Multilingual Voice Calls to Adjust Long-Acting Insulin for Adults With Type 2 Diabetes and Low Health Literacy in Pakistan (VOICE-TITR-PK)

Multilingual Voice-Based Insulin Titration for Adults With Type 2 Diabetes and Low Health Literacy in Pakistan: A Randomized Trial

This study will evaluate whether a multilingual, feature-phone interactive voice response (IVR) system with human-verified basal insulin titration improves glycemic control compared with standard clinic-based insulin titration among adults with type 2 diabetes and low health literacy in Pakistan. Approximately 220 participants will be randomly assigned to either the IVR-supported titration strategy or usual clinic-based care. Participants will be followed for 12 weeks, with the primary outcome being change in glycated hemoglobin (HbA1c) from baseline to Week 12. Secondary outcomes include fasting plasma glucose, insulin dose adjustment, hypoglycemia, treatment adherence, patient satisfaction, health literacy-related outcomes, and implementation measures.

Study Overview

• Status: Not yet recruiting
• Conditions: Type 2 Diabetes Mellitus (T2DM); Hyperglycemia Due to Type 2 Diabetes Mellitus
• Intervention / Treatment: Behavioral: Multilingual IVR-Supported Basal Insulin Titration; Other: Standard Clinic-Based Basal Insulin Titration

Detailed Description

Type 2 diabetes mellitus is highly prevalent in Pakistan, where many adults experience limited health literacy and face barriers to frequent clinic visits required for insulin dose adjustment. Delays in basal insulin titration contribute to prolonged hyperglycemia and poor diabetes outcomes.

This multicenter, pragmatic, individually randomized, assessor-blinded trial will compare a multilingual feature-phone interactive voice response (IVR) system with human verification for basal insulin titration against standard clinic-based insulin titration. Eligible adults with type 2 diabetes requiring basal insulin adjustment will be randomly assigned in a 1:1 ratio to either the intervention or control group.

Participants in the intervention arm will receive automated multilingual voice calls that collect fasting blood glucose values and provide algorithm-guided insulin dose recommendations that are reviewed by trained clinical staff before implementation. Participants in the control arm will receive routine clinic-based insulin titration according to standard practice.

Participants will be followed for 12 weeks. The primary outcome is change in glycated hemoglobin (HbA1c) from baseline to Week 12. Secondary outcomes include fasting plasma glucose, insulin dose, hypoglycemic events, medication adherence, patient satisfaction, quality of life, implementation outcomes, and healthcare utilization. Safety outcomes will be monitored throughout the study.

The study aims to determine whether a scalable, multilingual telemedicine-supported insulin titration strategy can improve glycemic control while increasing access to high-quality diabetes care for adults with low health literacy in Pakistan.

• Study Type: Interventional
• Enrollment (Estimated): 220
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Nadia Hussain, MD, PhD; Phone Number: 0505440153; Email: nadia.hussain@aau.ac.ae

Study Locations

• Pakistan
  • Lahore, Pakistan
    • Shifa Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age 18 years or older.
• Diagnosed with type 2 diabetes mellitus.
• Currently receiving basal insulin or considered by the treating clinician to require initiation or adjustment of basal insulin.
• Glycemic control considered inadequate and requiring basal insulin titration according to the study protocol.
• Low health literacy as determined using the study-approved screening method.
• Able to communicate in one of the languages supported by the study intervention.
• Has access to a functioning feature phone or mobile telephone and is able to receive automated voice calls.
• Able and willing to perform fasting blood glucose monitoring according to the study procedures.
• Willing and able to provide informed consent.
• Willing to comply with study procedures and complete the 12-week follow-up.

Exclusion Criteria:

• Type 1 diabetes mellitus, gestational diabetes, or another specific form of diabetes other than type 2 diabetes mellitus.
• Pregnancy, current breastfeeding, or planned pregnancy during the study period.
• Current use of an insulin pump.
• Severe hypoglycemia requiring assistance from another person within the period specified in the protocol before enrollment.
• Recurrent hypoglycemia or another clinical condition that, in the investigator's judgment, makes protocol-directed insulin titration unsafe.
• Acute metabolic decompensation, including diabetic ketoacidosis or hyperosmolar hyperglycemic state, at screening or within the period specified in the protocol.
• Severe renal, hepatic, cardiac, psychiatric, cognitive, hearing, or other medical impairment that would prevent safe participation or completion of the voice-call intervention.
• Inability to understand or respond to the study's supported voice-call languages.
• Inability to use the telephone or glucose-monitoring procedures, with or without assistance permitted by the protocol.
• Current participation in another interventional clinical trial that could interfere with the study outcomes.
• Any other condition that, in the investigator's judgment, would make participation unsafe or compromise adherence to the study procedures.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: IVR-Supported Basal Insulin Titration; Participants will receive multilingual feature-phone interactive voice response (IVR)-supported basal insulin titration with human verification. Automated voice calls will collect fasting blood glucose values, generate algorithm-guided insulin dose recommendations, and communicate dose adjustments after review by trained clinical staff. Participants will continue standard diabetes care throughout the study.	Behavioral: Multilingual IVR-Supported Basal Insulin Titration; Participants will receive basal insulin titration using a multilingual interactive voice response (IVR) system with human verification. Automated voice calls collect fasting blood glucose values and generate algorithm-guided insulin dose recommendations that are reviewed by trained clinical staff before implementation. Participants continue standard diabetes care throughout the study.
Active Comparator: Standard Clinic-Based Basal Insulin Titration; Participants will receive basal insulin titration according to routine clinic-based practice. Insulin dose adjustments will be made by healthcare providers during standard clinical care using existing institutional protocols. Participants will continue standard diabetes management throughout the study.	Other: Standard Clinic-Based Basal Insulin Titration; Participants will receive basal insulin titration according to routine clinic-based practice. Insulin dose adjustments will be made during scheduled clinical care using institutional protocols. Participants will continue to receive standard diabetes management throughout the study.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean Change From Baseline in Glycated Hemoglobin (HbA1c) at Week 12	HbA1c will be measured as a percentage at baseline and Week 12 using the study laboratory's standardized assay. For each participant, change will be calculated as the Week 12 HbA1c value minus the baseline HbA1c value. The outcome will be summarized as the mean change in HbA1c percentage points within each study arm.	Baseline and Week 12

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean Change From Baseline in Fasting Plasma Glucose at Week 12	Fasting plasma glucose will be measured in milligrams per deciliter (mg/dL) at baseline and Week 12 after an overnight fast. For each participant, change will be calculated as the Week 12 value minus the baseline value. The outcome will be summarized as the mean change in mg/dL within each study arm.	Baseline to Week 12
Mean Change From Baseline in Daily Basal Insulin Dose at Week 12	The prescribed total daily basal insulin dose will be recorded in international units per day (units/day) at baseline and Week 12. For each participant, change will be calculated as the Week 12 dose minus the baseline dose. The outcome will be summarized as the mean change in units/day within each study arm.	Baseline to Week 12
Percentage of Participants Experiencing at Least One Documented Hypoglycemic Event Through Week 12	A documented hypoglycemic event will be defined as a measured blood glucose concentration below 70 mg/dL, regardless of the presence of symptoms. The outcome will be calculated as the number of participants with at least one documented hypoglycemic event divided by the number of participants assessed, multiplied by 100.	From randomization through Week 12
Percentage of Participants Experiencing at Least One Severe Hypoglycemic Event Through Week 12	Severe hypoglycemia will be defined as an event associated with severe cognitive impairment requiring assistance from another person for recovery. The outcome will be calculated as the number of participants experiencing at least one severe hypoglycemic event divided by the number of participants assessed, multiplied by 100.	From randomization through Week 12

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of Recommended Basal Insulin Dose Adjustments Implemented Through Week 12	Adherence will be calculated for each participant as the number of recommended basal insulin dose adjustments implemented within the protocol-specified period divided by the total number of dose adjustments recommended for that participant, multiplied by 100. Participant percentages will be summarized within each study arm.	From randomization through Week 12
Mean Change From Baseline in Study-Specific Health-Related Quality-of-Life Score at Week 12	Health-related quality of life will be assessed using an 8-item study-specific questionnaire developed for this trial. The questionnaire covers physical well-being, emotional well-being, ability to perform usual daily activities, diabetes-related fatigue, sleep quality, confidence in managing diabetes, social participation, and overall perceived health. Each item is scored from 0 to 4, where 0 indicates the poorest outcome and 4 indicates the best outcome. Item scores are summed to produce a total score ranging from 0 to 32, with higher scores indicating better health-related quality of life. For each participant, change will be calculated as the Week 12 total score minus the baseline total score and summarized as the mean change within each study arm.	Baseline to Week 12

Collaborators and Investigators

• Sponsor: Shifa International Hospital
• Collaborators: Al Ain University

Study record dates

Study Major Dates

• Study Start (Estimated): September 25, 2026
• Primary Completion (Estimated): February 25, 2027
• Study Completion (Estimated): March 1, 2027

Study Registration Dates

• First Submitted: July 22, 2026
• First Submitted That Met QC Criteria: July 22, 2026
• First Posted (Actual): July 27, 2026

Study Record Updates

• Last Update Posted (Actual): July 27, 2026
• Last Update Submitted That Met QC Criteria: July 22, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Telemedicine; Mobile Health; Health Literacy; Digital Health; Type 2 Diabetes Mellitus; Pakistan; Glycemic Control; Interactive Voice Response; Insulin Titration; Basal Insulin
• Additional Relevant MeSH Terms: Endocrine System Diseases; Metabolic Diseases; Glucose Metabolism Disorders; Diabetes Mellitus; Nutritional and Metabolic Diseases; Diabetes Mellitus, Type 2
• Other Study ID Numbers: SH-67214358; SIAC-05821 (Other Grant/Funding Number: Shifa Hospital Research Council)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: De-identified individual participant data underlying the results reported in the primary publication will be shared, together with a data dictionary. Shared data may include baseline characteristics, treatment allocation, primary and secondary outcome data, and safety data. Direct identifiers and information that could reasonably permit participant re-identification will not be shared.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No