British South Asian patients’ views on text messages to support type 2 diabetes

South Asians make up around 7.5% of the UK population and about 11% of the type 2 diabetes population. British South Asians are up to six times more likely to have diabetes than the general population, to develop the condition at an earlier age, and to have diabetes-related complications. Digital health interventions aimed at supporting people to manage their condition better can potentially reduce complications. Mobile phone text messaging is widely used in healthcare. Research shows that text messages about managing diabetes can have positive impacts on patients’ blood sugar levels. It also shows that health interventions that are culturally adapted to the needs of specific ethnic groups are more likely to be relevant and acceptable. Grounded in users’ lived experience, they take account of language, cultural patterns, and values. Although the evidence to support the use of mobile health in diabetes is growing, we know little about the views of British South Asian patients, how best to adapt interventions to meet their needs, or whether adapting interventions is actually effective.

What we looked at

We aimed to explore the perceptions and views of South Asian patients on a text messaging system to support medicine-taking for type 2 diabetes. The SuMMiT-D (Support Through Mobile Messaging and Digital Health Technology for Diabetes) study, aimed at the general UK population, is looking at how to support people to effectively use their diabetes medicine with the help of text messages integrated with clinical care. A wide range of short, simple messages providing information and reminders were developed and checked for acceptability to patients (e.g. “Taking lots of tablets can be confusing. Ask your pharmacist for your tablets in a blister pack or buy a weekly pill box to help you.”)

What we did

We conducted eight exploratory focus groups with a range of South Asian communities in Leicester, England. The Centre for Black and Minority Ethnic Health, at the University of Leicester, helped us recruit 67 adults (including 4 carers) from community centres, places of worship, and a South Asian women’s centre. The people who took part in the focus groups were aged between 18 and 84 and came from some of the largest South Asian communities in the UK: Indian Punjabi Sikh, Pakistani Muslim, Indian Gujarati Hindu, Bangladeshi Muslim, and Indian Gujarati Muslim. Some participants regularly used mobile phones, others hardly ever or not at all. Some people were fluent in English, others spoke only a South Asian language. They talked about the challenges of living with diabetes, their support needs, and whether a text messaging system could help. The discussions were conducted in Punjabi, Bengali, Sylheti, Urdu, Hindi, and English. They were translated into English by Suman Prinjha and a professional translator.

South Asians make up around 7.5% of the UK population and about 11% of the type 2 diabetes population

What we found

Our participants felt that a text messaging system to support medicine-taking for diabetes could be useful to them. This was especially the case for people who regularly used mobile phones. They also felt that:

• The system should include messages to support other aspects of self-management too. Participants were particularly interested in content that gave them new information, including information about the impact of South Asian foods on blood sugar levels, commonly used herbs and spices, natural and herbal approaches used in the UK and South Asia, safe medicine taking when fasting, and exercise in women-only groups. They also wanted to know more about new research, new medications, side effects of current medicines, the impact of diabetes medication on kidney health, diabetes- related stress and stress management, and “reversing diabetes”.

• Text messages in English were acceptable because they were short, less than 160 characters. Some people felt that, though messages in South Asian languages would offer choice and should perhaps be ideally available, texts in English were acceptable given how brief they were. Participants noted that translating messages could be costly and challenging: some patients can speak but not read a South Asian language, and the translated texts might be too formal or difficult to understand.      

• Short text messages in English were acceptable because family members could translate for people unable to read or understand them. Participants felt that messages should be sent to family members as well as to patients (e.g. a son or daughter) as other people could explain or translate them for the patient. Some grown-up children were already receiving text messages on behalf of their parents about health-related appointments (e.g. for physiotherapy).

• Brief messages could be sent in various formats to support patients unable to understand messages in written English. Suggestions included sending audio messages in English and South Asian languages, and images. For people who do not use mobile phones, participants suggested having face-to-face groups (e.g. in community centres) where patients could discuss the message content with others, ideally with a health professional present to answer questions. “Human contact” with health professionals and other patients was seen as important and a good way to receive information.  

What we learnt

Talking to people living with diabetes and some carers, we learnt that a text messaging system to support medicine-taking for diabetes, aimed at the general UK population, would be acceptable to British South Asian patients and families.  For such a system to meet the needs of UK South Asian populations, it may also have to include culturally-relevant messages sent to people who choose to receive them. Sharing message content with patients who do not use digital devices is also important to help reduce health inequalities. Future research could look at co-designing and testing culturally-adapted messages with patients and other stakeholders.

Read our full paper here.

Further reading

Long H, Bartlett YK, Farmer AJ, French DP. Identifying brief message content for interventions delivered via mobile devices to improve medication adherence in people with type 2 diabetes mellitus: a rapid systematic review. J Med Internet Res 2019 Jan 09;21(1):e10421.

Dobson R, Whittaker R, Jiang Y, McNamara C, Shepherd M, Maddison R, Cutfield R, Khanolkar M, Murphy R. Long-term follow-up of a randomized controlled trial of a text-message diabetes self-management support programme, SMS4BG. Diabetic Medicine. 2020 Feb;37(2):311-318. doi: 10.1111/dme.14182.

Liu J, Davidson E, Bhopal R, White M, Johnson M, Netto G, et al. Adapting health promotion interventions to meet the needs of ethnic minority groups: mixed-methods evidence synthesis. Health Technol Assess 2012;16(44):1-469.

This study was funded by the National Institute for Health Research (NIHR; Programme Grants for Applied Research programme [RP-PG-1214-20003]). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.