MELINDA D. MARYNIUK, MED, RDN, CDCES
ANSLEY DALBO
JULIA STANITSKI
YASMIN KHAN, MD, MPH
Ideally, everyone with diabetes will have a diabetes care and education specialist (DCES) as part of their care team. Realistically, we know that does not happen. Data from the Centers for Disease Control and Prevention show that fewer than 7% of adults with diabetes receive diabetes self-management education and support (DSMES) services within the first year of diagnosis.1 These services are especially critical for populations and communities with limited access to health care. Furthermore, analysis of National Health and Nutrition Examination Survey data shows that only about half of all adults with diabetes achieve an A1C target of less than 7%.2 Thus, there is a need to explore additional ways to provide much needed education in a variety of formats to best address these gaps.
Diabetes technology is changing the way the DCESs and others provide care. This does not mean abandoning traditional methods (eg, one-to-one counseling and group classes) but for the DCES to think differently about additional ways to extend reach by learning new skills. According to the 2022 National Standards for DSMES, strong evidence supports DSMES delivery through virtual, telehealth, telephone, web-based/mobile phone applications, and text messages.3 Using text messages in health care is common as a way to remind patients about appointments and decrease no-show rates but is less commonly used as a way to provide educational information, reinforce key messages, and provide support despite its proven effectiveness. Access to cell phones is no longer seen as a barrier; the most recent data from the Pew Research Center shows that 97% of Americans now own a cell phone that can receive SMS texts.4
A recent umbrella review of text message programs for adults with type 2 diabetes concluded that such programs are a highly accessible and effective mode of communication, as shown by improvements in A1C, blood pressure, lipids, and diabetes self-management.5 Another review concluded that text messaging interventions targeting adults with type 2 diabetes increased patients’ self-awareness, knowledge, and management of diabetes and that patients felt “supported.”6 These reviews have also demonstrated high satisfaction and low attrition rates. Both bidirectional (2-way) text messaging programs and unidirectional text messaging programs were included in the reviews. Although bidirectional programs allow for more tailored messaging based on responses, one review concluded that both bidirectional and unidirectional text messaging programs can be effective.6
With such a strong evidence base, it is surprising that there has not been greater use of text messaging programs by DCESs in clinical practice. Through the use of brief, well-written text messages, people with diabetes can opt in to receive quick tips and new and/or reinforcing information and be reminded of the importance of engaging in specific behaviors. A text message program is also an ideal way to provide ongoing support.
We had the opportunity to design and pilot a text messaging program “Diabetes on the Go” for customers purchasing a store-brand meter from a big-box store. Participation was optional and entirely voluntary, yet over an 8-month pilot phase, over 1200 individuals enrolled in a nocost program in which they would receive 1 to 2 text messages a week for 22 weeks addressing educational topics in line with the ADCES7. Information inviting enrollment reached those who purchased a meter by either a sticker containing a QR code that was placed on about 2500 meters at the point of purchase and/or a pop-up informational box that appeared on the meter app encouraging enrollment. It is not clear how many people enrolled triggered by one source of information or the other. Content was developed with input from a CDCES and an endocrinologist. Most messages were under 160 characters and usually linked to a short handout, article, video, or simple visual image. Some messages suggested a request for engagement (eg, responding to a question or completing a survey). See Figure 1 for sample text messages.
For each topic, we measured both the clickthrough rate (CTR) and the unsubscribe rate. The CTR is a measure of the number of clicks on the content in a given message divided by impressions. A high CTR is a good indication that the message is useful and relevant. Typically, an expected “good” CTR for health care is 10% to 12%. The CTR for our messages ranged between 25% and 52%, an excellent indication that the messages were very useful and relevant. There was also a very low unsubscribe rate (less than 1% per message).
Three days after receiving the week 15 message, participants received a text with a link to a survey and were encouraged to share their feedback about the program. Data from approximately 180 respondents revealed the following:
97% enjoyed getting the text messages.
98% felt the messages were helpful in managing their diabetes.
77% found the program motivating to check blood glucose more often.
Surprisingly, there were no negative comments.
In addition, there was an opportunity to ask questions about diabetes that would be answered by an RD/CDCES during a live Facebook presentation to which all participants were invited. Although most questions were nutrition related, they covered a wide array of topics. Overall, the questions indicated a very basic understanding of diabetes. There were no questions regarding higher level topics, such as insulin adjustment, or the use of technology, such as continuous glucose monitoring. See Figure 2 for some of the more commonly asked questions. We also linked individuals to relevant sections on the American Diabetes Association website for additional information related to their question.
Text messaging is an extremely effective tool for reaching and engaging an audience of people with type 2 diabetes. From our experience, we share these tips as you think about incorporating a texting program into your practice.
In general, a brief message resulted in a higher CTR, and we speculated that this was because the call to action was clear and concise.
Whereas more than twice weekly seems to be too much, we found 1 to 2 messages a week to be just right.
In the text messages we originally designed, we had only text, but we learned that including a simple visual message helped increase engagement and the CTR. Using emojis is also helpful because there is evidence it can enhance communication and expression.
Not surprisingly, content related to food and recipes is consistently popular—but topics related to blood glucose numbers and target labs to follow were also well received. When we asked participants to text us their questions, it served as a good reminder of just how basic most people’s understanding of diabetes is.
Research shows that tailoring content is always beneficial but may be difficult. Include the person’s name receiving the message. A small step we took was sending messages from “Ansley@ DiabetesOnTheGo.” Using one of our names was reassuring to patients because they knew they were communicating with a real person, which in fact they were because a person, not AI, responded to every text message received.
As per the National Standards of DSMES, ongoing support is a critical element of diabetes self-management education. Text messaging programs are a perfect option to meet this standard. We kept the messages positive and used words of encouragement whenever possible.
If you are part of a health care center that already uses text messaging for appointment reminders, see if there are ways you can include diabetesrelated messages before a visit, such as reminders to bring meters, log books, and medications. Find out if there are ways to use the existing platform to send information and follow-up messages after visits, too.
Pay attention to the data to learn how your messages are received. Review data on click-through and unsubscribe rates. Occasionally ask for feedback to assess impact (but not too often). This can be as simple as asking for a “thumbs up,” soliciting questions, or asking a short survey question. Following your own data and responding to trends will help decrease unsubscribe rates and increase engagement. Don’t hesitate to experiment with different messages to see if click-through and unsubscribe rates change.
Some people prefer to read articles, and others like watching videos better. Delivering the necessary information through links to different media (including short articles, videos, simple graphics, and quizzes) can help ensure that you are reaching the broadest possible audience.
You don’t have to do this alone. If you are part of a health care center that has a text messaging service, there are many companies—small and large—that can help. Choose a platform that is HIPPA compliant and follows the latest regulations.
This program is reaching a large audience that may or may not see a DCES. The expertise of a DCES was a critical part of the team providing the design and implementation of the program. As more industries engage in the business of diabetes self-management, make sure a DCES is at the table to ensure the messages are practical, relevant, and accurate.
Text messaging is an effective and underutilized resource that can reach a wide audience, reinforce diabetes care and education messages, remind learners of key tasks, and provide ongoing support. DCESs have an opportunity to harness technology to create content that can benefit people with diabetes. There are opportunities to offer diabetes-related content for existing text messaging programs within health care systems and to work with industry.
Melinda D. Maryniuk, MEd, RDN, CDCES, is owner at Maryniuk & Associates Consulting in Dennis Port, MA. Ansley Dalbo and Julia Stanitski are with Diabetes What to Know in Atlanta, GA. Yasmin Khan, MD, MPH, is with Baltimore VA Medical Center in Baltimore, MD.
This pilot program was sponsored by ARKRAY USA, Inc to help educate and support Walmart customers with diabetes who purchased a ReliOn blood glucose monitor. Learn more at www.relionbgm.com/community
The authors declare having no professional or financial association or interest in an entity, product, or service related to the content or development of this article.
The authors declare having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.
Powers MA, Bardsley JK, Cypress M, et al. Diabetes Self-management Education and Support in Adults With Type 2 Diabetes: A Consensus Report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Educ. 2020;46(4):350-369.
Fang M, Wang D, Coresh J, Selvin E. Trends in diabetes treatment and control in U.S. adults, 1999-2018. N Engl J Med. 2021;384(23):2219-2228.
Davis J, Fischl AH, Beck J, et al. 2022 National Standards for Diabetes Self-Management Education and Support. Sci Diabetes Self Manag Care. 2022;48(1):44-59.
Pew Research Center. Mobile fact sheet: tech adoption trends. Accessed March 5, 2024. https://www.pewresearch.org/internet/fact-sheet/mobile/
Whittemore R, Siverly L, Wischik DL, Whitehouse CR. An umbrella review of text message programs for adults with type 2 diabetes. Diabetes Educ. 2020;46(6):514-526.
Sahin C, Courtney KL, Naylor PJ, et al. Patients’ evaluations of mobile text messaging studies for type 2 diabetes management: a systematic review and a meta-synthesis. J Technol Behav Sci. 2021;6:54-73.