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4/17/2015 BMCPublicHealth|Fulltext|Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippines
http://www.biomedcentral.com/14712458/13/423 1/13
2.32
Studyprotocol
Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippinesJosefienvanOlmen12*,GraceMarieKu13,MauritsvanPelt4,JeanClovisKalobu5,HeangHen4,ChristianDarras6,KristienVanAcker7,BalthazarVillaraza3,FrancoisSchellevis8 andGuyKegels1
BMCPublicHealth2013,13:423 doi:10.1186/1471245813423
Theelectronicversionofthisarticleisthecompleteoneandcanbefoundonlineat:http://www.biomedcentral.com/14712458/13/423
Received: 21February2013Accepted: 19March2013Published: 1May2013
2013vanOlmenetal.licenseeBioMedCentralLtd.
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Correspondingauthor:JosefienvanOlmen
DepartmentofPublicHealth,InstituteofTropicalMedicine,Brussels,Antwerp,Belgium
DepartmentofGeneralPractice&ElderlyCareMedicine,EMGOInstituteforHealthandCareResearch,VUUniversityMedicalCenter,Amsterdam,Thenetherlands
VeteransMemorialMedicalCenter,Quezon,Philippines
MoPoTsyo,PhnomPenh,Cambodia
Memisa,Kinshasa,DRCongo
Memisa,Brussels,Belgium
Diabetologist,workingatAlgemeenziekenhuisHeiligeFamilie,Reet&CentredeSantdesFagnes,Chimay,Belgium
NIVEL(NetherlandsInstituteforHealthServicesResearch),Utrecht,Netherlands&DepartmentofGeneralPracticeandElderlyCareMedicine/EMGOInstituteforHealthandCareResearchVUUniversityMedicalCenter,Amsterdam,TheNetherlands
Forallauthoremails,pleaselogon.
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4/17/2015 BMCPublicHealth|Fulltext|Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippines
http://www.biomedcentral.com/14712458/13/423 2/13
Abstract
BackgroundPeoplewithdiabetesfinditdifficulttosustainadequateselfmanagementbehaviour.SelfManagementSupportstrategies,includingtheuseofmobiletechnology,haveshownpotentialbenefit.Thisstudyevaluatestheeffectivenessofamobilephonesupportinterventionontopofanexistingstrategyinthreecountries,DRCongo,CambodiaandthePhilippinestoimprovehealthoutcomes,accesstocareandenablementofpeoplewithdiabetes,with480peoplewithdiabetesineachcountrywhoarerandomisedtoeitherstandardsupportortotheintervention.
Design/methodsThestudyconsistsofthreesubstudieswithasimilardesigninthreecountriestobeindependentlyimplementedandanalysed.ThedesignisatwoarmRandomisedControlledTrial,inwhichatotalof480adultswithdiabetesparticipatinginanexistingDSMEprogrammewillberandomlyallocatedtoeitherusualcareintheexistingprogrammeortousualcareplusamobilephoneselfmanagementsupportintervention.Participantsinbotharmscompleteassessmentsatbaseline,oneyearandtwoyearsafterinclusion.
Glycosylatedhaemoglobinbloodpressure,height,weight,waistcircumferencewillbemeasured.Individualinterviewswillbeconductedtodeterminethepatientsassessmentofchronicillnesscare,degreeofselfenablement,andaccesstocarebeforeimplementationoftheintervention,atintermediatemomentsandattheendofthestudy.
Analysesofquantitativedataincludingassessmentofdifferencesinchangesinoutcomesbetweentheinterventionandusualcaregroupwillbedone.Aprobabilityof
4/17/2015 BMCPublicHealth|Fulltext|Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippines
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servicesandvisits.Mobiletechnologycanbeparticularlybeneficialforthemanagementofachronicdiseaselikediabetes,forinstancebysupportingbehaviouralchangeandremindersfortakingmedicationandforappointmentswithcareproviders[911].Overall,theevidenceonthefeasibilityandadvantagesoftheuseofmobiletechnologyispositive,butmanystudiesaresmallandevidenceonitseffectivenessisnotveryrobust[1216].Despiteagrowingnumberofstudiesaboutmobilephoneapplicationsinlowincomecountries[17,18],weareawareofonlyonepublicationaboutafeasibilitystudyassessingtheuseofmobilephonesfordiabetessupportinsuchcontext.Thisstudyshowedthefeasibilityofmobilephoneuseforpeersupportandhealthmessaging.Theparticipantsreportedpositiveeffectsoftheintervention,forinstanceincreasedsocialsupportcoping,yettheirphysicalparametersdidnotimproveinthe6monthsfollowup[19].Theliteratureontheuseofmobiletechnologyforsupportingselfmanagementalsopointsouttheneedformoreprocessevaluationinordertobetterunderstandunderwhichconditionsandwhysuchinterventionswork.
Thisstudywilladdressthesegaps,byevaluatingtheeffectivenessofamobilephoneDSMSinterventionontopofanexistingDSMEstrategyinDRCongo,CambodiaandthePhilippines,usingarandomisedcontrolleddesignwithafollowupof24months.Theprojectaimstoevaluatenotonlytheeffectivenessoftheinterventionineachcountry,butalsotoassesstheprocessesandcontextualfactorsthatinfluencetheimplementationofmobilephonetechnologyforsupportingselfmanagementinordertounderstandhowitworks,forwhom,underwhichcircumstances.
Methods
ObjectivesTheprimaryaimofthisstudyistoevaluatetheeffectivenessofamobilephoneDSMSinterventioninadditiontoanexistingDSMEstrategyinthreecountries,DemocraticRepublicofCongo(DRC),CambodiaandthePhilippines,toimprovehealthoutcomes(HemoglobinA1C(HbA1C)level,bloodpressure,BodyMassIndex(BMI),waistcircumferenceanddiabeticfootproblems),accesstocare(failuretoattendrate,perceivedqualityofcareandhealthcareexpenditure)andenablement(knowledge,selfmanagementandfeelingofcoping)ofpeoplewithdiabetesparticipatinginadiabetesselfmanagementeducationprogramme.Thesecondaryaimistoidentifybarriersandfacilitatingfactors,includingadditionalcostviaanincrementalcosteffectivenessanalysis,fortheimplementationofmobilephonetechnologyforsupportingselfmanagementinlowtomiddleincomecountries.
StudydesignThestudyconsistsofthreesubstudieswithasimilardesigninthreelowtomiddleincomecountries,whichwillbeindependentlyimplementedandanalysed.ThedesignisatwoarmRandomisedControlledTrial(RCT),inwhichatotalof480adultswithdiabetes(type2or1)participatinginanexistingDSMEprogrammeineachcountry,willberandomlyallocatedtoeitherselfmanagementeducationasprovidedbytheexistingprogramme(usualcare)ortoselfmanagementeducationplusamobilephoneselfmanagementsupportintervention.Participantsinbotharmscompleteassessmentsatbaseline,oneyearandtwoyearsafterinclusion.
EthicalapprovalMedicalethicalapprovalforthisstudywasobtainedfromtheInstitutionalReviewBoardoftheInstituteofTropicalMedicineAntwerp(11245776),theMedicalEthicsCommitteeoftheUniversitairZiekenhuisAntwerpen(B300201111924),theNationalEthicsCommitteeforHealthResearchinCambodia(207NECHR),theUniversityofKinshasaintheDemocraticRepublicofCongo(ESP/CE/050/11)andtheVeteransMemorialMedicalCentreinthePhilippines(VMMC2011012).
StudycontextandpopulationThetargetpopulationconsistsofpersonswithdiabeteswhoarepresentlyparticipatinginexistingDSMEprogrammesintheDRC,CambodiaandthePhilippines.TheoverallprevalenceofdiabetesinDRCisestimatedbetween3.2%,inCambodiaat2.9%andinthePhilippinesat10.0%(IDF[20,21]).TheseexistingDSMEprogrammeshavebeendevelopedinreactiontotheirsurroundinghealthsystemanditswidersocial,culturalandeconomiccontext[22,23].Tosomeextent,thethreeDSMEprogrammescouldbeexplainedasexemplaryfortheircontext.
InDRC,thestudycontextisanestablishednetworkof60primarycarefirstlinecentresfordiabetescareinKinshasa,inwhichspecialisednurses,referredtoas
4/17/2015 BMCPublicHealth|Fulltext|Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippines
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Figure1.Context,studysitesandblockrandomisationoftheTEXTFORDSMstudy.
educators,acttoimplementtheDSMEprogramme.Fivecentreshavebeenpurposivelyselectedtorecruitstudyparticipants.SimilartoothercountriesinSubSaharanAfrica,professionalcareforpeoplewithdiabetesisusuallyprovidedathealthservices[24,25].TheDSMEprogrammeinthePhilippinesisprovidedbyanumberofspeciallytrainedBarangayorcommunityhealthworkersand/ornursingaides/midwivesaseducatorsinQuezonCity(MetroManila),intheCityofBatac(IlocosNorteProvince)andinthemunicipalityofPagudpud(IlocosNorteProvince).HealthsystemsinAsiancountrieshavealongstandingtraditionofsuchcommunityhealthworkersinthedeliveryofprimarycare.TheDSMEprogrammeinCambodiaisfacilitatedthroughcommunitybasedpeereducatornetworks,whichbeganin2005asarelativelynewdevelopment.PeereducatorsareresponsiblefortheDSMEprogrammeforpatientswholiveintheirarea,supportedbyaheadquarterofficeinPhnomPenh.Ninepeereducatorshavebeenpurposivelyselectedfromoneurbannetworkand6ruralnetworksin2provinces(KampongSpeuprovince,Takeoprovince).
BecauseofdifferencesintheexistingDSMEprogrammesineachcountry,thenumbersofdiabeticscaredforbyoneeducatoraredifferentinDRCongo,CambodiaandthePhilippines.Thepurposiveselectionofparticipatingcentresineachcountryisbaseduponcomparablepatientsize,qualityofDSMEprogramme,willingnessofDSMEprogrammestafftobepartofaresearchprojectandconveniencefactorssuchastraveldistance.Figure1showshowthedesignisimplementedineachcountry.
SamplesizecalculationTheprimaryoutcomemeasureonwhichthesamplesizecalculationisbasedisthedifferenceintheproportionofdiabeticswithawellcontrolledHbA1C(definedasHbA1C
4/17/2015 BMCPublicHealth|Fulltext|Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippines
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theirexistingDSMEprogrammeuptothelevelofaminimumpackage.Thiscomprisesacoherentstoryexplainingdiabetesforpatientsandkeymessagesaboutninespecificdimensionsofdiseasemanagement:1)explanationofdiabetes2)healthyeating3)physicalactivity4)monitoring5)medications6)footcare7)tobaccoandalcoholcontrol8)patientheldrecordsand9)problemsolvingbyandempowermentofpatients[31,32].TheminimumpackagehasbeendefinedthroughaconsultationprocesswithpeoplefromtheexistingDSMEprojectsandwithdiabetologistsprovidingexpertadvice.Theminimumpackageislocallyvalidatedandfinetunedtothelocalcontextbyeachcountryteam,incollaborationwithlocalprojectstaff,healthcareprovidersandpatients.TherewillbeawrittencurriculumoftheDSMEprogrammeineachcountry.
InterventionThecontentandprocessofDSMSisbasedupontheminimumDSMEpackageandonelementsofbehaviourtheory,aimingtoinfluencethemodifyingfactorsofbehaviour.DSMSmessagescan,forinstance,increaseknowledgeaboutcertainbehavioursandtheireffects,theycancreatenormativebeliefsandsocialpressureandtheycanprovideemotionalsupportandincreasetheperceptionofcontrolbypeoplewithdiabetes.MessagesforDSMSwillfollowtheninedimensionsofDSME,butwillbelocallydevelopedandvalidatedthroughconsultationswithDSMEstaffandpeoplewithdiabetes.Thelocalvalidationpertainstothelocalmeaningofhealthbehaviours(forinstancewhatisahealthydiet)butalsotolocallyrelevantmodifyingfactorsofbehaviour(constraintsfordoingphysicalexercise).Theparticipantsallocatedtotheinterventiongroupwillreceivearegularmobilephone.TheywillreceivestandardisedandindividualisedProjectInitiatedCommunication(ProjIC)throughShortMessagingServices(SMS),whichimpliesthemaximumlengthofmessagesbeing160characters.ThesoftwareFrontLineisusedtosendSMSinanconvenientway.Furthermore,peopleareencouragedtousethephonetocontactotherpeopleincludingfellowpatients,educatorsandproviderstoaskforadviceorprovideinformationwhenneeded,forinstancewhentheycannotcometoanappointment.Dependingonthearrangementswiththenationaltelephoneproviders,participantswillbeprovidedwithabudgetforcallsandmessages.ThisistermedPatientInitiatedCommunication(PatIC).
Tocontrolforthepotentialeffectofprovidingparticipantswitharegularmobilephone,theparticipantsallocatedtotheusualcaregroupwillalsoreceiveamobilephonebutwillnotreceiveProjIC.TheywillhowevercontinuetoreceiveassistancefromtheireducatorsaccordingtotheDSMEprogramme.
TheeducatorsarenotinvolvedintheinitiationofDSMSrelatedcommunication.However,alleducatorswillbeprovidedwitharegularmobilephonesothattheycanbereachedbypatients.Theywillreceiveamodestmonthlyallowancetocompensatethemfortheadditionalworkandcoststhattheywillhavebecauseoftheintervention:receivingmorecalls/SMSfrompatientstakingnecessaryactionupontheseandbeinginvolvedinthedatacollectionforphysicalexaminationandbloodsampling.TheywillcontinuetoprovideDSMEtotheirpatientsirrespectiveoftheirallocationtooneofthetrialarms.
ThestudyprojectmanagerineachcountryisthecentralpersoninprovidingProjICtothepeopleintheDSME+DSMSgroup.He/shewillbeprovidedwithasmartphonewithinstructionsandtrainingonhowtouseit.He/shewillenterpatientrelateddataintoadatabasethatisdevelopedandmanagedatnationallevelandsendoutProjICtopatientsthatbelongtotheDSME+DSMSgroupinthedifferentparticipatingcentres/fieldsites.Hewillsupportandgivefeedbacktoeducatorswhennecessaryandcoordinateresearchdatacollectionatsitelevel.
DatacollectionFromeachparticipant,wewillcollectdatalinkedtoeachoftheresearchquestionsandobjectives.ThevariablesarelistedinTable1includingtheinstrumentsusedandthewaystocollectthesedata.Thesevariableswillbecollectedforallparticipantsatbaseline,oneyearandtwoyearsafterinclusionbytrainedresearchstaffwhowillinterviewparticipantsguidedbywrittenquestionnaires,andwhowillperformphysicalexaminationandcollectbloodsamples.
Table1.Listofvariables,measuringinstrumentsanddatasources
Thepatientquestionnaire(Additionalfile1)includesseveralscalesthatmeasuredimensionsofchroniccare:theneeds&servicesscale,attitudescaleandcontrolscalewhichareallsubscalesfromtheDiabetesCareProfile(DCP)[34]thepatientenablementscore[35]andthePatientAssessmentofChronicIllnessCare(PACICScore)[39].Thesescaleshavebeenvalidatedinheterogeneouspopulationsinclinicalandcommunitysettingsinwesterncountries[34,33].Thepatientenablementscorehasbeenvalidatedinalowincomecountry[40].Thequestionnairewasdevelopedforastudyinvolvingpersonswithdiabetesinthe
4/17/2015 BMCPublicHealth|Fulltext|Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippines
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Philippines.Resultsofthatstudyareyettobepublished.Thequestionnaireswillbetranslatedintolocallanguagesandpretestedinallcountries.Wewillalsocollectthefollowingpersonalanddiabetes(care)relatedvariables:age,sex,education,diabeteshistory(yearofdiagnosis,hospitaladmissions,treatment,hypertension)andphysicalaccesstocare(distancetocareproviders).Fortheprocessanalysis,wewillassessthenumberofSMSsenttoeachparticipantintheinterventiongroupandthenumberofphonecalls/SMSthatparticipantsofbothgroupsmadetotheeducator.
Additionalfile1.Webannex1.PatientQuestionnaire.Format:DOCSize:443KBDownloadfileThisfilecanbeviewedwith:MicrosoftWordViewer
Foreachcountry,wecollectanumberofcontextualcharacteristicsfromprimaryandsecondarysources.Theseare:prevalenceofdiabetes,mobilephonepenetration,literacyrate,detailsabouttheexistingDSMEprogramme(numberofpatientspereducator,componentsofDSMEstrategies,frequencyofcontactbetweenpatientsandeducator,etc.),presenceofpatientorganisationsandknowledgeandprofessionalhabitsofdiabetescareproviders(throughselfadministeredquestionnairesenttodiabetescareprovidersintheenvironment).
DatawillbeelectronicallyenteredandcleanedthroughEpiInfo,usingadoubleentryprocedure.
DataanalysesAnalysesofquantitativedataincludingassessmentofdifferencesinchangesinprimaryandsecondaryoutcomesbetweentheinterventionandusualcaregroupwillbedonemakinguseofStataversion11.Aprobabilityof
4/17/2015 BMCPublicHealth|Fulltext|Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippines
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MulticountryanalysisAftertheanalysisoftheeffectivenessoftheinterventionineachcountry,wewillperformamulticountryanalysis.Wewillanalyseifanystatisticallysignificantdifferencesintheprimaryandsecondaryendpointscanbedetectedbetweenthethreecountries.Wewillusearealisticapproachtolookforfactorsexplaininganyidentifieddifferencesbetweencountries,explaininghowtheactualinterventionledtotheobservedresultsandwhytheresultsdiffer(ornot)betweencountries[4143].Projectdocuments,projectreportsfromthefieldsitesandobservationreportswillbecollected.Indepthinterviewswillbecarriedoutwithprojectmanagersanddiabeteseducatorsandfocusgroupdiscussionswithpatientsfrombothgroupswillbecarriedout.Triangulationofdatawillbedonebycomparingtheresultsfromthesesources.TheinterviewrecordingswillbetranscribedverbatimandenteredinNVivo.Qualitativedataanalysiswillbecarriedoutusingtheprogrammetheoryastheanalyticalframework[44,45].
CosteffectivenessanalysisInaddition,wewillconductanincrementalcosteffectivenessanalysis(CEA)comparingtheDSMSstrategyinadditiontotheexistingDSMEstrategywiththeDSMEstrategyonly.Theevaluationwilltakethesocietalviewpointtakingintoaccountbothpatientandprogrammecosts.Costsincurredbypatientsconsistofdirectmedical(e.g.costforconsultation,medicationandthecostforurgentcareandhospitalisation),directnonmedical(costforusingmobilephoneforPatIC,travelcost,foodcost,costrelatedtoexercise)andindirectcosts.Indirectcostsincludethevalueoftimespentbyparticipantsvisitingeducatorsandotherhealthcareprovidersandthelossofproductivityduetoillness.Programmecostsincludethecostfordevelopmentandmanagementoftheinterventionandthecostfortelecommunication.Informationaboutpatientdirectandindirectcostswillbecollectedbyatrainedfieldresearcherwithapatientquestionnaire(seesectionondatacollection).ThevalueoftimelosseswillbeestimatedfromsecondarysourcestakingtheGDPofthethreecountriesintoaccount.Theinformationonprogrammecostswillbecollectedprospectivelybykeepingadetailedaccountofallexpendituresattheprogrammelevel.ProgrammeeffectivenesswillbeexpressedintermsofthepercentageincreaseofpeoplewithdiabeteswithacontrolledHbA1Clevel[46,47].
Discussion
ThecentralhypothesisthatwillbetestedinthisstudyisthatamobilephoneDSMSinterventionontopofanexistingDSMEprogrammewillimproveclinicaloutcomesforpeoplewithdiabetes,measuredbytheirHbA1Clevel.Thewiderangeofsecondaryvariableswillyieldinformationonintermediaryoutcomesandonotheroutcomeswhicharealsoveryrelevantfortheorganisationofsupport.
Althoughtheinterventionitselfisrelativelysimple,itseffectsarerealisedthroughcomplexprocesses,likethebehaviour(change)ofpeoplewithdiabetes.Theeffectoftheinterventionwillpartlydependonfactorsrelatedtotheprocessitself(forinstance,thelevelofinteractionandpersonalisationofmessages),butalsoontheprofileofpeoplewithdiabetes(forinstancetheirattitudetowardstheirdiabetesandtheirfamiliaritywithmobilephones)andonthecontext[48,49].
Themulticountryanalysiswillaimtounderstandanydifferencesintheeffectsoftheinterventionandtheroleofthecontext,forinstancethedesignoftheexistingDSMEprogramme,knowledgeandprofessionalhabitsofdiabetescareproviders.
Themajorlimitationofourdesignwithindividualrandomisationatthelevelofthepatientisthatwithineachparticipatingcentre,therewillbepatientsintheDSMEonlygroupandintheDSME+DSMSgroup.PatientscanbeincontactwitheachotherandthismightcausesomecontaminationbetweenDSMEonlyandDSME+DSMSpatients,resultinginasubestimationofeffect.TheindividualtargetingofthemessagesandthecentralmanagementoftheDSMSinterventionwithoutinterferenceoftheeducatorsshouldminimisethiscontamination.Anothermethodologicalweaknessisthelackoflocalvalidationofthescaleswithinthequestionnaire,whichfellbeyondthescopeofourstudy.Pretestingandlocalfinetuningwillpartlyaddressthisissue.Sincewewillusethesamequestionnaire3timesalongthecourseofthestudy,weexpectthatfamiliaritywiththeinstrumentswillgrowovertime.
Thegrowingnumbersofpatientswithchroniclifelongconditions,suchasdiabetesandhypertension,putsanimmenseburdenonhealthsystemsandpopulations[50].Scarcityofresourcesandthelackofqualityandcontinuityofhealthcareresulttohighexpenditureandverypoorhealthoutcomes.Theinterventiontestedaddressestheproblemthatthegreaterpartofdiabetesmanagementtakesplacewithoutexternalsupportandthatmanychallenges,unforeseenproblemsand
4/17/2015 BMCPublicHealth|Fulltext|Theeffectivenessoftextmessagessupportfordiabetesselfmanagement:protocoloftheTEXT4DSMstudyinthedemocraticRepublicofCongo,CambodiaandthePhilippines
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1. FunnellM:Peerbasedbehaviouralstrategiestoimprovechronicdiseaseselfmanagementandclinicaloutcomes:evidence,logistics,evaluationconsiderationsandneedsforfutureresearch.Familypractice,27Suppl2010,1(June2009):i17i22.PublisherFullText
2. ShigakiC,KruseR,MehrD,SheldonK,BinG,MooreC,LemasterJ:Motivationanddiabetesselfmanagement.
questionsmostofthetimeoccurattheinbetweenmomentsofthescheduledcontactswiththesupportsystem,likehealthcareprovidersandeducators.Theprojectexploitstheavailabilityofwidelyaccessibleequipmentandcommunicationtechnologytonarrowthegapbetweenthesupportsystemandpeoplewithdiabetes.Inthisway,itaddressestheneedofpeoplewithdiabetestocombinetheirlifelongconditionwiththeirotherneedsandrolesinlifeandtocontributetotheirempowerment[51,52].ItwillbeinterestingtoevaluatetheimpactofthiscomplementaryDSMSstrategyontheworkloadoftheeducatorsandhealthprovides,animportantissueforfurtherscalingupingeneralservices(WHO[53]).Thestudyaddressesgapsinknowledgeandexperienceonutilizationofmobilephonetechnologytosupportpeoplewithdiabetesindevelopingcountries.Resultswillprovideinformationtodecisionmakersregardingconditionsofimplementationindevelopingcountriesandpossibleexpectedresults.
Abbreviations
DSMS:DiabetesselfmanagementsupportDSME:Diabetesselfmanagementeducation
Competinginterests
KristienVanAckerhasafunctionintheDiabetesFootProgrammeofIDF.
Noneoftheauthorshasanyfinancialcompetinginterest.
Authorscontributions
JVOiscoordinatinginvestigatorofthestudyanddraftedthefirstversionofthistext.JVO,GMK,MVP,JCK,HH,CD,BV,GKhavebeenallinvolvedinthedesignoftheproject,thewritingoftheprotocolanditsimplementation.GMKdesignedthepatientquestionnaire.FSandKVAhaveprovidedspecialistadviceaboutdiabetesandmethodology.Allauthorshavecontributedtothemanuscriptbyprovidingcontentrelatedfeedbackandimprovementsondraftversions.Allauthorsreadandapprovedthefinalmanuscript.
Acknowledgements
ThisprojectissupportedbyaBRIDGESGrantfromtheInternatiDiabetesFederation.BRIDGES,anInternationalDiabetesFederationproject,issupportedbyaneducationalgrantfromLillyDiabetes.
WearegratefulforthesupportofLimbanazoKapinduladuringthepreparationofthesoftwarefortheintervention.WethankWimVanDamme,BartCriel,ChristianaNoestlingerfortheirsupporttotheconceptualdevelopmentofthestudy.WethankDominiqueDubourg,VeerleVanLerbergheandJorisMentenfortheirsupporttothedataanalysisplanofthisprotocolandpaper.
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