Development of a diabetes self-management + mHealth program: Tailoring the intervention for a pilot study in a low-income setting in Mexico

Background: Type 2 diabetes (T2D) is a public health pandemic disproportionately affecting low- and middle-income countries. The purpose of this formative research was to adapt evidence-based diabetes self-management education programs to the context of Seguro Popular clinics in Mexico. A theory-based mHealth (pictorial text messaging) component was developed. Method: Our formative research and development of the program protocol consisted of six phases: (1) interviews and focus groups with stakeholders on the challenges to T2D management, curriculum content needs, and the use of mHealth as a supplement to a DSME program; (2) review of the theoretical underpinning, curriculum, and interactive strategies of four evidence-based DSME programs and modification to meet the needs of adults with T2D and systems of care in Mexico City; (3) development of theory-based illustrated text messages; (4) evaluation of text messaging acceptability and access in adults with T2D via focus groups; (5) development of program manual; and (6) development of a training program for health care providers. Results: The ¡Sí, Yo Puedo Vivir Sano Con Diabetes! included 7 group-based weekly lessons; simple, interactive content; weekly empowerment messages; video novellas; group activities; and goal setting. Adaptations to the cultural context of Mexico included content/activities on diabetes etiology (addressing cultural misconceptions), nutrition (indigenous foods and plate method), self-blood glucose monitoring, and diabetes-related stress/coping. We used the Health Action Process Approach to guide the text message development, which posits that adoption, initiation, and maintenance of health behaviors require the development of intentions, plans, coping, and self-efficacy. Our final text message bank consisted of 181 messages. There were approximately 20-30 messages for each process of behavior change (e.g., action planning, maintenance self-efficacy) and 30 messages for each content topic (e.g., eating healthy, physical activity). There were 96 messages that were illustrated. Training materials were also developed. Discussion: We used a systematic approach, collaboration with stakeholders, and a well-established behavior change theory to develop an evidence-based intervention to an international context and system of care. Collectively, this process has the potential to enhance the feasibility, acceptability, and efficacy of the program.