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Given the growing burden of diabetes in underserved communities and the complexity of diabetes self-management during pregnancy, the development of interventions to support low-income pregnant women with diabetes is urgently needed.
This study aims to develop and pilot test a theory-driven curriculum of SMS text messaging for diabetes support and education during pregnancy.
This was a prospective pilot investigation of a novel SMS text messaging intervention offered to pregnant women with pregestational or gestational diabetes mellitus and publicly funded prenatal care. Prior work yielded a conceptual model of diabetes self-management barriers and support factors in this population, which was used to guide curriculum development along with health behavior theories. Participants received three supportive or educational one-way text messages per week during pregnancy. In-depth semistructured interviews were performed at study exit to solicit feedback on the program. Narrative data were analyzed using the constant comparative technique to identify themes and subthemes.
Participants (N=31 enrolled and n=26 completed both interviews) consistently reported that SMS text messaging provided enhanced motivation for diabetes self-care, reduced diabetes-related social isolation, increased perceived diabetes-associated knowledge, enhanced comfort with the health care team, and reduced logistical burdens of diabetes during pregnancy. Participants requested enhanced interactive and customizable features in future intervention iterations.
Pregnant women with diabetes who were enrolled in this pilot study of an SMS text messaging curriculum for diabetes support described enhanced motivation, knowledge, and comfort with diabetes self-care activities as a result of the health education intervention. The next steps include enriching the interactive features of the intervention and investigating the effect of the intervention on perinatal outcomes.
Diabetes mellitus poses a significant health burden to pregnant women [
Technology support interventions for individuals with chronic diseases can improve knowledge, engagement, and self-management of health conditions [
Thus, we initiated a multiphase project toward developing an intervention for pregnant women with diabetes. We previously developed a model of barriers and facilitators to diabetes self-management, which informed our development of a theory-driven curriculum of SMS text messaging for diabetes support and education during pregnancy. The objective was to evaluate user experiences with this intervention, including feasibility, acceptability, and areas for improvement. We hypothesized that the delivery of a comprehensive curriculum of supportive and educational text messages aimed at promoting health during pregnancy with diabetes would be feasible and positively received.
This is a pilot investigation of a novel text message–based support intervention called
There were 3 learning and health behavior theories that were used to develop this intervention: the Cognitive Load Theory, the Health Belief Model, and the Theory of Self-Efficacy. Each is discussed herein. Prior work from our group has applied Cognitive Load Theory [
We worked with a multidisciplinary health professional team including obstetricians, Registered Dietitians, a Certified Diabetes Educator, an Advanced Practice Registered Nurse (Nurse Practitioner), and other clinic personnel to develop a comprehensive curriculum of >150 messages to be delivered via text message. Early versions of messages underwent cognitive testing with pregnant patients with both type 2 diabetes mellitus and GDM using
Messages were refined based on early provider and patient feedback. Messages were then organized into a curriculum of 3 messages per week using 3 theory-based content categories: logistical support, motivation, and information and education. For example, informational messages provide content about healthy foods using the Health Belief Model, whereas the Theory of Self-Efficacy Commonly guides motivational messages. Logistical messages primarily applied Cognitive Load Theory and offered tactical support such as appointment reminders or tips for the management of diabetes. Messages were designed to contain tips, motivational statements, or reminders that address barriers and facilitators identified in preliminary data (
Texting for Diabetes Success example messages.
Barrier or facilitator addressed | Example text messages | |
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Taking care of diabetes reduces your chance of high blood pressure and preeclampsia (toxemia). |
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Pregnancy hormones make your diabetes worse. Blame the placenta, then show it who's the boss! |
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Don’t get frustrated! Stick with your diabetes plan over time to get the healthy results you want for you and your baby. |
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Taking care of your diabetes during pregnancy gets you on track for life. Hard work now means a longer, healthier life |
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We know you have so much to do today. First thing on the list is making sure you and the baby are healthy - take care of your diabetes! |
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Do you feel like you have the support you need? A healthy support system will benefit you and baby! Talk to us about resources at clinic. |
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Craving something crunchy and sweet? Grab a small apple and small handful of nuts. Eat healthy to control your diabetes during pregnancy. |
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Try buying frozen veggies over raw ones, they can be cheaper and last longer! Vegetables can help control your blood sugar. |
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Sometimes women can experience stress from relationships in their lives. Talking about what's bothering you can be healthy for both you and baby. Tell us about it at clinic. |
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Identify your emotions. Say, “I feel upset, I'm not hungry” instead of reaching for the snack. |
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Needles? Blood sugar checks? Ultrasounds? Too much to handle? Take it one day at a time, a healthy baby in the end will be your reward. |
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You have an OB appointment at PAC tomorrow. Don't forget to come fasting and bring breakfast. |
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We know you can do this! You can beat your diabetes! |
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Are you feeling confident about your diabetes? Great, you've earned it! |
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Having a hard time keeping up with your diabetes? Everything you're doing now helps your baby! |
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Have kids at home? Your healthy behavior means you are a great role model. |
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Make eating healthy a family affair! Involve the whole family with your healthy meal plan. |
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Too hard to exercise near home? Try the park district or your neighborhood community center. |
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Everything you do now helps you live a longer life and be there for your baby. Good job! |
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Seeing target blood sugars? Good job, you're on the right track! If not, talk to us! |
aRepresents the concept that diabetes and/or pregnancy are new learning concepts for the individual.
bRepresents the concept that individuals may not believe that their actions will lead to the desired outcome.
cRepresents the concept that nutrition recommendations may be both challenging to understand and challenging to execute.
dRepresents the concept that having diabetes during pregnancy places a substantial burden on the patient to organize and complete logistical activities, scheduling, monitoring, appointments, and other health-related tasks, above and beyond normal pregnancy.
eRepresents the concept that individuals may have the support of other individuals (eg, family) or a supportive physical environment (eg, safe places to exercise).
fRepresents an individual’s ability to be responsive to feedback or data and then make subsequent changes in their health behaviors.
The overall curriculum was organized into 3 phases: a
After enrollment, participants completed demographic surveys that included queries on SMS text messaging access. Surveys were followed by brief interviews regarding experience with pregnancy and diabetes diagnosis, expectations for diabetes self-management requirements and burdens, and experiences with mHealth. Women then went through the remainder of the pregnancy receiving TDS.
After delivery, women underwent a 30-60 min exit interview about pregnancy struggles and support systems, experience of diabetes, and feedback about TDS. Feedback on TDS from this exit interview is the focus of this analysis. Women were asked about technical challenges, perspectives on content, positive and negative program features, favorite messages, feedback on frequency and timing of messages, and how the messages affected diabetes self-management. Women were asked about how the program supported them, if they would recommend it, and potential areas for expansion or improvement.
All interview questions were open-ended with probes as needed. Women were encouraged to speak freely and were informed that they could decline to answer any questions and that their responses would not affect their medical care. All interviews were audio recorded and conducted by trained research staff. We aimed to recruit a minimum of 30 participants to gain adequate feedback to facilitate future programmatic improvements, with the final sample size and stopping point determined based on the achievement thematic saturation [
Interviews were transcribed verbatim by a study team member. Dedoose (Dedoose, LLC), a secure qualitative data analysis software, facilitated thematic analysis of the transcripts by 3 authors using the constant comparative method [
Over an 8-month study period, 81 patients were seen in this practice and screened for eligibility, of whom 39 eligible women were approached for enrollment and 33 consented to participate. There were 6 women that declined participation because of insufficient time (n=3), plans to leave Chicago (n=1), or declining research participation (n=2). Of the 33 who consented, 1 was lost to follow-up (could not be reached) before the initiation of messaging and 1 was erroneously enrolled (did not have diabetes), leaving 31 participants who completed the first interview and received messages. Of these participants, 5 women were lost to follow-up before the final interview (could not be reached), leaving 26 participants who completed the exit interview (
Participant demographics (
Participant flow.
Participant demographic characteristics.
Characteristics | Values | |
Age (years), median (IQR) | 31 (27-34) | |
Public insurance, n (%) | 31 (100) | |
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Non-Hispanic Black | 14 (45) |
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Hispanic | 16 (52) |
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Asian | 1 (3) |
High school graduate or greater education, n (%) | 22 (71) | |
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Full time for pay | 5 (16) |
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Part time for pay | 7 (23) |
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Homemaker or student | 12 (39) |
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Unemployed | 7 (23) |
Multiparous, n (%) | 27 (87) | |
Married, n (%) | 12 (39) | |
Pregestational diabetes, n (%) | 21 (68) | |
Unlimited SMS text messaging plan, n (%) | 29 (94) |
Interviews explored participant experiences with TDS and perceived usefulness. Emergent key themes included
First, the theme of
I actually loved it…every time…I would see the message it was like okay what is it today?
Similarly, TDS prompted participants to interact with their health care team, leading to a perceived stronger connection. Additionally, text messages seemed to reduce social isolation associated with diabetes; Participant 9 noted it was helpful “knowing someone cared.”
The second theme was of
Some of the information was new, but some I already knew. But it’s not…hard to go over it again. Because a lot of us women that are diabetics, forget everything. You know and…me being 26 years old, we still don’t know everything about diabetes. It’s so much more out there, more to learn.
Similarly, Participant 25 stated:
Definitely…some of the messages encouraged me to look things online and just know a little bit more about the whole diabetes and being pregnant with it since there are so many risks with diabetes.
The third theme was
Yeah that was good because actually was forgetting and did forget one time that I had an appointment thinking it was in two weeks, and it was actually that week and [the message] came right in time letting me know that my appointment was the next day.
The fourth theme was of
It’s a way of motivation. To stay motivat[ed], you know help you understand it and give you ideas. And how to do reminders, you have [diabetes] but you can handle and take control of it.
Participants described how the messages motivated them not only toward positive behaviors but also away from negative behaviors. For example, participant 16 said:
Yeah, I mean they would stop me. Like the ones that would be like oh if you’re craving this, why don’t you eat an apple. And I was just like…how do they know! ...They would make me think before I did things or think like I wish I could be exercising right now.
The fifth theme was of
…you’re going through a lot of hormones when you’re pregnant. So it was like days I was feeling down. And I would just read the text messages and I would be like okay don’t give up, everything will be better. I don’t know, it was different [after receiving messages]
Participant experiences of Texting for Diabetes Success.
Themes | Exemplary quotations |
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“Yeah, I did and I remember one time I received a text message and I think it was one had to do with the fruit. And I ended up eating something sweet and it didn’t affect my blood sugar, but I was like oh I wish I would have gotten my message a few minutes earlier because it would have stopped me |
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“Um I didn’t really use like I didn’t really use the recipes or anything like that, but I’ll say that it was a reminder like hey you know if I’m- They’re random so I could have been going to the store or something and buying something, hey I wanna buy that, but then I get a text message and I’m like oh maybe I shouldn’t be buying that you know, maybe I should go for a healthier choice because I have gestational diabetes and I shouldn’t be eating that. So I – I guess it poses as a reminder to do better.” (Participant 14) |
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“Ya know, I love the text messages. The text messages, they really help me, they really help me figure out a lot of things too and more about my diabetes. More of getting activity, getting rest, stuff like that I will always get a text message in the morning” (Participant 20) |
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“I guess because when you’re in the situation of being diabetic you want to hear something you know funny or you know just to give a little fix to your little life there you know, it brings up…you know to do what you have to do and you know those type of sources [resources] will help a lot yeah.” (Participant 10) |
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“No I think it was pretty thorough but yeah the appointment reminders were very very good. I think it helps when you’re a mom already and you have things that you have to juggle around, the appointment reminders are helpful.” (Participant 13) |
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“Thanks to the text messaging, I got reminders of my appointments to help me keep track, reminding me when to go and like what kind of ideas I could um be eating to stay away from the foods that are high in carbs.” (Participant 2) |
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“That’s another support that you kind of have. Someone that’s not involved in your everyday life so to me it was very encouraging, you kind of have that little push.” (Participant 25) |
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“I mean I think it helped with the motivation a lot. I mean you know the days when you’re like, hey I don’t want to do this or it’s ok to have, have a couple of pieces of this instead of just none or half to go back and look and ok no you need to take care of this. This is for you, this is for you child, it’s not for anyone else.” (Participant 21) |
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“I think everything was perfect, because like I’m telling you I would forget sometimes to check my sugars and even sometimes when I was like getting stressed, those texts and someone would send me the text messages and they would lift me up.” (Participant 23) |
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“I liked the…sometimes when I, when I was like tired or you know just sitting down and I received that text that was like a little extra push you know. If you feel stressed or go out and drink water or the changes of the recipes they were kind of fun.” (Participant 26) |
Women were asked to highlight positive programmatic feedback, including describing whether they would participate in TDS again or recommend it to a friend. Of the 26 women who participated in the exit interview, 23 would recommend TDS to a friend, whereas 2 would not, both of whom said they would recommend future more personalized versions. Participant 10 noted:
I would [recommend TDS] especially if she’s in the same situation. I mean it’s going to be stressful, it’s going to be hard, but I would recommend just because it teach you more resources apart of the clinic.
Similarly, participants reflected on the stresses of pregnancy and how their experiences with TDS influenced their self-care and attitudes toward the intervention. In reflecting on this experience, like many other participants, Participant 20 explained the multitude of reasons why she felt positively about her participation:
Every text message that you have gave me, sent to me, it was very good. There were no text messages that were boring. They were, they were getting to the point. They were understandable. And it was like a wakeup call. This is what you gotta do for your baby and yourself, to have a healthy baby, to have a healthy life. Ya know, I love the text messages…they really help me, they really help me figure out a lot of things too and more about my diabetes. More of getting activity, getting rest, stuff like that I will always get a text message in the morning. And be like ok this is my daily routine.
When asked about TDS drawbacks, some participants explained that they could not identify any. Participant 30 stated:
I mean it pretty much kept me aware of you know staying on track and it also alerted me to keep up with my doctor’s appointment…and it also gave helpful tips…Everything was helpful. There wasn’t anything negative stuck out to me with text messages or anything.
Participant 32 similarly summarized:
They would help you understand what to do and how to do it as far as what to eat and if you were to forget something or if you were to overeat or something how you would handle that. So it was very helpful.
Participants were encouraged to share areas of improvement to aid future development (
The first theme was the desire for
If it was more individualized and I knew that I was receiving these text messaging for me personally for what I was going through and dealing with the diabetes then yes, it would have helped me more. Cuz then it would have prompted me to say, to read them, cuz I would say oh man okay you know this is something…I would have read it based on I knew it was for me.
The second area that was nearly universally highlighted was the desire for
It should be like chatting…If a diabetic don’t know what this is and she [texts] something, we can text her back what to do.
Other suggestions for an interactive platform were largely geared toward having user-friendly pictures, multimedia inclusion, or the ability to seek more information, suggestive of a smartphone app. For example, women desired pictures, links to resources, a library of resources, and a greater ability to access reliable content outside of the messages. Another interactive suggestion included the opportunity to share or read individualized stories of other pregnant women.
Third, women desired
I think it could be more, not annoying more but maybe like one more, just one in the beginning of the week and then one at the end of the week.
Participants commonly requested 4 to 5 messages per week, indicating that they were open to more frequent touch points for the motivational curriculum.
The fourth theme was the desire for
I would like to have seen more recipe or…suggestions how to change because very often you’re used to having mashed potatoes and if you want mashed potatoes it’s better to have sweet potatoes or you know alternatives. That I would have liked to see more of that stuff.
Texting for Diabetes Success areas for improvement.
Themes | Exemplary quotations |
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“Now that would have been very much helpful. If it was more individualized and I knew that I was receiving these text messaging for me personally for what I was going through and dealing with the diabetes then yes, it would have helped me more.” (Participant 4) |
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“Um during the week um or you know at the end of the week or at least once a weekend that will be very helpful to maintain those weekends because you know sometimes you have on your mind okay if I do really good during the week then you cheat on over the weekend” (Participant 12) |
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“That’s good because when you’re pregnant its hard, it’s very hard. Especially I mean, especially because of the baby you try to eat good you know but it’s still hard, but I think it just would work. I would put a bag of chips and then something nutritional next to it like kind of but yeah I think pictures would work out yeah, especially for an app.” (Participant 23) |
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“I think uh support stories would be fine to go in there you know women who have experienced it and you know overcame it or women who still have diabetes after gestational.” (Participant 30) |
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“Honestly I think that you should go up to five [messages]. ‘Cause once it get towards the end of the pregnancy, you need all the support you can get. Even if it’s from a text message that comes out of the blue like “hey, it’s almost over, we’re doing good, we can get through this.” Really you don’t know how much that really helped.” (Participant 28) |
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“The messaging program helped a lot. I would recommend like a couple recipes like once a week or once a month. Hey here’s a great snack recipe or here’s a great lunch recipe or something” (Participant 21) |
Diabetes during pregnancy is a major public health problem with important and long-lasting consequences for both women and their children. Innovative interventions to support pregnant women with diabetes self-management are lacking. Thus, we developed a theory-driven SMS text messaging program not only to provide psychosocial support but also to promote self-management skills and provide tactical support for pregnant women with diabetes. This intervention was feasible and well-received. Pregnant women with diabetes who were enrolled in this pilot study of an SMS text messaging curriculum for diabetes support described enhanced motivation and improved knowledge and comfort with diabetes self-care activities. Participants also had several suggestions for improvement, largely based on personalization and interactivity.
Although evidence-based mHealth interventions beyond general tracking and education provision for pregnant women are lacking, interest in such programs is high. The majority of pregnant women, including low-income and minority women, are interested in and have access to mHealth [
Treatment of diabetes during pregnancy poses particularly complex challenges for low-income women. Multidisciplinary teams and treatment plans aim to optimize glycemic control and prevent complications via implementation of medical nutrition therapy, exercise, medication, and enhanced maternal-fetal surveillance [
The next steps include enhancing the interactive features of TDS, scaling to a
A major strength of this study is the inclusion of a diverse group of participants who provided in-depth narrative perspectives. Furthermore, the intervention was developed with a robust theoretical underpinning and provided evidence-based, expert-driven content developed to meet the needs of the population of interest. Moreover, unlike interventions that primarily track glucose values, TDS included a curriculum for motivation and support. This approach is novel and supports the importance of patient-centered perspectives when developing health interventions.
However, there are several limitations to consider. Participants were primarily English-speaking women receiving care at a single academic medical center. Thus, as is common in qualitative research, findings are not widely generalizable, although they remain valuable for future intervention improvement. Second, although participants represented the demographics of the clinic population, participants may interact with mHealth differently than nonparticipants. Similarly, a small number of participants were unable to be reached for their exit interviews, and their experiences may have differed. Participants also included women with prior diabetes experience, including women with pregestational diabetes and women with gestational diabetes who had a history of gestational diabetes in prior pregnancies. Given the sample size, it was not possible to assess differential attitudes based on when diabetes was diagnosed or the type of diabetes diagnosis, although this topic is of critical importance for future intervention development. Future work may investigate differences in support needs and mHealth adoption based on diabetes type, prior experience with gestational diabetes, or other demographic characteristics, such as educational attainment. Finally, TDS was delivered without the ability to determine the proportion of messages received or read.
In summary, pregnancy is a critical time period to improve women’s short- and long-term health, and improving support for women with diabetes has the potential to positively affect the health of families [
gestational diabetes mellitus
mobile health
Texting for Diabetes Success
This study was supported by the Evergreen Invitational Women’s Health Grants Initiative. LY was supported by the NICHD K12 HD050121-11 at the time of the study.
None declared.