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Sweet Talk: A text messaging support system

Stephen Greene
, Victoria Franklin

Diabetes self-management is complex and demanding for any age group, but adolescence presents additional difficulties. Young people strive to form their own identity, to conform with their peer group and resist authority – these can all conflict with optimal diabetes management. In addition, puberty is associated with insulin resistance that can undermine self-care efforts (Amiel et al, 1986). Unsurprisingly, adherence to insulin regimens decreases during adolescence and this is associated with poor glycaemic control and an increased risk of ketoacidosis (Morris et al, 1997). Furthermore, clinic attendance rates frequently decline around the time of transition to adult care services. The challenge is to develop innovative ways of engaging young people with type 1 diabetes and support them in optimising their diabetes self-care. Sweet Talk is an automated text messaging system designed to offer regular support to young people with diabetes to help them optimise their diabetes self-management and glycaemic control.

Frequent contact with and support for our service users improves adherence to drug regimens and should improve metabolic control (Kirsht et al, 1981) and it is therefore recommended that contact should be as frequent as resources allow (Lorenz et al, 1996). However, increasing traditional face-to-face contact between health professionals and service users is costly and time-consuming for both parties. The challenge is to use innovations that are feasible within finite health service resources.  

Conventional methods of helping young people with diabetes include support groups and group behavioural interventions such as coping skills training and motivational interviewing (Grey et al, 2000; Viner et al, 2003). However, participation in such groups is frequently low and those most in need are least likely to attend (Farquhar J, 1986; Glasgow et al, 1999; Hanestad and Albreksten, 1993). 

Specialist support groups and chat lines are accessible via the internet and provide information on, for example, self-help strategies, patient-to-patient and professional-to-patient support (Eysenbach et al, 2004). They have the advantage of convenience and allow asynchronous communication and uninhibited sharing of emotions and issues. However, use of the internet does not have universal appeal and can create a ‘digital divide’, which may further disadvantage less motivated people or those without ready internet access (Pagliari et al, 2005).

Text messaging and young people
Recently published statistics reveal that 91% of 12-year-olds own a mobile phone (The Carphone Warehouse plc, 2006). The popularity of text messaging increased rapidly among teenagers in the late 1990s as it is a low-cost and socially acceptable method of communication. 

Health related text messaging interventions
The high levels of mobile phone ownership and use among young people mean that they have great potential as a communication tool between health professionals and their patients (Gimenez-Perez et al, 2002). 

Text message reminders have been used in the general practice setting for clinic reminders: in one study non-attendance rates were reduced at a young adult diabetes clinic (Summerton and Summerton, 2004); yet in an orthodontic surgery it had no impact on the failed appointment rate (Bos et al, 2005). 

Text message reminders have proved an effective means of improving adherence to vaccination schedules in travellers attending an immunisation clinic (Vilella et al, 2004) and it has been suggested that text messages could promote adherence with asthma medication (Neville et al, 2002). 

Text messaging has also been used as a method of transmitting blood glucose data to a web-based server (Ferrer-Roca et al, 2004). This data was used to calculate an estimated monthly HbA1c, which was fed back to the participant by text message. Although this study was not described as a behavioural intervention, such feedback may serve to enhance adherence to self-monitoring of blood glucose and, therefore, improve overall diabetes control. 

Text messaging has also been used to deliver a smoking cessation behavioural intervention to college students (Obermayer et al, 2004). In this non-controlled study, the rates of 24-hour quit attempts and smoking cessation after the 6-week programme were comparable or higher than minimal contact or self-help strategies. 

Finally, text messaging can also be used as a method of capturing symptom data and has been used by our group to collect information about hypoglycaemia (Tasker et al, in press). 

Text messaging has several potential advantages over paper-based symptom diaries because mobile phones have become an integral part of people’s lives and can be used to prompt people with diabetes to send their diabetes management data. 

Text messaging support for young people with diabetes
Teenagers can be difficult to engage in traditional health care and promotion (Wysocki et al, 1997), but as they are typically early adopters of new technology, there is an opportunity for developing interventions to engage young people using e-health strategies. Text messaging predominates in mobile phone use by young people and provides an inexpensive, convenient form of communication and its almost ubiquitous use (Gimenez-Perez et al, 2002)s make it a perfect medium for engaging this population in diabetes self-management issues.

The Sweet Talk intervention
Sweet Talk is a complex intervention at the heart of which is an automated and scheduled text messaging system designed to offer regular support to young people with type 1 diabetes to help them optimise their diabetes self-management. During the diabetes consultation, the Sweet Talk intervention involves setting and writing contracts of agreed personal diabetes self-management goals during the diabetes consultation. Based on these goals and profiles for age, sex and diabetes regimen, the Sweet Talk system schedules the automated delivery of a series of appropriately tailored messages, including daily messages to reinforce the individual’s personal diabetes self-management goals and a weekly reminder of their specific goals. 

The system draws on a database of messages that was created to encompass four main diabetes self-management tasks (insulin injections, blood glucose monitoring, healthy eating and exercise). Example text messages are shown in Table 1. In addition, the person with diabetes received occasional text ‘newsletters’ regarding topical diabetes issues or requests for tips and suggestions about living with diabetes and personal replies to any messages they sent to Sweet Talk. A detailed description of the development of the Sweet Talk system has been published previously (Franklin et al, 2003; Waller et al, 2006).

Evaluating the Sweet Talk system
The Sweet Talk system has been evaluated in a randomised controlled trial (Franklin et al, 2006). Young people aged 8–18 years with type 1 diabetes diagnosed over one year previously were invited to participate. All participants were given a card outlining the functions of the system, emphasising that Sweet Talk is not intended for emergency use or to replace ‘DiabNet’ (the emergency out-of-hours hotline for the Forth Valley, Tayside and Fife health boards; Figure 1).

Outcomes of the Sweet Talk intervention
Sweet Talk engaged adolescents, a typically difficult group to reach, achieving high representativeness with 73 % of the eligible clinic population participating. The Sweet Talk intervention was associated with significant improvements in diabetes self-management and adherence to testing and drug regimens (Franklin et al, 2006). Furthermore, the participants perceived a significant increase in the quantity of support provided by the diabetes team. Sweet Talk was not associated with significant improvements in glycaemic control. However, maintaining contact and communication with young people throughout adolescence and increasing diabetes self-efficacy is important, and these may translate into long-term beneficial effects on glycaemic control.

Eighty-two per cent of participants reported that Sweet Talk improved their diabetes self-management, and 90% wanted to continue receiving messages after the end of the study period. Participants reported that Sweet Talk messages had a positive influence on various aspects of their diabetes self-management routine, including healthy eating, blood glucose testing and exercise. Example views of the Sweet Talk system are shown in Table 2. Messages containing information relating to diabetes and those sharing peoples’ experience of living with diabetes were most valued by the participants. Also valued were the practical aspects of the system, including clinic visit reminders, ease of contacting the diabetes team and as a method of obtaining supplies. Receiving repeats of the same message was reported as the most annoying aspect of the Sweet Talk system.

Behavioural science in diabetes. Contributions and opportunities
Sweet Talk – the future
Sweet Talk is an innovative method of maintaining communication and contact with young people with diabetes between clinic visits. The Sweet Talk system could be readily adapted for use by other diabetes teams, by adapting the message content to reflect individual clinics’ philosophy, protocols and approach to diabetes care. The text message database could also be easily adapted to support people with other chronic and acute conditions and for the delivery of preventative strategies. The challenge will be to integrate such interventions into health service informatics systems and incorporate detailed cost-effectiveness interventions.

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