Digital Storytelling Intervention for Hemoglobin A1c Control Among Hispanic Adults With Type 2 Diabetes

Methodology

This was a multicenter, parallel-group randomized clinical trial conducted across two primary care networks in Minnesota (Hennepin Healthcare) and Arizona (Mountain Park Health Center). The study enrolled 451 Hispanic adults aged 18-70 years with type 2 diabetes and poor glycemic control (hemoglobin A1c ≥8%) who were receiving primary care at participating clinics. Participants were required to have had at least one office visit in the previous 12 months and to have been diagnosed with T2D for at least 6 months.

Permuted block randomization with blocks of 4 was used for group assignment, with stratification by site and gender. Data analysts were blinded to treatment condition. After obtaining informed consent and baseline measures, participants were randomized to either the intervention group (n=227) or control group (n=224). The intervention group viewed a 12-minute digital storytelling video featuring four Spanish-language narratives about diabetes self-management, covering healthful diet, physical activity, medication adherence, and glucose self-monitoring. Participants were provided access to the video via mobile app, DVD, flash drive, and web link, and received monthly automated text messages prompting self-assessment and video re-viewing. The control group received culturally tailored printed T2D education materials and usual care.

The primary outcome was glycemic control measured by hemoglobin A1c from whole blood samples analyzed by clinical laboratories at each site. During the COVID-19 pandemic, participants were given the option of home testing via validated point-of-care hemoglobin A1c tests (7.3% of tests). Secondary measures included blood pressure, low-density lipoprotein cholesterol, body mass index, and diabetes self-management behaviors assessed via the Summary of Diabetes Self-Care Activities Measure. Data were collected at baseline and 3 months. The primary analysis compared hemoglobin A1c levels between groups at 3 months using analysis of covariance, adjusting for baseline hemoglobin A1c values and covariate-adjusted for age, gender, education, and household income. Follow-up rate was 86% (390 of 451 participants).

Interventions

The intervention was a culturally and linguistically tailored digital storytelling video developed through community-based participatory research with the Rochester Healthy Community Partnership. The 12-minute video featured an introduction by a community partner, followed by four personal narratives from Hispanic storytellers (2 women and 2 men from Mexican, Central American, and South American backgrounds) who shared their experiences successfully managing type 2 diabetes. Each story reinforced one of four key diabetes self-management behavioral goals: healthful diet for diabetes, physical activity, medication adherence, and glucose self-monitoring. The video concluded with an educational message reinforcing these four goals.

Language- and culture-congruent study staff showed the video to each participant in a private room during their enrollment visit. To ensure comprehension, staff asked three questions immediately after viewing: (1) What is your reaction to the video? (2) What was the main message? (3) Does it motivate you to make changes? Participants received continued access to the video through multiple formats: a mobile phone application (available in Spanish or English based on phone language settings), DVD, flash drive, and web link. The mobile app also included culturally tailored educational material about each of the four T2D self-management goals.

To encourage ongoing engagement, participants received monthly automated text messages (5 total over the study period) that asked them to self-rate their motivation and self-efficacy for managing T2D on a 0-10 scale. If participants scored lower than 7, the text message recommended they re-watch the intervention video and provided a link and QR code for easy access. This mHealth component provided longitudinal support beyond the initial video viewing while maintaining low implementation burden.

Key Findings

At 3-month follow-up, participants in the digital storytelling intervention group demonstrated a small but statistically significant improvement in glycemic control compared to the control group in the adjusted analysis. Mean hemoglobin A1c decreased from 9.1% to 8.4% in the intervention group (change of -0.70%) compared to 9.4% to 8.8% in the control group (change of -0.64%), with an adjusted P value of .04 after controlling for baseline hemoglobin A1c, age, gender, education, and income. However, this difference was not statistically significant in the unadjusted model (P=.24). The odds of achieving a hemoglobin A1c level below 8% was 1.5 times higher in the intervention group, though this did not reach statistical significance (95% CI 1.0-2.4, P=.06).

The intervention demonstrated exceptionally high acceptability and narrative quality. Among intervention participants, 97.8% found the video acceptable, 97.3% reported it captured their attention, 98.6% felt more confident about managing their diabetes after watching, and 97.8% were motivated to make behavioral changes. Specific behavioral intentions included eating a healthier diet (70.6%), being more physically active (53.5%), improving blood glucose monitoring (20.6%), and taking medications as directed (18.4%). Narrative quality assessment showed strong story identification (mean 4.8 out of 5) and story transportation or emotional engagement (mean 4.9 out of 5), indicating participants strongly identified with the storytellers and were emotionally engaged with the narratives.

Secondary biometric outcomes showed no statistically significant differences between groups. Changes in systolic blood pressure, diastolic blood pressure, body mass index, weight, and LDL cholesterol were similar in both groups. Diabetes self-management behaviors assessed via standardized questionnaires also showed no significant improvements, despite the high levels of reported motivation and confidence. These findings suggest that while the intervention successfully influenced participants' psychological state (self-efficacy and motivation), it did not translate into measurable behavioral changes or broader metabolic improvements within the 3-month study period.

Comparison with other Studies

This study builds upon previous research on narrative-based interventions for chronic disease management. Houston and colleagues demonstrated in a randomized trial among African American adults that a culturally appropriate storytelling video intervention for hypertension produced efficacy comparable to adding a medication, with significant blood pressure reductions. Campbell and colleagues tested a narrative-based video intervention among 598 patients with T2D in Australia and found improvements in self-efficacy and self-care behaviors at 4 weeks, though they did not assess glycemic control. The current study is, to the researchers' knowledge, the first digital storytelling intervention specifically tested for T2D management, and the first to measure hemoglobin A1c as the primary outcome.

The findings align with previous research showing improved outcomes from culturally tailored T2D interventions for Hispanic populations. Fortmann and colleagues demonstrated that Dulce Digital, an mHealth SMS-based intervention tailored to Hispanic patients with T2D, improved glycemic control through an interactive text message platform. The current study's modest HbA1c improvement (approximately 0.06% difference) is smaller than the Dulce Digital effect, suggesting that the digital storytelling intervention may be most effective when combined with more intensive longitudinal engagement rather than as a standalone brief intervention. A systematic review by Lorenzo and colleagues of electronic health interventions for T2D and obesity in Hispanic adults supports this interpretation, finding that more intensive, interactive interventions typically produce larger effects.

The lack of improvement in secondary outcomes (blood pressure, BMI, LDL cholesterol) in this study differs from some other diabetes interventions but may be explained by the fact that mean baseline values for these measures were already within reference ranges, whereas poor glycemic control (HbA1c ≥8%) was a study eligibility requirement. This suggests that the intervention's effects were specific to glycemic-related motivation and behaviors rather than producing broad metabolic changes. The short 3-month follow-up period is also shorter than many diabetes intervention trials, which limits direct comparison with studies using longer follow-up periods. The study's focus on acceptability and scalability represents a pragmatic approach that differs from more intensive, resource-intensive interventions but may have greater potential for wide dissemination in under-resourced community health settings.

Journal Reference

Wieland ML, Vickery KD, Hernandez V, et al. Digital Storytelling Intervention for Hemoglobin A1c Control Among Hispanic Adults With Type 2 Diabetes: A Randomized Clinical Trial. JAMA Netw Open. 2024;7(8):e2424781. doi:10.1001/jamanetworkopen.2024.24781