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DOI:
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Address for correspondence: Dr Robin Maskey,
Department of Endocrinology, Internal Medicine,
BPKIHS, Dharan, Nepal.
E-mail: drmaskey@gmail.com
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How to cite this article: Maskey R, Mehta RS, Karki P. Text messaging
and quality of life of diabetics in tertiary care hospital of Eastern
Nepal. J Cardio Diabetes Metab Disord 2021;1:18-24.
Original Article
Text Messaging and Quality of Life of Diabetics in Tertiary Care
Hospital of Eastern Nepal
Robin Maskey1
, Ram Sharan Mehta2
, Prahlad Karki3
1
Department of Endocrinology, Internal Medicine, BPKIHS, Dharan, Nepal, 2
Medical-Surgical Nursing Department, BPKIHS, Dharan, Nepal, 3
Cardiology Department,
BPKIHS, Dharan, Nepal
Abstract
Background: Text messaging health service is used to improve quality of life of people living with diabetes in Eastern Nepal. It has
been projected that the number of diabetic patients has increased to 170% from 1995 to 2025 in developing countries and to 41% in
developed world. The objectives of the study were to assess the quality of life of people living with diabetes, to prepare and provide
health education, and to evaluate the effectiveness of health education program and mobile/telephone health services provided to the
diabetes patients. Materials and Methods: The study was conducted among consecutive stable ambulatory patients, 18 years old,
and 396 patients diagnosed with diabetes for at least 3 months were included in the study. The education intervention was continued
for 6 months by the principal investigator and a trained nurse. Results: Most of the respondents (53.3%) were of the age group 40–60
years; female (59.34%); Hindus (97%); and of the Janjati ethnic group (52.5%). The majority (96.5%) were married and self-employed
(70.7%). About 30% of the respondents belonged to the poor economic status group. Most of the respondents had type II diabetes
mellitus; about 34% of the respondents had a family history of (sibling) diabetes. Most of them were non-vegetarians (88.9%). About
16% of the respondents were obese. Regarding habits, 14% had tobacco chewing, 5% had gutka chewing, 8% had smoking, and
around 8% had alcohol consumption habits. Regarding treatment, about 84% were on oral hypoglycemic agent, 22% on insulin
therapy, 68% on diet control therapy, 58% on weight control, and 4.5% on herbal therapy. It was found that the mean knowledge score
before education intervention was 22.53 and after education intervention was 35.32. It was found that the difference in the mean score
calculated using t-test between knowledge before and after education intervention program was significant (P 0.01). Conclusion: It
can be concluded that the education intervention program and SMS mobile service provided to diabetes patients were found to be
very effective.
Keywords: Diabetes, health service, Nepal, text messaging
Introduction
One fifty million people were affected by diabetes in 2002,
180 million in 2003, and will reach 330 million in 2025.
This rising prevalence is especially occurring in developing
countries.
The reasons for increasing prevalence of diabetes
in developing countries are industrialization, socio-
economic development, urbanization, and changing life
style. Similarly, lack of public awareness regarding the
problems of diabetes and poor medical service was the
main reason for the increased prevalence of diabetes in
country.[1]
From January 1, 2014 to December 31, 2014, in
Endocrine and Diabetic Clinic of B.P. Koirala Institute of
Health Sciences, 802 patients (440 M and 362 F) attended
with diabetes mellitus (DM). Hence, the investigators tried
to explore the various facts or problems of the admitted
patients suffering from DM.
As per the study done by Mehta et al. in BPKIHS for
1 year among patients, 60.7% had hypertension, 39.3%
had ocular problem, and 25% had renal problems. The
majority of the subjects (82.1%) know about the disease
Submitted: 18-Oct-2020 Revised: 03-Feb-2021 Accepted: 03-Mar-2021
Published: 18-May-2021
[Downloaded free from http://www.cardiodiabetic.org on Monday, May 31, 2021, IP: 10.232.74.23]

Maskey, et al.: Text messaging and quality of life of diabetics in tertiary care hospital
Journal of Cardio-Diabetes and Metabolic Disorders ¦ Volume 1 ¦ Issue 1 ¦ January-June 2021 19
(DM) they were suffering, but limited subjects had
knowledge about causes, curability, treatment modalities,
diet, and other aspects. As the knowledge regarding
various aspects of DM is very low, there is a need for an
informational booklet in Nepali, and the health education
program among public was very useful.
The psychosocial needs of patients with diabetes are not
well understood by healthcare providers. Psychosocial
factors have important influences on diabetes outcomes,
and subjective quality of life is a worthwhile outcome in
its own right. Therefore, it is important to understand
how healthcare providers deal with their patients’
psychosocial needs.
By using the mobile phone, patients with diabetes will
receive regular SMS on diabetes management and
adherence to therapy along with the strategies to manage
complications. Patients can use their mobile phone to
receive information from their own home and get needed
information, and the investigators will also send the
information periodically so that adherence to therapy was
maximum. Hence, mobile heath service will increase the
adherence to therapy and improve the quality of life of
diabetes patients.
Materials and Methods
Consecutive 396 stable ambulatory patients 18 years of
age and diagnosed case of diabetes for at least 3 months
duration were included in the study, after taking consent
from subjects and IRB approval from our institute.
Sampling methods/techniques (specify)
The study was conducted among all the people living with
diabetes meeting the eligibility criteria and attending B. P.
Koirala Institute of Health Sciences Medical OPD. No
restrictions were based on sex, race, type of diabetes, or
location of patients.
Thesamplingframewaspreparedfromtheregisteravailable
at the BPKIHS Diabetes Clinic, obtaining the history from
the clients attending the clinic. Before starting the training
program, orientation was given to the nurses working in
medical OPD and ward, team members, involved doctor
and nurses, and those who were involved in the training
program as facilitators and resource persons.
The first pre-test was taken among all the 396 diabetes
patients, and education intervention was started for all the
diabetes patients attending the Diabetes Clinic of MOPD.
The education intervention was continued for 6 months
in diabetes clinic by the principal investigator and trained
nurse in the MOPD.
The contents of the self-management program were: basic
concepts of disease process, treatment, complications,
adherence to oral hypoglycemic agent (OHA) and insulin,
management of side effects of drugs, developing healthy
habits at home, prevention of hypo- and hyperglycemia,
management of common health problems at home, and
increased self-esteem. A training package was prepared
and provided to each patient after explanation. The self-
management program was validated before the study.
Interactive health education session at diabetes clinic
by trained nurses for 6 months includes A-V aids, print
resources, and booklets, in which all the diabetic patients
got three to four chances to participate in the program.
During the training program, detailed address of the
specified trained nurses and doctors was given to the
participants in written form, and instruction was given
to them how to contact through phone and when the
investigator will contact them. They were also trained how
to contact and how to communicate their problems to the
investigators. Two separate phone numbers were given to
them and they were asked to save these numbers, so that it
is easy to contact and receive the phone call.
During the training, all the required resources such as
booklet, pamphlets, posters, and the phone contact number
detail card were provided to them, and participants were
informed to contact the specified person (trained nurses
and doctors) for help if they required that specified phone
number and time. The participants were also informed that
the investigator would contact them in the number they had
given to the investigator. Telephone calls were done to find
out the situation and support related to self-management.
The intervention is a multi-component self-management
intervention which includes diet therapy, OHA, adherence,
exercise, management of complications, and elements of
cognitive behavioral therapy; it was included because the
focus is on self-management more broadly.
After the education intervention, 1 month was given for
follow-up and telephone counseling focus group discussion
and guidance. The participants were given the instruction
that they can contact the investigators when they need
help. After 6 months of education intervention, post-
test was taken among all the 396 diabetes patients. Four
focus group discussions were also arranged to find out the
effectiveness of the program and find out the obstacles,
so that they can be used for further implementation and
future plan.
Quality of diabetes instrument was used to assess the
component of quality of life and self-management
components. The instrument used is highly reliable, tested,
and commonly used worldwide.
Data analysis and interpretation
After the collection of data, they were checked for
completeness, organized, coded, and entered in Microsoft
Excel 2010, and converted into SPSS 16 version for the
statistical analysis. For the descriptive statistics, mean,
median, standard deviation, percentage, and frequency
are calculated for presenting sociodemographic variables


20 20 Journal of Cardio-Diabetes and Metabolic Disorders ¦ Volume 1 ¦ Issue 1 ¦ January-June 2021
and health risk behaviors. For inferential statistics,
appropriate χ2
test and t-test have been applied to find
the association between the variables. The findings of
the study are represented using the suitable tables, and
statistical tests have been presented based on the following
statistics:
1. Socio-demographic characteristics of the respondents;
2. Diabetes and risk factors of the respondents;
3. Therapies for diabetes received by the respondents;
4.
Knowledge score before and after education
intervention among the respondents;
5.
Evaluation of the educational program by the
respondents;
6. Association between pre-test and post-test mean
knowledge score;
7. Association among sociodemographic characteristics,
duration of illness, and risk factors with pre-test
knowledge score;
8. Association among sociodemographic characteristics,
duration of illness, and risk factors with post-test
knowledge score.
Results
Most of the subjects (53.3%) were of the age group
40–60 years; female (59.34%); Hindus (97%); and of
Janjati ethnic group (52.5%). The majority (96.5%) were
married and self-employed (70.7%). About 30% of the
respondents belonged to the poor economic status group.
The details are in Table 1.
Most of the respondents had type II DM; about 34% of
the respondents had a family history of (sibling) diabetes.
Most of them were non-vegetarians (88.9%). About 16%
of the respondents were obese. Regarding habits, 14%
had tobacco chewing, 5% had gutka chewing, 8% had
smoking, and around 8% had alcohol consumption habit.
The details are in Table 2.
Regarding treatment, about 84% were on OHA, 22%
on insulin therapy, 68% on diet control therapy, 58% on
weight control, and 4.5% on herbal therapy. The details
are in Table 3.
It was found that the mean knowledge score before
education intervention was 22.53 and after education
intervention was 35.32. The details are in Table 4.
Itwasfoundthatabout60%of therespondentshadstudied
this type of booklet earlier. Most of the respondents
reported that the booklet provided was very effective and
useful. The details are in Table 5.
It was found that the difference in the mean score
calculated using t-test between knowledge before and
after education intervention program was significant
(P 0.01). The details are in Table 6.
The association among sociodemographic characteristics,
durationof illness,andriskfactorswithpre-testknowledge
scores is calculated; there is significant association with
religion (P = 0.022) only. The details are in Table 7.
No significant association was found between
sociodemographic characteristics and obesity with post-
test knowledge scores. The details are in Table 8.
Discussion
Our study measures the effects of education intervention
andmobilephoneSMSondiabetesknowledge,medication
adherence, clinic attendance, and glycemic control for
patients with diabetes attending Diabetic Clinic of MOPD
of BPKIHS Nepal.
Using SMS as tools for medication and appointment
reminders, we disseminate health information and life-
style messages are easy technology that can be applied by
persons with minimum technical knowledge and skills. In
this study, SMS was sent to participants using a mobile.
Table 1: Sociodemographic characteristics of the
respondents (n = 396)
Characteristics Category Frequency Percentage (%)
Age group 40 51 12.9
Range: 17–90 40–60 211 53.3
Mean ± SD:
52.58±12.51
≥60 134 33.8
Gender Male 161 40.66
Female 235 59.34
Religion Hindu 384 97
Muslim 2 0.5
Others 10 2.5
Ethnicity Brahmin 72 18.2
Chhetri 24 6.1
Janjati 208 52.5
Others 92 23.2
Education Up to 10 260 65.7
Plus 2 79 19.9
Bachelor and more 57 14.4
Marital status Married 382 96.5
Unmarried 11 2.8
Widow 2 0.5
Separated 1 0.3
Occupation Self-employed 280 70.7
Business 51 12.9
Farmer 65 16.5
Saving Budget deficit 56 14.1
No saving or balance 101 25.5
5000 47 11.9
5000–25,000 92 23.2
25,000 100 25.3
Economic status Poor 121 30.6
Medium 152 38.4
High 123 31.1

Mobile phone SMS has the potential to communicate with
diabetes patients and to build awareness about the disease,
improve self-management, and avoid complications also
in resource-limited settings.
Sociodemographic characteristics of the respondents
Most of the subjects (87.1%) were of age group more than
40 years; female (59.34%); Hindus (97%); Janjati (52.5%);
married (96.5%); and self-employed (70.7%). About 30%
belonged to the poor economic status group.
Risk factors
It was found that majority (98.7%) of the respondents
had type II DM. It was found that nearly half (46.5%)
of the respondents were suffering from DM for 1–5 years;
whereas only 12.6% had less than 1 year and 4.8% had
more than 15 years.
About 34% of the respondents had a family history
(sibling) of DM, and 88.9% eat non-veg diet. More than
half of the respondents are overweight and obese; 5.6%
reported experiencing stress and 29.5% had blood pressure
more than 120/80 mmHg.
It was found that 14.1% had a habit of tobacco chewing,
2% betel chewing, 5% gutka chewing, 8.3% had smoking
habit, and 8.3% had alcohol consumption habit.
Treatment or therapy for DM
It was found that 84.3% of the respondents were on OHA,
22% on insulin, 68.4% on diet control therapy, 58.3%
on weight loss therapy, and 4.5% were receiving herbal
therapy.
Effectiveness of education intervention program
There were 10 areas of knowledge domain, i.e. disease
process, treatment, diet management, exercise, OHA,
insulin, hypoglycemic shock, follow-up, regularity
in treatment and regularity in treatment. The mean
knowledge score before educational intervention was
22.53 (45.06%) and after education intervention was 35.32
(70.64%), i.e. there is an increase of 12.79 (25.58%).
The opinion about effectiveness of the education
intervention and mobile communication was also assessed,
and the respondents reported that the booklet provided
was easily understandable (82.8%), content is appropriate
(60.95), is recommended for other (64.4%) and 32.6%
reported that it was very helpful, whereas 66.9% reported
the program as alright.
Regarding mobile communication and SMS, 11.4%
reported it to be very useful, 28.5% reported useful, 30.3%
reported alright, and 29.8% reported that they do not use
this service.
The mobile phone SMS messaging has been well accepted
by beneficiaries and may be an effective tool for providing
Table 3: Therapies for diabetes received by the respondents
(n = 396)
Characteristics Category Frequency Percentage
(%)
OHA received Yes 334 84.3
No 62 15.7
On insulin Yes 87 22.0
No 309 78.0
Diet control Yes 271 68.4
No 125 31.6
Weight loss Yes 231 58.3
No 165 41.7
Herbal Yes 18 4.5
No 378 95.5
Table 2: Details about the diabetes and the risk factors of the
Characteristics Category Frequency Percentage
(%)
Type of DM 1 5 1.3
2 391 98.7
Duration of disease
(years), mean±SD=
5.97±5.244
1 50 12.6
1–5 184 46.5
6–10 88 22.2
10–15 55 13.9
≥15 19 4.8
Family history of DM
(sibling)
Yes 135 34.1
No 261 65.9
Family history of DM
(parents)
Yes 101 25.5
No 295 74.5
For female Yes 36 15.3
Birth of large baby No 119 50.6
(n=235) Not sure 80 34.1
Diet Veg 42 10.6
Non-veg 352 88.9
Egg veg 2 0.5
BMI Underweight
(18.5)
15 3.8
Normal (18.5–25) 148 37.4
Overweight (25–30) 169 42.7
Obese (30) 64 16.2
Tobacco chewing Present 56 14.1
Not present 340 85.9
Betel chewing Present 8 2.0
Gutka chewing Present 20 5.1
Smoking habit Present 33 8.3
Alcohol consumption Present 33 8.3
Having stress Present 22 5.6
Blood pressure (mmHg)120/80 117 29.5
≥120/80 279 70.5


diabetes health education, clinic and appointment
reminders, medication reminders, and building awareness
about the disease.[2,3]
Various studies have shown that SMS
reminders improved adherence of type 2 diabetes patients,
especially the precision with which the patients followed
their prescribed regimen and that it was well accepted by
the patients.[4]
Numerous issues must be considered when
designing and implementing client-centered programs,
includingmobilephoneaccess,sharingof phones,language
and literacy, privacy, and technological challenges. More
information is needed about best practices for developing
content for text message delivery and the optimal timing
of messages.[5]
The web-based education and monitoring are beneficial
and can be used to complement healthcare provider visits
during time constraints.[6]
Increased access, whether in
person or electronic, to diabetes education and healthcare
providers can improve diabetes knowledge and self-
efficacy.[7]
The increased use of diabetes-related mobile
applications had improved self-management and diabetes
outcomes. But use of applications to provide education
and real-time feedback needs to be developed.[8]
The effective education strategies followed in National
Standards for Diabetes Self-Management Education
are worth applying to mHealth methods.[9]
Even limited
amount of education can result in improved weight
control and potentially reduced cardiovascular risk.[10]
Initial comparisons between in-person diabetes education
and education administrated through telemedicine
already demonstrated feasibility and equal effectiveness
of technology-supported methods.[11]
Most diabetes self-management applications do not
integrate educational information because it is often
generic and is not personalized to the individual patient
and mostly for commercial applications.[12]
Education and
personalized feedback are still underdeveloped features,
included in less than one-third of reviewed mHealth
Table 5: Evaluation of the educational program by the
Characteristics Category Frequency Percentage (%)
Studied education
booklet on diabetes
earlier
Yes 237 59.8
No 159 40.2
About booklet
Understandable Easily 328 82.8
With little
difficulty
68 17.2
Content covered Very appropriate 146 36.9
Appropriate 241 60.9
Not appropriate 9 2.3
Helpful Very helpful 129 32.6
All right 265 66.9
Overall evaluation Very good 159 40.2
Good 214 54.0
All right 23 5.8
Recommend to others Yes 255 64.4
Not sure 140 35.4
Usefulness of
educational program
Very useful 86 21.7
Useful 194 49.0
All right 116 29.3
Information provided
by sister/doctors in
MOPD related to
diabetes
Very useful 153 38.6
Useful 194 49.0
All right 49 12.4
Telephone/mobile
communication and
SMS service available
Very useful 45 11.4
Useful 113 28.5
All right 120 30.3
Not used 118 29.8
Table 6: Association between pre-test and post-test mean
knowledge scores
Characteristics Attainable
score
Obtained
score
Mean
value
P-value
Before education 10–50 12–37 22.53 0.001*
After education 10–50 25–46 35.32
* = t-test
Table 4: Knowledge score before and after education intervention among the respondents (n = 396)
Characteristics Before education After education
Knowledge about 1 2 3 4 5 1 2 3 4 5
Disease process 75 205 95 21 2 10 203 179 2
About treatment 68 212 95 21 10 205 179 2
Diet management 56 199 123 18 33 200 158 5
Exercise 40 166 154 36 13 242 141
OHA 41 192 126 37 1 6 173 214 2
Insulin 155 169 70 2 5 4 171 204 12
Complication (hypoglycemic shock) 179 136 59 22 9 92 242 53
Regular follow-up 47 147 166 36 50 89 218 39
Control of blood sugar 119 139 127 11 25 48 116 180 27
Regularity of taking OHA/insulin 7 103 208 78 4 83 256 53
Mean values 22.53 (45.06%) 35.32 (70.64%)

applications. Only 20% of the reviewed applications had
an education module, and only 26% of these met the
criteria for personalized education or feedback.
Task of personalizing rapidly growing information is
challenging, but it may be largely beneficial for diabetes
patients.[13]
Most widely used mHealth method for diabetes
education is SMS. Meta-analysis of current findings has
shown that mobile SMS education can improve glycemic
control. The glycemic control is even better if diabetes
education is done by a combination of SMS and internet
methods, i.e. 86% effect in comparison with 44% that is
achieved by SMS alone.[14]
Positive results of e-mail and
SMS education can also be seen in improved quality of
life.[15]
Numerous applications are available helping healthy
people or people with risk factors to assess their risk for
developing diabetes type 2 in the future. Only a few of
these apps disclose the name of the risk calculator used
for assessing the risk of diabetes; therefore, the quality of
their calculations is questionable.[16]
Conclusion
It was found that most of the subjects were suffering from
type II DM and receiving OHA. Nearly one-fourth of
the respondents were on insulin therapy. The education
intervention program and mobile SMS provided to
the respondents were effective as there is an increase in
knowledge of about 25%.
Table 7: Association between socio-demographic characteristics, duration of illness, and risk factors with pre-test knowledge
score (n = 396)
Sociodemographic characteristics Categories Pre-test knowledge scores P-value
60% ≥ 60%
Age group 60 233 29 0.370
≥60 115 19
Sex Male 143 19 0.842
Female 205 29
Religion Hindu 340 4 0.022
Others 8 4
Ethnicity Janjati 182 26 0.808
Others 166 22
Duration of illness 5 years 175 21 0.396
≥5 years 173 27
Blood pressure (mmHg) 120/80 97 20 0.050
≥120/80 251 28
Obesity (BMI) Normal 129 19 0.736
Abnormal 219 29
Economic status Poor 106 15 0.911
Others 242 33
Tobacco chewing Present 298 42 0.728
Absent 50 6
Gutka chewing Present 330 46 0.766
Absent 18 2
Smoking habit Present 316 47 0.495
Absent 32 1
Alcohol consumption Present 318 45 0.578
Absent 30 3
Table 8: Association among sociodemographic
characteristics, duration of illness, and risk factors with
post-test knowledge score (n = 396)
Socio
demographic
characteristics
Categories Post-test knowledge
scores
P-values
60% ≥ 60%
Age group 60 33 229 0.686
≥60 15 119
Sex Male 23 139 0.293
Female 25 209
Ethnicity Janjati 24 184 0.709
Others 24 164
Duration of
illness
5 years 24 172 0.941
≥5 years 24 176
Obesity (BMI) Normal 20 128 0.512
Abnormal 20 220
Economic status Poor 11 110 0.220
Others 37 238


Implication
Healthcare providers should actively select and adapt
technological self-management methods to extend
the reach of diabetes self-management to patients’
communities and homes, provide individualized care, and
provide just-in-time information.
People living with diabetes who have limited access to care
due to lack of transportation, physical restrictions, or other
limitations could benefit from technological interventions
that bring care to them. Additionally, with limited primary
care resources, technology can provide cost-effective
ongoing diabetes self-management education and support.
Use of mobile health technology for empowerment of
patients with diabetes is an emerging way to improve their
health and wellbeing. It can address almost every problem
of diabetic patients.
Limitation
• In OPD, most of the patients were in hurry and wanted
to consult the doctor earlier; hence, they give less
attention to hear the education message provided in
OPD.
• Most of the respondents did not had smart phone;
hence, it was difficult for them to read the sent SMS.
• The educational status of all the respondents was not
of the level to understand the message properly.
Recommendation
While technology can be effective for promoting diabetes
education, support, and self-management, patients report
a need for personal contact with healthcare providers in
addition to technology. Automated text messages were
sent, but participants stated that they preferred to think
of them as coming from the certified diabetes educator
(CDE) who enrolled them in the study. They also
appreciated weekly calls from the CDE to obtain feedback
on the experience and make adjustments to text messaging
as needed.
Some participants felt that the text messaging intervention
would not be effective for them without a person to
monitor and provide clinical support. A website that
provides diabetes education, monitoring, and support
through communication with a healthcare provider may
be most effective. Web-based interventions can be used in
conjunction with healthcare provider education and support
and as a follow-up to healthcare provider interventions.
Researchers and healthcare providers should include
participants in the development of technological
interventions and in the decision of which technology to
use. Patient needs must be explored to determine the best
method for individual needs, realizing that not all patients
will be amenable to technological interventions.
The future applications should be more personally
oriented, improved regarding usability and accessibility,
and based on accepted clinical guidelines.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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22 j cardio diabetesmetabdisord1118-4126632_112746