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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 18-24

Text messaging and quality of life of diabetics in tertiary care hospital of Eastern Nepal


1 Department of Endocrinology, Internal Medicine, BPKIHS, Dharan, Nepal
2 Medical-Surgical Nursing Department, BPKIHS, Dharan, Nepal
3 Cardiology Department, BPKIHS, Dharan, Nepal

Date of Submission18-Oct-2020
Date of Decision03-Feb-2021
Date of Acceptance03-Mar-2021
Date of Web Publication18-May-2021

Correspondence Address:
Dr Robin Maskey
Department of Endocrinology, Internal Medicine, BPKIHS, Dharan
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCDM.JCDM_5_20

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  Abstract 

Background: Text messaging health service is used to improve quality of life of people living with diabetes in Eastern Nepal. It has been projected that the number of diabetic patients has increased to 170% from 1995 to 2025 in developing countries and to 41% in developed world. The objectives of the study were to assess the quality of life of people living with diabetes, to prepare and provide health education, and to evaluate the effectiveness of health education program and mobile/telephone health services provided to the diabetes patients. Materials and Methods: The study was conducted among consecutive stable ambulatory patients, >18 years old, and 396 patients diagnosed with diabetes for at least 3 months were included in the study. The education intervention was continued for 6 months by the principal investigator and a trained nurse. Results: Most of the respondents (53.3%) were of the age group 40–60 years; female (59.34%); Hindus (97%); and of the Janjati ethnic group (52.5%). The majority (96.5%) were married and self-employed (70.7%). About 30% of the respondents belonged to the poor economic status group. Most of the respondents had type II diabetes mellitus; about 34% of the respondents had a family history of (sibling) diabetes. Most of them were non-vegetarians (88.9%). About 16% of the respondents were obese. Regarding habits, 14% had tobacco chewing, 5% had gutka chewing, 8% had smoking, and around 8% had alcohol consumption habits. Regarding treatment, about 84% were on oral hypoglycemic agent, 22% on insulin therapy, 68% on diet control therapy, 58% on weight control, and 4.5% on herbal therapy. It was found that the mean knowledge score before education intervention was 22.53 and after education intervention was 35.32. It was found that the difference in the mean score calculated using t-test between knowledge before and after education intervention program was significant (P < 0.01). Conclusion: It can be concluded that the education intervention program and SMS mobile service provided to diabetes patients were found to be very effective.

Keywords: Diabetes, health service, Nepal, text messaging


How to cite this article:
Maskey R, Mehta RS, Karki P. Text messaging and quality of life of diabetics in tertiary care hospital of Eastern Nepal. J Cardio Diabetes Metab Disord 2021;1:18-24

How to cite this URL:
Maskey R, Mehta RS, Karki P. Text messaging and quality of life of diabetics in tertiary care hospital of Eastern Nepal. J Cardio Diabetes Metab Disord [serial online] 2021 [cited 2021 Dec 6];1:18-24. Available from: http://www.jcdm.org/text.asp?2021/1/1/18/316098


  Introduction Top


One fifty million people were affected by diabetes in 2002, 180 million in 2003, and will reach 330 million in 2025. This rising prevalence is especially occurring in developing countries.

The reasons for increasing prevalence of diabetes in developing countries are industrialization, socio-economic development, urbanization, and changing life style. Similarly, lack of public awareness regarding the problems of diabetes and poor medical service was the main reason for the increased prevalence of diabetes in country.[1] From January 1, 2014 to December 31, 2014, in Endocrine and Diabetic Clinic of B.P. Koirala Institute of Health Sciences, 802 patients (440 M and 362 F) attended with diabetes mellitus (DM). Hence, the investigators tried to explore the various facts or problems of the admitted patients suffering from DM.

As per the study done by Mehta et al. in BPKIHS for 1 year among patients, 60.7% had hypertension, 39.3% had ocular problem, and 25% had renal problems. The majority of the subjects (82.1%) know about the disease (DM) they were suffering, but limited subjects had knowledge about causes, curability, treatment modalities, diet, and other aspects. As the knowledge regarding various aspects of DM is very low, there is a need for an informational booklet in Nepali, and the health education program among public was very useful.

The psychosocial needs of patients with diabetes are not well understood by healthcare providers. Psychosocial factors have important influences on diabetes outcomes, and subjective quality of life is a worthwhile outcome in its own right. Therefore, it is important to understand how healthcare providers deal with their patients’ psychosocial needs.

By using the mobile phone, patients with diabetes will receive regular SMS on diabetes management and adherence to therapy along with the strategies to manage complications. Patients can use their mobile phone to receive information from their own home and get needed information, and the investigators will also send the information periodically so that adherence to therapy was maximum. Hence, mobile heath service will increase the adherence to therapy and improve the quality of life of diabetes patients.


  Materials and Methods Top


Consecutive 396 stable ambulatory patients >18 years of age and diagnosed case of diabetes for at least 3 months duration were included in the study, after taking consent from subjects and IRB approval from our institute.

Sampling methods/techniques (specify)

The study was conducted among all the people living with diabetes meeting the eligibility criteria and attending B. P. Koirala Institute of Health Sciences Medical OPD. No restrictions were based on sex, race, type of diabetes, or location of patients.

The sampling frame was prepared from the register available at the BPKIHS Diabetes Clinic, obtaining the history from the clients attending the clinic. Before starting the training program, orientation was given to the nurses working in medical OPD and ward, team members, involved doctor and nurses, and those who were involved in the training program as facilitators and resource persons.

The first pre-test was taken among all the 396 diabetes patients, and education intervention was started for all the diabetes patients attending the Diabetes Clinic of MOPD. The education intervention was continued for 6 months in diabetes clinic by the principal investigator and trained nurse in the MOPD.

The contents of the self-management program were: basic concepts of disease process, treatment, complications, adherence to oral hypoglycemic agent (OHA) and insulin, management of side effects of drugs, developing healthy habits at home, prevention of hypo- and hyperglycemia, management of common health problems at home, and increased self-esteem. A training package was prepared and provided to each patient after explanation. The self-management program was validated before the study.

Interactive health education session at diabetes clinic by trained nurses for 6 months includes A-V aids, print resources, and booklets, in which all the diabetic patients got three to four chances to participate in the program. During the training program, detailed address of the specified trained nurses and doctors was given to the participants in written form, and instruction was given to them how to contact through phone and when the investigator will contact them. They were also trained how to contact and how to communicate their problems to the investigators. Two separate phone numbers were given to them and they were asked to save these numbers, so that it is easy to contact and receive the phone call.

During the training, all the required resources such as booklet, pamphlets, posters, and the phone contact number detail card were provided to them, and participants were informed to contact the specified person (trained nurses and doctors) for help if they required that specified phone number and time. The participants were also informed that the investigator would contact them in the number they had given to the investigator. Telephone calls were done to find out the situation and support related to self-management. The intervention is a multi-component self-management intervention which includes diet therapy, OHA, adherence, exercise, management of complications, and elements of cognitive behavioral therapy; it was included because the focus is on self-management more broadly.

After the education intervention, 1 month was given for follow-up and telephone counseling focus group discussion and guidance. The participants were given the instruction that they can contact the investigators when they need help. After 6 months of education intervention, post-test was taken among all the 396 diabetes patients. Four focus group discussions were also arranged to find out the effectiveness of the program and find out the obstacles, so that they can be used for further implementation and future plan.

Quality of diabetes instrument was used to assess the component of quality of life and self-management components. The instrument used is highly reliable, tested, and commonly used worldwide.

Data analysis and interpretation

After the collection of data, they were checked for completeness, organized, coded, and entered in Microsoft Excel 2010, and converted into SPSS 16 version for the statistical analysis. For the descriptive statistics, mean, median, standard deviation, percentage, and frequency are calculated for presenting sociodemographic variables and health risk behaviors. For inferential statistics, appropriate χ2 test and t-test have been applied to find the association between the variables. The findings of the study are represented using the suitable tables, and statistical tests have been presented based on the following statistics:

  1. Socio-demographic characteristics of the respondents;
  2. Diabetes and risk factors of the respondents;
  3. Therapies for diabetes received by the respondents;
  4. Knowledge score before and after education intervention among the respondents;
  5. Evaluation of the educational program by the respondents;
  6. Association between pre-test and post-test mean knowledge score;
  7. Association among sociodemographic characteristics, duration of illness, and risk factors with pre-test knowledge score;
  8. Association among sociodemographic characteristics, duration of illness, and risk factors with post-test knowledge score.



  Results Top


Most of the subjects (53.3%) were of the age group 40–60 years; female (59.34%); Hindus (97%); and of Janjati ethnic group (52.5%). The majority (96.5%) were married and self-employed (70.7%). About 30% of the respondents belonged to the poor economic status group. The details are in [Table 1].
Table 1: Sociodemographic characteristics of the respondents (n = 396)

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Most of the respondents had type II DM; about 34% of the respondents had a family history of (sibling) diabetes. Most of them were non-vegetarians (88.9%). About 16% of the respondents were obese. Regarding habits, 14% had tobacco chewing, 5% had gutka chewing, 8% had smoking, and around 8% had alcohol consumption habit. The details are in [Table 2].
Table 2: Details about the diabetes and the risk factors of the respondents (n = 396)

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Regarding treatment, about 84% were on OHA, 22% on insulin therapy, 68% on diet control therapy, 58% on weight control, and 4.5% on herbal therapy. The details are in [Table 3].
Table 3: Therapies for diabetes received by the respondents (n = 396)

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It was found that the mean knowledge score before education intervention was 22.53 and after education intervention was 35.32. The details are in [Table 4].
Table 4: Knowledge score before and after education intervention among the respondents (n = 396)

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It was found that about 60% of the respondents had studied this type of booklet earlier. Most of the respondents reported that the booklet provided was very effective and useful. The details are in [Table 5].
Table 5: Evaluation of the educational program by the respondents (n = 396)

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It was found that the difference in the mean score calculated using t-test between knowledge before and after education intervention program was significant (P < 0.01). The details are in [Table 6].
Table 6: Association between pre-test and post-test mean knowledge scores

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The association among sociodemographic characteristics, duration of illness, and risk factors with pre-test knowledge scores is calculated; there is significant association with religion (P = 0.022) only. The details are in [Table 7].
Table 7: Association between socio-demographic characteristics, duration of illness, and risk factors with pre-test knowledge score (n = 396)

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No significant association was found between sociodemographic characteristics and obesity with post-test knowledge scores. The details are in [Table 8].
Table 8: Association among sociodemographic characteristics, duration of illness, and risk factors with post-test knowledge score (n = 396)

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  Discussion Top


Our study measures the effects of education intervention and mobile phone SMS on diabetes knowledge, medication adherence, clinic attendance, and glycemic control for patients with diabetes attending Diabetic Clinic of MOPD of BPKIHS Nepal.

Using SMS as tools for medication and appointment reminders, we disseminate health information and life-style messages are easy technology that can be applied by persons with minimum technical knowledge and skills. In this study, SMS was sent to participants using a mobile. Mobile phone SMS has the potential to communicate with diabetes patients and to build awareness about the disease, improve self-management, and avoid complications also in resource-limited settings.

Sociodemographic characteristics of the respondents

Most of the subjects (87.1%) were of age group more than 40 years; female (59.34%); Hindus (97%); Janjati (52.5%); married (96.5%); and self-employed (70.7%). About 30% belonged to the poor economic status group.

Risk factors

It was found that majority (98.7%) of the respondents had type II DM. It was found that nearly half (46.5%) of the respondents were suffering from DM for 1–5 years; whereas only 12.6% had less than 1 year and 4.8% had more than 15 years.

About 34% of the respondents had a family history (sibling) of DM, and 88.9% eat non-veg diet. More than half of the respondents are overweight and obese; 5.6% reported experiencing stress and 29.5% had blood pressure more than 120/80 mmHg.

It was found that 14.1% had a habit of tobacco chewing, 2% betel chewing, 5% gutka chewing, 8.3% had smoking habit, and 8.3% had alcohol consumption habit.

Treatment or therapy for DM

It was found that 84.3% of the respondents were on OHA, 22% on insulin, 68.4% on diet control therapy, 58.3% on weight loss therapy, and 4.5% were receiving herbal therapy.

Effectiveness of education intervention program

There were 10 areas of knowledge domain, i.e. disease process, treatment, diet management, exercise, OHA, insulin, hypoglycemic shock, follow-up, regularity in treatment and regularity in treatment. The mean knowledge score before educational intervention was 22.53 (45.06%) and after education intervention was 35.32 (70.64%), i.e. there is an increase of 12.79 (25.58%).

The opinion about effectiveness of the education intervention and mobile communication was also assessed, and the respondents reported that the booklet provided was easily understandable (82.8%), content is appropriate (60.95), is recommended for other (64.4%) and 32.6% reported that it was very helpful, whereas 66.9% reported the program as alright.

Regarding mobile communication and SMS, 11.4% reported it to be very useful, 28.5% reported useful, 30.3% reported alright, and 29.8% reported that they do not use this service.

The mobile phone SMS messaging has been well accepted by beneficiaries and may be an effective tool for providing diabetes health education, clinic and appointment reminders, medication reminders, and building awareness about the disease.[2],[3] Various studies have shown that SMS reminders improved adherence of type 2 diabetes patients, especially the precision with which the patients followed their prescribed regimen and that it was well accepted by the patients.[4] Numerous issues must be considered when designing and implementing client-centered programs, including mobile phone access, sharing of phones, language and literacy, privacy, and technological challenges. More information is needed about best practices for developing content for text message delivery and the optimal timing of messages.[5]

The web-based education and monitoring are beneficial and can be used to complement healthcare provider visits during time constraints.[6] Increased access, whether in person or electronic, to diabetes education and healthcare providers can improve diabetes knowledge and self-efficacy.[7] The increased use of diabetes-related mobile applications had improved self-management and diabetes outcomes. But use of applications to provide education and real-time feedback needs to be developed.[8]

The effective education strategies followed in National Standards for Diabetes Self-Management Education are worth applying to mHealth methods.[9] Even limited amount of education can result in improved weight control and potentially reduced cardiovascular risk.[10] Initial comparisons between in-person diabetes education and education administrated through telemedicine already demonstrated feasibility and equal effectiveness of technology-supported methods.[11]

Most diabetes self-management applications do not integrate educational information because it is often generic and is not personalized to the individual patient and mostly for commercial applications.[12] Education and personalized feedback are still underdeveloped features, included in less than one-third of reviewed mHealth applications. Only 20% of the reviewed applications had an education module, and only 26% of these met the criteria for personalized education or feedback.

Task of personalizing rapidly growing information is challenging, but it may be largely beneficial for diabetes patients.[13] Most widely used mHealth method for diabetes education is SMS. Meta-analysis of current findings has shown that mobile SMS education can improve glycemic control. The glycemic control is even better if diabetes education is done by a combination of SMS and internet methods, i.e. 86% effect in comparison with 44% that is achieved by SMS alone.[14] Positive results of e-mail and SMS education can also be seen in improved quality of life.[15]

Numerous applications are available helping healthy people or people with risk factors to assess their risk for developing diabetes type 2 in the future. Only a few of these apps disclose the name of the risk calculator used for assessing the risk of diabetes; therefore, the quality of their calculations is questionable.[16]


  Conclusion Top


It was found that most of the subjects were suffering from type II DM and receiving OHA. Nearly one-fourth of the respondents were on insulin therapy. The education intervention program and mobile SMS provided to the respondents were effective as there is an increase in knowledge of about 25%.

Implication

Healthcare providers should actively select and adapt technological self-management methods to extend the reach of diabetes self-management to patients’ communities and homes, provide individualized care, and provide just-in-time information.

People living with diabetes who have limited access to care due to lack of transportation, physical restrictions, or other limitations could benefit from technological interventions that bring care to them. Additionally, with limited primary care resources, technology can provide cost-effective ongoing diabetes self-management education and support.

Use of mobile health technology for empowerment of patients with diabetes is an emerging way to improve their health and wellbeing. It can address almost every problem of diabetic patients.

Limitation

  • In OPD, most of the patients were in hurry and wanted to consult the doctor earlier; hence, they give less attention to hear the education message provided in OPD.
  • Most of the respondents did not had smart phone; hence, it was difficult for them to read the sent SMS.
  • The educational status of all the respondents was not of the level to understand the message properly.


Recommendation

While technology can be effective for promoting diabetes education, support, and self-management, patients report a need for personal contact with healthcare providers in addition to technology. Automated text messages were sent, but participants stated that they preferred to think of them as coming from the certified diabetes educator (CDE) who enrolled them in the study. They also appreciated weekly calls from the CDE to obtain feedback on the experience and make adjustments to text messaging as needed.

Some participants felt that the text messaging intervention would not be effective for them without a person to monitor and provide clinical support. A website that provides diabetes education, monitoring, and support through communication with a healthcare provider may be most effective. Web-based interventions can be used in conjunction with healthcare provider education and support and as a follow-up to healthcare provider interventions.

Researchers and healthcare providers should include participants in the development of technological interventions and in the decision of which technology to use. Patient needs must be explored to determine the best method for individual needs, realizing that not all patients will be amenable to technological interventions.

The future applications should be more personally oriented, improved regarding usability and accessibility, and based on accepted clinical guidelines.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas of insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998;352:837-53.  Back to cited text no. 1
    
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Deglise C, Suggs LS, Odermatt P Short message service (SMS) applications for disease prevention in developing countries. J Med Internet Res 2012;14:e3.   Back to cited text no. 2
    
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Horvath T, Azman H, Kennedy GE, Rutherford GW Mobile phone text messaging for promoting adherence to antiretroviral therapy in patients with HIV infection. Cochrane Database Syst Rev 2012;2012(3):Cd009756.  Back to cited text no. 3
    
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de Tolly K, Benjamin P Mobile Phones. The Handbook of Global Health Communication. UK: Wiley-Blackwell; 2012. p. 309-29. 10.1002/9781118241868.ch15.  Back to cited text no. 5
    
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Pacaud D, Kelley H, Downey AM, Chiasson M Successful delivery of diabetes self-care education and follow-up through eHealth media. Can J Diabetes 2012;36:257-62.  Back to cited text no. 7
    
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Goyal S, Cafazzo JA Mobile phone health apps for diabetes management: Current evidence and future developments. QJM 2013;106:1067-9.  Back to cited text no. 8
    
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Haas L, Maryniuk M, Beck J, Cax CE, Duker P, Edwards L, et al. National standards for diabetes self-management education and support. Diabetes Care 2014;37(Suppl. 1):S144-53.  Back to cited text no. 9
    
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Azar KMJ, Sukyung Chung M, Wang EJ, et al. Impact of education on weight in newly diagnosed type 2 diabetes: Every little bit helps. PLoS One 2015;10:e0129348.   Back to cited text no. 10
    
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Izquierdo RE, Knudson PE, Meyer S, Kearns J, Ploutz-Snyder R, Weinstock RS A comparison of diabetes education administered through telemedicine versus in person. Diabetes Care 2003;26:1002-7.  Back to cited text no. 11
    
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Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G Features of mobile diabetes applications: Review of the literature and analysis of current applications compared against evidence-based guidelines. J Med Internet Res 2011;13:e65.  Back to cited text no. 13
    
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Saffari M, Ghanizadeh G, Koenig HG Health education via mobile text messaging for glycemic control in adults with type 2 diabetes: A systematic review and meta-analysis. Prim Care Diabetes 2014;8:275-85.  Back to cited text no. 14
    
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Han Y, Faulkner MS, Fritz H, Fadoju D, Muir A, Abowd GD, et al. A pilot randomized trial of text-messaging for symptom awareness and diabetes knowledge in adolescents with type 1 diabetes. J Pediatr Nurs 2015;30:850-61.  Back to cited text no. 15
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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