Diabetes Disparities: Texting to Extend Treatment (DD-TXT)

One way to help Veterans improve their diabetes control is through the use of technology to help provide information, motivation, and reminders necessary to support diabetes self-management. The study will seek input from diverse groups of Veterans living with diabetes to help develop DD-TXT, a new customizable, interactive texting intervention that allows Veterans to choose what kinds of diabetes self-management support they need, and when. This diabetes support will be provided to Veterans through "Annie", a new VA texting system for self-management support. Patients will be randomized to receive DD-TXT or an education-only texting intervention called DSE that is based on a diabetes skills workbook in order to test the comparative effectiveness of DD-TXT.

Type 2 Diabetes is a common, complex health condition which can result in many serious and costly health complications if not treated and controlled properly. One in four Veterans are diagnosed with Type 2 Diabetes. Vulnerable Veterans, such as minority, low-income, or rural Veterans, and Veterans with comorbid mental health diagnoses, are disproportionately affected and are less likely to have their diabetes under control. The goal of this study, using a randomized comparative effectiveness design, is to test the comparative effectiveness of an interactive, tailored self-management texting protocol (DD-TXT), versus a traditional education-only intervention (DSE) in a sample of Veterans with uncontrolled diabetes. The investigators will recruit from Veterans age 18 years and above who are actively receiving care at the study sites (as determined by upcoming scheduled appointment) who have uncontrolled glucose (HbA1c >= 8.0% for at least 50% of the most recent 6 months). Participants who meet these conditions and enroll in the study will be randomized to one of two groups. Those randomized to the intervention group will receive text messages from the DD-TXT protocol for 6 months, and those in the comparison group will receive text messages from DSE, a diabetes skills education-only texting protocol, for 6 months. The primary outcome will be HbA1c percent time in control. Secondary outcomes include self-reported adherence to diabetes self-care recommendations (SCI-R), diabetes self-efficacy, diabetes distress, LDL, and blood pressure control. The investigators hypothesize that DD-TXT will result in better proximal health outcomes and diabetes self-management behaviors vs an education-only protocol (DSE).

Once consented by project coordinators, patients will be asked to complete the baseline survey instruments. Participants will then be randomized with stratification by gender, using a separate randomization table per site. The investigators will first recruit women, with the goal of achieving 10-20% of the sample at each site. The investigators will then recruit male Veterans until the investigators obtain 200 to DD-TXT and 200 to DSE, for a total of 400 enrolled across sites.

All participants will receive a texting intervention but they will not be told whether their intervention is part of the experimental or comparison arm.

Participants in this group will be signed up for an interactive, tailored self-management texting protocol (DD-TXT). The DD-TXT protocol will consist of: Core Messaging: Customizable core modules on medication management, blood sugar and blood pressure monitoring, preventive care, problem solving, appointment reminders, administrative messages; and Optional Messaging: A library of patient-selected modules (e.g. nutrition, physical activity, weight management, emotional coping, goal setting) designed to motivate and educate.

The comparison condition will be signed up for a one-way education-only protocol called Diabetes Skilled Education-Only (DSE). DSE contains only one-way educational content consisting only of content from the VA educational workbook entitled "Self-Care Skills for the Person with Diabetes", which was created in alignment with VA/DoD diabetes guidelines and is recommended for patients as part of usual care. Everyone in the DSE arm will receive the same daily text messages taken verbatim or almost verbatim from the content of the workbook but shortened to fit the 160-character limit of a text message. There will be no customizable or interactive content for the DSE arm.

Participants in this group will be signed up for an interactive, tailored self-management texting protocol (DD-TXT). The DD-TXT protocol will consist of: Core Messaging: Customizable core modules on medication management, blood sugar and blood pressure monitoring, preventive care, problem solving, appointment reminders, administrative messages; and Optional Messaging: A library of patient-selected modules (e.g. nutrition, physical activity, weight management, emotional coping, goal setting) designed to motivate and educate.

The comparison condition will be signed up for a one-way education-only protocol called Diabetes Skilled Education-Only (DSE). DSE contains only one-way educational content consisting only of content from the VA educational workbook entitled "Self-Care Skills for the Person with Diabetes", which was created in alignment with VA/DoD diabetes guidelines and is recommended for patients as part of usual care. Everyone in the DSE arm will receive the same daily text messages taken verbatim or almost verbatim from workbook content but shortened to fit the 160-character limit of a text message (See Appendix 3 for sample messages from workbook). There will be no customizable or interactive content for the DSE arm.

The investigators will examine the changes in HbA1c percent time in control. These data will be calculated using HbA1c measures pulled from the electronic medical record data.

Secondary outcomes include self-reported adherence to diabetes self-care recommendations (SCI-R). These will be collected from the patient via a questionnaire conducted over the phone.

Secondary outcomes include self-reported adherence to diabetes self-efficacy. These will be collected from the patient via a questionnaire conducted over the phone.

Secondary outcomes include self-reported diabetes distress. These will be collected from the patient via a questionnaire conducted over the phone.

Secondary outcomes include blood pressure control. These data will be pulled from the electronic medical record data.

Inclusion Criteria: Veterans active VHA patients with type 2 diabetes have had at least 4 VA outpatient encounters in the previous year have a future appointment scheduled, and not be hospitalized or institutionalized or have participated in Aim 1 DD-TXT development must have access to their own or a cohabiting family member's cell phone or smartphone for participation. --must be willing and able to text, not have any visual impairment that would prevent them from reading or replying to text messages, and must be cognitively capable of consent to participate. must also have HbA1c lab data (2+ values) for the 12 months prior to RCT recruitment. must have inadequate glycemic control for at least 50% of the 6 months before enrollment. Exclusion Criteria: -Non-Veterans