Dulce Digital-Me: An Adaptive mHealth Intervention for Underserved Hispanics with Diabetes

项目摘要。 低社会经济地位（SES）和少数民族地位的个人，包括西班牙裔，美国最大的种族 少数群体，不成比例地受到糖尿病的影响。医疗保健服务差和文化障碍 阻止最佳护理、依从性和临床获益，从而使西班牙裔人面临昂贵的糖尿病风险 并发症我们建立的学术-医疗-社区伙伴关系在以下方面拥有独特的经验： 开发和测试创新的、具有成本效益的和可持续的慢性病护理干预措施， 在服务水平低下的社区改善健康状况。我们最近开发了杜尔塞数字（即，“一项─ 尺寸适合所有人的”教育文本消息，护士监控患者发送的血糖值）， 在最近的一项随机对照试验中， (RCT)N=126例控制不佳的2型糖尿病（T2 DM）西班牙裔患者。我们的过程评估 表明从患者和提供者的角度来看，杜尔塞数字化是可行和可接受的;但是， 患者表示更倾向于个性化的干预，而提供者要求甚至 更加注重健康行为的改变。因此，拟议的RCT将检查 在N=414名低SES且控制不良的西班牙裔成人中，杜尔塞数字与“杜尔塞数字-我”（DD-Me）的比较 T2 DM来自社区医疗保健，圣地亚哥联邦合格的健康中心。引导患者， 提供商反馈，DD-Me包括杜尔塞数字组件以及个性化的目标设定和反馈， 对个人的需求和偏好做出反应。DD-Me自适应反馈组件将 通过自我管理模型和操作性条件反射理论的资源和支持，以及 基于个体在中间行为目标上的进展（即，药物依从性评估方法 无线传感器;基于移动的电话的饮食、体力活动、压力的简短评估）。反馈将 在50%的DD-Me参与者中通过算法驱动的自动化消息传递以及由护理团队提供 医疗助理在其余一半，以确定可行性和可接受性（鉴于据称 西班牙文化中人际关系的文化相关性），以及 每种交付方式的成本。糖尿病临床控制指标的变化[即，糖化血红蛋白 （HbA 1c）低密度脂蛋白胆固醇（LDL-C）、收缩压（SBP）]，患者-提供者 通信和患者依从性（即，药物治疗和其他糖尿病自我管理行为）将 在12个月内进行评估。全面的过程和成本效益分析将评估 DD-Me的可扩展性和可持续性潜力。我们对两种移动健康方法的比较评估将 阐明技术如何能够最有效地整合在现有的护士领导的慢性 护理方法，以满足控制不佳的T2 DM患者的复杂需求。

Project Summary. Individuals of low socioeconomic (SES) and ethnic minority status, including Hispanics, the largest U.S. ethnic minority group, are disproportionately affected by diabetes. Poor healthcare access and cultural barriers prevent optimal care, adherence, and clinical benefit, thus placing Hispanics at high risk for costly diabetes complications. Our established academic-healthcare-community partnership has unique experience in developing and testing innovative, cost-effective, and sustainable chronic care interventions to reduce disparities and improve health in underserved communities. We recently developed Dulce Digital (i.e., “one- size-fits-all” educational text messages, with nurse monitoring of patient-transmitted blood glucose values), which improved glycemic control across 6 months, relative to usual care in a recent randomized controlled trial (RCT) of N=126 Hispanic patients with poorly controlled type 2 diabetes (T2DM). Our process evaluation indicated that Dulce Digital was both feasible and acceptable from patient and provider perspectives; however, patients expressed a preference for a more individualized intervention, and providers requested an even greater focus on health behavior change. Thus, the proposed RCT will examine the comparative effectiveness of Dulce Digital versus “Dulce Digital-Me” (DD-Me) in N=414 Hispanic adults of low SES with poorly controlled T2DM from Neighborhood Healthcare, a San Diego Federally-Qualified Health Center. Guided by patient and provider feedback, DD-Me includes Dulce Digital components plus personalized goal-setting and feedback that is responsive to the individual’s needs and preferences. The DD-Me adaptive feedback component will be informed by the Resources and Support for Self-Management Model and Operant Conditioning Theory, and based on the individual’s progress on intermediate behavioral targets (i.e., medication adherence assessed by wireless sensor; brief mobile phone-based assessments of diet, physical activity, stress). Feedback will be delivered via algorithm-driven automated messaging in 50% of DD-Me participants and by the care team medical assistant in the remaining half to determine the feasibility and acceptability (given the purported cultural relevance of interpersonal relationships in the Hispanic culture), and the comparative effectiveness and cost of each delivery method. Changes in indicators of diabetes clinical control [i.e., glycosylated hemoglobin (HbA1c) low density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP)], patient-provider communication, and patient adherence (i.e., to medication and other diabetes self-management behaviors) will be evaluated across twelve months. Thorough process and cost-effectiveness analyses will evaluate the scalability and sustainability potential of DD-Me. Our comparative evaluation of two mHealth approaches will elucidate how technology can be integrated most effectively and efficiently within existing nurse-led chronic care approaches to meet the complex needs of underserved individuals with poorly controlled T2DM.