INcreasing the Uptake of DSMES Program and Addressing Social Needs in Low-Income VulneRablE Immigrants

In stage 1, the 8 family health center (FHC) clinics will be randomized 1:1 into Experimental Cohort A, which will receive the Community Health Worker (CHW)-enabled community-clinic linkage model (CCL) or Control Cohort B, with FHCs that will not receive the CHW-enabled CCL. Then, in stage 2, patients in clinics that received the CHW-enabled CCL will be randomized in a 1:1 ratio to Arm A who will receive text-based mhealth diabetes education videos or Arm B who will not receive mhealth.

Inclusion criteria

To be eligible to participate in this study, the patient participant must meet all the following criteria:

• ≥18 years old and ≤ 70 years old
• Self-identify their primary language as English, Mandarin, Cantonese, or Spanish
• Diagnosed with T2DM
• Has their most recent HbA1c ≥8% or have a new diagnosis of T2DM within the past 6 months

For patient participants randomized to the mHealth cohort, they must meet the below inclusion criteria

• Willing to receive text messages with brief videos regarding T2DM management

Exclusion criteria

• Unable or unwilling to provide informed consent
• Unable to participate meaningfully in the intervention (e.g. uncorrected sight and hearing impairment)
• Is currently pregnant (Pregnant women will be excluded from this study because they may have special dietary restrictions that are not covered by our DSMES videos for the general population with T2DM.)