Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial
Open accessAbstract
Background: Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes. Methods: StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals. Results: The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (− 0.08% (− 0.31 to 0.16) (IFCC − 0.82 mmol/mol (− 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was − 0.71% (− 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful. Conclusions: Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes. Trial registration: Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.
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Most SMS-based interventions are pilot tested (stage 3) or at large scale implementation stage (stage 4).
“most SMS based interventions are pilot tested (stage 3) [31,34,37,38,42,71] or at large scale implementation stage (stage 4) [28 -30,32,35].”
From Current evidence on the use of mHealth approaches in Sub-Saharan Africa: A scoping review (2023) · cites this paper as [32]
The Discussion (page unavailable) says StAR2D tested SMS messaging at scale, and the Methods describe a multicentre randomised trial. This supports citing it as an example of a large-scale SMS intervention, but the paper does not identify it as a stage 4 implementation; nor does one trial establish what stage most interventions have reached. (LLM, conf=0.78)
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- Authors
- Farmer, A., Bobrow, K., Leon, N., Williams, N., Phiri, E., Namadingo, H., Cooper, S., Prince, J., Crampin, A., Besada, D., Daviaud, E., Yu, L.-M., N’goma, J., Springer, D., Pauly, B., Tarassenko, L., Norris, S., Nyirenda, M., & Levitt, N.
- Affiliations
- University of Oxford (GB)
- University of Cape Town (ZA)
- South African Medical Research Council (ZA)
- Malawi Epidemiology and Intervention Research Unit (MW)
- Boston Consulting Group (United States) (US)
- Chris Hani Baragwanath Hospital (ZA)
- Corresponding author
- Farmer, A.
- ORCID
- Venue
- BMC Public Health
- Published
- 2021-10-21
- Volume
- 21
- Issue
- 1
- Pages
- 1907-1907
- ISSN
- 1471-2458 (ISSN-L)
- PMC
- PMC8529732
- OpenAlex
- W3204911885
- Cited by
- 29
- References
- 29
- Citations by year
- 2026: 7 · 2025: 8 · 2024: 8 · 2023: 4 · 2022: 2
- FWCI
- 3.93
- Type
- journal article
- Language
- en
- Update notices
- correction (2022-04-13)
- Open access
- gold
- doi.org
- Locations
- BMC Public Health (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, other-oa)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion, cc-by-sa)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Open University of Cape Town (University of Cape Town) (submittedVersion, cc-by)
- Funders
- Medical Research Council (MR/M016498/1)
- Topics
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Family Practice › Medication Adherence and Compliance
- Keywords
- type 2 diabetes, safety management systems, mobile health, medication adherence, HbA1c, glycemic control, behaviour change theory, systolic blood pressure, cardiovascular risk, treatment goals, South Africa, Malawi, resource-limited settings, digital health interventions, patient acceptability, barriers to adherence, patient-centered care
- MeSH terms
- Adult, Diabetes Mellitus, Type 2, Humans, South Africa, Cell Phone, Medication Adherence, Text Messaging
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