Patient Perspectives on a Targeted Text Messaging Campaign to Encourage Screening for Diabetes: Qualitative Study

Abstract

Background: A sizeable proportion of prediabetes and diabetes cases among adults in the United States remain undiagnosed. Patient-facing clinical decision support (CDS) tools that leverage electronic health records (EHRs) have the potential to increase diabetes screening. Given the widespread mobile phone ownership across diverse groups, text messages present a viable mode for delivering alerts directly to patients. The use of unsolicited text messages to offer hemoglobin A_1c (HbA_1c) screening has not yet been studied. It is imperative to gauge perceptions of "cold texts" to ensure that information and language are optimized to promote engagement with text messages that affect follow-through with health behaviors.

Objective: This study aims to gauge the perceptions of and receptiveness to text messages to inform content that would facilitate engagement with text messages intended to initiate a mobile health (mHealth) intervention for targeted screening. Messages were designed to invite those not already diagnosed with diabetes to make a decision to take part in HbA_1c screening and walk them through the steps required to perform the behavior based solely on an automated text exchange.

Methods: In total, 6 focus groups were conducted at Wake Forest Baptist Health (WFBH) between September 2019 and February 2020. The participants were adult patients without diabetes who had completed an in-person visit at the Family and Community Medicine Clinic within the previous year. We displayed a series of text messages and asked the participants to react to the message content and suggest improvements. Content was deductively coded with respect to the Health Belief Model (HBM) and inductively coded to identify other emergent themes that could potentially impact engagement with text messages.

Results: Participants (N=36) were generally receptive to the idea of receiving a text-based alert for HbA_1c screening. Plain language, personalization, and content, which highlighted perceived benefits over perceived susceptibility and perceived severity, were important to participants' understanding of and receptiveness to messages. The patient-physician relationship emerged as a recurring theme in which patients either had a desire or held an assumption that their provider would be working behind the scenes throughout each step of the process. Participants needed further clarification to understand the steps involved in following through with HbA_1c screening and receiving results.

Conclusions: Our findings suggest that patients may be receptive to text messages that alert them to a risk of having an elevated HbA_1c in direct-to-patient alerts that use cold texting. Using plain and positive language, integrating elements of personalization, and defining new processes clearly were identified by participants as modifiable content elements that could act as facilitators that would help overcome barriers to engagement with these messages. A patient's relationship with their provider and the financial costs associated with texts and screening may affect receptiveness and engagement in this process.

Keywords: clinical decision support; diabetes; diabetes screening; electronic health records; mHealth; mHealth intervention; mobile health; text messaging.