الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
T2DM is associated with an elevated risk of various health complications. Its prevalence is increasing, and mismanagement is commonly attributed to factors such as poor nutrition leading to obesity, lack of physical activity, medication non-adherence, insufficient glucose monitoring, and inadequate support. Given the widespread presence of these issues, there remains a need for educational and supportive interventions aimed at improving glycemic control. Receiving support from healthcare providers and peers can foster feelings of empowerment and self-efficacy, which in turn can contribute to better glycemic control outcomes. The Standards for DSME/S recommend the provision of continuous DSME/S programs. However, many healthcare facilities currently offer one-time face-to-face programs that lack ongoing support tailored to individual needs and effective behavior change strategies. Implementing a comprehensive DSME/S program could offer patients the necessary support, knowledge, and self-care techniques to encourage them to adopt actions aligned with a holistic approach to managing their diabetes effectively.
Studies have demonstrated the effectiveness of DSME/S delivered through text messages in helping patients improve and sustain glycemic control. The use of mobile phone technology serves as an excellent tool for addressing barriers in healthcare caused by distance and time constraints. mHealth interventions have the potential to support risk factor management among patients with T2DM by sending reminders and motivational messages to encourage a healthier lifestyle, providing accurate perceptions about diabetes, increasing self-efficacy, and enhancing perceived support for diabetes management. Implementing a DSME/S program using text messaging has several advantages. It is a simple and cost-effective approach, reaching many individuals. It allows for interactive communication of diabetes information and education, enabling patients to overcome limitations and improve their healthcare. The delivery of DSME/S through text messages effectively improves communication between patients and healthcare providers, promotes medication adherence, enhances self-care behaviors, and increases knowledge, leading to improved glycemic control.
Direct patient care was identified as the most critical responsibility of expert pharmacists working in primary care. Diabetes patients visit a pharmacist more frequently than they visit their primary care physician. Pharmacists are underutilized healthcare providers who can provide DSME/S services if given the proper resources. Continuous pharmacist involvement in primary health care is a low-cost method that has been identified as critical for supporting patients with diabetes in managing their disease. Interventions led by pharmacists in primary care can improve glycemic control in adults with T2DM. Medication therapy management provided by pharmacists is another discipline-specific counseling that improves DSME/S. The COVID-19 pandemic has altered the way pharmacists and other health-care practitioners provide care. Pharmacist-led diabetes care has been modified to better serve patients throughout the pandemic due to the extensive usage of virtual and online platforms for service delivery.
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The aim of this study was to study the effect of using mobile phone short message service to improve glycemic control and adherence to treatment for type 2 diabetes in an urban area of Alexandria. The specific objectives were:
1.
To design and implement an educational intervention for patients with type 2 diabetes using mobile phone short message service.
2.
To assess the effect of the intervention on patients with type 2 diabetes in terms of: Glycemic control (HbA1c level), adherence to the prescribed hypoglycemic medications and diabetes related knowledge.
Subjects and Methods:
The study was conducted as a 6-months quasi-experimental; non-randomized pre- post-test control group intervention study among adult patients diagnosed with T2DM receiving care at selected PHCs in Alexandria. Patients were not included if they had clinical conditions that might interfere with the study such as pregnancy, mental illness, poor eyesight, hearing, or vocalization, visual, renal, or liver impairment, other serious illnesses, or comorbidities requiring hospitalization.
The study was conducted in urban PHCs at Al-Montazah district in Alexandria. Two centers (Al-Amrawy was assigned for the intervention group, and Al-Mandara, was assigned for the control group) were selected conveniently from a list of centers that fulfill the family medicine accreditation requirements in providing an affordable community-based basic curative and diagnostic health services package to all family members. The study took place in the family medicine outpatient clinics.
A predesigned structured interviewing questionnaire was used to collect data from 100 patients (50 per each group). The collected data included: sociodemographic data including age, sex, marital status, level of education and occupation; mobile phone use habits including mobile phone usage and frequency of use; medical history, smoking, physical activity, family history of diseases, and diabetes care.
The ARMS-SF was employed to evaluate baseline self-reported medication adherence. Knowledge about diabetes mellitus was assessed at baseline, and it comprised 25 items, adapted from the validated Arabic Simplified Diabetes Knowledge Test. The level of HbA1c; weight and height; and BP were evaluated at baseline for both groups. Educational SMS addressing disease and complications, examinations, medications, healthy diet, physical activity, and diabetes self-management behaviors were sent 6 days per week to the intervention group mobile phones and continued for 6 months. To assess the effect of the educational SMS on the HbA1c, medication adherence, self-management behaviors, and diabetes related knowledge, the assessment was repeated after three and six months following the SMS intervention..
Results:
Baseline data
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Smartphones were the most common mobile phone types owned by the participants, representing 6666% and 8080% in the intervention and the control groups, respectively.
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Most participants used their phones to access the internet, representing 60% and 72% of the intervention and the control groups, respectively.
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The internet was the most common source of knowledge about diabetes among the participants, representing 74% of the intervention group and 82% of the control group.
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Over half of the participants visited the physician as needed, representing 62% and 64% of the intervention and the control groups, respectively.
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Over half of the participants assessed HbA1c during the last year, representing 73% and 60% of those who reported testing HbA1c in the intervention and the control groups, respectively.
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Over half of the participants assessed lipid profile during the last year, representing 61% of those who reported testing lipid profile in both the intervention and the control groups, respectively.
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Over half of the participants had fundus examination during the last year, representing 61% and 58% of those who reported fundus examination in the intervention and the control groups, respectively.
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The most common place for testing blood sugar level was home, representing 85% and 88% of those who reported testing blood sugar level in the intervention and the control groups, respectively.
Effect of the intervention program on diabetes self-management
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The change in the reported walking from baseline did not differ significantly between groups after 3 months (p=0.841) and 6 months (p=0.208), with an overall non-significant difference over the 6 months intervention (p=0.725). Considering within group difference for the intervention group, there was a significant improvement in the reported walking after 3 months (p=0.024).
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The change in the reported frequency of walking from baseline did not differ significantly between groups after 3 months, (p=0.451) however it differed significantly after 6 months (p=0.04), with an overall non-significant difference over the 6 months intervention (p=0.113). Considering within group difference for the intervention group, there was an overall significant improvement in the reported walking frequency over the 6 months intervention (p=0.002).
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The change in the reported duration of walking from baseline did not differ significantly between groups after 3 months, (p=0.948), however it differed significantly after 6 months (p=0.01), with an overall significant difference over the 6 months intervention (p=0.02) in favor of the intervention group.
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The change in the reported other physical activities than walking from baseline did not differ significantly between groups after 3 months (p=0.051), however, it
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differed significantly after 6 months (p=0.003), with an overall significant difference
over the 6 months intervention (p=0.003) in favor of the intervention group.
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The change in the reported frequency of other physical activities from baseline did not differ significantly between groups after 3 months (p=0.062), however, it differed significantly after 6 months (p=0.016), with an overall non-significant difference over the 6 months intervention (p=0.075).
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The change in the BMI from baseline did not differ significantly between groups after 3 months (p=0.727) and after 6 months (p= 0.335), with an overall non-significant difference over the 6 months intervention (p=0.139).
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The change in self-reported general health status from baseline differed significantly between groups after 3 months (p=0.007) and after 6 months, (p=0.001), with an overall significant difference over the 6 months intervention (p=0.001) in favor of the intervention group.
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The change in the BP from baseline did not differ significantly between groups after 3 months (p= 0.59), however, it differed significantly after 6 months (p=0.026), with an overall non-significant difference over the 6 months intervention (p=0.462). Considering within group difference for the intervention group, there was an overall significant change over the 6 months intervention (p=0.039).
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The change in reported testing of blood sugar level from baseline differed significantly between groups after 3 months (p=0.02) and after 6 months (p= 0.024), with an overall significant difference over the 6 months intervention (p=0.001) in favor of the intervention group.
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The change in reported checking feet from baseline differed significantly between groups after both 3 and 6 months, (p=0.001), with an overall significant difference over the 6 months intervention (p=0.001) in favor of the intervention group.
Effect of the intervention program on glycemic control
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After 3 months, the change in HbA1c from baseline did not differ significantly (Δ 0.2%; IQR 7.2 to 9.1; p=0.189), with a median DROP of -0.05% in the intervention group and a median increase of +0.15% in the control group. After 6 months, the change in HbA1c from 3 months differed significantly (Δ 0.4%; IQR 7.27 to 9.23; p=0.026), with a median DROP of -0.2% in the intervention group and a median increase of +0.2% in the control group. However, after 6 months, the change in HbA1c from baseline did not differ significantly (Δ 0.6%; IQR 7.18 to 9.23; p=0.39), with a median DROP of -0.25% in the intervention group and a median increase of +0.35% in the control group.
Effect of the intervention program on medication adherence
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After 3 months, the change in medication adherence scores on the ARMS-SF from baseline differed significantly (Δ 4; IQR 10 to 15.25; p=0.001), with a median DROP of -1 in the intervention group and a median increase of +3 in the control group.
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After 6 months, the change in medication adherence scores on the ARMS
-SF from 3 months differed significantly (Δ 0.5; IQR 10 to 16; p=0.001), with no change in median in the intervention group and a median increase of +0.5 in the control group. After 6 months, the change in medication adherence scores on the ARMS-SF from baseline differed significantly (Δ 4.5; IQR 10 to 16; p=0.001), with a median DROP of -1 in the intervention group and a median increase of +4.5 in the control group.
Effect of the intervention program on diabetes-related knowledge
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After 3 months, the change in diabetes-related knowledge test scores from baseline did not differ significantly (Δ 0.5; IQR 18 to 25; p=0.182), with a median increase of +3.5 in the intervention group and no change in median in the control group. After 6 months, the change in diabetes-related knowledge scores test from 3 months did not differ significantly (Δ 0; IQR 18 to 25; p=0.482), with a median DROP of -0.5 in the intervention group and no change in median in the control group. After 6 months, the change in diabetes-related knowledge test scores from baseline did not differ significantly (Δ 0; IQR 18 to 25; p=0.916), with a median increase of +3 in the intervention group and no change in median in the control group. Considering within group difference for the intervention group, there was a significant increase in the median diabetes-related knowledge test scores after 3 months and 6 months (p=0.001), with an overall significant increase over the 6 months intervention (p=0.001).
6.2. Conclusion
The following can be concluded from the present study:
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Educational SMSs interventions encourages distant healthcare, patient education, effective collaboration between healthcare provider and patient.
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Texting services can be valuable for outpatient clinics in PHCs nationwide, specifically for patients with T2DM. The simplicity of using texting services makes it a feasible communication tool for future interactions with PHC patients.
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SMS led to a significantly higher number of intervention patients to achieve a DROP in their HbA1c levels at 6-months evaluation, however, there was an overall non-significant improvement in HbA1c compared to no intervention following 6 months intervention.
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Considerable improvements were found in secondary outcomes such as medication adherence and self-managing behaviors.
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Adhering to prescribed medications had outstandingly better scores for intervention patients at 6 months.
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More intervention patients became physically active and in a better general health status thought the intervention.
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The rates of adhering to follow-up examinations went substantially better for intervention patients at 6 months. More intervention patients tested their blood sugar level and checked their feet daily thought the intervention.
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The SMS intervention has improved diabetes-related knowledge for the intervention patients.
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Delivering DSME/S through SMS may result in increased patient self-management behaviors as well as an improved glycemic control level.
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Improvement in HbA1c levels and self-managing behaviors, are all elements that highlight the feasibility of the SMS intervention among patients with T2DM in Alexandria-Egypt.
6.3. Recommendations
1. Recommendations to Ministry of Health and Population:
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Implement texting services that allow patients to choose whether to use the service, respecting their autonomy in healthcare decisions.
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Apply the text messaging intervention on recently diagnosed patients with T2DM and pre-diabetic patients, especially for patients with modest education who use regular mobile phones and seniors who are typically less proficient in using modern technology.
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PHCs’s healthcare staff providing the care for patients with T2DM, involving the pharmacists, health promotors, and nurses should be trained on applying the intervention to increase the intervention’s utility.
2. Recommendations to researchers:
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Subsequent programs planned to investigate innovative and current interventions for improving glycaemic control and diabetes self-managing behaviours are urgently required.
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The effectiveness of the educational SMS intervention over conventional approaches needs more research.
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Subsequent studies examining the SMS intervention need to emphasize on enrolling bigger and diverse samples from multiple facilities to be more generalizable to a greater population. Furthermore, multiple geographical sites could yield variable data on differences among the examined locations.
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RCTs of longer duration and larger sample size are required to evaluate SMS’s clinical effectiveness and ensure the generalizability of the findings. A longer study is recommended to go at least 12 months to find significant differences in HbA1c,
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and grant changes in behaviours
because the impact of the SMS intervention depended on continuous motivation.
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Applying texting in an interactive two-way manner. This could be done by sending patients healthy lifestyle tips regarding diet and physical activity; appointment and medical examination reminders; diabetes-related self-care reminders; medication adherence reminders; disease-related information; and receiving questions, concerns, and medical results from patients.
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Investigate personalized SMSs per specific patient condition. By making tailored programs per each patient’s specific needs and lifestyle habits, the patient could be more willing to comply.
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Consider other media techniques (using a multimedia versus a single media method) to communicate health messages and support patients achieving better outcomes.
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Qualitative research may better study the dynamic drives behind a patient’s progress or decline in many aspects applying the SMS intervention.
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Evaluating patient satisfaction and feedback to identify whether patients found the messages easy to understand, would consider ongoing engagement, and whether the intervention was a satisfactory mean to get diabetes education and support.
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Other forms of mHealth including using the internet, social media, and smartphone apps, which are other platforms for reaching more diabetic patients for being commonly used nowadays, hence, they could be utilized and evaluated as future educational approaches.
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Studies could expand to cover patients with other non-communicable diseases.
3. Recommendations to patients:
Patients with T2DM should seek to improve their diabetes self-management behaviors to improve their blood sugar levels, HbA1c values, and overall general health; and decrease the potential for developing diabetes-related complications. It is recommended to find out more about credible mobile phones’ interventions targeting T2DM, and to get familiar with how to use mobile phone features.