as well as the development and evaluation of health services and research. It aims to raise questions about the value of young people’s contribution to care delivery, while touching on the broader themes relating to healthcare organization, management, policy, and health professionals’ behavior. Although accepting that these participants have achieved relatively effective management of their diabetes and are not, therefore, necessarily representative of a general population of young people with diabetes, their control of diabetes has not always been either straightforward or successful. Their position as either IDF or DAWN Youth Ambassadors has provided them with the opportunity to meet other young people with diabetes and understand in depth the challenges and successes of daily life as a young person with diabetes. Each person interviewed can tell a story of their continuing battle to deal with the feelings of anger, guilt, and despair at the injustice of having diabetes, as well as their motivation for positivity, hope, and compassion for others with diabetes. Their focus here is to provide a platform for those who are successfully managing diabetes to share their knowledge and understanding with others involved in the delivery of diabetes care.

Changing the future of diabetes

The DAWN Youth International Advisory Group: Henk-Jan Aanstoota, Barbara Andersonb, Thomas Dannec, Larry Deebd, Alexandra Greenee, Francine Kaufmanf, Karin Langeg, Anja Østergren Nielsenh, Mark Peyroti and Kari Rosenfeldj aDiabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands; bBaylor College of Medicine, Houston, TX, USA; cCentre for Children and Adolescents with Diabetes, Kinderkrankenhaus auf der Bult, Hannover, Germany; dUniversity of Florida and Florida State University, FL, USA; eHealth Services Research Unit, University of Aberdeen, Aberdeen, UK; fKeck School of Medicine and Annenberg School of Communications of USC, Children’s Hospital of Los Angeles, Los Angeles, CA, USA; gDepartment of Medical Psychology, Hannover Medical School, Hannover, Germany; hYouth Ambassador, DAWN Youth Advisory Board, and University of Copenhagen, Copenhagen, Denmark; iDepartment of Sociology, Loyola University Maryland, and Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA; and jInternational Diabetes Federation, Brussels, Belgium