MoDD

MoDD is a web-based application with integrated short message service (SMS) capabilities. Notably, MoDD was designed for independent use by individuals with diabetes and does not rely on the involvement of healthcare professionals. Using MoDD, individuals record their daily blood glucose (BG) readings either by typing them directly into the MoDD website or by sending them to a MoDD-dedicated phone number using SMS or voice calls. Based on these daily readings and their associated temporal context (when the readings were captured in relation to an individual’s daily activities – eg, before breakfast or after lunch), MoDD identifies daily glycemic control patterns that are systematically higher or lower than the ranges recommended by healthcare providers (between 70 and 130 for fasting BG, and between 70 and 180 for after-meal BG). MoDD organizes these readings into patterns (upon waking, before or after a meal, before bed, etc.), displays them to users in a way that highlights deviations between average readings for each pattern and the recommended BG ranges, and asks users to engage in a problem-solving process that includes the following steps: 1) select a glycemic control pattern they wish to improve (eg, “High blood glucose after breakfast”); 2) choose a potential behavioral trigger – a behavior that is a known contributor to the selected glycemic control pattern (eg, “Lack of protein for breakfast”) – from an extensive MoDD knowledge base; 3) select an alternative healthier behavior from a list of offered choices and set an action-oriented goal related to this behavior (eg, “Include a tablespoon of peanut butter or a boiled egg with breakfast”); and 4) implement the new behavior while monitoring for possible changes in the selected BG readings (eg, changes in BG after breakfast) and progress towards achieving the BG target range. These steps were identified during our formative studies of DSME and are consistent with the published literature on problem solving in diabetes self-management.¹⁴

In addition, on each of the steps identified above, MoDD uses data collected through self-monitoring to retrieve and display evidence- and practice-based knowledge related to diabetes self-management. The foundational engine of MoDD is its extensive knowledge base, which includes eight common glycemic control problems and over 200 behaviors related to diet, lack of exercise, sleep patterns, and stress (among many others) that are known to contribute to these glycemic control problems. Each of these behavioral triggers is coupled with a short educational text explaining why this particular behavior may lead to spikes or drops in BG levels, a motivational message encouraging users to persist with self-care, and up to five alternative behaviors that may lead to improved glycemic control. Moreover, all the content in the knowledge base is tailored to individuals’ level of nutritional literacy, their current dietary patterns, their amount of exercise, and their readiness to improve these behaviors, which are all assessed, using validated measures, as part of the MoDD registration process. The knowledge base was designed through a participatory design process with academic Certified Diabetes Educators (CDEs) and was evaluated on its accuracy, coverage, and appropriateness with practicing diabetes educators, as part of the MoDD project.²⁶

Because MoDD primarily targets individuals from economically disadvantaged communities, who may have limited access to computing technologies, it relies on text messages as the primary mode of two-way interaction between the application and users. These messages are used to remind individuals to use MoDD on a regular basis. Once a day (at 9 a.m.), MoDD users receive an automatically generated text message; the content of the message is dependent on the individual’s use of the system. For example, these text messages may note that no new BG reading has been reported within the last 24 hours or that no new goal has been set within the last 7 days. In addition, individuals can elect to receive reminders to check their BG levels at their chosen times. Finally, once the users set their goals, the messages are used to provide users with feedback on changes in their BG levels after setting specific goals. The MoDD web interface is optimized for periodic use, to review captured data and set new goals (once per week). For individuals who do not have access to a computer or the Internet, kiosks were installed at the participating CHCs. At these kiosks, the study participants could log onto their MoDD pages, review their collected data, and progress through the other steps of the problem-solving process independently or with the assistance of a research assistant.