Mobile phone technologies have emerged as an essential tool for strengthening health systems and improving disease outcomes in many countries (1). In recent years, the government of Bangladesh and the World Health Organization have adopted information technologies for health in their strategic plans. However, data to support a successful model of mobile phone short message service (SMS) in diabetes management are scarce. In this trial, we assessed whether the addition of an automated SMS service to standard diabetes care would improve glycemic control in patients with type 2 diabetes.
A total of 236 adult patients with type 2 diabetes (diagnosed within the previous 5 years) on oral medication therapy with access to SMS and attending the outpatient department of the Bangladesh Institute of Health Sciences in Dhaka, Bangladesh, were recruited (September 2013–August 2014) and randomly assigned 1:1 to SMS intervention and standard care groups. Data were collected through face-to-face interviews with a structured questionnaire, anthropometric measurements, and blood tests for HbA1c using standard procedures (2). A total of 36 participants with missing HbA1c data were excluded from the analysis. All participants in the intervention group received 90 SMSs, based on the principles of behavioral learning theory, randomly, once a day, over a 6-month period (2). An SMS delivery manager Web site was created and the SMSs were delivered in partnership with Grameenphone Bangladesh.
The demographics and baseline characteristics of the study groups were generally well balanced and similar to the general population with diabetes in Bangladesh (3). The mean ± SD age of the participants was 48.1 ± 9.7 years, and 54.2% were female. The majority of the participants were married (89.4%), had completed secondary education (70.3%), and had a family history of diabetes (65.7%). The median (Q1, Q3) duration of diabetes was 1 (0, 3) years. The mean ± SD HbA1c at baseline was 8.4 ± 2.6% (68 ± 28.4 mmol/mol).
The least squares mean difference of HbA1c from baseline to after 6 months (primary end point) was −0.85 (95% CI −1.05, −0.64) in the SMS group and −0.18 (−0.41, 0.04) in the control group (Table 1). The difference between means was −0.66 (−0.97, −0.35; P < 0.0001). In a secondary analysis, the mean medication adherence score (using the Morisky 8-Item Medication Adherence Questionnaire with the following cutoff scores: >2 = low adherence, 1 or 2 = medium adherence, and 0 = high adherence) decreased significantly in both the SMS and the control groups, indicating greater self-reported adherence to medication over time. There was no significant difference between the groups. Post hoc subgroup analyses suggested that the SMS intervention worked better in women, those with a baseline HbA1c >8%, and those with a shorter duration of diabetes.
Difference in HbA1c (%) between baseline and 6 months
| Primary outcome . | Least squares mean (95% CI) . | P . |
|---|---|---|
| SMS group (n = 106) | −0.85 (−1.05, −0.64) | |
| Control group (n = 94) | −0.18 (−0.41, 0.04) | |
| Difference between means | −0.66 (−0.97, −0.35) | <0.0001 |
| Primary outcome . | Least squares mean (95% CI) . | P . |
|---|---|---|
| SMS group (n = 106) | −0.85 (−1.05, −0.64) | |
| Control group (n = 94) | −0.18 (−0.41, 0.04) | |
| Difference between means | −0.66 (−0.97, −0.35) | <0.0001 |
This is the first study to our knowledge that measured the effects of mobile phone SMS on glycemic control in a developing country. Our reported changes in HbA1c in the intervention group seem to be lower than reports from previous studies (4,5). Our study participants were required to have access to a mobile phone SMS, thus generalizing the results to rural areas or poorer parts of society may not be possible.
This study demonstrates the effectiveness of a simple SMS-based intervention as an addition to standard care for type 2 diabetes in urban Bangladesh. The intervention is low cost and scalable and therefore could improve diabetes care in Bangladesh and potentially other low-income countries.
Article Information
Acknowledgments. The authors are grateful to International Center for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B) core donors, the German Academic Exchange Service (DAAD), the Federal Ministry for Economic Cooperation and Development (BMZ), and the Higher Education Excellence in Development Cooperation (Exceed) for the support of their study. The authors are also grateful to several faculty at Ludwig-Maximilians-Universität, Helmholtz Zentrum München, ICDDR,B, and Bangladesh University of Health Sciences for providing support to develop and implement the study.
Funding. This study was supported by the Center for International Health, Ludwig-Maximilians-Universität; the German Federal Ministry of Education and Research (BMBF); and ICDDR,B (GR#01014).
Duality of Interest. No potential conflicts of interest relevant to this article were reported.
Author Contributions. S.M.S.I. conceived the study and was the principal investigator and designed and implemented the study. L.W.N., U.F., L.A., J.S., and A.L. contributed to the study design, implementation, and data analysis and supported the manuscript writing. A.L. was involved in data analysis and overall supervised the study. All authors contributed to refinement of the study protocol and approved the final manuscript. A.L. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
German Clinical Trials Register DRKS00005188, http://www.drks.de.
