# A Culturally Tailored Diabetes Self-Management Education Program With Mobile Health Integration for Chinese Americans With Type 2 Diabetes: Development and Pilot Evaluation Study

## TL;DR

A culturally tailored diabetes education program with mobile health tools was developed and tested for Chinese Americans with type 2 diabetes, showing promising improvements in health outcomes.

## Contribution

The study introduces a culturally adapted DSME program with integrated mHealth technology for Chinese Americans, a population underrepresented in diabetes research.

## Key findings

- The pilot study showed a significant reduction in HbA1c levels among participants after 3 months.
- Participants demonstrated improved self-efficacy, quality of life, and stress-coping skills.
- The program's use of WeChat and wireless monitoring devices was feasible and effective in supporting diabetes management.

## Abstract

Although progress has been made in improving the efficacy of Diabetes Self-Management Education (DSME) programs, there remains a dearth of research on culturally adapted, evidence-based DSMEs for Chinese Americans (CAs) with type 2 diabetes.

Through collaborative partnerships with 2 large community recreation centers and the AHMC Hospital Network in San Gabriel Valley, California, we developed and pilot-tested a culturally tailored DSME program with integrated mobile health (mHealth) technology, entitled Culturally Appropriate Strategies for Chinese Americans with Diabetes (CASCADe).

The CASCADe program utilized a combined, theoretically driven, and community-participatory approach and was developed based on information gleaned from focus groups, semistructured interviews, and a questionnaire survey conducted among CA patients with diabetes, physicians, and nurses, as well as from extensive literature reviews of evidence-based program curricula. A single-group pre- and posttest design with a 3-month study period was then employed to assess the program’s preliminary efficacy. The study protocols were registered on ClinicalTrials.gov.

The CASCADe program consisted of (1) a home visit in the first month for training in monitoring device use and WeChat app (a mobile instant-messaging platform widely used in the Chinese population) usage, as well as for acquiring family support; (2) 8 weekly sessions over the following 2 months, delivered in a combined format of group classes, games, group exercises, videos, and discussions; and (3) WeChat follow-up involving education tips, monitoring data summaries, and group discussions after each of the 8 weekly sessions. Topics covered in the weekly sessions included recognition of diabetes and its complications, risk factors, nutrition knowledge, dietary practices, exercise, behavioral self-monitoring, medication adherence, and stress management. The monitoring system used a smartphone to coordinate cloud-based data transmission from a set of wireless devices to capture daily monitoring data on physical activity, body weight, blood pressure, and blood glucose levels. Behavioral self-monitoring was further facilitated by the WeChat app, which provided daily messages related to the diabetes education curriculum; weekly summary reports of monitoring data; feedback; bidirectional 1-on-1 communication between intervention providers and participants; and group discussions among participants regarding readings and the implications of monitoring results. The pre- and postcomparison from the 3-month pilot trial showed a significant reduction in glycated hemoglobin (HbA1c; 7.48 vs 7.09, P=.03), with all but 1 participant demonstrating a reduction and 7 out of 12 (58%) achieving a >0.5 decrease in HbA1c. Significant improvements were also observed in self-efficacy in diabetes management (6.59 vs 8.01, P=.003), quality of life (3.21 vs 3.69, P=.005), and stress-coping skills (3.18 vs 3.74, P=.01) at 3 months after baseline among CA patients with type 2 diabetes.

Our pilot study demonstrated the feasibility of implementing the CASCADe program among CAs to improve diabetes self-management skills and yielded promising results, warranting further evaluation in a larger randomized trial.

ClinicalTrials.gov NCT04737499; https://clinicaltrials.gov/ct2/show/NCT04737499