Development and Feasibility of an App to Decrease Risk Factors for Type 2 Diabetes in Hispanic Women With Recent Gestational Diabetes (Hola Bebé, Adiós Diabetes): Pilot Pre-Post Study

Ellen W Seely, Patricia Flynn Weitzman, Dharma Cortes, Sara Romero Vicente, Sue E Levkoff, Ellen W Seely, Patricia Flynn Weitzman, Dharma Cortes, Sara Romero Vicente, Sue E Levkoff

Abstract

Background: Hispanic women have increased risk of gestational diabetes mellitus (GDM), which carries an increased risk for future type 2 diabetes, compared to non-Hispanic women. In addition, Hispanic women are less likely to engage in healthy eating and physical activity, which are both risk factors for type 2 diabetes. Supporting patients to engage in healthy lifestyle behaviors through mobile health (mHealth) interventions is increasingly recognized as a viable, underused tool for disease prevention, as they reduce barriers to access frequently experienced in face-to-face interventions. Despite the high percentage of smartphone ownership among Hispanics, mHealth programs to reduce risk factors for type 2 diabetes in Hispanic women with prior GDM are lacking.

Objective: This study aimed to (1) develop a mobile app (¡Hola Bebé, Adiós Diabetes!) to pilot test a culturally tailored, bilingual (Spanish/English) lifestyle program to reduce risk factors for type 2 diabetes in Hispanic women with GDM in the prior 5 years; (2) examine the acceptability and usability of the app; and (3) assess the short-term effectiveness of the app in increasing self-efficacy for both healthy eating and physical activity, and in decreasing weight.

Methods: Social cognitive theory provided the framework for the study. A prototype app was developed based on prior research and cultural tailoring of content. Features included educational audiovisual modules on healthy eating and physical activity; personal action plans; motivational text messages; weight tracking; user-friendly, easy-to-follow recipes; directions on building a balanced plate; and tiered badges to reward achievements. Perceptions of the app's acceptability and usability were explored through four focus groups. Short-term effectiveness of the app was tested in an 8-week single group pilot study.

Results: In total, 11 Hispanic women, receiving care at a federally qualified community health center, aged 18-45 years, and with GDM in the last 5 years, participated in four focus groups to evaluate the app's acceptability and usability. Participants found the following sections most useful: audiovisual modules, badges for completion of activities, weight-tracking graphics, and recipes. Suggested modifications included adjustments in phrasing, graphics, and a tiering system of badges. After app modifications, we conducted usability testing with 4 Hispanic women, with the key result being the suggestion for a "how-to tutorial." To assess short-term effectiveness, 21 Hispanic women with prior GDM participated in the pilot. There was a statistically significant improvement in both self-efficacy for physical activity (P=.003) and self-efficacy for healthy eating (P=.007). Weight decreased but not significantly. Backend process data revealed a high level of user engagement.

Conclusions: These data support the app's acceptability, usability, and short-term effectiveness, suggesting that this mHealth program has the potential to fill the gap in care experienced by Hispanic women with prior GDM following pregnancy. Future studies are needed to determine the effectiveness of an enhanced app in a randomized controlled trial.

Trial registration: ClinicalTrials.gov NCT04149054; https://ichgcp.net/clinical-trials-registry/NCT04149054.

Keywords: Hispanic; Latina; diabetes prevention; gestational diabetes mellitus; intervention; mHealth; mobile apps.

Conflict of interest statement

Conflicts of Interest: None declared.

©Ellen W Seely, Patricia Flynn Weitzman, Dharma Cortes, Sara Romero Vicente, Sue E Levkoff. Originally published in JMIR Formative Research (http://formative.jmir.org), 31.12.2020.

Figures

Figure 1
Figure 1
Screenshots from the ¡Hola Bebé, Adiós Diabetes! app.

References

    1. American Diabetes Association Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020 Jan;43(Suppl 1):S183–S192. doi: 10.2337/dc20-S014.
    1. Headen IE, Davis EM, Mujahid MS, Abrams B. Racial-ethnic differences in pregnancy-related weight. Adv Nutr. 2012 Jan;3(1):83–94. doi: 10.3945/an.111.000984.
    1. Chasan-Taber L, Schmidt MD, Pekow P, Sternfeld B, Solomon CG, Markenson G. Predictors of excessive and inadequate gestational weight gain in Hispanic women. Obesity (Silver Spring) 2008 Jul;16(7):1657–66. doi: 10.1038/oby.2008.256. doi: 10.1038/oby.2008.256.
    1. Brawarsky P, Stotland NE, Jackson RA, Fuentes-Afflick E, Escobar GJ, Rubashkin N, Haas JS. Pre-pregnancy and pregnancy-related factors and the risk of excessive or inadequate gestational weight gain. Int J Gynaecol Obstet. 2005 Nov;91(2):125–31. doi: 10.1016/j.ijgo.2005.08.008.
    1. Walker LO, Hoke MM, Brown A. Risk factors for excessive or inadequate gestational weight gain among Hispanic women in a U.S.-Mexico border state. J Obstet Gynecol Neonatal Nurs. 2009;38(4):418–29. doi: 10.1111/j.1552-6909.2009.01036.x.
    1. Casagrande SS, Linder B, Cowie CC. Prevalence of gestational diabetes and subsequent Type 2 diabetes among U.S. women. Diabetes Res Clin Pract. 2018 Jul;141:200–208. doi: 10.1016/j.diabres.2018.05.010.
    1. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care. 2002 Oct;25(10):1862–8. doi: 10.2337/diacare.25.10.1862.
    1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012 Feb 1;307(5):491–7. doi: 10.1001/jama.2012.39.
    1. Obesity and Hispanic Americans. . 2020. Mar 26, [2020-10-29]. .
    1. Paz K, Massey KP. Health Disparity among Latina Women: Comparison with Non-Latina Women. Clin Med Insights Womens Health. 2016;9(Suppl 1):71–4. doi: 10.4137/CMWH.S38488.
    1. Cortés DE, Millán-Ferro A, Schneider K, Vega RR, Caballero AE. Food purchasing selection among low-income, Spanish-speaking Latinos. Am J Prev Med. 2013 Mar;44(3 Suppl 3):S267–73. doi: 10.1016/j.amepre.2012.11.012.
    1. Morrill KE, Lopez-Pentecost M, Ballesteros G, Pfander JL, Hingle MD, Klimentidis YC, Thomson CA, Garcia DO. Weight loss interventions for Hispanic women in the USA: a protocol for a systematic review. Syst Rev. 2019 Dec 01;8(1):301. doi: 10.1186/s13643-019-1213-3.
    1. Bautista L, Reininger B, Gay JL, Barroso CS, McCormick JB. Perceived barriers to exercise in Hispanic adults by level of activity. J Phys Act Health. 2011 Sep;8(7):916–25. doi: 10.1123/jpah.8.7.916.
    1. Neighbors CJ, Marquez DX, Marcus BH. Leisure-time physical activity disparities among Hispanic subgroups in the United States. Am J Public Health. 2008 Aug;98(8):1460–4. doi: 10.2105/AJPH.2006.096982.
    1. Centers for Disease ControlPrevention (CDC) Prevalence of regular physical activity among adults--United States, 2001 and 2005. MMWR Morb Mortal Wkly Rep. 2007 Nov 23;56(46):1209–12.
    1. Larsen BA, Pekmezi D, Marquez B, Benitez TJ, Marcus BH. Physical activity in Latinas: social and environmental influences. Womens Health (Lond Engl) 2013 Mar;9(2):201–10. doi: 10.2217/whe.13.9.
    1. Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer X, Fowler S, Kahn SE, Diabetes Prevention Program Research Group Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab. 2008 Dec;93(12):4774–9. doi: 10.1210/jc.2008-0772.
    1. Hernan WH, Brandle M, Zhang P, Williamson DF, Matulik MJ, Ratner RE, Lachin JM, Engelgau MM, Diabetes Prevention Program Research Group Costs associated with the primary prevention of type 2 diabetes mellitus in the diabetes prevention program. Diabetes Care. 2003 Jan;26(1):36–47. doi: 10.2337/diacare.26.1.36.
    1. Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study. Am J Prev Med. 2008 Oct;35(4):357–63. doi: 10.1016/j.amepre.2008.06.035.
    1. Nicklas JM, Zera CA, Seely EW, Abdul-Rahim ZS, Rudloff ND, Levkoff SE. Identifying postpartum intervention approaches to prevent type 2 diabetes in women with a history of gestational diabetes. BMC Pregnancy Childbirth. 2011;11:23. doi: 10.1186/1471-2393-11-23.
    1. Perrin A, Turner E. Smartphones help blacks, Hispanics bridge some-but not all- digital gaps with whites. Pew Research Center. 2019. [2020-04-22].
    1. Anderson M. Racial and ethnic differences in how people use mobile technology. Pew Research Center. 2015. [2020-04-22]. .
    1. Descubrimiento Digital: The Online Lives of Latinx Consumers (Rep) The Nielsen Company. 2018. [2020-10-28]. .
    1. Bentley-Lewis R, Levkoff S, Stuebe A, Seely EW. Gestational diabetes mellitus: postpartum opportunities for the diagnosis and prevention of type 2 diabetes mellitus. Nat Clin Pract Endocrinol Metab. 2008 Oct;4(10):552–8. doi: 10.1038/ncpendmet0965.
    1. Rich-Edwards JW, McElrath TF, Karumanchi SA, Seely EW. Breathing life into the lifecourse approach: pregnancy history and cardiovascular disease in women. Hypertension. 2010 Sep;56(3):331–4. doi: 10.1161/HYPERTENSIONAHA.110.156810.
    1. Beckles G, Thompson-Reid P. Diabetes & Women's Health across the Life Stages: A Public Health Perspective. Atlanta, GA: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 2001.
    1. Phelan S. Pregnancy: a "teachable moment" for weight control and obesity prevention. Am J Obstet Gynecol. 2010 Feb;202(2):135.e1–8. doi: 10.1016/j.ajog.2009.06.008.
    1. Bandura A. Self-efficacy: The Exercise of Control. New York, NY: WH Freeman/Times Books/Henry Holt & Co; 1997.
    1. Bandura A. The Explanatory and Predictive Scope of Self-Efficacy Theory. Journal of Social and Clinical Psychology. 1986 Sep;4(3):359–373. doi: 10.1521/jscp.1986.4.3.359.
    1. Desharnais R, Bouillon J, Godin G. Self-efficacy and outcome expectations as determinants of exercise adherence. Psychol Rep. 2016 Sep 01;59(3):1155–1159. doi: 10.2466/pr0.1986.59.3.1155.
    1. Nansel TR, Haynie DL, Lipsky LM, Wang J, Mehta SN, Laffel LM. Relationships among parent and youth healthful eating attitudes and youth dietary intake in a cross-sectional study of youth with type 1 diabetes. Int J Behav Nutr Phys Act. 2013;10(1):125. doi: 10.1186/1479-5868-10-125.
    1. What is MyPlate? Chose MyPlate, US Department of Agriculture. 2020. [2020-12-18]. .
    1. Sallis JF, Pinski RB, Grossman RM, Patterson TL, Nader PR. The development of self-efficacy scales for healthrelated diet and exercise behaviors. Health Educ Res. 1988;3(3):283–292. doi: 10.1093/her/3.3.283.
    1. Sallis JF. Self-Efficacy for Diet and Exercise. . [2020-10-28]. .
    1. Green LW, Kreuter MW. Health promotion planning: An educational and environmental approach. New York: McGraw-Hill Humanities; 2004.
    1. Wang A, An N, Lu X, Chen H, Li C, Levkoff S. A classification scheme for analyzing mobile apps used to prevent and manage disease in late life. JMIR Mhealth Uhealth. 2014 Feb 17;2(1):e6. doi: 10.2196/mhealth.2877.
    1. Bernstein JA, Quinn E, Ameli O, Craig M, Heeren T, Lee-Parritz A, Iverson R, Jack B, McCloskey L. Follow-up after gestational diabetes: a fixable gap in women's preventive healthcare. BMJ Open Diabetes Res Care. 2017;5(1):e000445. doi: 10.1136/bmjdrc-2017-000445.
    1. Committee on Practice Bulletins—Obstetrics Practice Bulletin No. 180: Gestational Diabetes Mellitus. Obstet Gynecol. 2017 Jul;130(1):e17–e37. doi: 10.1097/AOG.0000000000002159.
    1. Wilkinson SA, Lim SS, Upham S, Pennington A, O'Reilly SL, Asproloupos D, McIntyre HD, Dunbar JA. Who's responsible for the care of women during and after a pregnancy affected by gestational diabetes? Med J Aust. 2014 Aug 04;201(3 Suppl):S78–81. doi: 10.5694/mja14.00251.
    1. La Oportunidad Latinx: Cultural currency and the consumer journey. The Nielson Company. 2019. [2020-04-22].

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner