Among African American women with diabetes who have inadequate glycemic control (A1c>8%) who receive care in community clinics in Los Angeles County, we propose to evaluate the impact of an intervention that identifies and supports intrinsic motivation for improved diabetes control through combined in-person, phone, and SMS contact and also, for one arm of the study, a behavioral economics intervention that uses monetary incentives to reward improved glycemic control. The randomized controlled trial (RCT), a multicomponent intervention to boost intrinsic motivation for improved glycemic control will randomize patients within participating clinics to one of three groups;1) Usual care (("Control" condition), 2) An intervention to boost intrinsic motivation to lower A1c through in-person visits, telephone calls, and tailored text messages delivered by cell phone ("IM/SMS" condition), and 3) An intervention that adds periodic monetary incentives, whose size depends on the degree of reduction in A1c, and lottery participation to boost motivation to participate in diabetes self care and reach A1c goals ("IM/SMS+lncentives" condition). We will assess the effect ofthe IM/SMS and IM/SMS+lncentives interventions on glycemic control over a 12 month period and determine whether improvements in Ale compared to the control arm are sustained for 6 additional months after the SMS and monetary incentives are discontinued. We will also assess the costs of the interventions and their effect on resource use. The primary study outcome is change in A1c. To gain insights into possible mechanisms forthe impact ofthe intervention, we will also assess the effects of the intervention on self-management behaviors, patient activation, changes in medication regimens, number of physician visits, weight, quality of life, trust in the health care system, participants'self-reported experiences with the intervention, and spillover effects ofthe intervention on blood pressure control. We hypothesize that, compared with the control group, women in the IM/SMS or the IM/SMS+incentive arms will have lower A1c levels (and will be more likely to achieve the target A1c of 7.0%), both while the interventions are in place and 6 months after the regular contact and monetary incentives are discontinued. We also hypothesize that glycemic control will be better at 12 months forthe IM/SMS+lncentive group than the IM/SMS group, but will be similar 6 months after the interventions are discontinued.
Diabetes is a major public health problem that is associated with substantial health disparities for African American women compared to African American men or white men and women. This project will incorporate new technology whose use is high among African Americans (cell phone text message reminders) and strategies from the emerging field of behavioral economics to encourage and support self care behaviors that lead to improvements in diabetes control.
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