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2023 HSR&D/QUERI National Conference Abstract

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1158 — Incorporating Veteran Preferences into Designing a Customizable Diabetes Self-Management Text Messaging System

Lead/Presenter: Popy Shell,  Malcom Randall Department of Veteran Affairs Medical Center, Gainesville
All Authors: Shell P (Malcom Randall Department of Veteran Affairs Medical Center, Gainesville), Am L (Center for Healthcare Organization and Implementation Research, Bedford), Gardner JM (Jesse Brown Department of Veteran Affairs Medical Center, Chicago), Peoples-Robinson K (Jesse Brown Department of Veteran Affairs Medical Center, Chicago), Beck MJ (Malcom Randall Department of Veteran Affairs Medical Center, Gainesville), Robinson SA (Center for Healthcare Organization and Implementation Research, Bedford), Mullins H (Boston University School of Medicine), Gordon HS (Center of Innovation for Complex Chronic Healthcare, Chicago), Uphold CR (Malcom Randall Department of Veteran Affairs Medical Center, Gainesville), Vimalananda VG (Center for Healthcare Organization and Implementation Research, Bedford), Cutrona SL (Center for Healthcare Organization and Implementation Research, Bedford), Hogan TP (Center for Healthcare Organization and Implementation Research, Bedford), Smith BM (Center of Innovation for Complex Chronic Healthcare, Chicago), Huo Z (Center of Innovation for Complex Chronic Healthcare, Chicago), Irvin D (Center of Innovation for Complex Chronic Healthcare, Chicago), Brown G (Jesse Brown Department of Veteran Affairs Medical Center, Chicago), Vargas-Correa J (Jesse Brown Department of Veteran Affairs Medical Center, Chicago), Orejuela M (Malcom Randall Department of Veteran Affairs Medical Center, Gainesville), & Shimada SL (Center for Healthcare Organization and Implementation Research, Bedford)

Objectives:
Texting-based educational interventions can support chronic health management through the promotion of positive health behavior change in high-risk populations. Text messaging programs offer virtual support for self-management of chronic diseases such as diabetes. The current study sought to incorporate Veteran preferences and feedback into the design of an interactive, customizable, self-management texting protocol to support diabetes self-management delivered through VA’s Annie text messaging system.

Methods:
A participatory design process was leveraged to create the diabetes texting protocol. Veterans living with diabetes were recruited to be part of the study team as long-term study consultants and attended weekly team meetings. Additionally, Veterans with Type 2 diabetes across the US were recruited through mailed surveys. Recruitment intentionally oversampled women, rural, minority, and low-income Veterans. Veteran constructive feedback shaped the texting protocol by altering message content, wording, and frequency. Surveys asked Veterans to rate, rewrite, and suggest alternatives to various text messages and respond to general questions about diabetes self-management including preferences regarding timing and frequency of texts and favored topics. Additionally, we interviewed 23 survey respondents to gather in-depth feedback. Interviews were analyzed by rapid analysis with a structured notes template. Veteran consultants helped incorporate feedback into protocol design.

Results:
Ninety Veterans completed the mailed survey and 23 participated in interviews. Survey respondents were 60% (N = 54) male, 40% (N = 35) Black/African American, 52% (N = 46) married, 43% (N = 38) retired, and 58% (N = 52) indicated having a hard time paying for basics, such as food and heating/cooling. The mean age was 64 years (SD = 7.1). Survey respondents were most interested in educational texts or “tips” about physical activity, healthy eating, and managing blood sugar and in reminders to measure blood sugar and blood pressure or to be physically active. Veterans felt favorably towards texts inspired by other Veterans living with diabetes and many contributed their own messages. Most Veterans preferred messages be sent between 7am and 6pm. It was not possible to identify one preferred time for all Veterans, as 50% preferred customized times to receive messages, compared to a default time to receive messages. Planning around time preferences help us delve into the acceptability and feasibility of the text messages. Survey and interview results show that timing is critically important for certain topics such as medication and checking blood sugar. Interviewed Veterans preferred tips for managing blood sugar and healthy eating [83% (N = 19) and 78% (N = 18), respectively] but only 30% (N = 7) were interested in diabetes medication reminders 30% (N = 7). When shown different calendar options for frequency of messages over the week, the majority (52%) preferred 1-2 messages per day, 35% preferred receiving more than 2 reminders (e.g., medication, activity), and 13% did not want daily messages.

Implications:
Most Veterans living with diabetes are interested in receiving daily or more frequent text messages from a customizable diabetes self-management support program which allows them to customize frequency, timing, and content of messaging according to their needs.

Impacts:
Participatory design processes that incorporate Veterans’ diverse preferences can yield interventions that are better aligned with patient needs and preferences.