Connecting Health and Technology: Validation of Instant Messaging for Use as Diabetes Mellitus Control Strategy in Brazilian Older Adults

1. Introduction

In Brazil, population aging is a reality. In 2022, 15.6% of the Brazilian population were elderly (1). With the increase in life expectancy and the process of globalization, which encouraged a sedentary lifestyle and poor eating habits, individuals have become more likely to develop chronic non-communicable diseases (NCDs), including diabetes mellitus (DM)(2,3).

DM is reaching epidemic proportions. Worldwide, in 2021, in the age group of 20 to 79 years, 537 million adults and older adults were diagnosed with DM, and approximately 6.7 million people died from the disease and its complications. In the ranking of countries with the highest number of people diagnosed with DM, in the same age group, Brazil is in 6th place, generating an expenditure of 966 billion dollars, in 2021, with DM (4).

DM treatment aims to prevent and delay micro and macrovascular complications and optimize the individual’s quality of life (5). To this end, treatment is based on glycemic control (6), which can be achieved by promoting a healthy lifestyle, maintaining an ideal body weight, eating an adequate diet, and exercising regularly (7).

Health education in DM is the primary strategy to ensure self-care, placing the individual at the center of care, encouraging them to change their lifestyle and raising awareness of the risks of the disease if glycemic control is not achieved (8). Educational actions should awaken in DM patients an interest in understanding how the disease works so that this knowledge can help them in self-care, promoting health and well-being (9).

Because of the COVID-19 pandemic in 2020, healthcare activities were affected, and it was necessary to strengthen the use of technologies to meet healthcare demands, reformulate strategies, and make them possible to be executed online. The use of digital technologies became even more representative (10). The period of social isolation during the covid-19 pandemic drove older adults to the digital environment (11). Therefore, the World Health Organization (WHO) proposed the Global Health Strategy 2020-2025, encouraging the use of information and communication technologies to develop digital health. This strategy aims to strengthen the healthcare systems to guarantee the health and well-being of the population (12).

Digital and educational technologies are used to promote effective interventions in the health of older adults (13,14). Several types of educational technologies have been used to achieve better glycemic control in people diagnosed with DM (15–19). However, most of these educational messages convey the content in text format, without the use of images that improve understanding.

For technology to be well accepted by the older population, it must be adapted to their daily needs, be easy to use through simple and intuitive navigation, have appropriate language, an attractive design and be rich in images that are part of everyday life (20). Among the telecommunication modalities, the use of social networks stands out, and among social networks, instant messaging applications are well accepted by older adults (21).

WhatsApp is a widely used instant messaging application that allows real-time interactivity, connectivity, portability and multifunctionality (22), features that help meet communication demands, overcome time and space barriers, and maintain contact between health professionals and patients (23). It is part of the Brazilian lifestyle used by 147 million Brazilians, of which 86% use the application daily to exchange text messages and images (24). Older adults also use the tool to clarify doubts about health care (25).

The use of WhatsApp in health education actions and monitoring of DM treatment has been described in studies as an important tool for understanding the disease (26) improving self-efficacy and self-management of DM (27); glycemic control (28); encouraging medication adherence (29); and reducing acute complications of DM (30). In this sense, this study aimed to develop and validate instant messages with educational content related to glycemic control through applications for use as a type 2 DM control strategy in Brazilian older adults.

2. Materials and Methods

2.1. Study Design and Ethical Approval

This methodological study resulted in an educational technology, in the form of instant messages containing text and images to be sent via the instant messaging application (WhatsApp). This study constituted the initial stage of a randomized clinical trial to evaluate the effectiveness of educational messages in the glycemic control of elderly individuals diagnosed with type 2 DM. The project was approved by the Research Ethics Committee of the Ceilândia Faculty of the University of Brasília – CEP/FCE/UNB (4.876.336 CAAE 45733521.0.0000.8093) and by the Research Ethics Committee of the Foundation for Teaching and Research in Health Sciences of the Health Department of the Federal District – CEP/FEPECS/SESDF (4.980.237 CAAE 45733521.0.3001.5553). The ethical requirements for human research followed the Declaration of Helsinki.

2.2. Preparation of Educational Messages

The content of the educational messages involved knowledge about the disease, encouragement of self-care and interventions necessary for glycemic control, such as physical exercise and healthy eating. The leading national content of the Brazilian Association for the Study of Obesity and Metabolic Syndrome (31), the Brazilian Ministry of Health (33–37), and the Brazilian Diabetes Society (8,37,38) were used as references.

The educational messages were created by members of the Health, Care and Aging Research Group (GPeSEn), made up of professors, postgraduate and undergraduate students from nursing, nutrition and physical education courses at the University of Brasília (UnB).

After selecting the content, a character named Dora (a nurse) was created to present the messages and support the content of the messages. To strengthen the relationship between the health professional, a dialogue resource between the nurse Dora and an older adult was used. The name was chosen in reference to the nurse Dorothea Elizabeth Orem, who developed the Self-Care Theory (39).

In preparing educational messages, aspects related to language, images, illustrations and layout are currently considered. Simple language was used, appropriate to the socioeconomic and cultural context, suitable for the target audience and consistent with the messages to be transmitted. Since the target audience is older adults, the vocabulary used was easy to understand, with short sentences to facilitate understanding at home and encourage self-care (40,41).

When selecting the illustrations, racial and ethnic aspects were considered to show people from a wide range of groups and ethnicities. The illustrations were always placed close to the text to which they referred (41) and most of then were created by a graphic design professional. The messages and illustrations were prepared in the Canva application, with Open Sans font, sizes 20 and 22 for text. The messages were created and validated in Portuguese and after validation was translation for English in free translation.

2.3. Content Validation by Experts

The validation of the content of the educational messages occurred in December 2023, with a group of experts selected using different strategies through research on the Lattes Platform of the National Council for Scientific and Technological Development (CNPq), on the websites of the leading Brazilian universities and indication of other experts by de experts who alredy participated.

The inclusion criteria adopted were: being a physical education, nursing, or nutrition professionals; voluntarily accepting to participate in the research; answering all the research forms and achieving a score > 5 points in the Fehring criteria (42). The points were distributed as follows: master’s degree (4 points); master’s degree with dissertation in the area of interest (1 point); research in the area of interest (2 points); published article in the area of interest (2 points); doctorate with thesis in the area of interest (2 points); professional experience in the area of interest (2 points); specialization in the area of interest (2 points).

The invitation letter was emailed with the research objectives and a Google Drive link that allowed access to: the Free and Informed Consent Form (FICF); the educational messages; and the validation instrument. The experts signed the FICF electronically and received a copy signed by the researchers via email.

The message evaluation instrument was structured in three parts: a) characterization of the experts; b) validation questionnaire divided into three blocks: objectives; structure and presentation; relevance; c) final evaluation of the messages. The validation instrument was adapted from other studies that validated educational technologies in the health area (43–45). A period of 30 days was granted to complete the validation instrument, and if it was not completed, a new message was sent every 7 days to reinforce the invitation.

A 5-point Likert Scale was used to measure the level of agreement and disagreement in the experts’ responses. The responses were divided into: 1 - I completely disagree; 2 - I disagree; 3 - I neither agree nor disagree; 4 - I agree; 5 - I completely agree. If the experts marked answers 1 and 2, they were asked to make a comment or suggestion, which was reviewed until a consensus was reached. After the experts’ evaluation, the comments were organized in a table and analyzed by the research group regarding the coherence of the requested changes. All recommendations relevant to the methodology and purpose of the study were accepted. Minimal changes were made on the messages and no new content was added.

The responses were tabulated in Excel and exported to the Statistical Package for Social Sciences (SPSS) version 25.0. The Content Validity Index (CVI) was adopted to measure the experts’ agreement regarding the content validity of the educational messages. To determine the level of agreement among the experts, the CVI was calculated by the number of experts who answered 4 or 5 divided by the total number of experts who evaluated the item. The average of the CVI of all the messages (S-CVI/Ave) and the content validity of the individual items (I-CVI) were calculated. The I-CVI of the items was considered to be greater than or equal to 0.75 (46,47). The exact binomial distribution test indicated for small samples was used, statistically significant with p>0.05 and a proportion of 0.95 of agreement to estimate the statistical reliability of the CVI.

3. Results

3.1. Preparation of Educational Messages

A total of 61 text messages were created with illustrations, divided into three themes: 1) presentation of the proposal and basic information about DM (n= 16); 2) physical exercise (n= 5) and 3) healthy eating (n= 40) (Table 1) (Appendix A).

Table 1. Theme, content and quantity of educational messages.

Theme	Content of educational messages	Amount
1	Presentation of the proposal and basic information on type 2 DM	9
	Information on body weight control and anthropometry	7
2	Guidance on physical exercise	4
3	Importance of healthy eating, natural, minimally processed, processed and ultra-processed	7
	Information on the consumption of sugar, sweeteners, diet, light, and zero foods and drinks	5
	Information on cardioprotective nutrition and hygiene of fruits and vegetable	3
	Information about foods that should be consumed in moderation, in smaller quantities, and avoided	4
	Information on food proportions and number of meals per day	4
	Information about hypoglycemia and its treatment	5
	General tips related to meal preparation	10
	General tips for making the most of your meals	3

Table 1. Theme, content and quantity of educational messages.

Theme	Content of educational messages	Amount
1	Presentation of the proposal and basic information on type 2 DM	9
	Information on body weight control and anthropometry	7
2	Guidance on physical exercise	4
3	Importance of healthy eating, natural, minimally processed, processed and ultra-processed	7
	Information on the consumption of sugar, sweeteners, diet, light, and zero foods and drinks	5
	Information on cardioprotective nutrition and hygiene of fruits and vegetable	3
	Information about foods that should be consumed in moderation, in smaller quantities, and avoided	4
	Information on food proportions and number of meals per day	4
	Information about hypoglycemia and its treatment	5
	General tips related to meal preparation	10
	General tips for making the most of your meals	3

3.2. Content Validation by Experts

A total of 623 experts were invited to participate in the validation process by email, with weekly reminders. From them, 37 experts agreed to participate and completed the questionnaire.

Regarding the expert’s profile, 81% were female (n= 30), with an average age of 45 years, 43% were nurses (n= 16), 35% were nutritionists (n= 13) and 22% were physical education professionals (n= 8). Regarding their qualifications, 82% (n= 32) were Ph.D. and 24% (n= 5) had master’s degrees, with an average of 20 years of professional experience in teaching, research and assistance. About 62% (n= 23) of the experts had published articles in the area of interest.

Despite obtaining CVI above 0.80 (S-CVI/Ave) for all messages regarding objective, content and language (Table 1), the experts suggested some changes. The main changes, after input from experts, were: a review of the rules of the Portuguese language; rewriting of some sentences; addition, replacement or removal of words and/or images that could confuse or improve the understanding of the content by older adults; and highlighting of certain words in bold.

Table 1. Validation questionnaire for educational messages by expert experts.

Variables		I-IVC*
1	Objective	0.84
1.1	The contents meet the needs of people with DM2.	0.86
1.2	The contents are useful for improving self-care for people with DM2	0.89
1.3	These contents can influence changes in ideas, behavior and attitude.	0.81
1.4	It is suitable for sharing in the scientific community of the area.	0.78
1.5	It meets the objectives of healthcare professionals working with people with T2DM.	0.86
2	Content	0.85
2.1	The information is presented clearly and objectively.	0.81
2.2	The information is scientifically correct.	0.81
2.3	There is a logical sequence in the proposed topics.	0.95
2.4	The information is written according to the rules of the Portuguese language.	0.92
2.5	The writing is appropriate for the proposed target audience.	0.84
2.6	The font size is adequate.	0.81
2.7	The illustrations are clear and sufficient.	0.86
2.8	The number of messages is adequate to be used in twelve weeks.	0.78
3	Language	0.86
3.1	The topics cover the key aspects that need to be emphasized.	0.84
3.2	The messages encourage the construction of knowledge for self-care.	0.81
3.3	The messages include the topics necessary to build people’s knowledge about DM2.	0.89
3.4	The messages are appropriate for use by any healthcare professional.	0.89
Total IVC		0.85

Source: Authors’ data, 2024. Legend: I- CVI: content validity of individual items; DM2: type 2 diabetes mellitus; *Statistical significance by Binomial test > 0.05.

Table 1. Validation questionnaire for educational messages by expert experts.

Variables		I-IVC*
1	Objective	0.84
1.1	The contents meet the needs of people with DM2.	0.86
1.2	The contents are useful for improving self-care for people with DM2	0.89
1.3	These contents can influence changes in ideas, behavior and attitude.	0.81
1.4	It is suitable for sharing in the scientific community of the area.	0.78
1.5	It meets the objectives of healthcare professionals working with people with T2DM.	0.86
2	Content	0.85
2.1	The information is presented clearly and objectively.	0.81
2.2	The information is scientifically correct.	0.81
2.3	There is a logical sequence in the proposed topics.	0.95
2.4	The information is written according to the rules of the Portuguese language.	0.92
2.5	The writing is appropriate for the proposed target audience.	0.84
2.6	The font size is adequate.	0.81
2.7	The illustrations are clear and sufficient.	0.86
2.8	The number of messages is adequate to be used in twelve weeks.	0.78
3	Language	0.86
3.1	The topics cover the key aspects that need to be emphasized.	0.84
3.2	The messages encourage the construction of knowledge for self-care.	0.81
3.3	The messages include the topics necessary to build people’s knowledge about DM2.	0.89
3.4	The messages are appropriate for use by any healthcare professional.	0.89
Total IVC		0.85

Source: Authors’ data, 2024. Legend: I- CVI: content validity of individual items; DM2: type 2 diabetes mellitus; *Statistical significance by Binomial test > 0.05.

4. Discussion

The instant messages, with educational content related to glycemic control, were prepared by nursing, nutrition and physical education professionals, based on the main validated and published content of the Brazilian Association for the Study of Obesity and Metabolic Syndrome, Brazilian Diabetes Society and the Brazilian Ministry of Health related to type 2 diabetes mellitus and healthy eating (8,32–39), aiming to facilitate the access to the information from these materials by older adults. The educational messages were produced according to the preferences of older adults concerning the authors’ training level content, text, illustrations and access (48). The proposed content aimed to promote adequate nutrition and healthy lifestyle habits.

The instant educational messages were written in a simple, objective and easy-to-understand language, appropriate to the educational and cultural level of most Brazilian older adults to ensure that the information is transmitted in a clear and accessible manner, including among those with low levels of education. Adapting the language to the specific needs of this group is essential to ensure that the guidelines are not only understood, but also applied in everyday life. The texts were arranged in short sentences, with an easy-to-read font and size (48). Illustrations were used to facilitate understanding of the texts. The illustrations support population diversity in relation to race, sex, and body composition. Furthermore, using illustrations can attract older adults (49).

Instant messaging will be made available online due to the ease of storing information and the possibility of easy access to content when needed (48). For example, the PronutriSenior Project, carried out in Portugal, showed that information about nutrition and health is essential to empower older adults living in the community about their food choices, with a preference for receiving audiovisual material with images (50).

Older adults are adapting to the digital age and are interested in online health-related information, especially after the COVID-19 pandemic. The challenge is to gather reliable information for the elderly population (51). To ensure greater accuracy in the validation of educational messages, experts with experience in the subject were selected. This process was essential to ensure that the evaluation was carried out by professionals with knowledge. Even though the messages were evaluated as adequate, the qualitative analysis was carried out through the subjective recommendations of the experts, as they received comments that were accepted and changes were made to make them more didactic and inviting.

Health education is essential to empower people, making them protagonists in managing their own condition. However, information provided through traditional, in-person lectures may not be appropriate for older adults who face physical or geographic challenges, such as mobility limitations or transportation difficulties. This can make it difficult to participate in events that require travel, especially for those who live in remote or hard-to-reach areas, a reality observed in some Brazilian regions. In this context, seeking alternatives considering these limitations, such as digital technologies, is important. In Australia, participants over 55 y/o stated that they felt comfortable using smartphones and sought reliable, up-to-date health information specific to the older population and allowing for easy sharing with others (52).

Technologies play a crucial role in strengthening the guidance of health professionals and enabling the acquisition of knowledge, skills, and responsibility to effect attitude changes and increase decision-making power. This integrated approach can promote more effective health management and encourage self-care, essential for successful glycemic control, as it can help patients avoid risky behaviors (53,54).

Health professionals who care for older adults, especially those with chronic diseases, should be familiar with health technologies that allow patients to take better care of themselves, be active in their health care, and improve their quality of life. This study considered that messages are an artifact that mediates the relationship between health professionals and the target audience and is part of health education, which should be a dialogical practice, with efficient communication to stimulate autonomy and generate changes in risk behaviors; not prescriptive, imposing, or verticalized. Thus, messages allow for co-responsibility for care, as they value the role of the subject in the health and disease process (55,56).

5. Conclusions

Sixty-one text messages supported by illustrations were developed to be sent via instant messaging applications to help older adults manage type 2 DM. In validation by experts, these messages were considered relevant and clear for older adults to be included in the digital environment and to the objective of helping to manage type 2 DM.

The messages have the potential to prove that educational actions through digital media can improve people’s glycemic control, promoting changes in eating patterns and healthy lifestyle habits without the need to travel frequently for in-person appointments with healthcare professionals.