ACKNOWLEDGEMENTS

The World Health Organization and International Telecommunication Union gratefully acknowledge the contributions made to this report by the following individuals:

The handbook was prepared by the WHO ITU Be He@lthy, Be Mobile team: Sameer Pujari, Allison Goldstein, Virginia Arnold, Vinayak Prasad, Susannah Robinson, Surabhi Joshi, Liliane Chamas, Hani Eskandar, Suzanne Hodgkinson, and Per Hasvold.

Content was developed by Be He@lthy, Be Mobile mDiabetes informal expert group members: Line Kleinebreil, Ambady Ramachandran, Nalini Saligram, Nigel Unwin, Nikhil Tandon, Josefien Van Olmen, and Robyn Whittaker.

Overall guidance was provided by the Be He@lthy, Be Mobile steering committee members, from WHO: Douglas Bettcher, Najeeb Al-Shorbaji, and Nick Banatvala, and from ITU: Yushi Torigoe, Eun-Ju Kim, and Kemal Huseinovic.

Contributions to the report were made by: Gojka Roglic, Slim Slama, Cherian Varghese, Benoit Varenne, Elisa Prieto, Nyo Nyo Kyaing, Clayton Hamilton, Ahmed Mohamed Amin Mandil, Heba Fouad, Hani Farouk Abdel Hai Mohamed, Angela Pratt, Kelvin Khow, Mark Landry, Edouard Tursan d’Espaignet, and David Novillo Ortiz.

Administrative support was provided by Zahra Ali Piazza. Copyediting and proofreading was done by Elisabeth Heseltine and layout and design was done by Aram Melikyan.

Table of Contents

List of tables and figures

Introduction

Purpose

Background

What is an mDiabetes programme?

Developing a national mDiabetes programme

1. Operations management

1.1 Needs assessment

1.2 Programme leadership and partnerships

1.3 Work plan development

2. Preparation and adaptation of programme content

3. Promotion and recruitment

4. Technology

5. Monitoring and evaluation

5.1 Establishing an evaluation framework

5.2 Questions and considerations in planning an evaluation

5.3 Possible study designs

References

Annex 1. mDiabetes implementation and message content in Senegal

Annex 2. mDiabetes message content in India

Overview

References

Annex 3. Arogya World mDiabetes implementation and message content

Overview

Annex 4. Examples of mDiabetes programmes and studies

Annex 5. Purpose, roles and questions of the Technical Advisory Group

Annex 6. Budget template

Acronyms

List of tables and figures

Tables

Tables

Table 1. Themes and considerations for a needs assessment

Table 2. Content checklist of a project document for an mDiabetes programme

Table A.1. Worldwide mDiabetes studies

Figures

Figures

Figure 1. The mDiabetes continuum of prevention and care

Figure 2. Proposed types of mDiabetes interventions within the continuum

Figure 3. Segmenting the diabetes population

Figure 4. Proposed structure of an mDiabetes management team

Figure 5. Framework of an mDiabetes programme

Introduction

Purpose

“Be He@lthy, Be Mobile” (BHBM) is a global initiative, led by the World Health Organization (WHO) and the International Telecommunication Union (ITU), based on mobile technology (mHealth) and particularly text messaging and apps, to help combat noncommunicable diseases (NCDs) such as diabetes, cancer, cardiovascular diseases and chronic respiratory diseases. The origins of the Initiative lie in the response to the Moscow Declaration on NCDs, the Political Declaration on NCDs to identify concrete actions to be undertaken by Member States, and actions of the WHO Global NCD Action Plan 2013-2020, marking when the WHO decided to scale up activities to reduce the global burden of NCDs using innovative technologies.

This handbook was prepared by an international group of experts in mDiabetes for WHO and ITU to provide evidence-based operational guidance and resources to assist countries and governments in drawing up a detailed work plan for the development and deployment of a national mDiabetes programme to prevent or control diabetes by healthy living. This handbook describes the considerations and decisions to be made in planning for a national mDiabetes programme in five areas:

• Operations management

o Needs assessment

o Programme leadership and partnerships

o Work plan development

• Content development and adaptation

• Technology

• Promotion and recruitment

• Monitoring and evaluation

The handbook also contains annexes that include samples of message libraries, examples of mDiabetes programmes, and templates and considerations for project management.

Background

Many studies have been conducted on the use of text messaging in disease management and disease prevention. Reviews of these studies indicate that text messaging is effective in many aspects of health behaviour change and disease management (1, 2), although most have been conducted in developed countries and only a few studies have been conducted in resource-poor settings. As mHealth is a new area, the trials to date have tended to be small and fairly heterogeneous. Several organizations, including WHO, and experts are working to determine best practices for research to build a robust evidence base for mHealth. Although the evidence of effectiveness is not yet complete, the dramatic increase in worldwide mobile phone use, from 1 billion subscriptions in 2002 to over 7 billion in 2015 (corresponding to a penetration rate of 97%), makes mHealth one of the most attractive areas of public health intervention (3). One-way push mobile text messaging is the least advanced but the most widely used tool for mHealth. The use of text messaging varies globally from 89% in Mexico to 48% in India (4).

According to WHO, 80% of cases of diabetes, 80% of heart disease and 40% of cancer could be prevented by avoiding tobacco, increasing physical activity and adopting a healthy diet (5). While better management of diabetes and improving treatment and care are important, it is globally recognized that, in the case of NCDs and especially diabetes, prevention through lifestyle changes is critical and cost–effective (6–20). Prevention occupies centre stage in both the WHO Global Action Plan (20) and the 2011 United Nations Political Declaration on NCDs (21), which encourage governments to commit to action and engage with individuals to change their behaviour. Use of mHealth at a population level could be an effective way to achieve behaviour change, especially in lower- and middle-income countries where mobile phone use is growing exponentially and transmission is inexpensive.

Compelling evidence that diabetes can be prevented through behaviour change is provided by the landmark clinical trial of the Diabetes Prevention Program (6), which showed that intensive lifestyle intervention reduced the incidence of diabetes by 58% in 3234 high-risk adults in the USA and that lifestyle changes were better than the commonly used diabetes medication metformin (which reduced diabetes incidence by 31%). A follow-up study showed that prevention or delay of diabetes by lifestyle changes or metformin can persist for at least 10 years (7).

What is an mDiabetes programme?

A population-based diabetes prevention programme should account for the wide diversity of individuals and their motivation to change their lifestyle. While the majority of a population does not have diabetes, some individuals may be interested in the programme because they know someone with diabetes; others are at high risk or have undiagnosed diabetes. The programme should therefore provide information and at the same time enhance prevention, motivate testing in people at risk and provide appropriate, culturally relevant guidance for both people with diabetes and the general population. The factors that contribute to diabetes may differ geographically even within a country or as a result of income disparity. The significance of dietary habits, physical activity and access to health care must be considered.

A comprehensive mDiabetes programme in a large geographical area should cover the spectrum of disease, appropriate technologies and the needs and cultural norms of the population. mDiabetes interventions should be embedded in the continuum of prevention and care, as mHealth can be useful at all levels. mHealth activities ideally should be integrated with the healthcare delivery system to ensure optimum impact. This could include activities such as endorsement, enrollment and monitoring in mHealth programs by healthcare workers. It could also include integration with broader public health programs utilizing schools, mothers, employers as well as national awareness campaigns. Figures 1 and 2 show the five main areas in which mDiabetes programmes may be useful within a broader, structured national diabetes programme: prevention, screening, long-term management, secondary prevention of complications and for specific conditions (e.g. gestational diabetes and type 1 diabetes). Some examples of ways that mHealth programmes have been used to address diabetes include:

1) Arora et al. (2012) showed that for resource-poor inner city patients in the United States with diabetes (median HbA1c 8.9%) who received 3 text messages daily for 3 weeks in Spanish or English, healthy behaviors increased. Daily consumption of fruits and vegetables increased from 56.5% of subjects before the intervention to 83% after; the number of students exercising improved from 43.5% of subjects before to 74% after; self-efficacy, measured by the Diabetes Empowerment Scale—Short Form, improved from 3.9 to 4.2; and scores on the Morisky Medication Adherence Scale improved even more dramatically from 3.5 to 4.75. Ninety percent of participants indicated they would like to continue the program, and 100% said they would recommend the program to family or friends. This proof-of-concept study demonstrated that text messages increased healthy behaviors, improved diabetes self-efficacy and medication adherence, and improved patient satisfaction (8).

2) Ramachandran et al. (2006) found that lifestyle modifications can prevent diabetes in Indian populations as well, despite the Indian target population being leaner, more insulin resistant, and with an onset of diabetes 10 years earlier than Western counterparts (12). A similar randomized controlled trial of 2 year duration, among Asian Indian prediabetic men, found that mobile phone messaging was an acceptable method to deliver advice and support for lifestyle modification to prevent type 2 diabetes (22). The trial is the first to show benefit from this technology in prevention of diabetes, with a 36% relative risk reduction with this intervention versus standard care, in a 2 year period. A further pilot study of 1 year duration among 200 type 2 diabetic patients from the clinic showed that mobile phone messaging based on the principles of diabetes management helped to improve healthcare outcomes. HbA1c values and plasma lipids improved significantly in the intervention group versus those who received usual care (23).

3) Since 2013, Be He@lthy, Be Mobile has been working with Senegal, one of its official countries, to develop a national mDiabetes programme. The programme uses SMS messages to increase awareness about diabetes, train health workers, provide remote consultation services and provide management support for diabetics. In addition to the official countries, others have started to use the tools Be He@lthy, Be Mobile is developing to create their own national programmes. For example, in 2015 the Government of Egypt, with minimal technical support from the Initiative, utilized the lessons learned from the Be He@lthy, Be Mobile initiative to successfully create the foundations of their own national mDiabetes programme.

Some of the lessons learned in the field from these programmes, as well as other large-scale international programmes, will be presented throughout this document.

Developing a national mDiabetes programme

1. Operations management

1.1 Needs assessment

A needs assessment provides a vehicle for consolidating information for planning, identifying gaps in knowledge and helping with decision-making. Conducting a needs assessment will provide an understanding of the setting for the operations management teams. The needs assessment will involve visiting, observing, and interviewing key informants and stakeholders and documenting existing resources. The data will inform the development and implementation of a national mDiabetes programme, and act as a baseline measure from which the programme can be monitored and evaluated. Table 1 lists the considerations for conducting a needs assessment.

1.2 Programme leadership and partnerships

To facilitate planning, implementation and monitoring of interventions in the mDiabetes programme, a leadership team should be established, with clear responsibilities and accountability for the programme (Figure 4):

• a steering committee for overall direction and agreements,

• an international technical advisory group of experts to advise and support the in-country project team,

• a national technical advisory group of in-country leaders to manage operations, technical specifications, content development and adaptation, recruitment and promotion, and monitoring and evaluation.

Steering committee

It is important that collaboration be established between the Ministry of Health and the Ministry of Communications, and both should be represented on the steering committee. Representatives from WHO and ITU headquarters should also be members and contribute to decisions in order to maintain the overall coherence of “Be He@lthy, Be Mobile” and to share lessons between countries.

The steering committee will be responsible for presenting the mDiabetes “Be He@lthy, Be Mobile” programme to their governments and to international agencies to secure funding for widescale, sustainable implementation.

WHO, ITU, and Informal Expert Group

An mDiabetes programme should be designed with the user in mind; therefore, international groups, such as the NCD Alliance and the International Diabetes Federation, are important supporting organizations at both a high and an operational level. A large network of member associations of the Federation could be leveraged to ensure successful initiatives in other countries. It is equally important to include stakeholders from international information technology organizations to advise on legal issues, choice of platforms and feasibility, as well as health economists and business development experts to advise on models for sustainability.

National technical advisory group (National TAG)

This TAG should support, inform and advise the programme throughout its inception, development, implementation and evaluation. It should include those necessary to make decisions around funding and planning, those who will be involved in implementing, promoting and evaluating the program, those who can contribute to the long-term sustainability of the program, and someone who understands or represents the mobile network environment in the country. Regular meetings should be held for information sharing and updates on progress. The TAG will assign roles and responsibilities to various organizations in the different phases of development, adaptation, implementation, evaluation and continuing service provision. They should encourage discussion on overall programme ownership, funding and contracts or agreements on dealing with technical and other issues. The TAG will assist the national operational team in making decisions about the target population, type of programme, programme objectives, programme design, promotion of the programme and the evaluation plan.

National operations, technology, content, promotion, and monitoring and evaluation project leaders

These groups include the people who will actually develop or adapt the programme for cultural relevance and technical accuracy, promote the programme, operationalize and maintain it, integrate it into the health system and health promotion services and evaluate it. This group may include diabetes and public health specialists, evaluators and statistical experts, health promoters, behaviour change and communications experts and consumer groups. These teams would report to or be a subset of the TAG.

For more detail on the roles and questions for consideration by the TAG, see Annex 5.

1.3 Work plan development

This section is intended as a checklist or template for developing a project work plan for use and adaptation by any country intending to implement an mDiabetes programme (Table 2).

2. Preparation and adaptation of programme content

Experience demonstrates that despite the best efforts of an expert group to appropriately craft messages for a particular audience, critical improvements are made to programmes through a primary research driven message refinement process. The following steps should be considered in preparing and adapting the message content for mDiabetes programmes:

1) The national TAG should review any existing mHealth or diabetes programmes, taking into account both the content and the rules for implementation of the programme.

2) In writing the text messages, the following should be considered:

• the language, tone, clarity, health literacy, technological literacy;

• provision of both motivation and information;

• salience of practical tips and strategies for the population;

• tailoring for specific groups (e.g. diabetes and healthy populations, rural and urban, different socio-economic status, ethnic group, age, gender);

• whether the information should be static or dynamic, depending on whether the programme is uni- or bi-directional, fully interactive via an app or based on input from the user; and

• Length of text messages allowed in the country.

3) When setting the rules and logistics of the programme, the following should be considered:

• the timing, frequency and duration of intervention;

• collection and storage of baseline and accumulating research data;

• registration, opt-in and opt-out process and administrative communication (if any);

• whether there will be two-way interaction;

• degree of choice and flexibility in the programme;

• possibility of stopping and/or changing the programme; and

• extent of interaction with clinicians or the health service system.

4) Local experts should help guide the adaptation process. This should include focus groups and consumer pre-testing, translation, changing the wording, removing and adding new messages, changing the rules in the system, and designing the registration, opt-in, and administration functions of the new program. The target population should be given the opportunity to comment on the intent, the media and channels used, the interaction flow, and the key communications involved in the program. The following two-step process can provide a cost and time balanced approach to message adaptation:

i. Establish focus groups for pre-testing in the target population. This may consist of a small number of in-person focus groups (e.g. five groups of 8-10 participants) designed to provide feedback on the totality of the program through review of the program objective and all of the messages in the one sitting. Focus group composition should include the key demographics of the geography (e.g. rural, urban, language group, income, diabetics, non-diabetics, etc.). The number of participants will depend on the number of different target populations, the degree of change from an existing tested program, and the initial feedback from participants. Some focus groups can be substituted by phone interviews if needed. The results of these focus groups will provide information about any major gaps in the program before it is rolled out. It is important to note that receiving a text message on a mobile phone in a normal day is different from sitting down to read a number of text messages on paper. It is best to conduct testing under the conditions in which the programme will ultimately be received, although this is not always feasible or practical. Focus groups are thus necessary before the launch but may not be sufficient, and addition of real-world consumer testing is important, although time-consuming.

ii. In real-world consumer testing for refining the message, the revised programme is sent live to a pilot group of people who are opting-in to the mHealth diabetes programme. The group is surveyed periodically during the programme mainly to determine the appropriateness of the messages. The results are used in designing the final programme.

5) The national TAG must finalize the database of messages and agree on a plan for maintaining the database. Messages might have to be reviewed and updated regularly; it should be clear to the TAG who is responsible for doing so.

For examples of message content libraries used in other interventions, see Annexes 1–3.

3. Promotion and recruitment

Promotion of the programme to the public is an important and potentially expensive component. Consumer recruitment and enrolment of culturally and socio-economically diverse populations is likely to be a challenge in any nationwide programme and should be considered early in planning. The strategy should include consideration of:

• the target audience and the best means of reaching them with promotional material;

• whom the public sees as the “owner” of the programme, as the operational model may well direct the promotional campaign;

• whether the campaign can be linked to or leveraged by organizations or notable personalities currently involved in mass media campaigns for diabetes control or prevention and whether there are lessons to be learnt about effective promotional techniques;

• how people will register or sign up, e.g. directly by text message, online, by telephone, in person, or through a third party, and the amount of data to be collected at baseline to allow tailoring and to ensure follow-up;

• the local mobile network environment, e.g. whether sending unsolicited text messages is allowed (contravenes network codes of conduct in some countries), which may also be an important consideration in the potential effectiveness of or engagement in the programme: whether a population that has been desensitized to receiving unsolicited health-related text messages will be likely to read mDiabetes text messages;

• use of incentives to encourage participation;

• the effectiveness of mobile outreach for enrolment: the response rates to messages asking people to subscribe to a service are < 1% even if it is free;

• whether marketing and promotional campaigns can be leveraged by e.g. stakeholder agencies, including technical partners; and

• the timing of the campaign, perhaps with a “soft launch” before the promotional campaign, to ensure that all processes are working well before many participants sign up.

Steps to be considered in this stream are preparation of a media and promotion plan, with roles, activities, timelines, targets and a budget.

4. Technology

The following technical aspects of an mDiabetes programme must be considered by the national TAG from the start, in collaboration with local partners:

• type of mHealth intervention, channels to be used (SMS, voice, apps, etc.);

• availability of technology options within the public sector and/or private sector;

• process for procurement and adaption of technology;

• dashboard development and access;

• procurement of a short code;

• negotiation with Telecom regulators, aggregators and operators for pricing;

• data security;

• technology pre-testing and scale-up plans.

It is important to note that mobile communications network environments differ by country. The specificities should be considered in the planning stage by including technical representatives (e.g. of telecommunications companies) or individuals knowledgeable about the communications network in the country on the TAG. Networks, telecommunications companies or an industry organization can be helpful in setting up the programme and advising on its sustainability. Some providers may consider their support of such a programme as good publicity or as a useful addition to their offers.

In the absence of such support, a programme can be delivered by a contractual arrangement with an “aggregator” or “gateway” company that has established relations with all telecommunications companies and networks. This can be a cost–effective method for delivering messages to a large number of participants, regardless of their carrier or location, without establishing these interfaces individually. Although the aggregator adds a cost to the programme, this decreases with an increase in scale; using an aggregator is more cost–effective than attempting these activities “in house”.

When thinking about the technical aspects of an mHealth programme, the TAG may also consider the following questions:

• Partnerships: What sort of arrangement with telecommunications companies and/or the aggregator will best suit long-term implementation of the programme?

• Communicating messages: Should one-way text, voice, interactive messaging or Interactive voice response systems be used? What are the capacity, cost–effectiveness and reach of the available technologies in the country?

• Free access: How can we ensure that the programme is free and available to all consumers regardless of their carrier, network or location?

• Market research: Who will conduct interviews and on which system?

• Data ownership, privacy, security and interoperability with health systems: What are the considerations, and how should a central database best be maintained?

• Sustainability: What are the operating costs of the programme, such as per message, and how will these affect the size of the programme?

• Contracts: In establishing contractual arrangements with partners, what are the issues with regard to intellectual property, security and privacy of mobile phone numbers, testing, expectations of involvement in monitoring and evaluation and service agreements? Who will hold the contractual arrangements, and what support will be given for maintenance and any other problems?

• The TAG should also consider logistics and the functional plan and finalize the functional specifications in collaboration with technical partners, who will build the appropriate systems and interfaces and test internal and user acceptance.

5. Monitoring and evaluation

5.1 Establishing an evaluation framework

The following steps should be considered when thinking about a programme evaluation:

1) Establish a framework and evaluation plan from the beginning in order to understand the level of evidence and the outcomes that may be required by local decision-makers for sustaining or extending the programme. For an example, see Figure 5, based on current strategies being implemented by Senegal’s national mDiabetes programme and proposed strategies that may be implemented by the government in the future. Evaluations of both process and outcomes are useful, as they provide lessons for others and inform local improvements in the programme. The following aspects of a monitoring and evaluation plan should be agreed upon by the TAG:

• Outcomes to be measured: health (e.g. evidence of behaviour change or intent to change), technical impact, economic impact, social impact and the effectiveness of the business model. Other outcomes can be included when appropriate

• Desired degree of demographic stratification of results and sample size

• Research design: randomized clinical trial, pre–post study, survey or questionnaire

• Validation

• Continual monitoring of the programme and targeted research

• Costs of evaluation and operational costs of monitoring

2) Agree on a publication plan to share results of the evaluation.

3) Collect data on the programme wherever possible, e.g. through text messages, online questionnaires or interviews with a sample of participants. This can provide real-time data for the administration and operation of the programme, and can also be used for monitoring.

More expensive, independent evaluations could be scheduled less frequently to answer specific questions about impact. The benefits of evaluation include:

• management of the operation of the programme,

• feedback for continuous improvement of the programme,

• external reporting to funders on overall performance and impact to justify further investment, and

• lessons on implementation of the programme that could be used elsewhere (e.g. other mHealth programmes).

Figure 5. Framework of an mDiabetes programme

5.2 Questions and considerations in planning an evaluation

Is the programme reaching the right people?

• The programme must be accessible to the entire target population, which should be specified at the start, with an estimate of the potential number.

• The possible barriers to reaching the right people include: inadequate exposure to programme advertisements, lack of access to the appropriate technology, cost and cultural or personal perception that the programme is not appropriate or is unlikely to be effective. All potential barriers should be considered in designing questions for the evaluation.

• Questions for identifying barriers are suggested by the monitoring and evaluation framework:

○ What proportion of patients with pre-diabetes and diabetes have minimum access to a mobile phone?

○ What proportion of each targeted population can read or write in the language used in the SMS?

○ What proportion of each targeted population can afford the mHealth programme?

○ What proportion of each targeted population is unwilling to engage in mHealth projects for cultural or personal reasons?

○ What proportion of each targeted population lives in an area covered by a mobile network?

• Once the programme is operational, reports should be made on:

○ the number of participants, which may be reported as:

− the proportion of the target population who take up the programme;

− the proportion of people at risk, with pre-diabetes or with diabetes in the target populations who take up the programme (e.g. by age group, location, ethnicity, income);

− where participants heard about the programme (e.g. mass media, posters, recommended by a professional or service, recommended by family or friends, Internet);

(A questionnaire to assess pre- and post-knowledge among participants may be required.)

○ the actual cost of participating in the programme;

○ depending on the type of programme and the target audience, objective measures of impact, such as:

− the most common HbA1c level (a measure of long-term diabetes control);

− changes in diabetes risk screening scores over time;

− blood glucose levels over time;

− attendance at health services (e.g. retinal screening, podiatry, diabetes, primary care);

− attendance at an emergency unit for ketoacidosis (children and adults);

− attendance at an emergency unit during Ramadan;

− cardiovascular risk;

− evidence of microvascular disease at routine screening;

− evidence of renal disease;

− initiations of dialysis;

− ulcer scores; and

− lower limb amputation.

• Separate scheduled evaluations may be conducted to gather more information, such as:

○ the effectiveness of mass media and other promotional campaigns in informing people about the programme by population-based surveys to determine recognition, awareness and attitudes; and

○ the reasons that people at risk for or with pre-diabetes or diabetes have not taken up the programme.

This information should be used directly in planning promotional campaigns for the programme.

Are we providing a high-quality programme?

Quality is reflected in several aspects of the programme:

• Is the content of the messages appropriate and helpful?

• Are the messages reliable? (Do they arrive when they are supposed to?)

• Do the registration process and interactive components work as they are advertised?

• Are there are any unexpected technical issues?

Programme metrics could include:

• the number of people who text STOP to stop receiving messages. This can be used as a proxy measure of people who are unhappy with the programme for any reason but may also include people who feel fully educated about the risk factors and effects of diabetes and therefore consider that they no longer need the messages. When presented as a proportion of participants over time, an increasing trend can indicate a problem with the quality of the programme.

• the number of participants using the interactive components of the programme. A very low number may indicate lack of engagement with the programme, which could be due to a perception of poor quality or lack of understanding of the components.

• administrative reports on the steps in registration. This can be useful for identifying timeliness and any issues arising during registration, e.g. large numbers who register an interest but fail to complete the full registration process.

• Aggregator companies can usually report on the reliability of message delivery, with confirmation of delivery and reports on any technical issues.

• Unscheduled text messages from participants may alert staff to unexpected technical issues.

Is the programme having an impact?

The effectiveness of mDiabetes programmes is usually measured by monitoring whether patients with pre-diabetes and diabetes have made serious attempts to adopt a healthier diet, increase their amount of exercise, monitor their blood sugar level regularly and undergo routine foot checks to prevent complications or amputation.

A scheduled evaluation can elicit more detailed feedback from a subsample of participants, such as:

• whether they feel that the programme informed them about risk factors for diabetes,

• which aspects of the programme were helpful,

• what they like and dislike about the programme,

• how the programme could be improved to be more helpful and

• whether they consider that two-way personalized messages are more beneficial than one-way automated messages.

Broader programme metrics could include:

• the proportion of the population reached who complete the programme, whether the user experience was enjoyable and the proportion who changed their behaviour and claim that they will continue to do so; and

• whether the content of the mHealth programme was useful in informing the population and the extent to which it triggered behaviour.

After about one year, an evaluation of effectiveness should be scheduled. The messages should be reviewed every 1–2 years, when messages may be added or dropped.

Does the programme have any negative consequences?

Programme administrators should be aware of any negative consequences of the programme. Unexpected consequences may be picked up from incoming text messages. Systems should be set up for early identification of and response to predictable issues, such as technical problems. Managers might also consider asking about potentially important issues, such as traffic accidents while reading messages on a mobile phone. Data could be collected by continuous reporting, monitoring (e.g. surveys) and scheduled evaluations involving either all participants, subsamples or whole populations.

Continuous monitoring should be part of routine operation of the programme, including interim “dip-stick” checks to ensure that people are receiving messages, assessment of the numbers and demographics of participants and indicators of engagement. A useful process indicator is the opt-out rate.

Size of study and stratification: If a full study is required (i.e. of a new programme that has not been tested previously), it is recommended that both local researchers and researchers experienced in large-scale technology-based intervention trials be included in the group. The sample size for an evaluation of effectiveness should be based on pre-identified diversity in the population (e.g. geography, income, diabetic versus non-diabetic). Understanding effectiveness at this level will allow the development of future mHealth programmes that are tailored to the needs of different target populations; these are the natural next step after initial population-based approaches. These will become much more feasible and cost-effective with advances in mobile technology.

Ethics review and informed consent: At country level, the appropriate approvals should be sought for an mDiabetes initiative, from an independent ethics review committee at an academic institution of high standing or another government-approved organization. The documents for approval should be prepared as per the specifications of the agency, with full disclosure of:

• the type of population to be evaluated;

• the survey instrument to be used;

• any compensation for the trial respondents; and

• details of the method to be used, including market research design, statistical norms, empirical considerations by country demographics, controls and analysis plan.

Informed consent must be obtained from the respondents recruited for the survey, including details for longer-term post-programme evaluation.

5.3 Possible study designs

Controlled trial: prospective comparison of people receiving the mDiabetes intervention with a control group of people who are not. The number of participants should be determined on the basis of the degree of stratification required (i.e. at what demographic level are statistically significant results required).

Village study: a concept that represents additional targeted research. For example, in such a study, all inhabitants of one village could be given access to a mobile health programme and compared analytically with the inhabitants of a similar village without access. Rural health care workers could measure relevant biomarkers (e.g. body mass index, HbA1c). The advantage of such studies is that they provide robust insights about a population of particular public health concern. They also provide an opportunity to evaluate how a mobile health programme can be integrated with other activities of formal and informal health sectors.

Longitudinal study: additional research to understand the effect of programme duration and the duration of effects on individuals. Many studies address the effects of a short-term programme on short-term outcomes; however, it is important to determine the optimum duration of an mDiabetes support programme and how long behaviour changes are maintained after the end of the programme. Evaluation of a 1-year programme with additional content would provide important guidance for future programmes.

References

1. Free C, Phillips G, Galli L, Watson L, Felix L, Edwards P, et al. The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review. PLoS Med 2013;10:e1001362.

2. Liang X, Wang Q, Yang X, Cao J, Chen J, Mo X, et al. Effect of mobile phone intervention for diabetes on glycaemic control: a meta-analysis. Diabet Med 2011;28:455-463.

3. ICT Facts and Figures 2015. Geneva: International Telecommunication Union; 2015 (http://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2015.pdf, accessed 10 March 2016).

4. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev 2010;32:56-69.

5. Preventing chronic diseases: a vital investment: WHO global report. Geneva: World Health Organization; 2005 (http://www.who.int/chp/chronic_disease_report/full_report.pdf, accessed 1 August 2015).

6. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.

7. Diabetes Prevention Program Research Group. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcome Study. Lancet 2009;374: 1677-1686.

8. Arora S, Peters A, Agy C, Menchine M. A mobile health intervention for inner city patients with poorly controlled diabetes: proof-of-concept of the TExT-MED Program. Diabet Technol Ther 2012;14:492-497.

9. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev 2010;32:56–69.

10. Free C, Knight R, Robertson S, Whittaker R, Edwards P, Zhou W, et al. A randomised controlled trial of mobile (cell) phone text messaging smoking cessation support: txt2stop. Lancet 2011;378:49-55.

11. Hanauer D, Wentzell K, Laffel N, Laffel L. Computerized automated reminder diabetes system (CARDS): e-mail and SMS cell phone text messaging reminders to support diabetes management. Diabet Technol Ther 2009;11:99-106.

12. Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217–230.

13. Quinn CC, Clough SS, Minor JM, Lender D, Okafor MC, Gruber-Baldini A. WellDoc™ mobile diabetes management randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction. Diabet Technol Ther 2008;10:160-168.

14. Quinn C, Shardell M, Terrin M, Barr E, Ballew S, Gruber-Baldini A. Cluster-randomized trial of a mobile phone Personalized Behavioral Intervention for Blood Glucose Control. Diabetes Care. 2011; 34:1934–42.

15. Ramachandran A, Snehalatha C, Simon M, Mukesh B, Bhaskar A, Vijay V, et al. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1) Diabetologia 2006;49:289-297.

16. Ramachandran A, Snehalatha C, Yamuna A, Mary S, Ping Z. Cost-effectiveness of the interventions in the primary prevention of diabetes among Asian Indians. Within-trial results of the Indian Diabetes Prevention Programme (IDPP). Diabet Care 2007;30:2548–2552.

17. Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2012;11:CD006611.

18. Yoo HJ, Park M, Kim T, Yang S, Cho G, Hwang T, et al. A ubiquitous chronic disease care system using cellular phones and the Internet. Diabet Med 2009;26:628-635.

19. Shariful Islam SM, Niessen LW, Ferrari U, Ali L, Seissler J, Lechner A. Effects of mobile phone SMS to improve glycemic control among patients with type 2 diabetes in Bangladesh: a prospective, parallel-group, randomized controlled trial. Diabet Care  2015;38:e112-e113.

20. Global Action Plan for the Prevention and Control of NCDs 2013-2020. Geneva: World Health Organization; 2013 (http://www.who.int/nmh/events/ncd_action_plan/en/, accessed 1 August 2015).

21. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (document A/66/L.1). New York: United Nations; 2011 (http://www.un.org/ga/search/view_doc.asp?symbol=A/66/L.1, accessed 1 August 2015).

22. Ramachandran A, Snehalatha C, Ram J, Selvam S, Somon M, Nanditha A, et al. Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial. Lancet Diabet Endocrinol 2013;1:191–198.

23. Shetty AS, Chamukuttan S, Nanditha A, Raj RK, Ramachandran A. Reinforcement of adherence to prescription recommendations in Asian Indian diabetes patients using short message service (SMS): a pilot study. J Assoc Physicians India. 2011;59:711-714.

Annex 1. mDiabetes implementation and message content in Senegal

Overview

The “Be Hea@lthy, Be Mobile” initiative, in collaboration with the Senegalese Ministry of Health, launched the mRamadan campaign in June 2014 to support patients with diabetes during Ramadan by sending text messages with general educational and diabetes management recommendations. This successful campaign was followed by a full mDiabetes campaign on various aspects of diabetes prevention and management in four tracks: mAwareness for the general population, mEducation for patients with diabetes, mDiabeticfoot for management of complications and mTraining for health care professionals. More information on these campaigns can be found at http://www.mdiabete.gouv.sn/. The lessons learnt are cited in relevant parts of this document.

Examples of the messages (translated from French) and the follow-up evaluation form are provided below.

mRamadan campaign

Programme

Time
frame

Message

Character
count

Category

Senegal: mRamadan

Messages sent daily between 09:00 and 10:00 at the same time, one message per day, 10 days before Ramadan

Ramadan is coming up! Consult your doctor, and make sure your blood sugar is normal: between 0.90 and 1.20 g/L. More information at www.mdiabete.gouv.sn

152

Warning! If you take insulin, it’s best not to fast. More information at www.mdiabete.gouv.sn

93

Warning! If you are pregnant and have diabetes, it’s best not to fast. More information at www.mdiabete.gouv.sn

111

Warning! If you have a diabetes-related heart, kidney or eye condition, it’s best not to fast. More information at www.mdiabete.gouv.sn

135

Ask your doctor to adjust your medication dosage and blood-sampling schedule before you fast. More information at www.mdiabete.gouv.sn

134

Warning! If your blood sugar is above 2.5 g/L, consult your doctor about controlling your diabetes. More information at www.mdiabete.gouv.sn

140

Drink about a litre of water each morning when you fast. More information at www.mdiabete.gouv.sn

97

Drink about a litre of water after breaking your fast each day. More information at www.mdiabete.gouv.sn

104

Be careful not to overeat, and avoid sugary foods, particularly dates. More information at www.mdiabete.gouv.sn

112

Don’t exercise until at least two hours after breaking your fast. More information at www.mdiabete.gouv.sn

106

Senegal: mRamadan

messages sent during Ramadan

Remember to check your blood sugar every day in the late morning and mid-afternoon. More information at www.mdiabete.gouv.sn

124

If your blood sugar drops to 0.7 g/L at midday or in the early afternoon, it’s best to stop fasting and eat something. More information at www.mdiabete.gouv.sn

159

If your blood sugar rises above 2.5 g/L, stop fasting, and consult your doctor. More information at www.mdiabete.gouv.sn

120

Don’t forget to keep drinking lots of water (1 litre morning and evening), and avoid excessive sugar, fat and salt. More information at www.mdiabete.gouv.sn

156

Senegal: mRamadan

messages sent a week after Ramadan

Well done! You completed the fast. See your doctor for a check-up on your diabetes. Déwenati! More information at www.mdiabete.gouv.sn

134

Thanks for participating. We’d like to have your feedback. Contact us at 800 00 50 50 (Ministry of Health and Social Welfare free hotline) or at www.mdiabete.gouv.sn

165

mDiabetes programme

Programme

Time
frame

Message

Character
count

Category

Senegal: mDiabetes, mAwareness group

Week 1

mDiabetes: For every 100 people in Senegal, 4–6 have diabetes, and 2–3 of them don’t know it. Are you at risk for diabetes? Speak with a health professional. Learn more at www.mdiabete.gouv.sn

192

mDiabetes: There are two types of diabetes: type 1 (pancreas doesn’t produce enough insulin) and type 2, which is more common (insulin is ineffective). Learn more at www.mdiabete.gouv.sn

186

mDiabetes: Type 2 diabetes can be prevented, and some people are more at risk than others. Prevent diabetes by knowing the risks. Learn more at www.mdiabete.gouv.sn

164

mDiabetes: Diabetes means having too much sugar in your blood (hyperglycaemia), because the pancreas doesn’t produce enough insulin to process the sugar you eat. Learn more at www.mdiabete.gouv.sn

196

mDiabetes: In certain cases (particularly if you are obese or have a lot of belly fat: waist > 94 cm), the insulin you do produce can be less effective. Learn more at www.mdiabete.gouv.sn

188

mDiabetes: Knowing the risk factors can help you prevent type 2 diabetes. Now is the time to change! Learn more at www.mdiabete.gouv.sn

135

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn

84

Senegal: mDiabetes, mAwareness group

Week 2

mDiabetes: Do you have a close relative (father, mother or sibling) with diabetes? Are you overweight, with a waist > 94 cm? You are at increased risk for diabetes. Learn more at www.mdiabete.gouv.sn

199

mDiabetes: Are you over 40, with high blood sugar and high cholesterol? You are at increased risk for diabetes. Learn more at www.mdiabete.gouv.sn

146

mDiabetes: Do you eat fatty foods and drink sugary drinks? Little or no exercise? Warning! You are increasing your risk for diabetes. Learn more at www.mdiabete.gouv.sn

168

mDiabetes: Have you given birth to a baby over 4 kg? Have you had multiple miscarriages? You are at risk for diabetes. Learn more at www.mdiabete.gouv.sn

153

mDiabetes: Worried you may be at risk for diabetes? Have your blood sugar (blood glucose) checked at least once per year. Learn more at www.mdiabete.gouv.sn

156

mDiabetes: Worried about diabetes... but your blood sugar (blood glucose) is normal? To prevent diabetes, focus on health and stay in shape. The time to change is now! Learn more at www.mdiabete.gouv.sn

202

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn

84

Senegal: mDiabetes, mAwareness group

Week 3

mDiabetes: Do you urinate overfrequently? Have you lost weight despite a normal appetite? These are symptoms of diabetes. Have your blood sugar checked right away! Learn more at www.mdiabete.gouv.sn

198

mDiabetes: If your fasting blood sugar is 1.26 g/L or higher in two tests in a row, you have diabetes (even if you don’t have symptoms). See a doctor right away. Learn more at www.mdiabete.gouv.sn

196

mDiabetes: If you have classic symptoms and your blood sugar is over 2.0 g/L at any point in the day, you have diabetes. See a doctor right away. Learn more at www.mdiabete.gouv.sn

180

mDiabetes: Do you have risk factors for diabetes, but your fasting blood sugar is below 1.1 g/L? You are not yet diabetic, but you should be careful. Learn more at www.mdiabete.gouv.sn

184

mDiabetes: Fasting blood sugar between 1.1 g/L and 1.25 g/L is abnormal. You are not yet diabetic, but you need to take steps to prevent it. The time to change is now! Learn more at www.mdiabete.gouv.sn

202

mDiabetes: If you don’t have diabetes but do have risk factors, you need to take preventive action. The time to change is now! Learn more at www.mdiabete.gouv.sn

161

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn

84

Senegal: mDiabetes, mAwareness group

Week 4

mDiabetes: Have your blood sugar checked at the pharmacy today! Make a note of the result, and ask your doctor about it at your next appointment. Learn more at www.mdiabete.gouv.sn

180

mDiabetes: Weigh yourself, take your blood pressure and measure your waist today! Make a note of the results and ask your doctor about it at your next appointment. Learn more at www.mdiabete.gouv.sn

198

mDiabetes: Today’s challenge: Lose excess weight by eating smaller portions and avoiding fried foods and sugary drinks. Learn more at www.mdiabete.gouv.sn

154

mDiabetes: Today’s challenge: Ask your doctor about your diet. If you’re over 40 and have diabetes in your family, it’s worth having a check even if your weight, blood pressure and blood sugar are normal. Learn more at www.mdiabete.gouv.sn

239

mDiabetes: Today’s challenge: Stay healthy by walking or doing exercise that you enjoy for 30 minutes every day. Discuss it with your doctor. Learn more at www.mdiabete.gouv.sn

176

mDiabetes: A balanced diet and regular physical exercise will keep you in shape, plus it’s good for your muscles, heart and overall health. Learn more at www.mdiabete.gouv.sn

174

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn

84

Senegal: mDiabetes, mAwareness group

Week 5

mDiabetes: During digestion, food is broken down into sugar, and some foods contain more than others. Get information about eating a balanced diet.

147

mDiabetes: To put together a balanced meal, include all five food groups: 1 – grains and starches, 2 – protein, 3 – vegetables, 4 – fruit, 5 – milk and dairy.

158

mDiabetes: Try to eat more vegetables and fewer grains and starches. Avoid soda and fried foods. Check for changes in your weight and blood sugar.

146

mDiabetes: Even if your blood sugar is normal, you should check it every 6 months. Be vigilant to make sure it stays normal over the long term.

143

mDiabetes: For a trimmer waistline and a healthier heart and muscles, eat a balanced diet and walk 30 minutes each day.

120

mDiabetes. To prevent diabetes, develop a healthy lifestyle and consult your doctor once or twice per year. Spread the word!

124

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn

84

Senegal: mDiabetes, mAwareness group

Week 6

mDiabetes: This week’s challenge: Share information about diabetes with your friends and family. Now is the time for them to change as well!

140

mDiabetes: Today’s challenge: Persuade your family to avoid fried foods, sugary drinks and oversize portions at mealtimes.

123

mDiabetes: In the cafeteria at work, talk to your co-workers about healthy eating and preventing diabetes. Include the cook in the conversation.

145

mDiabetes: Today’s challenge: Persuade a parent or friend to join you for a 30-minute walk. Try to fit 30 minutes of daily exercise into your schedule this week.

161

mDiabetes: See all messages from the regular programme and get more information at www.mdiabete.gouv.sn

103

mDiabetes: Did you find these messages helpful? If so, you’ll also receive nutrition support information in March. Or you can unsubscribe by calling XXX (free phone number provided by the Ministry of Health) or going to www.mdiabete.gouv.sn

240

Senegal: mDiabetes, mLearning group (for people with diabetes)

First message

mDiabetes: You are going to receive a series of messages that will help you control your diabetes. More detailed information and recommendations available at www.mdiabete.gouv.sn

178

Senegal: mDiabetes, mLearning group (for people with diabetes)

Week 1

mDiabetes: No one chooses to have diabetes, but you can choose to do what it takes to control it. Ready to find out how? Learn more at www.mdiabete.gouv.sn

155

mDiabetes: Does your mother or father have diabetes? Do you have high blood pressure? Are you obese? Fasting blood sugar over 1.26 g/L in two tests? You obviously have diabetes. Learn more at www.mdiabete.gouv.sn

212

mDiabetes: Did you see a doctor after losing weight, feeling thirsty and urinating frequently, with glucose levels (amount of sugar in the blood) over 2.0 g/L? You obviously have diabetes. Learn more at www.mdiabete.gouv.sn

223

mDiabetes: Diabetes means your muscles have trouble using the sugar you ingest. That means sugar stays in the blood for too long, which can damage various organs. Learn more at www.mdiabete.gouv.sn

197

mDiabetes: Your doctor can explain the difference between type 1 diabetes (the pancreas doesn’t produce enough insulin) and type 2 (insulin is ineffective). What type do you have? Learn more at www.mdiabete.gouv.sn

214

mDiabetes: To stay in shape and avoid complications from diabetes, you should control not just your blood sugar but also your blood pressure and weight. Learn more at www.mdiabete.gouv.sn

187

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: controlling your blood sugar.

126

Senegal: mDiabetes, mLearning group (for people with diabetes)

Week 2

mDiabetes: Change is never easy, but you’re ready to get your blood sugar under control and live a healthy lifestyle. Find out how to check your blood sugar. Learn more at www.mdiabetes.gouv.sn

193

mDiabetes: Ideally, your blood sugar should never be over 1.2 g/L before breakfast or 1.8 g/L two hours after a meal. Learn more at www.mdiabetes.gouv.sn

153

mDiabetes: Ideally, your glycated haemoglobin (HbA1c) – which gives an overall picture of your blood-sugar levels over 3 months – should be under 7%. Learn more at www.mdiabetes.gouv.sn

185

mDiabetes: Eating too much grain or starch, skipping medication or getting an infection can all raise your blood sugar. Learn to recognize the signs of hyperglycaemia. More at www.mdiabetes.gouv.sn

197

mDiabetes: If your blood sugar is too high, you might urinate frequently, have a dry mouth or feel thirsty and tired, it is URGENT that you see a doctor. Learn more at www.mdiabetes.gouv.sn

189

mDiabetes: Sometimes diabetes treatment can cause blood sugar to drop too low. You might sweat profusely, have trouble speaking or feel dizzy, hungry, irritable or faint. These are signs of hypoglycaemia: your body needs sugar. Learn more at www.mdiabetes.gouv.sn

263

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: monitoring your diabetes.

122

Senegal: mDiabetes, mLearning group (for people with diabetes)

Week 3

mDiabetes: Too much fat and sugar in your diet and too little exercise can make diabetes worse. Stay in shape and avoid complications of diabetes by changing your lifestyle. Learn more at www.mdiabetes.gouv.sn

209

mDiabetes: Today, weigh yourself and measure your waistline, blood pressure and blood sugar. Keep track of each figure in a diabetes notebook. Learn more at www.mdiabetes.gouv.sn

178

mDiabetes: Today, make sure you have your latest glycated haemoglobin (HbA1c) test result noted down. If you don’t, ask your doctor about it at your next appointment. Learn more at www.mdiabetes.gouv.sn

202

mDiabetes: Today, see how many stair steps you can climb without losing your breath and having to stop. Keep track of the number in your notebook. It’s important to monitor your heart’s health. Learn more at www.mdiabetes.gouv.sn

229

mDiabetes: Today, start keeping track of what you eat each day in your notebook. Show it to your doctor at your next appointment. Learn more at www.mdiabetes.gouv.sn

165

mDiabetes: Change is never easy, but wanting to live healthily is the first step. You’re on the right track. Learn more at www.mdiabetes.gouv.sn

144

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week, the base of the diabetes-treatment pyramid: diet.

146

Senegal: mDiabetes, mLearning group (for people with diabetes)

Week 4

mDiabetes: No matter what type of diabetes you have, the most important thing is learning not to eat more than your body can process. Try to eat only a little sugar at a time. Learn more at www.mdiabetes.gouv.sn

211

mDiabetes: During digestion, food is broken down into sugar. Some foods contain more sugar than others. Get informed about a balanced diet. Learn more at www.mdiabetes.gouv.sn

175

mDiabetes: To put together a balanced meal, combine all five food groups: 1 – grains and starches, 2 – protein, 3 – vegetables, 4 – fruit, 5 – milk and dairy. Learn more at www.mdiabetes.gouv.sn

194

mDiabetes: On a given day, take your blood sugar 2 hours after a meal. If your blood sugar is over 1.8 g/L, the meal wasn’t appropriate for you. Find out what your body is able to process. Learn more at www.mdiabetes.gouv.sn

224

mDiabetes: How many lumps worth of sugar are there in 150 g of rice or millet: 5, 20 or 50? What about a serving of grilled fish? A serving of green vegetables? Learn more at www.mdiabetes.gouv.sn

196

mDiabetes: One serving (150 g) of rice or millet = 36 lumps of sugar. A serving of grilled fish = 0 lump. A serving of green vegetables = only 3 lumps. Learn more at www.mdiabetes.gouv.sn

187

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week, the middle of the diabetes-treatment pyramid: physical exercise.

161

Senegal: mDiabetes, mLearning group (for people with diabetes)

Week 5

mDiabetes: A working muscle uses sugar for energy. This means that physical exercise can help lower your blood sugar. Learn more at www.mdiabetes.gouv.sn

153

mDiabetes: Even if you don’t lose much weight from exercising, it still keeps your heart and muscles healthy. It also helps lower your blood sugar. Learn more at www.mdiabetes.gouv.sn

183

mDiabetes: Diabetes can be as tiring as hard work. Regular physical exercise will help you relax, plus it lowers your blood sugar. Great news! Learn more at www.mdiabetes.gouv.sn

178

mDiabetes: Make room in your daily schedule for 30 minutes of walking or other exercise you enjoy. Discuss it with your doctor. Learn more at www.mdiabetes.gouv.sn

163

mDiabetes: If you can, check your blood sugar before and after 30 minutes of sustained exercise. This helps prevent hypoglycaemia. Learn more at www.mdiabetes.gouv.sn

166

mDiabetes: After exercising, don’t forget to drink water and have a snack if it’s not meal time. This helps prevent hypoglycaemia. Learn more at www.mdiabetes.gouv.sn

166

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week, the top of the diabetes-treatment pyramid: medication.

151

Senegal: mDiabetes, mLearning group (for people with diabetes)

Week 6

mDiabetes: Work with your doctor to find the best form of treatment for you: on top of diet and exercise, you might need pills or insulin injections. Learn more at www.mdiabetes.gouv.sn

185

mDiabetes: Do you have type 1 diabetes? You will need daily insulin injections to stabilize your blood sugar and help you live a healthy life. Insulin therapy has existed for 80 years and saves lives. Learn more at www.mdiabetes.gouv.sn

236

mDiabetes: Do you have type 2 diabetes? A balanced diet and regular physical exercise (strict health regimen) can be enough to stabilize your blood pressure in the long term. Learn more at www.mdiabetes.gouv.sn

210

mDiabetes: Do you have type 2 diabetes? If lifestyle changes alone aren’t enough, you can take pills to help stabilize your blood sugar. If these are ineffective, there is always insulin. Learn more at www.mdiabetes.gouv.sn

223

mDiabetes: There are several types of pills and insulin treatments. Find out how to adjust your insulin levels and avoid hypoglycaemia. Learn more at www.mdiabetes.gouv.sn

171

mDiabetes: The three levels of the diabetes-treatment pyramid are: diet, exercise and medication. Two of them are up to you... take control of your health! Get the facts from your doctor or the Senegalese Association to Support People with Diabetes (ASSAD). Learn more at www.mdiabetes.gouv.sn

293

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn.

85

mDiabetes: Did you find these messages helpful? If so, you’ll also receive nutrition support information in March. Or you can unsubscribe by calling XXXXXXX or going to www.mdiabete.gouv.sn

189

Senegal: mDiabetes, mFootCare group

First message

mDiabetes: You will receive a series of messages to help you control your diabetes and take care of your feet. More detailed information and advice is available at www.mdiabete.gouv.sn

185

Senegal: mDiabetes, mFootCare group

Week 1

mDiabetes: No one chooses to have diabetes, but you can choose to do what it takes to control it. Get informed about diabetes.

126

mDiabetes: Diabetes occurs when your muscles have trouble using the sugar you ingest. That means sugar stays too long in the blood, which can damage various organs as well as your feet.

185

mDiabetes: Over time, uncontrolled diabetes can cause nerve damage (neuropathy) and blocked arteries (arterial disease), particularly in the legs and feet. Learn how to prevent this.

182

mDiabetes: Nerve damage causes deformity and lack of sensitivity in the feet. The danger is that you might hurt yourself without realizing it.

142

mDiabetes: 80% of diabetes-related amputations are avoidable through simple preventive techniques.

98

mDiabetes: Stay in shape and avoid complications by inspecting your feet every day and keeping your blood sugar and blood pressure under better control.

152

See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: important to-dos.

104

Senegal: mDiabetes, mFootCare group

Week 2

mDiabetes: Diabetes makes your feet vulnerable. You need to protect them from any injury, even a small or painless one.

119

mDiabetes: Never walk barefoot, even in the house or on the beach. Avoid open-toed sandals. Closed shoes that are roomy and soft provide the best protection.

157

mDiabetes: Use a pumice stone on your feet every day to reduce hyperkeratosis and the risk of open sores that might get infected.

129

mDiabetes: After bathing, dry thoroughly between your toes and apply a pH-neutral lotion on the heels and soles of your feet, but never between the toes.

153

mDiabetes: Important: Always file your toenails rather than using cutters or scissors, which can make you bleed and potentially lead to infection.

146

mDiabetes: Inspect and touch your feet every day, noting any change in colour or temperature. Make sure there are no open sores, even small ones.

145

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: necessary precautions.

120

Senegal: mDiabetes, mFootCare group

Week 3

mDiabetes: Before putting your shoes on, feel to see that there is nothing inside the shoe that could hurt your feet. Remember, your feet are vulnerable.

153

mDiabetes: Prevent burns by not walking on hot surfaces, washing your feet in hot water or putting them too close to a fire. Nerve damage stops you feeling pain, which can lead to serious burns.

194

mDiabetes: If you have trouble trimming your toenails or removing calluses, ask for help. Never use sharp objects or chemical corn-removers on your feet.

153

mDiabetes: Inspect the soles of your feet carefully with your hand and in a mirror, or show them to someone in order to detect sores early.

139

mDiabetes: Nerve damage makes your skin dry. Apply hydrating lotion to your feet every evening and avoid products like henna that dry out the skin.

147

mDiabetes: The shoes you wear have a big impact on foot health. There are special shoes designed to protect the feet of people with diabetes.

141

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: first-aid tips.

113

Senegal: mDiabetes, mFootCare group

Week 4

mDiabetes: Open sore on your foot? Carefully wash the foot, including the sore, with soap and water. Rinse thoroughly. Do not apply cream – only gauze.

152

mDiabetes: Make sure nothing rubs against your sore, so that it can heal. It is very important that you consult a doctor.

121

mDiabetes: If the sore is on the sole of your foot, you must put a special insole in your shoe to protect it. Walk as little as possible.

137

mDiabetes: If the sore hasn’t healed after a few days, take a photo and ask your doctor to send it to a foot specialist. Take advantage of convenient remote-diagnosis options.

175

mDiabetes: Important: each time you touch an open sore, be careful to wash your hands afterwards. Avoid spreading germs.

120

mDiabetes: Remember that 80% of amputations are avoidable if you check your feet regularly and carefully treat even the smallest cuts.

134

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: medical monitoring.

116

Senegal: mDiabetes, mFootCare group

Week 5

mDiabetes: Have your doctor check the level of nerve damage in your feet. The more severe the damage, the more careful you should be, even about the smallest sore.

163

mDiabetes: Diabetes patients should have their feet examined at every check-up. This should be done regularly. Discuss it with your doctor.

140

mDiabetes: Ask your doctor about the extent of your nerve damage, and follow all recommendations given during check-ups. Prevention is key.

139

mDiabetes: Your blood sugar must be stable for your feet to heal properly. Your doctor should check your glycated haemoglobin (HbA1c).

134

mDiabetes: Your circulation (blood flow) must also be good for your feet to heal. Your doctor should check your blood pressure.

127

mDiabetes: Remember that 80% of amputations are avoidable if you watch out for your feet and follow your doctor’s recommendations.

130

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: controlling your diabetes.

123

Senegal: mDiabetes, mFootCare group

Week 6

mDiabetes: Ideally, your blood sugar should never be over 1.2 g/L before breakfast or 1.8 g/L two hours after a meal.

118

mDiabetes: Ideally, your glycated haemoglobin (HbA1c) – which gives an overall picture of your blood-sugar levels over 3 months – should be under 7%.

150

mDiabetes: Eating too much grain or starch, skipping medication or getting an infection can all raise your blood pressure. Learn to recognize the signs of hyperglycaemia.

171

mDiabetes: If your blood sugar is too high, you might urinate frequently, have a dry mouth or feel thirsty and tired. You should see a doctor URGENTLY.

152

mDiabetes: Too much fat and sugar in your diet and too little exercise can make diabetes worse. Stay in shape and avoid the complications of diabetes by adopting a healthy lifestyle.

182

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn.

85

Senegal: mDiabetes, mFootCare group

Final message

mDiabetes: Did you find these messages helpful? If so, you’ll also receive nutrition support information in March. Or you can unsubscribe by calling XXXXXXX or going to www.mdiabete.gouv.sn

189

Senegal: mDiabetes, mTraining group (health care professionals)

First message

mDiabetes: You are going to receive a series of text messages to help you prevent diabetes and its complications. More information and detailed recommendations are available at www.mdiabete.gouv.sn

198

Senegal: mDiabetes, mTraining group (health care professionals)

Week 1

mDiabetes: Definition of diabetes: Chronic hyperglycaemia due to defects in insulin secretion and/or action, caused by hereditary and/or environmental factors. Learn more at www.mdiabete.gouv.sn

194

Definition, diagnosis, classification

mDiabetes: Patients over 45 years should be screened systematically, especially if they have a family history of diabetes, overweight, mother of a macrosomic baby, multiple miscarriages, high blood pressure or dyslipidaemia. Learn more at www.mdiabete.gouv.sn

259

Definition, diagnosis, classification

mDiabetes: Consider diagnosing diabetes if the patient has classical symptoms: frequent urination, excessive thirst, increased appetite, weight loss and/or nerve damage, foot lesions, cataracts. Learn more at www.mdiabete.gouv.sn

229

Definition, diagnosis, classification

mDiabetes: The diagnosis is confirmed by fasting blood sugar ³ 1.26 g/L in two tests or ³ 2.0 g/L at any point combined with classical symptoms. Learn more at www.mdiabete.gouv.sn

179

Definition, diagnosis, classification

mDiabetes: People with type 1 diabetes produce insufficient insulin and diabetes is often diagnosed before they reach 30 years; people with type 2 diabetes are often overweight adults with high blood pressure. Learn more at www.mdiabete.gouv.sn

244

Definition, diagnosis, classification

mDiabetes: Gestational diabetes first appears during pregnancy. Fasting blood sugar is ³ 0.92 g/L or glucose tolerance test (in 6th month) shows ³ 1.8 g/L 1 hour after eating or ³ 1.53 g/L after 2 hours. Learn more at www.mdiabete.gouv.sn

238

Definition, diagnosis, classification

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: example clinical situations.

125

Definition, diagnosis, classification

Senegal: mDiabetes, mTraining group (health care professionals)

Week 2

mDiabetes: Young patient with intense polyuria, polyphagia, extreme weight loss with or without weakness. Hyperglycaemia (blood sugar > 2.5 g/L), with or without ketonuria. Probably type 1 diabetes. Learn more at www.mdiabete.gouv.sn

233

Examples of clinical situations

mDiabetes: Polyuria, polydipsia, weight loss, lack of appetite and stomach pains; blood sugar > 2.5 g/L and ketonuria. Warning: ketoacidosis. Learn more at www.mdiabete.gouv.sn

176

Examples of clinical situations

mDiabetes: Adult patient with moderate polyuria and polyphagia, overweight or moderate weight loss. Fasting blood sugar is 2.0 g/L. Probably type 2 diabetes. Learn more at www.mdiabete.gouv.sn

192

Examples of clinical situations

mDiabetes: Adult patient with no symptoms but risk factors (family history, overweight, high blood pressure). Fasting blood sugar is 2.0 g/L during screening. Probably type 2 diabetes. Learn more at www.mdiabete.gouv.sn

219

Examples of clinical situations

mDiabetes: Adult with possible complications (e.g. infection, nerve damage, impotence, foot lesions, cataracts) and high fasting blood sugar. Probably type 2 diabetes. Learn more at www.mdiabete.gouv.sn

202

Examples of clinical situations

mDiabetes: Female patient with history of gestational diabetes and/or macrosomic infant and miscarriages. Overweight and/or classical symptoms. High fasting blood sugar. Probably type 2 diabetes. Learn more at www.mdiabete.gouv.sn

230

Examples of clinical situations

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: evaluating and monitoring diabetes.

132

Examples of clinical situations

Senegal: mDiabetes, mTraining group (health care professionals)

Week 3

mDiabetes: First steps: check patient’s blood sugar, rule out secondary diabetes, classify as type 1 or 2, and look for related complications and disorders. Learn more at www.mdiabete.gouv.sn

191

initial management: evaluation and monitoring

mDiabetes: Normal fasting blood sugar is 0.8–1.0 g/L. Should aim for glycated haemoglobin (reflects blood glucose levels over 3 months) of < 7%. Learn more at www.mdiabete.gouv.sn

179

initial management: evaluation and monitoring

mDiabetes: Significant weight loss with or without pancreatitis or hyperglycaemic endocrinopathy (e.g. Cushing syndrome, hyperthyroidism) may indicate secondary diabetes. Learn more at www.mdiabete.gouv.sn

205

initial management: evaluation and monitoring

mDiabetes: Secondary diabetes or other hard-to-classify cases should be referred to a specialist before beginning treatment. Learn more at www.mdiabete.gouv.sn

159

initial management: evaluation and monitoring

mDiabetes: Check for complications like nerve damage or moderately increased albuminuria; perform serum creatinine and clearance tests (MDRD), electrocardiography and eye and dental exams. Learn more at www.mdiabete.gouv.sn

223

initial management: evaluation and monitoring

mDiabetes: Check for related disorders: blood pressure ³ 140/90; body mass index > 25 = overweight, body mass index > 30 = obese; total cholesterol ³ 2.0 g/L and/or HDL < 0.35 g/L and/or LDL > 1.3 g/L. Learn more at www.mdiabete.gouv.sn

236

initial management: evaluation and monitoring

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: starting treatment.

116

initial management: evaluation and monitoring

Senegal: mDiabetes, mTraining group (health care professionals)

Week 4

mDiabetes: Educate your patient: calm any fears, start a dialogue and support his or her acceptance of the illness and participation in and adherence to treatment and follow-up. Learn more at www.mdiabete.gouv.sn

212

Treatment: educating the patient

mDiabetes: Financial constraints, eating habits and the options available should be considered in planning the diet. Explain what should be avoided or forbidden and how to balance quality and quantity at family meals. Learn more at www.mdiabete.gouv.sn

252

Treatment: educating the patient

mDiabetes: A balanced diet = 50% carbohydrates, 30% fats and 20% protein. Food groups: 1 – grains and pasta, 2 – meat, fish and eggs, 3 – vegetables, 4 – fruit, 5 – milk and dairy. Learn more at www.mdiabete.gouv.sn

215

Treatment: educating the patient

mDiabetes: The diet should be nutritious, adapted to local customs, personalized and discussed with the patient. Normal calorie content if patient is normal or underweight, low calorie content if overweight or obese. Learn more at www.mdiabete.gouv.sn

251

Treatment: educating the patient

mDiabetes: Regular physical exercise and a diet plan help stabilize blood sugar, reduce other risk factors and prevent weight gain. Learn more at www.mdiabete.gouv.sn

166

Treatment: educating the patient

mDiabetes: Adapt the exercise plan to the patient’s environment, tastes and state of health. The patient should gradually work up to 30 minutes of endurance training each day. Learn more at www.mdiabete.gouv.sn

210

Treatment: educating the patient

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn. Next week: insulin therapy.

113

Treatment: educating the patient

Senegal: mDiabetes, mTraining group (health care professionals)

Week 5

mDiabetes: The two main types of diabetes medication are synthetic insulin and oral medications. New treatments include those based on incretin.

145

Treatment: insulin therapy

mDiabetes: In Senegal, regular rapidly acting insulin brands are available (e.g. Actrapid, Insulet Rapide). Duration: 6–8 hours; thrice-daily subcutaneous injection before meals.

178

Treatment: insulin therapy

mDiabetes: Intermediate-acting insulin (e.g. Insulatard, Insulet Lente) have a duration of 12–16 hours; twice-daily subcutaneous injections before meals.

153

Treatment: insulin therapy

mDiabetes: Pre-mixed insulin treatments (intermediate- and rapidly acting, e.g. Mixtard 30, Insulet Mix’30, Novomixt 30) require twice-daily subcutaneous injections before meals.

178

Treatment: insulin therapy

mDiabetes: Calculate the beginning daily dose of rapidly acting insulin: 0.6–0.8 units per kg of body weight. Adjust from 2 units to 2 units every 2 days until normoglycaemia.

175

Treatment: insulin therapy

mDiabetes: A dose of intermediate-acting or pre-mixed insulin corresponds to two thirds of a rapidly acting dose (e.g. 30 units of rapidly acting = 20 units of long-acting).

173

Treatment: insulin therapy

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn.

85

Treatment: insulin therapy

Senegal: mDiabetes, mTraining group (health care professionals)

Week 6

mDiabetes: Types of oral medication for type 2 diabetes: biguanides, sulfonylureas, meglitinides, alpha-glucosidase inhibitors and DPP-4 inhibitors

147

Treatment: oral medications

mDiabetes: Metformin (e.g. Glucophage) is a biguanide that increases sensitivity to insulin. Digestive side-effects. Increase dose gradually from 500 to 2000 mg.

161

Treatment: oral medications

mDiabetes: Biguanides can be prescribed as a first-line treatment if diet and exercise prove insufficient in regulating blood glucose after 3–6 months.

151

Treatment: oral medications

mDiabetes: Sulfonylureas are a second-line treatment that stimulates insulin secretion. Examples: glimepiride (1–4 mg/day), glipizide (30–120 mg/day).

150

Treatment: oral medications

mDiabetes: DPP-4 inhibitors stimulate insulin secretion. Both DPP-4 inhibitors and sulfonylureas can be combined with metformin: precombined therapies are available.

165

Treatment: oral medications

mDiabetes: Insulin therapy is essential for type 1 diabetes. It may be necessary for type 2 diabetes – alone or combined with metformin – if a combination of oral medications proves ineffective.

194

Treatment: oral medications

mDiabetes: See this week’s messages and get more information at www.mdiabete.gouv.sn.

85

Treatment: oral medications

Senegal: mDiabetes, mTraining group (health care professionals)

Final message

mDiabetes: Did you find these messages helpful? If so, you’ll also receive nutrition support information in March. Or you can unsubscribe by calling XXXXXXX or going to www.mdiabete.gouv.sn

189

Annex 2. mDiabetes message content in India

Overview

Ramachandran et al. (2006) found that lifestyle modifications can prevent diabetes in Indian populations, even though the target population was leaner, more insulin-resistant and with an onset of diabetes 10 years earlier than western men (Mohan et al., 2007). A similar randomized controlled trial of 2 years’ duration among 537 Asian Indian men with pre-diabetes found that mobile phone messaging was an acceptable method for delivering advice and support for lifestyle modification to prevent type 2 diabetes (Ramachandran, 2013). The trial was the first to show the benefit of this technology in the prevention of diabetes, with a 36% reduction in relative risk as compared with standard care within 2 years. A further pilot study of 1 year’s duration among 200 patients with type 2 diabetes in the clinic showed that mobile phone messages about the principles of diabetes management helped to improve health care outcomes. HbA1c values and plasma lipids improved significantly in the intervention group as compared with those who had standard care (Shetty, 2011). The messages listed below are from Ramachandran et al. (2013).

Programme

Time
frame

Message

Character
count

Category

India mDiabetes:
Ramachandran

Eat healthy, be healthy and happy.

50

Dietary advice

Too much of anything is bad.

44

Dietary advice

Regular eating pattern helps you to maintain normal blood sugar.

80

Dietary advice

Starchy foods and oils can be taken in moderation.

66

Dietary advice

Do not skip any meal.

37

Dietary advice

Monitor your weight regularly.

46

Dietary advice

Monitor your weight at least once a month and keep a record of it.

82

Dietary advice

Maintain your body weight by eating right and exercising daily.

79

Dietary advice

Fruits have antioxidants, vitamins, minerals that are essential for a healthy life.

99

Dietary advice

Avoid snacks while watching TV. You may overeat.

61

Dietary advice

Take timely food and avoid overeating.

51

Dietary advice

Intake of fruits is the best natural protection against high BP and high cholesterol and thereby prevents heart disease.

133

Dietary advice

Avoid sweets and sugars in any form, as they increase your blood sugar.

84

Dietary advice

Take three meals a day with healthy snacks in between.

67

Dietary advice

Starchy and oily foods should be consumed in moderation.

69

Dietary advice

Increase fibre-rich foods such as fruits, vegetables, whole cereals, grains and pulses.

100

Dietary advice

Sugar substitutes can be used in place of direct sugar.

68

Dietary advice

Do not skip any meal; you may overeat at the next meal.

68

Dietary advice

Make your plate colourful by adding lots of vegetables.

68

Dietary advice

Eat one fruit daily as a snack not along with the meal.

68

Dietary advice

Avoid overeating at any meal.

42

Dietary advice

Adequate amount of low-fat milk and milk products builds healthy bones.

84

Dietary advice

Use minimum oil for cooking.

41

Dietary advice

Prefer fish or chicken to beef, mutton or pork.

60

Dietary advice

Prefer boiled, grilled, baked fish or chicken to fried ones.

73

Dietary advice

Reduce use of coconut in foods.

44

Dietary advice

Avoid any form of sugar: sweets, jaggery, honey, jam, jelly, chocolates and ice-cream.

99

Dietary advice

Small frequent feeds every 3-4 hours are good.

59

Dietary advice

Have a cup of tea, coffee, milk or a light snack before doing any exercise.

88

Dietary advice

Cereals such as rice, wheat, jowar, bajra, ragi and oats should be taken in limited quantities.

108

Dietary advice

Three light meals and a snack in between help to maintain blood sugar.

83

Dietary advice

Fruits are delicious and nutritious; include them as part of your diet, not along with food.

105

Dietary advice

Make your diet plate colourful with green leafy vegetables and fruits.

83

Dietary advice

Garnish your food plate with colourful vegetables and fruits; relish it.

85

Dietary advice

Your plate will be colourful and tempting with raw vegetables and fruits, try it.

94

Dietary advice

Take six split servings instead of three big servings of food.

75

Dietary advice

Have a healthy meal always.

40

Dietary advice

Use sugar-free substitutes in moderate quantities.

63

Dietary advice

Nuts are good for your heart.

42

Dietary advice

Regular intake of 8 to 10 nuts a day is good for the heart.

72

Dietary advice

Avoid sweets and sugars in any form to keep blood glucose at normal levels.

88

Dietary advice

Take fruits as a whole and not as juice.

53

Dietary advice

A meal with cereals, dhal, vegetables and milk products is a complete meal.

88

Dietary advice

Moderate dose of tea or coffee can stimulate mental performance but can cause ill effects in large doses.

118

Dietary advice

Porridges and starchy vegetables such as potato and tapioca increases blood sugar rapidly.

103

Dietary advice

Skipping breakfast will make you overeat at lunch.

63

Dietary advice

Avoiding sweets and sugars in any form is a tool to prevent diabetes.

82

Dietary advice

Avoid sweets and sugars in any form to keep blood sugar at normal level.

85

Dietary advice

Fried items can increase cholesterol levels.

57

Dietary advice

Avoid fried and salty foods.

41

Dietary advice

Fibre-rich fruits and vegetables prevent rise in blood sugar.

74

Dietary advice

Soft drinks, sherbets, malted drinks etc. have invisible sugar.

76

Dietary advice

Eat fibre-rich vegetables and fruits and enjoy better health.

74

Dietary advice

Tea and coffee contain caffeine. Take these in moderate quantities.

80

Dietary advice

Too much caffeine present in coffee increases blood pressure.

74

Dietary advice

Healthy diet is essential; relish your food.

57

Dietary advice

Drink water when you feel like drinking beverages.

64

Dietary advice

Avoid snacks with meals as they impair digestion and lead to loss of appetite.

91

Dietary advice

Junk food is not healthy; avoid it.

48

Dietary advice

Oats, beans and green vegetables have plenty of food fibre.

73

Dietary advice

Eat foods such as whole grains, oats, lentils, beans, apples and raw vegetables that release their sugar content slowly.

133

Dietary advice

Eat protein with every meal or snack. Whole grains, brown rice, dhal and chicken are good sources of protein.

122

Dietary advice

Eat fish such as salmon, mackerel and herring three times a week, and pumpkin or flax seeds, for their omega 3 essential fatty acids.

146

Dietary advice

Eat plenty of fruits and vegetables.

49

Dietary advice

Green tea is good to control your blood sugar.

59

Dietary advice

Lose extra weight; a moderate weight loss of 7% may reduce diabetes risk.

86

Dietary advice

Cut fat and extra calories in the diet; it will help to lose weight.

82

Dietary advice

Include plenty of fibre-rich foods; 14 g of dietary fibre for every 1000 calories are recommended.

111

Dietary advice

Go for whole grains, which are rich in nutrients and fibre.

72

Dietary advice

Avoid alcohol, which increases the risk of developing diabetes.

76

Dietary advice

Drinking alcohol mixed with sugared soda or cola increases blood sugar.

84

Dietary advice

Control emotional eating (joy or stress).

54

Dietary advice

Emotional eating is habitual; get the support of your family to avoid it.

86

Dietary advice

Eat raw vegetables when you feel like eating something.

68

Dietary advice

Many raw vegetables are crunchy and can help the urge to chew or crunch something.

95

Dietary advice

Control your emotions such as joy or stress, which may lead you to overeat.

88

Dietary advice

Emotions such as stress, depression, anger or joy make you overeat. Avoid them.

92

Dietary advice

It is healthier to eat real foods rather than sugar-free or no-sugar-added foods.

94

Dietary advice

It is attitude that matters to change your lifestyle.

66

Dietary advice

Snacks should be small. Do not store junk foods; you may tend to consume them.

91

Dietary advice

Eating junk foods! Associated with hypertension and heart diseases.

80

Dietary advice

Be aware that high-calorie foods are prepared and consumed during holiday weekends, celebrations and festivals.

124

Dietary advice

Snacking or munching is entirely preventable.

58

Dietary advice

White turkey meat is lower in fat, higher in protein and higher in B vitamins than dark turkey meat.

113

Dietary advice

If you desire to live a healthy lifestyle, you can do it. You are worth it.

88

Dietary advice

Fruits are low in calories, fat-free, high in fibre and rich in vitamins A and C.

94

Dietary advice

Vegetables are fat-free, cholesterol-free, rich in vitamins and high in fibre.

91

Dietary advice

Red wine (5 mL only) is high in heart-healthy antioxidants. Pay attention to consumption.

102

Dietary advice

Greens are low in calories, rich in vitamins and high in fibre.

77

Dietary advice

Spinach is low in calories, high in vitamins A and K and high in fibre.

84

Dietary advice

Green beans are low in calories, high in vitamins C and K and high in fibre.

89

Dietary advice

Green peas are high in vitamins C and K and high in fibre.

71

Dietary advice

Cinnamon controls blood sugar.

43

Dietary advice

Cinnamon reduces the risk of diabetes.

51

Dietary advice

Food is to be enjoyed in moderation.

49

Dietary advice

Learn to enjoy food in moderation.

47

Dietary advice

Move away from people who overeat.

47

Dietary advice

On a holiday, enjoy foods in moderation, and be physically active.

80

Dietary advice

Salt intake in moderate amount is good for health.

63

Dietary advice

High and low levels of salt intake lead to health problems.

71

Dietary advice

Moderate salt intake is associated with the lowest risk of cardiovascular events.

92

Dietary advice

High intake of salt is associated with increased risks of stroke, heart attack and other heart diseases.

115

Dietary advice

A moderate intake of salt controls blood pressure.

61

Dietary advice

Replace white bread with brown, whole-grain bread.

61

Dietary advice

Replace butter, cheese and mayonnaise with unsaturated fat from avocados, olive oil, nuts and vegetable oil.

119

Dietary advice

Healthy diet pattern prevents diabetes and heart disease even without weight loss.

93

Dietary advice

Nuts such as badam, pista, almond and walnut are rich in essential fatty acids, which are good for health.

117

Dietary advice

Nuts such as badam, pista, almond and walnut are good for health when taken in moderate amounts.

107

Dietary advice

Sweet potatoes, pumpkin and carrots are fat-free, rich in vitamins A and C and high in fibre.

104

Dietary advice

Reduce the intake of refined carbohydrates such as white bread and pasta.

84

Dietary advice

Low carbohydrate and high protein helps in weight loss.

66

Dietary advice

Amount of carbohydrate eaten at each meal is important

65

Dietary advice

Whole grains and cereals are beneficial in weight management.

72

Dietary advice

45–60 g of carbohydrate per meal are good for weight management and diabetes prevention.

99

Dietary advice

Complex carbohydrate such as rice, ragi and wheat in moderate quantities delay digestion and help in regulating blood sugar level.

141

Dietary advice

Carbohydrate should be 40–55% of total calories, with the rest as protein and fibre.

95

Dietary advice

Carbohydrate content of a weight-losing diet may range from 100 to 200 g/day.

88

Dietary advice

If you are overweight or obese, reduce 7% of your total weight.

74

Dietary advice

Fibre-rich foods are good for health and slow the rise in blood sugar.

81

Dietary advice

Fibre slows stomach emptying, keeping a sense of fullness longer.

76

Dietary advice

Intake of food fibre reduces cholesterol and risk of diabetes and heart disease.

91

Dietary advice

The benefit of protein is high when dieting.

55

Dietary advice

Use olive oil, nuts and fish to add more unsaturated fats to your diet.

82

Dietary advice

Eat a light snack before exercise.

45

Dietary advice

Drink a cup of tea, coffee, milk or any other liquid before you start doing any exercise.

100

Dietary advice

Never skip any meals.

32

Dietary advice

Have three light meals a day and two or three healthy snacks in between.

83

Dietary advice

The meal plan should be at least three meals a day and a snack in between meals.

91

Dietary advice

Don’t let anyone tell you not to eat fruit; it’s a natural antioxidant.

82

Dietary advice

Fruits are rich in fibre, vitamins and minerals, which are good for health.

86

Dietary advice

Eat the fruit, not as juice.

39

Dietary advice

Did you know, fruits help in preventing cancer, eye diseases and circulatory problems.

97

Dietary advice

There are lots of low-calorie vegetables; add those to your diet.

76

Dietary advice

Vegetables are rich in vitamins, minerals, fibre and antioxidants and very low in calories and carbohydrates.

120

Dietary advice

Fill half your plate with vegetables, one fourth of your plate with protein and the rest with cereals.

113

Dietary advice

Include high-protein snacks like sprouts and sundal instead of fried items like bajji bonda or chaat.

112

Dietary advice

Soya beans, tofu and soya milk are excellent vegetable sources of protein.

85

Dietary advice

Avoid reusing the same oil for frying foods.

55

Dietary advice

Consume consistent protein from staple foods like rice or wheat at every meal.

89

Dietary advice

A mixed meal is better than a mono meal.

51

Dietary advice

White foods such as rice, milk, salt and sugar should be taken in limited amounts.

93

Dietary advice

A cereal–pulse combination in the ratio of 3:1 is beneficial in providing essential amino acids; e.g. idli and pongal.

129

Dietary advice

Vegetables should be taken in plenty to reduce weight.

65

Dietary advice

Metabolism of food and exercise both require the support of fluids; hence, drink more water.

103

Dietary advice

Drinking 2–2.5 L of water per day is good.

53

Dietary advice

Sugar or sweets do not cause diabetes. It’s the calories present in sugar and sweets that trigger diabetes.

118

Dietary advice

Eat at least one fruit a day.

40

Dietary advice

Oranges are always good for health, rich in vitamin B and C and a very good source of folic acid.

108

Dietary advice

Oranges are rich in vitamins B and C, which improves the body’s resistance to stress.

96

Dietary advice

Apple, broccoli, fish, whole grains, nuts, soya beans, olive oil, chillies, cinnamon and garlic help in reducing blood sugar.

136

Dietary advice

Cutting down sugary drinks and snacks will reduce food craving in general and help to reduce your blood sugar level.

127

Dietary advice

Green tea helps to reduce weight.

44

Dietary advice

Green tea helps to reduce weight, helps to restore health and strengthens immunity.

94

Dietary advice

Strawberry is helpful in reducing weight to a great extent.

71

Dietary advice

Strawberries stimulate metabolism and suppress appetite.

67

Dietary advice

Include vegetables in every meal.

44

Dietary advice

If you can control what you eat, you will be much better off.

72

Dietary advice

Avoid buying crunchy and salty foods.

49

Dietary advice

Eat your snacks and meals sitting down; it reduces mindless eating.

78

Dietary advice

Make your lifestyle more active with a hobby that promotes movement, and you will enjoy time.

104

Dietary advice

Drink 2–2.5 L of water.

36

Dietary advice

Eat smaller servings by using a smaller plate or filling half the plate with vegetables.

99

Dietary advice

Although you really like fried foods, have those treats for special occasions.

89

Dietary advice

Check your body weight once a month and keep a record of it.

71

Dietary advice

If you intend to change your lifestyle, be sure you can live with whatever you decide to change.

107

Dietary advice

Make your own diet plan that you can live with.

58

Dietary advice

Think of healthier alternative foods that you might choose instead of high-calorie food.

99

Dietary advice

India mDiabetes:
Ramachandran

Walk for 20–30 minutes a day.

45

Physical activity

Walking is a simple, easy, beneficial and effective physical activity.

86

Physical activity

Regular walking keeps you healthy and fit; enjoy walking.

73

Physical activity

Exercise helps to reduce the risk of heart disease.

67

Physical activity

Physical activity helps to maintain normal blood sugar and blood pressure.

90

Physical activity

Obesity is a major risk factor for several diseases like diabetes, heart diseases and stroke.

109

Physical activity

Lifestyle modification enhances quality of life.

64

Physical activity

Good health improves quality of life.

53

Physical activity

An active life lets you live longer.

52

Physical activity

Physical activity is good for your heart.

54

Physical activity

Moderate, but regular physical activity and healthy eating habits are keys to good health.

103

Physical activity

Moderate physical activity keeps you healthy.

58

Physical activity

Feeling bored? Go for a walk, and enjoy it. It is good for health.

79

Physical activity

Desk-bound job? Take a short walk to relax your body and mind.

75

Physical activity

Physical and mental exercises would improve your health.

69

Physical activity

Do regular physical activity; go for 2.5-hours walk per week.

74

Physical activity

Keep telling yourself that I can do this, I can walk, I can reduce weight.

87

Physical activity

Identify behaviour that triggers unhealthy habits; avoid them.

75

Physical activity

Avoid situations that trigger a change in your healthy lifestyle.

78

Physical activity

You are responsible for your own behaviour.

56

Physical activity

A break in your routine healthy behaviour may lead to withdrawal from healthy lifestyle.

101

Physical activity

Weekend is meant only to relax from job not from healthy lifestyle.

80

Physical activity

Nothing will happen unless you take the step to change.

68

Physical activity

Change won’t happen overnight; it is a process that happens day by day.

85

Physical activity

If you desire to live a healthy lifestyle, you can do it.

70

Physical activity

If watching TV triggers eating, limit your time of TV watching.

76

Physical activity

TV watching leads to physical inactivity; you may be eating as well.

82

Physical activity

Standing is also a form of exercise.

49

Physical activity

Standing and watching TV is better than sitting and watching TV.

77

Physical activity

Watch TV while walking on a treadmill or cycling on a static cycle.

81

Physical activity

Go for a small walk during commercial break.

57

Physical activity

Walk a few yards during commercial break.

54

Physical activity

Inactivity is nothing but you sitting doing nothing.

65

Physical activity

Physical activity will burn calories.

50

Physical activity

Exercise builds and strengthens muscles.

53

Physical activity

Physical activity burns calories and helps to lower your blood sugar.

82

Physical activity

Hypertension is often associated with diabetes and heart disease.

79

Physical activity

Excess salt intake increases blood pressure. Blood pressure is associated with diabetes and heart diseases.

121

Physical activity

Obesity is a strong risk factor for type 2 diabetes.

65

Physical activity

Physical inactivity is a major contributor for diabetes.

69

Physical activity

A sedentary lifestyle combined with high-calorie intake is a double dose of poison.

96

Physical activity

Desk-bound job? Must go for a walk.

49

Physical activity

Keep yourself active while working.

48

Physical activity

Diabetes is a not always accompanied by symptoms such as excessive thirst, hunger, frequent urination, weight loss and non-healing of wounds.

154

Physical activity

Diabetes is a preventable disease with adequate lifestyle modifications.

85

Physical activity

Diabetes can be prevented or postponed by a healthy lifestyle such as regular exercise and healthy diet.

117

Physical activity

Love to watch TV? Less than 10 hours per week.

59

Physical activity

Identify ways that you could exercise and the number of times that you could exercise.

100

Physical activity

Make exercise the priority.

40

Physical activity

Always have alternative exercise for varying conditions.

69

Physical activity

On a holiday, don’t engage in watching TV, movie or computer; prefer to walk or play outdoor games.

112

Physical activity

Physical activity is something to be done everyday.

64

Physical activity

In case it is too cold outside, walk inside the house.

67

Physical activity

If it’s raining or cold outside, climb stairs inside the house.

76

Physical activity

Concentrate only on the positives you receive from the new lifestyle; do not dwell on what you are giving up.

122

Physical activity

Concentrate on exercise that is helpful in weight management.

74

Physical activity

Walking, jogging and swimming are the best exercise for weight management.

87

Physical activity

Exercise is the key for healthy life.

50

Physical activity

Swimming helps to burn calories and helps you to lose weight as well.

83

Physical activity

Happiness is a habit; we have the power to create our own happiness.

81

Physical activity

Neither fast nor feast; eat a limited, balanced diet.

66

Physical activity

Idle young man becomes unhappy old man; be active always.

70

Physical activity

Nothing is impossible to a willing heart.

54

Physical activity

Avoid stress and be happy.

39

Physical activity

Too much stress or tension can affect health; he who laughs last!

78

Physical activity

A good exercise can keep your mind fresh.

54

Physical activity

Use stairs instead of lift.

40

Physical activity

Get off the bus one or two stops ahead, and walk to your destination.

82

Physical activity

Park you vehicle at the far end of the parking area, and walk to your destination.

95

Physical activity

Walk to the place of worship or market that is close by.

69

Physical activity

Brisk walk for 30 minutes a day keeps you healthy.

63

Physical activity

Include walking or cycling as part of the daily routine while going to market, place of worship or even to your office.

132

Physical activity

Physical activity builds muscles, improves blood supply and improves metabolism.

93

Physical activity

Physical activity gives you deep sleep, increases mental efficiency and makes you feel fresh.

106

Physical activity

Physical activity improves blood circulation and strengthens heart and lungs.

90

Physical activity

Exercise should not be strenuous to make you feel tired.

70

Physical activity

Choose a form of exercise that suits your interest.

64

Physical activity

Physical and mental exercises are activities performed for bettering yourself.

91

Physical activity

Actively use your body muscle for some task, walking, jogging, running, cycling, skipping, swimming, lifting weights or stretching.

144

Physical activity

Physical activity can reduce stress and stress-related diseases.

77

Physical activity

The only way to stop smoking is not to start it.

61

Physical activity

Strenuous exercises may cause muscle stiffness and should be avoided.

82

Physical activity

Stretching, flexing, exerting, relaxing and moving keep both your body and mind fresh and healthy.

111

Physical activity

All you need is 30 minutes of moderate physical activity on most days of the week.

95

Physical activity

Relaxation techniques help in metabolic control.

61

Physical activity

Drink something after good exercise.

49

Physical activity

Hope it has been a healthy week.

45

Physical activity

Physical activity helps proper digestion.

54

Physical activity

Be relaxed; anger is never without a reason, but seldom with a good ones.

86

Physical activity

A good exercise can keep your mind fresh.

54

Physical activity

The key to relaxing your body is to focus on the physical sensation of relaxation.

95

Physical activity

Were there many missed walks this month?

53

Physical activity

Are you stressed out? Stress increases blood sugar; go for a walk and relax.

89

Physical activity

Physical activity helps to reduce, control or maintain your body weight.

85

Physical activity

Mental agitation can affect health. Hope enables endurance of physical and mental hardship.

104

Physical activity

India mDiabetes:
Ramachandran

Quit smoking; within 24 hours of quitting, your nerve endings start re-growing, which leads to enhanced ability to smell and taste.

147

Smoking

Quit smoking, breath healthily, and live happily.

65

Smoking

Smoking increases your blood pressure; avoid smoking.

70

Smoking

Quitting smoking makes one happy and healthy.

61

Smoking

If one person smokes, the whole family may get cancer; quit smoking.

84

Smoking

Smoking INJURES you health. No smoking INSURES your health.

75

Smoking

Smoking ENDURES poor health. No smoking ENSURES good health.

76

Smoking

Smoking TORTURES your health. No smoking NURTURES your health.

78

Smoking

Smoking ENDS your life. No smoking MENDS your health.

69

Smoking

Smoking SCARES your health. No smoking CARES your health.

70

Smoking

Smoking IMPAIRS poor health. No smoking IMPROVES your health.

74

Smoking

Quit smoking. By smoking, you develop wrinkles around your eyes and mouth much earlier and stains in your tooth and fingers.

137

Smoking

Alcohol and smoking can ruin you; avoid them.

58

Smoking

Avoid smoking and alcohol; don’t love anything at the cost of your health.

87

Smoking

Avoid smoking and excess alcohol; don’t nourish the cause today to get the effect tomorrow.

104

Smoking

India mDiabetes:
Ramachandran

Crash dieting is not good for health as it lacks many vital nutrients.

86

General Health

Drink a glass of water on an empty stomach when you wake up. This will make you feel more alert.

112

General Health

To reduce your stress level, meditate for 15-20 minutes daily. Meditation will also restore your body to a calm state.

134

General Health

To cut calories when eating out in a restaurant, order salad as an appetizer.

93

General Health

Choose fresh fruit instead of fruit juices. Fruit juices contain lots of sugar.

95

General Health

Exercising is not only to lose weight, but also for relieving stress.

85

General Health

Eat without distractions to prevent overeating.

63

General Health

Regular intake of handful of nuts (not fried) is good for health and heart.

91

General Health

Climbing stairs is a good exercise, which strengthens you leg muscles.

87

General Health

Whenever possible, start your meal with a low-calorie soup. This will reduce your hunger and help you eat less.

124

General Health

Drink a big glass of water whenever you feel hungry and 30 minutes before every meal, as it makes you feel fuller and helps in portion control.

156

General Health

Maintain a food diary. It is one of the most important tools for weight loss or any dietary changes, as it makes it easier to identify areas for change.

165

General Health

Avoid crash dieting: When you crash diet, your body goes into starvation mode, and it stores your fat and burns your muscle.

137

General Health

Store vegetables and fruits in plastic bags to stop them from decaying, particularly leafy greens and others that do not have an outer skin.

153

General Health

Eat plain popcorn instead of salted or buttered. It’s a good alternative to snacks like potato chips and cookies.

126

General Health

People with high blood pressure should avoid foods like pickles, papad, savouries, dry fish etc, which contain excess salt.

136

General Health

Include garlic in your diet, as it good for your heart.

68

General Health

Listen to soothing music to reduce your heart rate and blood pressure. This reduces your risk of stroke and other health problems over time.

153

General Health

Eat nuts to strengthen bones. Most nuts are a very good source of potassium, calcium and phosphorus, which are required for stronger bones.

152

General Health

Smile all day, everyday. Studies have shown that smiling improves your mood, reduces stress and suppresses pain both emotionally and physically.

157

General Health

Avoid drinking cold (chilled) water after every meal.

66

General Health

Do not drink tea or coffee immediately after a meal, as it can interfere with the absorption of non-haem iron (found in plants) consumed in the meal.

162

General Health

Include watermelon in your diet. They are not only low in calories and fat but also healthy for your heart.

120

General Health

Apart from burning calories, aerobic exercises like jogging can suppress your appetite for up to 3 hours by reducing levels of hunger hormones.

156

General Health

Read a lot; it not only improves your vocabulary, but it is also a great exercise for your brain; it is a stress buster too.

137

General Health

Drink water regularly to help in weight loss, as some studies suggest that even mild dehydration can slow your metabolism.

135

General Health

If you are overweight by more than 20 kg, prefer cycling or swimming over running, as they put less stress on your hips and knees.

143

General Health

Eat coloured, fresh fruits and vegetables, as they contain higher concentrations of vitamins, minerals and antioxidants.

133

General Health

Choose fresh fruit instead of fruit juices. Fruit juices contain a lot of sugar to sweeten them up.

112

General Health

Sleeping is a matter of taking rest. Too much sleep is unwise, and too less is harmful.

100

General Health

Sleep 6-8 hours a day; less or more is harmful for your body and mind.

83

General Health

Tea and coffee contain caffeine; take them in moderate quantities.

79

General Health

Refresh your mind and body with balanced physical activity.

72

General Health

Make it a principle to keep your body fit and healthy.

67

General Health

Be cool and relaxed; mind control is greatly helped by meditation and yoga.

88

General Health

It is not advisable to drink too much tea or coffee; don’t make it a habit.

88

General Health

Happiness is a habit; we have the power to create our own happiness.

81

General Health

Nothing is impossible to a willing heart; avoid stress, and be happy.

82

General Health

Too much stress and tension can affect you. He who laughs lasts ....

81

General Health

Happiness and misery are just mental states; you can change both.

78

General Health

Always think “life is good”, “I choose happiness”; you can be happy if you want to be.

99

General Health

Calmness of mind does not mean you should stop your activity. Real calmness could be found in the activity itself.

127

General Health

Strength of the mind is exercise, not rest.

56

General Health

“Believe yourself”; have faith; you can handle stressful events at ease.

85

General Health

If possible, instead of phoning, walk over to co-workers and talk in person.

89

General Health

Sprouting seeds, nuts or grains are a good way to increase the amount of vitamins, minerals and proteins.

118

General Health

To increase the nutritional value of roti or chappathi, add oats to the flour. This increases the fibre content.

125

General Health

Watching TV or reading books while eating is a bad habit. You may end up eating more than you should.

114

General Health

Wake up early; it is the best time for personal development. Quiet morning time is often the time when your mind is the clearest.

142

General Health

Keep a water bottle at your desk and sip regularly. To work efficiently and to think better, your brain depends on water flowing through your body.

160

General Health

Listen to music when you are in stress. It can divert your attention and encourage relaxation.

107

General Health

To avoid weight gain during weekends, try to wake up at the same time as you do during the week. This way, your eating timings are not ruined.

155

General Health

Solving puzzles is a great exercise for your brain. They can enhance memory, attention, concentration and more.

124

General Health

Wake up early to meditate. In the morning, your brain is relaxed and you get few interruptions. It can help reduce stress and lower blood pressure.

160

General Health

In case of a deviation in your diet plan, do not give up the whole diet. Instead, focus on getting back to your plan from your next meal.

150

General Health

To cut calories when eating out in a restaurant, order an appetizer as your main dish. If you are still hungry, order a salad.

139

General Health

For a good sleep and to wake up fresh, try to eat a light dinner 2 hours before sleeping, Also, avoid coffee, sugar or alcohol just before going to bed.

165

General Health

If possible, leave the dining table as soon as you finish eating. The longer you sit at the table, the more you will eat.

134

General Health

Practice meditation daily for 15-20 minutes, as it lowers your heart rate. This helps to reduce the workload on your heart.

136

General Health

Eating spicy foods like pepper can improve blood circulation in your body, resulting in better functioning of heart, liver and kidneys.

148

General Health

Use the stairs when going down. A study shows walking down stairs or downhill can reduce blood sugar levels more than walking uphill.

146

General Health

India mDiabetes:
Ramachandran

Walking is the best physical activity for good health.

70

General Health and Diabetes

Household chores are not as good as walking.

61

General Health and Diabetes

Normal household work cannot be considered physical activity.

77

General Health and Diabetes

Jogging and running are good physical activities.

65

General Health and Diabetes

Indoor games are not considered to be good exercise.

68

General Health and Diabetes

Yoga is a good exercise for the mind.

53

General Health and Diabetes

Cycling is a good exercise.

44

General Health and Diabetes

Cycling is an alternative to walking, jogging or running.

73

General Health and Diabetes

Climbing stairs is good exercise.

49

General Health and Diabetes

Manual labour and gym exercises are good exercise.

63

General Health and Diabetes

Exercising daily for 30 minutes to 1 hour is healthy.

66

General Health and Diabetes

Walking 30 minutes a day for 5 days a week is ideal.

65

General Health and Diabetes

Include lots of vegetables. They make you healthy.

64

General Health and Diabetes

Eat fibre-rich vegetables.

39

General Health and Diabetes

Root (starchy) vegetables can be taken in moderation.

66

General Health and Diabetes

Milk is a healthy drink, as it contain vitamins and minerals; it is the best source of calcium.

108

General Health and Diabetes

Red meat has a high fat content and can be taken once in a fortnight.

83

General Health and Diabetes

Pulses or sprouts are rich in protein and good for health.

71

General Health and Diabetes

Avoid foods that are fried and high in fat.

56

General Health and Diabetes

Soft drinks contain lots of sugar; avoid them.

59

General Health and Diabetes

Bakery products are high in calories; restrict them.

65

General Health and Diabetes

Taking small feeds (light snacks at regular intervals) is a good practice.

87

General Health and Diabetes

Whole cereals are considered to be healthier than refined cereals.

79

General Health and Diabetes

Wheat and ragi are good for health.

48

General Health and Diabetes

Fish is a healthy diet, which is good for your heart.

66

General Health and Diabetes

Root vegetables are high in carbohydrates and starch; restrict them.

82

General Health and Diabetes

Timely meals reduce quantity, avoid overeating, and keep you healthy.

82

General Health and Diabetes

Sweets and sugars are high in calories and increase your blood sugar levels; avoid them.

101

General Health and Diabetes

Periodic medical checkup help you to be healthy.

61

General Health and Diabetes

Sound sleep keeps you healthy.

43

General Health and Diabetes

Regular exercise should be part of your life.

58

General Health and Diabetes

Exercise regularly, daily.

39

General Health and Diabetes

More fruits and vegetables keep you healthy.

57

General Health and Diabetes

Doctors are the best source of advice on health.

61

General Health and Diabetes

Correct information on health can be obtained from doctors, health workers, newspapers, TV and radio.

115

General Health and Diabetes

The symptoms of diabetes are frequent urination, weight loss, giddiness and excessive hunger.

107

General Health and Diabetes

Excessive thirst, non-healing of wounds, tiredness are also symptoms of diabetes.

94

General Health and Diabetes

Hereditary overweight or obesity, stress and physical inactivity are the risk factors for diabetes.

112

General Health and Diabetes

High-calorie (high-fat) food and excess intake of sweets and sugar may also cause diabetes.

104

General Health and Diabetes

Diabetes during pregnancy is a risk factor for diabetes in the future.

84

General Health and Diabetes

All patients with diabetes will develop complications.

67

General Health and Diabetes

Uncontrolled diabetes will affect vital organs like eyes, heart, kidneys and feet.

95

General Health and Diabetes

Prevention of diabetes is possible.

48

General Health and Diabetes

Regular physical activity like walking, cycling. jogging, running, yoga or meditation and diet control and weight reduction will help to prevent diabetes.

167

General Health and Diabetes

Diet control (fibre-rich vegetables, fruit, sprouts, timely meals, reducing sugar and avoiding sweets) will help you to prevent diabetes.

150

General Health and Diabetes

Avoiding high-calorie foods (high-fat and deep-fried food, mutton, sweets, sugar, bakery items) will help you to prevent diabetes.

143

General Health and Diabetes

References

Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217–230.

Ramachandran A, Snehalatha C, Simon M, Mukesh B, Bhaskar A, Vijay V, et al. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1) Diabetologia 2006;49:289-297.

Ramachandran A, Snehalatha C, Ram J, Selvam S, Somon M, Nanditha A, et al. Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial. Lancet Diabet Endocrinol 2013;1:191–198.

Shetty AS, Chamukuttan S, Nanditha A, Raj RK, Ramachandran A. Reinforcement of adherence to prescription recommendations in Asian Indian diabetes patients using short message service (SMS): a pilot study. J Assoc Physicians India. 2011;59:711-714.

Annex 3. Arogya World mDiabetes implementation and message content

Overview

A global health NGO, Arogya World, with Nokia, informed 1 million people in India about diabetes and its prevention by lifestyle changes. People with Nokia Lifeplatforms on their mobile phones opted-in and were sent diabetes messages twice a week, in one of 12 languages, for 6 months. The messages were prepared at the Rollins School of Public Health at Emory University (Atlanta, Georgia, USA) and were reviewed for cultural relevance and technical accuracy with medical, health promotion and consumer communications experts in India and elsewhere. The messages were subsequently refined in a primary research testing and pilot studies. The programme is being evaluated by “test versus control” and “pre versus post” comparisons, with self-reported assessment of behaviour change as an outcome measure. Arogya World used a public–private partnership to fund and operationalize the programme; the partners other than Nokia and Emory University included Johnson & Johnson and Aetna. Arogya World’s mDiabetes programme had an impact of about 15%; i.e. about 15% of consumers who received the messages made or maintained four simultaneous healthy behaviors, whereas controls showed little or no change

Programme

Time
frame

Message

Character count

Theory

Category

Arogya World mDiabetes

Week 1 (send messages in the order listed here)

Diabetes is a huge problem. At least 5 crore people in India live with diabetes. Diabetes kills 10 lakh Indians each year. Arogya World

145
(International Diabetes Federation, India Diabetes Map)

Know impact

*Medical*

People with diabetes cannot control their blood sugar properly. High blood sugar for long periods harms the body. Arogya World

147 (JDRF, High Blood Sugar)

Know impact

*Medical*

High blood sugar due to diabetes can cause problems in your eyes, kidneys, heart, feet and nerves. Arogya World

122 (ADA,
Complications)

Know impact

*Medical*

Type 2 diabetes can be avoided by doing physical activity and eating healthy foods. This has been shown by medical studies. Arogya World

149 (ADA, Prevention)

Become aware

*Lifestyle*

Message 5

Healthy eating means eating plenty of fresh vegetables and fruits. Commit to eating more fresh vegetables and fruits daily. Arogya World

148 (ADA, Making Healthy Food Choices)

Become aware

*Nutrition*

Arogya World mDiabetes

Week 2

If you have diabetes, your blood sugar can go too high or too low. Keep blood sugar in the proper range (80–120 mg/dL). Eat healthy. Walk often. Arogya World

168 (ADA, Checking Your Blood Glucose)

Control risks

*Lifestyle*

Eat fruit as a snack if you are hungry between meals. Try apples, bananas, oranges, mango and papaya. Arogya World

129 (ADA, Snacks)

Choose
alterna-tive

*Nutrition*

Arogya World mDiabetes

Week 3

To avoid diabetes, women should have a waist size of < 80 cm and men < 90 cm. Arogya World

143 (H. Ranjani)

Become aware

*Medical*

Decide to be physically active every day. Walk as much as you can. Try to walk more than you did last time. The extra steps are good for your health! Arogya World

172 (ADA, Physical activity)

Commit to change

*Fitness*

Arogya World mDiabetes

Week 4

If you have family members with diabetes, you may be at risk. Reduce your risk by taking a walk a few times each week. Arogya World

140 (ADA, Genetics of Diabetes)

Control risk

*Medical*

By receiving these messages you are learning to improve your health. Learning about diabetes can help you live better with the disease. Arogya World

156
(International Diabetes Federation, Self-management Education)

Become aware

*Think*

Arogya World mDiabetes

Week 5

Eat fewer high-fat foods. Limit namkeens, bhajjias, samosas, ladoos, jalebis, halwa. Avoid food made in ghee. Arogya World (North)

139 (North) (ADA, Fats and diabetes)

Choose
alterna-tives

*Nutrition*

Eat fewer high-fat foods. Limit bhajji, bondas, vadas, jhangri, badusha. Avoid food made in ghee or coconut oil. Arogya World (North)

141 (South) (ADA, Fats and diabetes)

Choose
alterna-tives

*Nutrition*

Walk more each week. Week 1: walk 10 minutes on 2 days of the week. Week 2: walk 10 minutes on 3 days. Week 3: walk 15 minutes on 3 days, and so on. Arogya World

172 (ADA, Food and fitness)

Commit to change

*Fitness*

Arogya World mDiabetes

Week 6

Try eating small meals and snacks throughout the day to maintain blood sugar. Long gaps between meals can cause your blood sugar to drop. Arogya World

157 (ADA, Snacks)

Control
risk

*Nutrition*

Eat healthy foods rich in protein. Try low-fat curds, low-fat milk, beans, eggs, pulses, nuts, chicken and fish. Eat these to avoid diabetes. Arogya World

173 (ADA, Lean meats)

Choose
alternatives

*Nutrition*

Arogya World mDiabetes

Week 7

Be physically active to achieve a proper weight and healthy waist size. Being overweight and having a large waist size increase the risk for diabetes. Arogya World

169 (ADA,
Overweight)

Control risks

*Fitness*

Eat less fried foods and sweets. Take larger amounts of vegetables and fruits. This will help avoid diabetes. Arogya World

134 (ADA, Making healthy food choices)

Choose
alternatives

*Nutrition*

Arogya World mDiabetes

Week 8

Diabetes is the most common cause of kidney failure. If you have diabetes, ask your doctor more about kidney disease. Arogya World

172 (National Kidney and Urologic Diseases Information
Clearinghouse

Know impact, seek support

*Medical*

To help avoid diabetes, eat vegetables. Try carrots, green beans, spinach, sprouts, cucumber, cauliflower, cabbage, capsicum and gourds. Arogya World

170 (ADA, Non-Starchy Vegetables)

Choose
alternatives

*Nutrition*

Arogya World mDiabetes

Week 9

If you are overweight or have a large waist size, then you are at risk for diabetes. Control your weight. Arogya World

127 (ADA, Overweight)

Control risks

*Medical*

Small changes in the way you eat can help you avoid diabetes. Eat more vegetables and fruits. Eat less rice and roti. Arogya World

142 (ADA, Making healthy food choices)

Choose alternatives

*Nutrition*

Arogya World mDiabetes

Week 10

Tobacco is harmful to health and makes diabetes complications more severe. Avoid smoking cigarettes and chewing tobacco. Arogya World

143 (Mayo Clinic, Diabetes care)

Control risks

*Medical*

Do physical activity. Daily activities are walking, climbing stairs or household work. Planned exercise is a morning walk, sports or yoga. Arogya World

163 (ADA, Physical activity)

Commit to change

*Fitness*

Arogya World mDiabetes

Week 11

Do you know someone with type 2 diabetes? Tell him or her that healthy eating and physical activity can help control their diabetes. Arogya World

152 (National
Kidney and Urologic Diseases Information Clearinghouse, Kidney disease of diabetes)

Seek support

*Think*

Medical studies show that you should do daily physical activity and eat healthy foods to help you avoid type 2 diabetes. Arogya World

143 (National
Kidney and Urologic Diseases Information Clearinghouse, Kidney disease of diabetes)

Know impact

*Medical*

Arogya World mDiabetes

Week 12

Diabetes causes kidney disease, heart disease, eye disease, skin disease and foot ulcers. These are called diabetes complications. Arogya World

156 (ADA,
Complications)

Know impact

*Medical*

Take a morning or evening walk to help avoid diabetes. Use shoes made for walking to help avoid injury. Arogya World

134 (ADA, Walk away a winner)

Commit to change

*Fitness *

Arogya World mDiabetes

Week 13

If you have diabetes in your family, you are at risk for diabetes yourself. Go to a clinic to have your blood sugar checked. Arogya World

154 (ADA, Genetics of diabetes)

Control risks

*Medical*

Send an SMS to a friend to join you for a walk, join a gym or go to yoga class. Physical activity is more fun with a friend! Arogya World

150 (ADA, Physical activity)

Seek support

*Lifestyle*

Arogya World mDiabetes

Week 14

Walking more and eating healthy foods can help protect your heart. Heart disease is responsible for 50–80% of deaths in people with diabetes. Arogya World

165 (WHO, Diabetes)

Know impact and Become aware

*Medical*

A proper weight and healthy waist size can help you manage diabetes. Eat less fat. Reduce sugary sweets. Be physically active often. Arogya World

157 (ADA,
Overweight)

Commit to change

*Lifestyle*

Arogya World mDiabetes

Week 15

If you have diabetes, visit an eye doctor (ophthalmologist). People with diabetes are 25 times more likely to become blind. Arogya World

152 (Centers for Disease Control and Prevention, USA)

Seek support

*Medical*

Add a little physical activity each day to avoid diabetes. Climb stairs. Walk to the temple, mosque, church or vegetable shop. Arogya World

147 (ADA, Physical activity)

Commit to change

*Fitness*

Arogya World mDiabetes

Week 16

Did you know that high blood sugar can increase your risk for heart disease? 50–80% of people with diabetes die of heart disease. Arogya World

147 (WHO, Diabetes)

Know impact

*Medical*

To live a healthy life, learn as much as you can about diabetes. Manage diabetes by eating healthy food and walking often. Arogya World

144 (WHO,
Self-management education)

Become aware

*Think*

Arogya World mDiabetes

Week 17

Type 2 diabetes can be avoided, but once a person gets diabetes it cannot be cured. Fortunately, you can avoid diabetes by living a healthy lifestyle. Arogya World

174 (H. Ranjani)

Become aware

*Medical*

Eat a healthy breakfast every day. Eating breakfast gives you energy and helps maintain your blood sugar levels properly. Arogya World

146 (ADA, Breakfast on the go)

Commit to change

*Nutrition*

Arogya World mDiabetes

Week 18

If you smoke, especially if you have diabetes, take steps to quit smoking today. Ask family and friends for support. Arogya World

143 (Mayo Clinic, Diabetes Care)

Control risks and Seek support

*Lifestyle*

If you have diabetes, keep your blood sugar levels in the proper range. Eat healthy foods. Be physically active. Sometimes medications are needed. Arogya World

169
(International Diabetes Federation, Management of Diabetes)

Control risks

*Medical*

Arogya World mDiabetes

Week 19

If you have diabetes, ask your doctor to perform the test to see if your kidneys are working properly. Arogya World

163 (National Kidney and Urologic Diseases Information Clearinghouse, Kidney disease of diabetes)

Become aware and Seek support

*Medical*

Fruit is good to eat if you are hungry between meals. Try apples, bananas, mosambi, grapes, mango, papaya, guava, sapota and jackfruit. Arogya World

168 (ADA, Fruits)

Choose alternatives

*Nutrition*

Arogya World mDiabetes

Week 20

The most deaths from diabetes occur in developing countries like China and India. Diabetes kills 10 lakh Indians each year. Arogya World

160 (International Diabetes Federation, Diabetes atlas)

Know impact

*Medical*

Eat healthy whole grains to help avoid diabetes. Try bajra, jowar, ragi, pulses, oats, brown rice, barley and whole-wheat atta. Arogya World

158 (ADA, Whole grains)

Choose alternatives

*Nutrition*

Arogya World mDiabetes

Week 21

WHO says that eating healthy, doing physical activity and avoiding tobacco can prevent 80% of diabetes cases. Arogya World

178 (WHO, Unhealthy diets and physical inactivity)

Control risks and benefit

*Medical*

If you have diabetes, you can still live a normal life. Learn as much as you can about diabetes and maintaining your blood sugar. Arogya World

150 (International Diabetes Federation, Self-management Education)

Become aware, benefit

*Think*

Arogya World mDiabetes

Week 22

Stopping smoking is one of the best things you can do for your health! If you want to stop smoking but are having trouble, get help from your doctor. Arogya World

175 (ADA, Smoking)

Control risks and benefit

*Lifestyle*

Take larger amounts of foods like raw vegetables and fresh fruit. Take smaller amounts of sugery sweets like gulab jamoon and jilebi. Arogya World (North)

Take larger amounts of foods like raw vegetables and fresh fruit. Take smaller amounts of sugary sweets like mysore pak or jilebi. Arogya World (South)

Take larger amounts of foods like raw vegetables and fresh fruit. Take smaller amounts of sugary sweets like rasagulla or sandesh. Arogya World (East)

161 (North),

156 (South),

156 (East)

(ADA, Making healthy food choices)

*Nutrition*

Arogya World mDiabetes

Week 23

Changing habits is difficult. Congratulate yourself for even small change. What changes have you made to improve your health? Arogya World

169

Reward self

*Lifestyle*

If you do not like the taste of raw vegetables, flavour them with different masalas or lemon juice. Try cucumbers, carrots or tomatoes. Arogya World

177 (MyPlate, Tips to help you eat vegetables)

Choose alternatives

*Nutrition*

Arogya World mDiabetes

Week 24

Prolonged high blood sugar from diabetes can cause problems in your eyes, kidneys, heart and feet. These are called diabetes complications. Arogya World

178 (ADA, Hypoglycaemia)

Know impact

*Medical*

Half of what you eat should be vegetables like carrots and tomatoes. One fourth should be rice or chappati and the rest protein like eggs or dahl. Include curds. Arogya World

178 ( Diabetes Community Lifestyle Improvement Program, Madras Diabetes Research Association, Emory University)

Choose alternatives

*Think*

Arogya World mDiabetes

Week 25

Stop using tobacco. If you have diabetes, smoking cigarettes and chewing tobacco lead to more severe complications (heart disease, nerve damage). Arogya World

177 (Mayo Clinic, Diabetes Care)

Control risks

*Medical*

Manage diabetes by eating healthy foods like vegetables and fruit and doing physical activity. Arogya World

118 (Diabetes Prevention Program, Overview; H. Ranjani)

Commit to change

*Medical*

Arogya World mDiabetes

Week 26

Learn as much as you can about diabetes to help you take care of yourself and your family. Arogya World (for women)

Learn as much as you can about diabetes. Knowing how to care for yourself can help you stay healthy and active. Arogya World (for men)

120 (women),

133 (men)

Become aware

*Think*

Be physically active every day. Go for a walk. Physical activity can help lower your risk for heart disease and diabetes. Arogya World

145 (ADA, Physical activity)

Control risks

*Fitness*

Annex 4. Examples of mDiabetes programmes and studies

Table A.1. Worldwide mDiabetes studies

Study

Country

Description

Objectives

Advantages

Disadvantages

Links

Care4Life

USA

Two-way SMS coaching and education programme for diabetes self-management. Sends text messages with reminders to support blood sugar monitoring and educational tips

Encourage progression towards personal health goals

Results indicated a personalized diabetes text-messaging intervention can be effective in a targeted population. Text-messages available in English and Spanish

Sample size relatively small, and study conducted over a short period. Gaps in clinical data meant many patients were not followed up

http://www.techandaging.org/mHealth_HealthInsight.html

https://www.care4life.com/‎

Agada Healthcare

India

Two-way SMS pilot intervention for diabetes self-management

Improve education and health information for diabetes patients to increase adherence and reduce the overall cost of patient care

Interactive SMS in which patients can respond or ask questions is more effective than one-way messages. Potential to extend study with use of smartphones, rural reach and other chronic diseases

Cost of SMS is a concern, as many in India pay per text message

http://agadadiabetes.net/AgadaApp/index.aspx

http://webcache.googleusercontent.com/search?q=cache:r_GZ6eSQR6IJ:mobilehealthdesign.files.wordpress.com/2013/06/mhd-fiona-akhtar-agada-6-10-13.pptx+)+Designing+a+mobile+health+intervention+for+diabetes+management+in+India&cd=1&hl=en&ct=clnk&gl=uk

LifeChart

Finland

Patient can send plasma glucose levels to a database that can be monitored by a doctor via the Internet. Two-way SMS messages (comments and questions) sent between patients and doctors

Making patient self-care and disease management more effective, reducing the cost of patient care

Personal records accessible at any time, enabling active patient monitoring Communication and feedback through mobile phones creates positive relationships between patients, caregivers and health care providers

-

http://lifecharts.com/

http://onlinelibrary.wiley.com/doi/10.1002/pdi.642/abstract

WellDoc

USA

Provides patients and their health care providers with real-time, actionable information on blood glucose levels via SMS

Improve the lives of people with chronic diseases, improve metabolic outcomes and reduce health care costs

Health care provider and patient satisfaction with the system was clinically and statistically significant.

-

http://www.welldoc.com/Clinical-Trials.aspx

Chinese Aged Diabetes Assistant

China

Interactive diabetes self-management support system on smartphones for robust elderly population with diabetes in urban and rural China taking insulin, oral medications or both

Consider the users, tasks and social contexts while measuring usability empirically

Age- and culturally appropriate system. Software free of charge, user-centred approach to develop software that reflects the preferences and capabilities of the targeted population

-

http://www.cadaproject.com/

Medinet Healthcare Management System

Trinidad and Tobago

Mobile phone-based health care management system for diabetes and cardiovascular disease. Relays information from patient monitoring devices to a central server via a cellular network. System can send suggestions to patients via SMS or pre-recorded voicemail

Long-term goal is to build a network that integrates medical resources and promotes sharing of medical information and expertise

Personalization at both group (general characteristics) and individual level (specific characteristics)

Mobile services may be disrupted when there is lack of connectivity. Security concern (patients sending private or sensitive data to a remote server)

http://healthmarketinnovations.org/programme/medinet-healthcare-management-system

http://research.microsoft.com/en-us/events/ersymposium2009/healthcare_mgt_sys_cell_phone_tech.pdf

http://www.bloomsburyacademic.com/view/mHealth-In-Practice/chapter-ba-9781780932798-chapter-009.xml

Sweet Talk

United Kingdom

Low-cost automated text-messaging system for young people with type 1 diabetes. Scheduled messages tailored to patient profiles and diabetes self-management goals (focused on insulin injection, blood glucose testing, diet and exercise)

Support patients between clinic visits with text messages sent to a mobile phone

High patient satisfaction. Could be readily adapted to suit other chronic diseases and age groups

www.sweettalkdiabetes.com/‎

http://www.ncbi.nlm.nih.gov/pubmed/18653444

Few Touch Application

Norway

Diabetes diary application acts as a self-help tool enabling food habit registration, blood glucose data management and physical activity registration

Provide personalized decision support for achievement of personal health goals

Empowers patients to take a more active role in managing their own health and enhances discussion between patients and professionals

http://www.ncbi.nlm.nih.gov/pubmed/20307393

http://www.ehealth-innovation.eu/fileadmin/eHealthInnovation/documents/eHInno%20Case%20Study%20EHTEL%20c3%20Norway%20v06.pdf

SMS Diabetes

Gabon

Two-way SMS-based diabetes education and support platform allowing health care professionals to provide information to thousands of patients with limited access to medical consultations. Questions are addressed daily and patients quizzed weekly.

Inform people on how to control diabetes

Potential to expand to other diseases (e.g. TB, HIV/AIDS) if the project is successful among diabetes patients. Granted free short code, saving 10 000 € a year. Large discounts by phone companies

http://ghf.globalhealthforum.net/2011/12/09/2351/

Care Smarts

USA

Text message-based diabetes programme offered to all University of Chicago employees with diabetes. Patients receive daily interactive texts from an automated system, daily reminders about medication, glucose monitoring and foot care, and educational facts about diabetes

Encourage diabetes patients to manage their illness and make healthy lifestyle choices

Patients found this a convenient way to self-manage their illness.

http://news.medill.northwestern.edu/chicago/news.aspx?id=215360

TEXT4DSM

Cambodia, Democratic Republic of the Congo and Philippines

Two-arm randomized controlled trial. SMS messages used to provide information and assistance. Nine key messages

Evaluate the effectiveness of a mobile phone intervention in addition to an existing diabetes self-management education strategy

Shows that widely accessible equiptment and communication technology can narrow the gap between the support system and people with diabetes

Limitation of design, with individual randomization at patient level. Diabetes self-management education and group may not be mutually exclusive. Lack of local validation of scales used on the questionnaire

http://www.biomedcentral.com/1471-2458/13/423

MyDoctor

@Home

Italy, pilot launched in Brazil

Remote diagnostics service allowing patients with chronic diseases to measure parameters such as glucose levels from home

Reduce the number of patients in hospital for chronic conditions, increase health data quality and reduce costs for health care provider

Patients can self-manage their illness

-

http://www.gsma.com/connectedliving/wp-content/uploads/2012/11/11-12-GSMA-HCP-Stakeholder-WP_l.pdf

Diabetes

Interactive

Diary

Italy, Spain, United Kingdom

Several functions, including an automatic carbohydrate/insulin bolus calculator in a mobile phone and a telemedicine system based on communication between health care professional and patient by text messages

Increase the proportion of patients who benefit from flexible diabetes management

In phase 1, system was judged “excellent” or “good” by 94% of patients.

Useful, safe and easy to use to help diabetes patients manage their disease

Methodological flaws found in similar devices. Tool is being evaluated for effectiveness. Main limitation is slowness of the software and lack of some foods in list and pictures

http://www.touchendocrinology.com/articles/diabetes-interactive-diary-useful-tool-diabetes-management?page=0,3

Text-

message

Based

Diabetes

Care

Program

USA (urban African–American population)

Pilot test (18 participants in 4-week pilot study). Automated SMS messages sent to participants with personalized mediction, foot care and appointment reminders. Text messages on adherence sent to participants

Improve diabetes self-management in urban African-Americans

Participants responded to messages 80% of the time. Felt text messaging was easy and helped in diabetes self-care

Half the participants were initially uncomfortable with text messaging

http://www.ncbi.nlm.nih.gov/pubmed/22027326

Text

Messaging

for

Chronic

Disease

Manage-

ment

USA

Quasi-experimental pilot study of text messaging to send blood sugar measurement prompts and appointment reminders

Assess the feasibility of engaging adults with diabetes in self-management behaviour between clinic visits

Participants reported more social support, that the programme “made them accountable” and increased awareness of health information. Mostf patients sent glucose readings when prompted.

-

http://www.ncbi.nlm.nih.gov/pubmed/22435883

Cellular

Phone

Self Blood

Glucose

Monitor-

ing

Finland

One-year study. 100 patients with diabetes given a cellular phone containing a menu for transmitting blood glucose values to a database. Doctors checked results once a week and sent a text message giving instructions.

Transmission of glucose values by cellular phone in the treatment of type 1 diabetes

Worked well technically, and no patient had difficulty in transmitting glucose values

Phone system not associated with overall improvement in HbA1c, perhaps due to few measurements

http://onlinelibrary.wiley.com/doi/10.1002/pdi.642/abstract;jsessionid=
FA15E662CF40A3F29A3
BF8C55F91A77C.d04t01

SMS/

Telephone

Follow-ups

by Nurses

Islamic Republic of Iran

Sample of 77 patients

Compare effectiveness of SMS and telephone follow-up of adherence of patients with type 2 diabetes for 3 months

Both interventions had a significant mean changes in glycosylated haemoglobin

No significant difference in diet adherence, physical exercise and medication taking adherence in either groups

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2011.03951.x/abstract

SMS and standard diabetes care

Bangladesh

236 adult patients with type 2 diabetes

Mean difference in HbA1c between baseline and 6 months was −0.85 (95% CI ,−1.05, −0.64) in the SMS group and −0.18 (−0.41, 0.04) in the control group; difference in means was −0.66 (−0.97, −0.35; P < 0.0001). Mean medication adherence score decreased significantly in both groups, indicating better self-reported adherence to medication over time.

http://care.diabetesjournals.org/content/38/8/e112.full

Annex 5. Purpose, roles and questions of the Technical Advisory Group

The purpose of the TAG will be to:

• Assign roles and responsibilities to the various organizations involved in the phases of development or adaptation, implementation, evaluation and continuing service provision. This should include discussions on overall programme ownership, funding, contracts or agreements for dealing with technical and other issues.

• Agree on the target population(s), type of programme, objectives of the programme, programme design, support for the programme, integration with existing diabetes services and programmes and the evaluation plan.

• Support implementation and promotion of the programme.

Initial questions to be considered by the TAG should include:

• What is the overall purpose and philosophy of the programme? That is, what is the intention: to support people with diabetes, to prevent diabetes in healthy populations, or both? What is the theoretical basis or mechanism by which it might work? How valid is the relevant behaviour change theory and technique? How ready are people to change their behaviour and their use of mobile phone technology?

• Can an existing programme be adapted for the local population and context? Will a new programme have to be developed? Are there any relevant local cultural models of health promotion or successful text or or voice campaigns?

• Who is the target audience? Is it urban or rural, rich or poor? Is it healthy people or people with diabetes or patients with diabetes at high risk? Which part of the population in greatest need? Who is most likely to benefit from such a programme?

• What are the best ways to promote the programme to the target audience? How will people opt-in or sign up?

• How will the mDiabetes programme fit into existing health promotion and diabetes services and other related programmes? Are there lessons to be learnt or links with existing programmes that are popular or effective in the target population?

• Is the programme effective and cost–effective? Is the evidence strong?

• How will the programme be operationalized? Are there lessons to be learnt from operationalization of mHealth programmes elsewhere, or should local models be followed? Who will be responsible and accountable for the programme? What are the roles and responsibilities?

• What is the budget for the programme, including TAG establishment and meetings, message development and refinement, translation and transmission, promotion and enrolment, evaluation of effectiveness and publication?

• Who will pay? The government, the private sector or consumers? Can the programme be free to maximize its public health impact?

• Are there regulatory restrictions, such as for privacy, text message transmission or opting out of the programme?

• Could epidemiological data be collected in the programme?

The TAG should consider conducting a needs assessment and building an evidence base to answer these questions and whether more data or research are required.

Annex 6. Budget template

Activity

Type of expense

Phase component

Product or outcome

Estimated cost (US$)

Formulation, design and development

Capital (one-time expense)

Operations management

Formative research and Successful evidence Review

Formation of an informal international experts group

Compilation of best practices and lessons learned

Assessment of resources/technology available and mapping to needs assessment

Engagement with ministries of Health, ICT and local stakeholders

Identification and formation of a national m-Health for NCD taskforce

Consultation meetings of national taskforce

Country workshop with local and international experts to learn from international experience and finalize project concept and design.

Development of a Program Initiation Document (PID)

Content

Content development + Adaptation + Focus groups evaluation for adaptation (to develop culturally appropriate new content prototype for the country (content type, level of interaction of SMS, etc.)

Focus groups held to translate content into local languages and modify for cultural acceptability

Technology

Develop/adapt technical platform/solution

Develop database for the country

Piloting and deployment at country level
- Telecoms provider / SMS gateway integration
- Multi-language set-up and user language tracking

Application maintenance and fine tuning

Platform hosting and maintenance

Testing technical platform and messages

Implementation and support

Capital (one-time expense)

Promotion and recruitment

Promotion, marketing, preparation of materials to recruit participants

Strengthen human resource capacity to effectively implement m-Health for NCD projects

Operations
management

Train local partners in project design, platform, SMS database, sampling, results framework and evaluation of results

Training in use of mTraining tools

Operational

Promotion and recruitment

Marketing

Patient communication (telecommunications company)

Maintenance of infrastructure

Programme management

Operational

Operations management

Project team (one senior staff, one junior staff and one administration support)

Miscellaneous (e.g. travel, meetings, communication)

Monitoring and evaluation

Capital (one-time expense)

Monitoring and evaluation

Develop method for data collection and analysis of results, sample size and results framework

Adapt global mHealth impact assessment indicators for country

Adapt global mHealth impact data collection instrument for country

Develop reporting and analysis module for monitoring and evaluation

Develop cost impact assessment model for sustainable financing based on global model

Operational

Monitoring and evaluation

Continuous evaluation and assessment

Analysis and reporting

Results dissemination

Continuous adjustments

Miscellaenous

Total operational expenditure (annually recurring)

Total capital expenditure (one-time)

Total cost (capital + operational for 1 year)

Acronyms

BHBM “Be He@lthy, Be Mobile”

ITU International Telecommunication Union

mHealth Mobile technology

NCDs Noncommunicable diseases

SMS Short message system

TAG Technical Advisory Group

WHO World Health Organization