Diabetes is a major risk factor for the development of cardiovascular disease, the leading cause of death in the United States, further highlighting the need for improved diabetes management, particularly among individuals from ethnic minorities or low socioeconomic status

Mehawej, Jordy

Paul, Tenes

Philis-Tsimikas, Athena

English

eScholarship@UMMS

UMass Chan Medical School eScholarship@UMassChan Open Access Publications by UMass Chan Authors 2021-09-30 Digital health tools to promote diabetes education and management of cardiovascular risk factors among under-resourced populations Tenes Paul University of Massachusetts Medical School Et al. Let us know how access to this document benefits you. Follow this and additional works at: https://escholarship.umassmed.edu/oapubs  Part of the Cardiovascular Diseases Commons, Endocrine System Diseases Commons, Health Information Technology Commons, Nutritional and Metabolic Diseases Commons, Public Health Education and Promotion Commons, and the Race and Ethnicity Commons Repository Citation Paul T, Mehawej J, Philis-Tsimikas A. (2021). Digital health tools to promote diabetes education and management of cardiovascular risk factors among under-resourced populations. Open Access Publications by UMass Chan Authors. https://doi.org/10.1016/j.cvdhj.2021.09.005. Retrieved from https://escholarship.umassmed.edu/oapubs/4927 Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License. This material is brought to you by eScholarship@UMassChan. It has been accepted for inclusion in Open Access Publications by UMass Chan Authors by an authorized administrator of eScholarship@UMassChan. For more information, please contact Lisa.Palmer@umassmed.edu. PERSPECTIVEDigital health tools to promote diabetes education andmanagement of cardiovascular risk factors amongunder-resourced populationsTenes Paul, DO,* Jordy Mehawej, MD, ScM,* Athena Philis-Tsimikas, MD†From the *Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts,and †Scripps Whittier Diabetes Institute, San Diego, California.Type 2 diabetes mellitus is a growing cause of significantmorbidity and mortality in the United States and worldwide.1Among developed nations, the United States currently hasthe highest prevalence (11%) of type 2 diabetes. The Centersfor Disease Control and Prevention estimates that by 2050approximately 1 in 3 Americans will have type 2 diabetes.Moreover, this condition disproportionately affects ethnicminorities and individuals from low socioeconomic back-grounds, with Hispanic individuals experiencing both higherincidence of type 2 diabetes and poorer glycemic control thantheir white counterparts.2 Diabetes is a major risk factor forthe development of cardiovascular disease, the leading causeof death in the United States,3 further highlighting the needfor improved diabetes management, particularly among indi-viduals from ethnic minorities or low socioeconomic status.The content and implementation of any interventionaimed at improving diabetes management in these commu-nities must be carefully orchestrated to ensure efficacy andthe advancement of health equity. As such, culturallytailored, in-person education programs have been shown toimprove outcomes in diabetes and cardiometabolic careamong under-resourced populations.4 These programs helppatients overcome cultural barriers to care that may impedeadherence to treatment plans, help fill in potential gaps intheir knowledge, and empower patients to play a more activerole in their health, thus improving their health outcomes.4Unfortunately, there are major limitations to these in-person programs: cost; logistical concerns, including trans-portation availability and difficulties in scheduling; andcultural or systemic barriers such as negative feelings towardthe healthcare system and the perception that these programsare not crucial for their health.5,6 These limitations, especiallyin the context of growing access to technology in the UnitedStates, yield an opportunity for the use of digital technologyto increase accessibility and bring patient education programsto the populations most in need.Project Dulcewas launched in 1997 as a collaboration be-tween San Diego State University, community clinics, andthe county’s public health department to deliver diabetescare and education to under-resourced and underserved pop-ulations throughout Southern California (Figure 1). The proj-ect relied on a team-based approach with a nurse-led clinicalteam and nonprofessional peers trained to deliver culturallytailored classes in diabetes education. The peer educationprogram was American Diabetes Association certified,included 8 2-hour sessions with a curriculum suitable forbroad literacy levels, and was adapted for different ethnicgroups and cultures. Project Dulce recruited 153 participantswith type 1 and type 2 diabetes over 2 years, 72% of whomidentified as Hispanic. The cohort also included AfricanAmerican, Vietnamese American, and Filipino American in-dividuals. The study group was 69% female with an averageage of 51 years. Approximately two-thirds of participants hadan annual income less than $10,000, and one-half had aneighth-grade education or less. The results of this programon diabetes care were impressive, demonstrating a 30%reduction in serum levels of HbA1c, 7% decrease in LDL-cholesterol levels, subjective improvement in diabetesknowledge, positive treatment satisfaction, and a shift towarda stronger internal locus of control when compared to a con-trol group receiving usual care.4Though in-person, culturally tailored diabetes self-management education could empower patients and provideimproved outcomes, requiring physical study visits was abarrier to accessibility.7 Digital solutions can help circum-vent these issues. To promote use among older and low-income individuals and remain cognizant of the “digitaldivide,” the Dulce Digital project was developed to use alow-cost short messaging service (SMS) program that didnot require a smart phone to provide educational and motiva-tional text messages, medication reminders, and bloodglucose monitoring reminders.5 The messages were offeredin either English or Spanish, with the majority choosingSpanish-language texts. The project also included a bloodglucose monitoring protocol, which requested patients trackKEYWORDS Cultural sensitivity; Diabetes management; Latino; Hispanicdigital health; Under-resourced populations (Cardiovascular Digital HealthJournal 2021;2:298–300)Address reprint requests and correspondence: Dr Tenes Paul, 55 LakeAve North, Worcester, MA 01655. E-mail address: tenes.paul@umassmed.edu.2666-6936/© 2021 Heart Rhythm Society. This is an open access article under the CC BY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).https://doi.org/10.1016/j.cvdhj.2021.09.005their blood glucose values via texts to the study team, withmarkedly elevated values, low values, or no values prompt-ing a call from research coordinators, who would encouragea follow-up with the individual’s primary care physician.Like the parent Project Dulce project, most Dulce Digitalparticipants identified as Hispanic or Mexican, had lessthan a ninth-grade education, and had a combined monthlyhousehold income of less than $2,000. After 6 months,DulceDigital achieved a statistically significant 1% reduction inserum HbA1c compared with the usual care group.5 Notably,there was a general trend toward a greater reduction inHbA1c levels among participants who had higher levels ofengagement with the program. Participants reported highsatisfaction with the program, demonstrating that a simpleand low-cost SMS-based diabetes management program iseffective in improving glycemic control in patients with dia-betes compared to usual care. However, post-study surveyssuggested that participants would have preferred moretailored messaging for purposes of enhancing individualizedcontent that better addressed their own needs and progress.5A subsequent study, Dulce Digital-Me, is underway and willevaluate an adaptive approach to personalize text exchangeswith patients based on wirelessly transmitted glucose values,pill box use, and ecological momentary assessments of phys-ical activity, diet, and stress.8,9A recent extension of these projects was born of the direneed for addressing the major healthcare barriers that havearisen owing to the ongoing COVID-19 pandemic. TheDulce Digital-COVID Aware (DD-CA) trial was launchedamid the pandemic with the aim of reducing these barriersin diverse, underserved Hispanic communities, improvingglucose control, and lowering transmission of COVID-19 af-ter hospital discharge. Critically, DD-CA integrated COVIDeducational messaging into the glucose management textmessaging to offer information about testing, exposure, andresources to a community disproportionately affected bythe pandemic.10 The primary outcome will look at the rateof readmission over the subsequent 30 days and secondaryoutcomes will assess the rate of readmission over 180 daysas well as changes in level of HbA1c. This ongoing effortfurther demonstrates the wide range of opportunities to applydigital health tools to address gaps in chronic care of patientswith diabetes and address acute public health issues amonghighly vulnerable populations.The studies and interventions under the umbrella of Proj-ect Dulce have demonstrated the potential for low-cost, dig-ital translations of traditional, in-person, culturally tailoredprograms to increase accessibility to diabetes and cardiovas-cular education and improve meaningful outcomes for pa-tients. Novel digital heath tools, such as continuous glucosemonitors, insulin pumps that work synergistically withcontinuous glucose monitors to recommend insulin dosingand timing, and Bluetooth-connected insulin administrationpens that show when and how much medication has beenadministered, are currently being incorporated into clinicsthat work with federally qualified health centers to comple-ment the recent surge of telehealth visits required by theCOVID-19 pandemic. These technologies allow more directengagement between patients and their providers and placemore knowledge and power into patients’ hands.The proliferation of technology provides a growing op-portunity for digital solutions to enhance patient educationand engagement, and ultimately leads to better prognoses,quality of life, and long-term outcomes. Tailoring these tech-nologies in conjunction with culturally competent practicesincreases accessibility for our most vulnerable, historicallyunder-resourced populations. Not only can this approachimprove healthcare-related morbidity, but it can also helpbuild a more inclusive digital community.AcknowledgmentThe information presented in the article is from proceedingsof the Diagnostics and Disease Management Tools for Use inUnderserved Populations: An NHLBI Research & Imple-mentation Workshop, Virtual Workshop, April 14–15, 2021.Figure 1 Timeline of Project Dulce’s prior and ongoing studies.4,5,7Paul et al Perspective 299Funding SourcesThe ongoing research described in this article, Dulce Digital-Me and Dulce Digital-COVID Aware, are funded by theNational Institute of Diabetes and Digestive and Kidney Dis-eases, grants 1R01DK112322-01A1 and 1R01DK112322-05S1, respectively.DisclosuresThe authors have no financial disclosures or conflicts of inter-est.AuthorshipAll authors attest they meet the current ICMJE criteria forauthorship.Patient consentN/AEthics StatementN/A.DisclaimerGiven his role as Editor-in-Chief, Dr DavidMcManus had noinvolvement in the peer review of this article and has noaccess to information regarding its peer review. Fullresponsibility for the editorial process for this article wasdelegated to Dr David Duncker.References1. Newman J, Schwartzbard A, Weintraub H, Goldberg I, Berger J. Primary preven-tion of cardiovascular disease in diabetes mellitus. J Am Coll Cardiol 2017;70:883–893.2. Centers for Disease Control and Prevention. Diabetes Report Card. 2014. Ac-cessed July 7, 2021. https://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf.3. Fox C, Golden S, Anderson C, et al. Update on prevention of cardiovascular dis-ease in adults with type 2 diabetes mellitus in light of recent evidence. Circulation2015;132:691–718.4. Philis-Tsimikas A, Walker C, Rivard L, et al. Improvement in diabetes care ofunderinsured patients enrolled in Project Dulce. Diabetes Care 2004;27:110–155.5. Fortmann A, Gallo L, Garcia M, et al. Dulce Digital: an mHealth SMS-basedintervention improves glycemic control in Hispanics with type 2 diabetes. Dia-betes Care 2017;40:1349–1355.6. Horigan G, Davies M, Findlay-White F, Chaney D, Coates V. Reasons why pa-tients referred to diabetes education programmes choose not to attend: a system-atic review. Diabet Med 2016;34:14–26.7. Philis-Tsimikas A, Fortmann AL, Lleva-Ocana L, Walker C,Gallo LC. Peer-led diabetes education programs in high-risk MexicanAmericans improve glycemic control compared to standard approaches:a Project Dulce promotora randomized trial. Diabetes Care 2011;34:1926–1931.8. Philis-Tsimikas A. Innovative solutions to care for individuals with diabetes inunderserved populations. Diabetes Spectr 2019;32:291–292.9. Fortmann AL, Savin KL, Clark TL, Philis-Tsimikas A, Gallo LC. Innovative dia-betes interventions in the US Hispanic population. Diabetes Spectr 2019;32:295–301.10. Gil R, Marcelin J, Zuniga-Blanco B, Marquez C, Mathew T, Piggott D. COVID-19 pandemic: disparate health impact on Hispanic/Latinx population in the UnitedStates. J Infect Dis 2020;222:1592–1595.300 Cardiovascular Digital Health Journal, Vol 2, No 6, December 2021

Digital health tools to promote diabetes education and management of cardiovascular risk factors among under-resourced populations

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Digital health tools to promote diabetes education and management of cardiovascular risk factors among under-resourced populations

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