18 Trusted messages? Exploring the role of trust in Mhealth for diabetes prevention in rural Bangladesh

Background The prevalence of type 2 diabetes is rising rapidly in Bangladesh, and there is an urgent need to engage populations in preventing and controlling diabetes. Mhealth may offer a scalable way to deliver educational advice, information and motivation for behaviour change. We conducted qualitative research to explore how a population-based mobile health (mhealth) voice messaging intervention could be effective in this context. The intervention was tested through a cluster randomised controlled trial and, despite high coverage of messages, there was no evidence of effect. Our analysis identified the role of trust as a key mediator. Aim To analyse the role of trust as a causal mechanism in mhealth messaging. Methods We conducted non-participant observation while messages were being received, and four focus group discussions (FGDs) with men and women who had subscribed to messages, and one key informant interview. We conducted descriptive content analysis in Nvivo as a team. Results Mass messaging for advertising was common in the study context, and despite efforts to identify messages, this may have affected receipt. The Diabetic Association of Bangladesh was a well-known and trusted institution which meant that mhealth messages were believed and trusted, and therefore it was beneficial to establish this early in message content. We found that many felt the messages were irrelevant as they did not feel at risk of diabetes. Messages being delivered by a trusted organisation was of limited use for diabetes prevention, because this framed messages within a disease paradigm which many felt that they didn’t fit into. Conclusion Trust was a mediator of intervention effect, but association with diabetes may have made the intervention less attractive for populations who believe themselves not to be at risk. Participatory design of mhealth messaging may be equally as important as the trustworthiness of the implementing organisation.