EVALUATION OF A WHATSAPP-DELIVERED DIABETIC SELF-MANAGEMENT EDUCATION PROGRAM FOR PEOPLE WITH TYPE 2 DIABETES: A MIXED METHODS STUDY

Abstract

Diabetes is a severe chronic health and potentially devastating medical condition that has increased in prevalence over the past few decades to constitute a significant public health challenge of the twenty-first century. Inadequate diabetes management can result in severe complications, including cardiovascular diseases and strokes, impacting the quality of life. Effective self-management is crucial, with individuals making daily decisions related to their diabetes care. Diabetes self-management education and support (DSMES) provides people with type 2 diabetes mellitus (T2DM) the necessary knowledge, skills, and confidence to manage their condition. It has been found that increasing individual knowledge regarding disease and its complications has significant benefits in compliance with treatment and decreasing complications associated with diabetes. Traditionally, such programs are conducted via face-to-face group sessions. However, there are challenges in accessing face-to-face programs due to factors such as geographic location and travelling distances. In regions where digital technology and social media are pervasive, there is potential to increase innovative delivery methods such as social media platforms to provide accessible and flexible DSMES, thereby reaching a wider audience and improving health outcomes for individuals with T2DM. Considering the widespread use of WhatsApp in Saudi Arabia, online delivery of the DSMES may serve as a viable platform to decrease the burden and impact of living with T2DM. All research in this thesis was conducted in Saudi Arabia using a mixed-methods experimental design to examine the effectiveness of DSMES delivered via WhatsApp for people with T2DM. There are three phases in this study. In Phase One, a qualitative descriptive study was conducted using semi-structured phone interviews. The objective of this phase was to gain an in-depth understanding of the experiences and perceptions of people with T2DM regarding diabetes self-management. Insights from this phase guided the development of the teaching materials for the online diabetes self-management education program implemented in Phase Two. In Phase Two, a randomised controlled trial (RCT) was conducted. The objective of the RCT study was to evaluate the effectiveness of the WhatsApp-based DSMES in enhancing self-efficacy and diabetic knowledge (primary outcomes), as well as evaluating its impact on glycemic control (HbA1c), health-related quality of life (HRQoL), and levels of anxiety and depression (secondary outcomes). Subsequently, the third phase was a process evaluation to explore the experiences of people with T2DM who participated in the newly developed WhatsApp-based DSMES. In Phase One (qualitative interviews), nineteen (n=19) participants were recruited from the diabetes centres located within Jazan General Hospital and King Fahd Central Hospital in the Jazan region, Saudi Arabia. Themes generated from the qualitative analysis included knowledge deficit regarding disease management and its complications, difficulties in coping with the disease, adjusting to lifestyle changes and coping mechanisms influenced by a blend of culture and religion. Participants shared their experiences in accessing diabetic services via social media. Data generated from Phase One were used to develop an intervention that was tailored to the specific needs and experiences of people with T2DM in Saudi Arabia, as identified through the qualitative inquiry. The intervention was developed based on self-efficacy theory and aimed to enhance the self-management skills of people with T2DM through a structured educational delivered via WhatsApp. Common outcomes of WhatsApp-based DSMES for people with DM is to increase motivation to modify behaviours, adopt healthier lifestyles and adhere to prescribed medications. The educational content of the WhatsApp-based DSMES included general diabetes care information, signs and symptoms of diabetes, pathophysiology, aetiology, diet therapy, exercise, and other self-care behaviours. The intervention was delivered over six weeks, with each week focusing on a specific topic related to diabetes management. Participants received text messages, photos, and videos through a WhatsApp group, and were encouraged to interact, share experiences, and ask questions. The educational sessions were designed to take about one hour per week, and participants indicated their engagement by sending a thumbs-up emoji or the word "done" after reviewing the weekly content. In Phase Two (RCT), 80 participants were recruited from the diabetes centres at Jazan General Hospital and King Fahd Central Hospital in the Jazan region, Saudi Arabia were randomly assigned into intervention (n=40) and control groups (n=40). The intervention group received a 6-week intervention via WhatsApp, while the control group received usual care. The primary outcomes measured included UK-Diabetes Management Self-Efficacy Scale (DSMES-UK) and the Diabetes Knowledge Test2 (DKT2). The secondary outcomes measured included glycaemic blood test (HBA1C), the Hospital Anxiety and Depression Scale (HADS), and Diabetes Quality-Of-Life scale (DQOL). These outcomes were assessed at three time points: baseline, immediate post intervention at 6th week and two months after the intervention at 12th week. Findings at 6- and 12-week time points showed significant improvement in DSMES-UK and DKT2 in the intervention group compared to the control group. No significant difference in secondary outcomes was observed in HbA1c, total HADS, total DQoL, T0 to T1. In Phase Three (process evaluation), twenty-three (n=23) participants from the intervention group were recruited. Those who had previously consented during Phase Two and had indicated their willingness to share their experiences of the intervention were invited to participate in semi-structured phone interviews. Qualitative analysis found the participants expressed positive feedback surrounding the acceptability, flexibility, and relevance of the intervention content along with elements of cultural inclusion of the WhatsApp-based program. The participants also supported that the 6-week WhatsApp-based DSMES intervention enhanced a healthy change in lifestyle choices. They offered recommendations for enhancing the WhatsApp-based DSMES including more interactive and real-time features, the inclusion of allied health professionals for specialized support, the involvement of family members, and the integration of the program into standard diabetes care practices. These suggestions could increase the WhatsApp-based DSMES effectiveness, engagement, and overall impact on diabetes management. Findings of this study highlighted the positive effects of a WhatsApp-based DSMES on self-efficacy and diabetic knowledge of people with T2DM. Findings also provided feasibility data for the delivery of an evidence-based social media intervention to achieve optimal diabetes control, health outcomes, and quality of life for people with T2DM within communities. Findings further demonstrated DSMES was easily accessible, flexible, and assisted participants in modifying their behaviours to adopt a healthier lifestyle. By incorporating social media and culturally specific needs into DSMES, we can enhance health outcomes for people with T2DM and alleviate disease burden. Healthcare providers and policymakers may improve health outcomes for people living with T2DM by implementing the delivery of DSMES via social media platforms such as WhatsApp. Future research should focus on multicentre clinical trials with longer follow-up periods to investigate the long-term and cost-effectiveness of WhatsApp-based DSMES. Future studies should also explore the perspectives of diabetes educators and nurses and the readiness of healthcare centres to implement such online educational interventions. Expanding the scope to include a family-centred approach may lead to more sustainable interventions to promote self-management skills for people living with T2DM within communities.