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Article

Stakeholder Perspectives on Implementing DiabeText: Exploring Barriers and Facilitators for a Personalized Diabetes Self-Management SMS Intervention in Spain

by
Elena Gervilla-García
1,2,
Patricia García-Pazo
1,3,
Mireia Guillén-Solà
1,3,
Federico Leguizamo
1,2,
Ignacio Ricci-Cabello
1,4,*,
María Jesús Serrano-Ripoll
1,5,
Miquel Bennasar-Veny
1,3,4,
Maria Antònia Fiol-deRoque
1,5,
Escarlata Angullo-Martínez
1,6 and
Rocío Zamanillo-Campos
1,*
1
Health Research Institute of the Balearic Islands (IdISBa), 07120 Palma, Spain
2
Department of Psychology, University of the Balearic Islands, 07122 Palma, Spain
3
Department of Nursing and Physiotherapy, University of the Balearic Islands, 07122 Palma, Spain
4
Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, 28029 Madrid, Spain
5
Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), 08007 Barcelona, Spain
6
Primary Health Care Center, Balearic Health Service, 07002 Palma, Spain
*
Authors to whom correspondence should be addressed.
Diabetology 2026, 7(1), 17; https://doi.org/10.3390/diabetology7010017
Submission received: 8 September 2025 / Revised: 29 October 2025 / Accepted: 23 December 2025 / Published: 8 January 2026
Browse Figure
Versions Notes

Abstract

Background/Objectives: Mobile health (mHealth) interventions can enhance chronic disease management, but their integration into public healthcare systems remains complex. DiabeText is the first SMS-based intervention in Spain delivering personalized diabetes self-management support using electronic health record data. This study explored perceived barriers and facilitators to the implementation of DiabeText in the Spanish public health context from the perspective of key stakeholders. Methods: A qualitative study was conducted using semi-structured interviews with 14 purposively selected stakeholders involved in digital health, diabetes care, data protection, and healthcare management across several Spanish regions. Interviews were thematically analyzed using Braun and Clarke’s approach and guided by the Implementation Research Logic Model. Results: Participants reported several barriers, including concerns regarding data protection, uncertainty about long-term sustainability, insufficient training and engagement of healthcare professionals and low digital literacy among certain patient groups. Facilitators included favorable institutional momentum for digital innovation, funding availability, perceived clinical utility and scalability of DiabeText, and growing patient familiarity with digital tools. Recommended strategies included integration into existing healthcare systems and workflows, professional training and use of familiar communication platforms. Conclusions: Effective implementation of DiabeText requires addressing regulatory, organizational, and equity-related barriers while leveraging institutional support and readiness for innovation. Early involvement of healthcare professionals, robust data governance, and investment in digital literacy are essential to ensure sustainable and equitable adoption. These findings provide actionable insights to support the integration of mHealth tools into chronic disease care in Spain and similar settings.

1. Introduction

Type 2 diabetes mellitus (T2DM) represents one of the most pressing global public health challenges of the 21st century, exerting a substantial burden on individuals and healthcare systems. According to recent estimates from the International Diabetes Federation, around 589 million adults aged 20–79 were living with diabetes in 2024, accounting for 9.3% of all global deaths and 12% of global health expenditure [1]. In Spain, T2DM affects nearly 1 in 9 adults, corresponding to a prevalence of approximately 11% [1]. These trends underscore the urgent need for scalable, cost-effective strategies that support early diagnosis, promote patient self-management, and prevent diabetes-related complications.
In this context, digital health technologies—particularly mobile health (mHealth) solutions—are gaining recognition as effective tools to support chronic disease management [2,3]. Evidence suggests that mHealth solutions, such as SMS-based systems, can improve treatment adherence, patient activation, and lifestyle behaviors in people with T2DM [4,5,6,7]. These tools are especially advantageous due to their low cost, wide reach, and adaptability to diverse populations, including those in rural or underserved areas [8,9]. Importantly, personalized and theory-based digital tools have shown greater potential to support self-management and reduce diabetes-related complications [10,11,12], particularly when integrated with clinical workflows and tailored to patient characteristics and preferences [13].
DiabeText is an mHealth intervention co-designed with patients [14] and healthcare providers [15] in Spain that sends personalized, theory-informed text messages to people with T2DM to support medication adherence and healthy behaviors [16]. It delivers 2–5 messages per week over a 12-month period, covering topics such as diet, physical activity, medication adherence, and general information about T2DM and its complications. The content is tailored using both clinical data extracted from electronic health records (blood A1c and cholesterol, IMC, diabetic foot, smoking status, hypertension, chronic kidney disease, neuropathy) and patient-reported outcomes (MEDAS-14, IPAQ, Ramadan follow-up, use of the internet on the mobile phone). Users also receive extra SMS when new information is registered in their electronic health records about upcoming appointments in primary care, next drug dispensing at the pharmacy and blood test results for A1C and body weight. In a recent pragmatic phase III randomized controlled trial conducted in primary care settings in the Balearic Islands (n = 742) [17], DiabeText did not show significant differences in glycemic control (A1c) compared to usual care. However, DiabeText significantly improved self-reported medication adherence, diabetes self-efficacy, and health-related quality of life, supporting its utility as a scalable tool to enhance self-management in real-world conditions [18].
Although several mobile health solutions have been developed internationally—such as SMS4BG (New Zealand) [19], REACH [20], Noom [21] and Dulce Digital (USA) [22], TEXT4DSM (Belgium) [23], SUMMIT-D (UK) [24,25], and iCareD (Korea) [26,27]—most have not been integrated into routine clinical workflows or adapted to the Spanish healthcare context. In Spain, the most used solutions, such as Sendo Diabetes or Social Diabetes, lack scientific evidence of their effectiveness [28]. DiabeText stands out for its simplicity, accessibility, and integration with electronic health records, which allows for real-time personalization and automated updates. Unlike app-based solutions that may pose usability challenges for older adults or those with limited digital literacy, DiabeText’s SMS format helps bridge the digital divide. Furthermore, its development has followed the European regulatory roadmap for medical device software and incorporates robust privacy safeguards for handling personal health data.
The successful translation of DiabeText from research to routine practice requires a nuanced understanding of the broader systemic, regulatory, and organizational factors that influence adoption and implementation. Evidence from implementation science emphasizes that the success of digital health tools depends not only on their clinical efficacy but also on their alignment with real-world workflows, data governance structures, and the values and capabilities of users and decision-makers [29]. In this regard, qualitative research plays a critical role in uncovering these factors, particularly within complex public health systems, where technological innovation must navigate diverse stakeholder interests, resource constraints, and evolving digital infrastructures [30].
Building on these conclusions, the current qualitative study aimed to explore the perceived barriers and facilitators to implementing DiabeText within the Spanish public healthcare system, from the perspectives of key decision-makers in digital health and diabetes care. Understanding these perspectives is essential to inform the development of effective implementation strategies and support the sustainable integration of digital health interventions in routine chronic disease management.

2. Materials and Methods

2.1. Recruitment of Participants

Key informants were selected using a non-probabilistic combination of purposive and snowball sampling to ensure diverse professional perspectives on diabetes care and digital health implementation in the Spanish public healthcare system. Initial participants were identified based on predefined eligibility criteria, which included holding strategic roles in healthcare management, information systems, digital innovation, data protection, or diabetes care within the Spanish public or private healthcare system. These individuals were subsequently invited to suggest additional relevant stakeholders. To be eligible, participants were required to occupy strategic or decision-making positions (e.g., project leads, innovation managers, program directors) and have at least one year of relevant professional experience. Individuals without practical experience in the implementation or management of digital health solutions, or those who declined participation, were not included. No additional exclusion criteria were applied beyond the lack of alignment with the inclusion criteria. While participants were drawn from various Spanish regions, particular emphasis was placed on those affiliated with the Balearic Islands Health Service (IbSalut).

2.2. Data Collection

Semi-structured interviews were carried out from May to July 2023 either in person or through secure online platforms, depending on participant location and preference. Interview duration ranged from 42 to 76 min. A trained member of the research team (RZC) conducted the interviews using a structured topic guide developed for this study (see Appendix A). Topics included the perception and usefulness of digital patient tools in the future of healthcare services, as well as the challenges and steps needed for the implementation of DiabeText in the healthcare system, including aspects such as data protection, automation and potential scalability to other pathologies. Before initiating the interview questions, participants were provided with a brief overview of the research project and the DiabeText digital tool to ensure contextual understanding.
Interviews were transcribed verbatim using Cockatoo software (Cockatoo Inc., Tempe, AZ, USA, 2023 version) and transcripts were cross-checked against the original recordings by a researcher (EGG) to ensure accuracy. All data were anonymized and processed in compliance with current data protection regulations.

2.3. Data Analysis

Thematic analysis was conducted following Braun and Clarke’s six-step approach [31] and it was guided by the Implementation Research Logic Model as an analytical framework to link emergent themes with established implementation science constructs [32].
The process consisted of several stages: initially, one researcher (EGG) conducted iterative coding of all transcripts involving memo writing, category creating and theme development. Preliminary themes related to the perceived value of digital tools and the implementation of DiabeText were then reviewed and refined in collaboration with three experienced qualitative researchers (PGP, FLB, MGS), who independently analyzed transcripts and contributed to thematic refinement. Subsequent analytical meetings, first in pairs, then the full team, enabled consolidation of categories and subthemes. Discrepancies were addressed through consensus meetings, during which the original data were revisited and interpretations thoroughly discussed until a shared understanding was achieved. Rather than focusing on inter-coder reliability, this process was designed to foster critical reflection and deepen the interpretative richness of the analysis. Thematic saturation was achieved when no new concepts emerged in the final stages of analysis.
To enhance the credibility of our findings, we employed prolonged engagement in the field to deeply understand the context, and triangulated our analysis across multiple researchers to ensure diverse perspectives and minimize individual bias. To strengthen the dependability and confirmability of the analysis, we applied a code-recode strategy to ensure consistency over time, complemented by peer examination to validate the coding framework and interpretations. Additionally, we engaged in reflexive practices throughout the research process to critically assess our positionality and potential biases, and ensured data transparency by systematically linking our findings to the original data sources.

3. Results

Fourteen participants (36% females) provided informed consent and agreed to be interviewed and audio-recorded. The majority were physicians (57%), while the remaining participants came from diverse academic and professional backgrounds (see Table 1).
The findings are structured around the core components of the Implementation Research Logic Model: determinants, implementation strategies, mechanisms of action, and implementation outcomes (see Figure 1). Determinants are factors that influence the implementation positively or negatively, including contextual, organizational, professional, or intervention-related elements. Implementation strategies are intentional actions—educational, structural, or organizational—aimed at promoting adoption and effective use. Mechanisms of action explain how these strategies lead to changes in practice or behavior. Implementation outcomes, while not reflecting clinical impact, measure how well the intervention could be delivered and integrated into routine practice.

3.1. Determinants

3.1.1. Data Protection and Security Concerns

Participants consistently identified data protection and security as primary barriers. There was notable apprehension about handling the volume and sensitivity of patient-generated data, as well as the confidentiality of transmitted messages. The selection of a responsible entity for data processing, coupled with the need for robust security integration, emerged as key considerations.
“One of the main challenges is the integration of information security. Equally important is the issue of data volume—the sheer amount of data generated by patients on a daily basis is immense. Therefore, it’s essential to consider how this data is effectively managed.”
[MDP-BI]
The importance of specialized personnel for data governance and compliance was also emphasized.

3.1.2. Sustainability Challenges and Advantages

Concerns were raised about the long-term viability of DiabeText, especially regarding resource allocation post-pilot, ongoing maintenance, and regulatory compliance. Participants stressed the importance of stable financial support to ensure adequate resource allocation for both initial implementation and ongoing system maintenance.
“The project could fail because you have overlooked an important aspect by not considering how to finance its continuation.”
[MPHC-BI]
“For a digital tool to have a wide reach, it needs a strong core that ensures its survival, which requires dedication and funding. This core must be able to interact, though not necessarily with everyone. The key concept is sustainability, understood as the tool’s ability to remain effective, adapt, and endure over time.”
[FHS-BI]
“All data relating to illnesses or health status must always be protected with authentication.”
[MDP-BI]
The financial model was debated, with some participants advocating for a value-based approach, arguing that demonstrated impact on patient outcomes should drive sustainability rather than development costs alone.
“Sustainability should not be defined by the company that develops a solution or its associated costs, but rather by the value it delivers to the population. For me, that is the true foundation of sustainability. If I have a tool that educates my diabetic patients and helps them manage their condition more effectively—making them ‘less diabetic,’ so to speak—then it is sustainable, because it generates a significant impact. It allows me to avoid future complications and costly interventions, ultimately saving substantial healthcare resources.”
[MHS-MU]
Participants acknowledged DiabeText’s potential to be adapted for other chronic conditions, highlighting the opportunity to apply its approach across various health issues. This broader applicability could enhance its cost-effectiveness and justify further investment.
“This tool is effective for managing conditions such as diabetes, heart failure, and ischemic cardiovascular disease, among others. Its main function is to educate users about cardiovascular risk factors and help minimize them. It promotes healthier lifestyle habits and provides real-time guidance to correct behaviors as needed.”
[MHS-MU]

3.1.3. Healthcare Professional Training and Involvement

Participants highlight the importance of providing adequate training to frontline healthcare professionals, as well as accompanying the use of the tool with ongoing support from health experts, to ensure effective implementation and appropriate use.
“Training healthcare professionals is essential, especially when they are overwhelmed, so they can prescribe new tools or resources. The training should highlight the benefits for both patients and professionals, particularly in challenging cases like non-adherent patients. Just making the tool available is not enough; professionals need to be properly trained to use it.”
[FPP-BI]
“Training, training, and training for professionals to use the tool.”
[MPHC-BI]
The need for coordination with healthcare professionals, including administrative staff, is recognized to optimize time and resources, as well as to resolve potential doubts and ensure effective implementation in all healthcare centers.
“The goal is for this tool to be adopted and shared by healthcare professionals as if it were their own, even though it was developed by a team of researchers—which is natural, as innovation often begins with such groups. Ideally, professionals, especially nurse educators, should feel that the tool speaks directly to their patients. For example, they might say: ‘Don’t worry—besides what I’ve explained about taking your medication or insulin, you’ll also receive reminders. These messages contain useful information, and if you click the link on your phone, you’ll access additional resources. If not, you can also view them on your computer.”
[FHS-BI]

3.1.4. Patient Education and Technology Skill Levels

Participants noted that disparities in digital literacy among patients could hinder adoption of DiabeText. While some patients, especially younger or more digitally engaged patients, are comfortable using mobile technologies, others, particularly older adults or those with limited technological experience, may require additional support to interact effectively with the system. In this context, involvement of family members or informal caregivers was also noted as a potentially valuable strategy to support patient engagement and mitigate the effects of the digital divide.
“There is a significant digital divide in the community, involving access to the internet, devices, and digital literacy. It is essential to invest in closing this gap, even more than in developing tools, to prevent only the most privileged groups from adopting digital transformation. Those in poorer health —older adults, rural populations, and people with lower socioeconomic status— are the ones who most need to benefit from it. This investment must be a collective effort as a society.”
[FPP-BI]
Growing digital literacy among patients was seen as a facilitator for adopting tools like DiabeText.
“As a family doctor, I prefer to have a trained group of patients who know how to take care of themselves than to have a group of patients for whom I had to be consulted for everything.”
[FHS-BI]
“We think we have patients in their 60s, and 70s, for whom technology is too big when in fact they are avid consumers of technology products every day.”
[MITC-BI]

3.1.5. Favorable Timing for Digital Health Innovation

Stakeholders recognized a current momentum for digitalization in Spanish healthcare, with a perceived shortage of similar tools and a clear demand for innovative solutions like DiabeText.
“I believe it is essential for health services to begin offering digital solutions, integrating them thoughtfully and evaluating key aspects—such as who will benefit, how they will be implemented, and what outcomes are expected. These results must be measured effectively. This is not an evitable shift, but rather a present reality that we must actively embrace.”
[MDHS-MA]
Furthermore, the availability of dedicated funding streams was identified as a key factor in enabling the development and long-term sustainability of technological tools like DiabeText. Its demonstrated acceptability and effectiveness in clinical trials strengthen the case for continued investment, reinforcing its relevance within health innovation agendas.
“Since the COVID pandemic, there has been a global and regional boom in digital health tools. However, in the Balearic Islands, there is a sense of lag, with a still rudimentary and limited tool. Thanks to European financial investment, significant development is expected in the next two to three years.”
[MDHS-BI]
Participants highlighted the ‘key’ and ‘indispensable’ nature of DiabeText for digital transformation in healthcare. They expressed very favorable opinions about DiabeText, considering it an excellent and necessary tool. They perceived it as aligned with the current Spanish Digital Health Strategy and capable of breaking new ground in the treatment of diabetes.
“Excellent first point aligned with the health strategy.”
[FHS-BI]
In addition, there was widespread recognition of the need for tools such as DiabeText, given that there are currently few similar applications available on the market. There was also consensus that DiabeText should be integrated into the corporate tools of health services and being prescribed by health professionals in a shared decision-making process with the patient.
“It is extremely valuable for the patient’s primary healthcare professional to be the one prescribing the digital tool. However, the tool becomes more effective when the decision is personalized and shared during the consultation. The professional suggests the tool as support for a specific issue, and the patient actively decides whether to use it and in which areas (medication, exercise, nutrition). This shared decision-making enhances the patient’s sense of control, making the tool more functional and impactful.”
[FPP-BI]

3.2. Implementation Strategies

3.2.1. Integration into Existing Healthcare Systems

Participants emphasized the necessity to integrate DiabeText into the current public healthcare system, in close collaboration with internal workers, to ensure effective implementation and widespread adoption.
“It’s essential to have professionals who not only support the project but are also capable of promoting it internally. When a project originates within the Health Service, is backed by professionals, and undergoes a validation process—like the one you’ve carried out—it is more likely to face fewer barriers to implementation.”
[MDHS-MA]
They also recommended leveraging platforms already familiar to patients, such as the regional Patient Portal.
“Enrollment could also be facilitated through the patient portal, which many patients actively use and where they increasingly expect more services. For example, adding a subscription option to DiabeText directly on the medication sheet—where prescribed treatments are displayed—could be effective. Including a brief explanation and even a short video about the tool would likely attract more patients and encourage engagement.”
[MITC-BI]

3.2.2. Training and Support for Healthcare Professionals

Training healthcare professionals and proactively managing resistance to change are important enablers for the successful implementation of digital health interventions. As highlighted by one stakeholder, effective change management requires that all professionals are adequately informed about the objectives, processes, and expected outcomes of the project.
“These projects require effective change management, ensuring that all professionals are informed about what is being done and how it will be implemented. Beyond that, I don’t foresee many other initial barriers.”
[MDHS-MA]
“When dealing with a specific tool, it’s easier to train professionals because they don’t need to apply techniques like motivational interviewing in every clinical situation—just in relation to that particular tool. A simple script with clear steps, explanatory videos, and a sample interview can be created. Online self-training is feasible, and a short in-person meeting can help clearly explain the project’s benefits, preventing it from being seen as just another burden.”
[FPP-BI]
Moreover, it is relevant that nurses and doctors actively prescribe DiabeText, and the integral participation of professionals in the development and continuous updating of the tool.
“The real challenge in digital health projects is not the initial launch, but medium-term maintenance. Even if the initial package is well-designed with updated advice and treatments, scientific advances demand ongoing updates. The issue lies in determining who updates the content, how experts are coordinated, and how changes are implemented—making the sustainability of the project more complex.”
[FHS-BI]

3.2.3. Customization Options for Different Patient Needs and Preferences

Adaptation to the specific needs of different patient groups, such as those requiring insulin or other injectable drugs or people with limited mobility will ensure personalized care minimizing recruitment bias. Participants also pointed that the channel for receiving messages should be customizable, giving different options such as WhatsApp, push-ups notifications or SMS, to suit individual user preferences.
“In diabetes management, it’s essential to recognize that different population groups have distinct characteristics and needs. You can’t communicate the same way with a 40-year-old as with an 85-year-old, because their contexts and comfort levels differ significantly.”
[MDS-BI]
However, participants agreed that, for now, SMS can reach more people with type 2 diabetes:
“Text messages are a simple and effective way to reach a wide audience, but they can often feel somewhat limited or flat. However, if the goal is specifically to reach patients affected by the digital divide, then this format serves its purpose well.”
[MHS-MU]
Allowing messages to be received by caregivers, family members, or others living with the patient can significantly extend the tool’s reach and effectiveness.
“Often, we rely on caregivers—who typically manage most aspects of the patient’s care—to act as digital guides. They help elderly patients navigate the application and access the information we aim to share, especially when the patients face difficulties using digital tools.”
[MHS-MU]

3.3. Mechanisms of Action

3.3.1. Patient Empowerment and Self-Management

Patient empowerment is a process that gives individuals control and power over their own health. Stakeholders recognized that DiabeText provides clear and accessible information about diabetes self-management for patients to acquire confidence and proactively manage their health. This transforms them from mere recipients of care into active and competent collaborators in their own self-care, fostering their autonomy and responsibility.
Essentially, information serves as a catalyst that empowers individuals to make more informed decisions, better adhere to treatment plans, and ultimately improve their long-term health outcomes. This concept of information as a catalyst aligns perfectly with the goal of fostering independence and precision in self-care:
“The app aims to empower individuals by helping them better understand their health and take care of themselves independently. The goal is for people to have greater accuracy in their self-care without constantly relying on professionals for guidance.”
[MHS-MU]
“If a patient has neuropathy, they may be advised to avoid certain types of physical activity and instead follow safer alternatives, right? Similarly, in cases of diabetic foot, guidance focuses on effective wound care and healing strategies specific to that.”
[MPH-BI]

3.3.2. Enhanced Healthcare Communication and Efficiency

Stakeholders highlighted the importance of providing timely and relevant health information, such as patient location in emergency contexts (as the recent COVID-19 pandemic). The DiabeText system was perceived as a valuable tool for rapidly disseminating key messages, thereby reducing the need for individual outreach efforts and enhancing communication efficiency during critical situations. As one institutional representative noted:
“Sometimes I have to speak to the press to clarify that something is wrong, for example, with a specific medication or health service. Well… do you have that kind of reach? By keeping everyone informed with just one short message, I can reach 70,000 people—that’s 70,000 phone calls I don’t need to make.”
[MITC-BI]
Participants emphasized the relevance of incorporating feedback mechanisms into the system to enable two-way communication between patients and healthcare professionals. A simplified feedback option, allowing users to indicate the usefulness of the messages received, was seen as beneficial for improving care quality and patient engagement. This functionality was also considered important for supporting patient autonomy and disease self-management:
“The issue is that you don’t know whether the message has been read, because there’s no feedback mechanism—that’s where the system falls short. The next step would be to integrate that feedback and build a chatbot around it.”
[MHS-MU]

3.4. Implementation Outcomes

The implementation outcomes of DiabeText were evaluated according to the Implementation Research Logic Model [14] across four key dimensions: acceptability (how stakeholders perceive the intervention), adoption (the decision to use the intervention), feasibility (the extent to which the intervention can be successfully carried out), and fidelity (the degree to which the intervention is delivered as it was designed).

3.4.1. High Acceptability Due to Consistency with Broader Public Health Strategies

Stakeholders expressed a strong perception of the usefulness and necessity of DiabeText, frequently describing it as a valuable tool to support diabetes management and improve patient outcomes. Several participants noted that the intervention could contribute to optimizing healthcare resources by enhancing medication adherence and encouraging self-care, which they perceived as particularly relevant in a system with limited capacity.
The intervention was also described as consistent with ongoing digital health strategies, which reinforced its potential feasibility and acceptability within the healthcare system.
“We are currently undergoing a major transformation. It’s evident that there will always be a shortage of doctors, while the number of patients continues to grow—that’s an undeniable reality. Face-to-face care is extremely costly, and change is necessary.”
[MDP-BI]
Additionally, the automation of processes through the DiabeText system was viewed as a way to improve healthcare efficiency. By facilitating self-management and reducing unnecessary clinic visits, the tool was seen as contributing to a more streamlined and patient-centered care model:
“Technology empowers users to self-manage their conditions, allowing us to take control of our health. When it’s something I can manage as a patient, I can do it myself through digital tools—without needing to visit a health center.”
[MDHS-BI]

3.4.2. Facilitating Adoption Through Prescription by Healthcare Professionals

Active prescription by healthcare professionals was identified as a critical factor influencing the adoption of DiabeText. Stakeholders highlighted the importance of clinician engagement in facilitating uptake.
“It is important to have professionals who serve as prescribers or facilitators.”
[MDHS-MA]

3.4.3. Feasibility and Sustainability Through Integration into the Healthcare System

The identified need for integration with existing healthcare systems is a critical aspect of DiabeText’s feasibility. This integration ensures that the tool complements current workflows rather than disrupting them and it also ensures that the tool follows health security requirements.
“I believe this tool must be integrated into the broader development of the Health Service’s information systems. It should be a sophisticated solution tailored to a specific chronic condition, but it must operate through communication channels already recognized as valid by the Health Service—otherwise, its implementation won’t be permitted.”
[FHS-BI]
However, there is also recognition of potential challenges in sustainability and data management, which need to be addressed to ensure long-term feasibility.
“The ideal solution would be a mobile app integrated into the patient portal. Ultimately, the goal is to provide a single, centralized source where patients can access everything they need—from dosage information and reminders to their medical history. Without this, the strategy becomes fragmented: one message via push notification, another by SMS, another in a printed pack, another on paper…”
[MDP-BI]

3.4.4. Fidelity Through Personalization and Feedback

Allowing users to select their preferred communication channel and provide feedback on the messages would facilitate a more personalized experience, increasing engagement with the tool, and generating valuable data for continuous improvement.
“If communication is limited to the passive reception of SMS messages, its long-term effectiveness is likely to diminish. Over time, recipients may become indifferent to these messages. To maintain engagement, it’s essential to incorporate more active or interactive elements—allowing users to personalize or refine the information they receive, request additional details on specific topics, or receive supplementary content that captures their interest.”
[FHS-BI]

4. Discussion

This study explored the perceptions of key stakeholders regarding the implementation of DiabeText, a digital health intervention aimed at improving type 2 diabetes management, within the Spanish public healthcare system. Overall, DiabeText was positively received, with stakeholders recognizing its alignment with broader health strategies and its potential to improve diabetes management and patient outcomes. The favorable policy context for digital health innovation further reinforced its perceived value. However, several implementation barriers were also highlighted, including concerns about data protection, long-term sustainability, the need for integration in current workflows and training for health professionals, and persistent digital disparities among patient populations.

4.1. Implications for the Implementation and Scale-Up of Digital Health Interventions

The findings of this study have several important implications for the implementation of digital health tools like DiabeText. Firstly, there is a clear need for seamless integration of such tools into existing healthcare systems, accompanied by comprehensive training programs for healthcare professionals. This integration should aim to complement current workflows rather than disrupt them, as suggested by previous research on health information technology adoption [33].
Secondly, the implementation of robust data protection measures must be implemented to address concerns regarding patient privacy and information security. Ensuring compliance with legal and ethical standards is foundational for building trust among patients and providers. In the European context, data governance remains a widely cited barrier to digital health uptake [34], particularly in interventions that use personal health information to deliver tailored content. In this regard, the apprehension expressed by Spanish health stakeholders reflects both regulatory requirements and heightened public scrutiny after high-profile data incidents [35].
Furthermore, the long-term viability of digital health tools should be considered from the outset, including strategies for ongoing maintenance, updates, and resource allocation beyond the initial implementation phase. Challenges related to sustainability, funding, and system maintenance, mirror those commonly observed in international digital health initiatives [29,36]. Importantly, the possibility of adapting such tools for other chronic diseases presents an opportunity for a broader impact on healthcare delivery and patient outcomes, potentially leading to more efficient and effective management of multiple chronic conditions.
As shown in our results, training and buy-in among healthcare professionals emerged as critical issues in our study, consistent with reviews showing that professional engagement and workflow integration are prerequisites for adoption of digital self-management interventions [30]. Notably, our finding that some clinicians feel digital tools may disrupt established care patterns underscores the importance of participatory implementation strategies, co-design, and continued support [37,38,39].
At the same time, the digital divide—an issue highlighted by our informants—remains a major equity concern. For example, older adults, those with limited technology experience, and underserved populations consistently show lower adoption and engagement rates in digital health, a trend observed globally [40]. Addressing usability, family support, and alternative modalities beyond SMS will be vital for inclusive implementation.
Conversely, stakeholders identified a policy window for innovation in Spain, aligning with reports of accelerated digital transformation following the COVID-19 pandemic [34]. In this context, institutional commitment and targeted health innovation funding may act as key drivers of change, provided that strong governance, rigorous evaluation, and effective scalability strategies are implemented.

4.2. Strengths and Limitations

This study offers several methodological and contextual strengths. It provides in-depth insights from a strategically selected group of decision-makers across multiple domains of digital health and diabetes care in the Spanish public healthcare system. The inclusion of diverse professional profiles—from digital strategy leads to diabetes program managers—adds richness and relevance to the findings, enhancing their credibility. The use of the Implementation Research Logic Model to guide both data collection and thematic analysis further strengthens the study’s methodological rigor and supports the transferability of findings to similar healthcare contexts. Additionally, the timing of the study, conducted shortly after the completion of a large pragmatic clinical trial of DiabeText, allowed participants to reflect on the intervention in light of real-world evidence, thereby increasing the practical relevance of their perspectives.
Nevertheless, some limitations should be acknowledged. The generally positive perspectives expressed by stakeholders may be subject to social desirability bias or influenced by enthusiasm for innovation, potentially underestimating some of the practical barriers to implementation. As is common in qualitative research, findings are context-dependent and may not be fully generalizable to other regions or healthcare systems beyond the Balearic Islands, from which the majority of the participants came. However, this contextual specificity is also a strength, as it provides a nuanced understanding of implementation dynamics in a real-world setting. Future research should explore the views of other relevant actors, including patients and frontline healthcare professionals, and assess how these perspectives evolve as DiabeText moves toward broader implementation.

5. Conclusions

The successful implementation of digital health interventions such as DiabeText requires more than clinical efficacy; it demands alignment with real-world healthcare systems, proactive stakeholder engagement, and a strong emphasis on long-term sustainability and health equity. This study highlights both the enthusiasm and the concerns of key decision-makers, underscoring the importance of early planning around data governance, integration into existing clinical workflows, and professional and patient readiness. By addressing these challenges and leveraging existing facilitators such as institutional momentum, policy alignment and funding opportunities, DiabeText and similar digital tools have the potential to enhance chronic disease management in Spain. These findings offer actionable guidance for designing implementation strategies that are both context-sensitive and scalable.

Author Contributions

Conceptualization, I.R.-C., M.A.F.-d. and R.Z.-C.; methodology, R.Z.-C., I.R.-C. and E.G.-G.; formal analysis, E.G.-G., P.G.-P., M.G.-S. and F.L.; investigation, R.Z.-C.; resources, R.Z.-C., M.J.S.-R. and E.A.-M.; data curation, E.G.-G. and R.Z.-C.; writing—original draft preparation, E.G.-G., R.Z.-C. and I.R.-C.; writing—review and editing, P.G.-P., M.G.-S., F.L., M.J.S.-R., M.B.-V., M.A.F.-d. and E.A.-M.; supervision, I.R.-C.; project administration, I.R.-C. and R.Z.-C.; funding acquisition, I.R.-C. and M.A.F.-d. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by Ministerio de Ciencia, Innovación y Universidades (Proyectos I + D + i «Pruebas de Concepto» 2021. Programa Estatal de I + D + i Orientada a los Retos de la Sociedad, en el marco del Plan Estatal de Investigación Científica y Técnica y de Innovación 2017–2020), grant number PDC2022-133257-I00.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Balearic Islands Research Ethics Committee (CEI-IB) on 1 April 2023 (approval number IB 5174/23 PI).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors on request. Raw data are anonymized transcriptions from participants in Spanish or Catalan.

Acknowledgments

We thank the participants for their time and helpful insights.

Conflicts of Interest

The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Abbreviations

The following abbreviations are used in this manuscript:
HbA1cHemoglobin A1c
IRLMImplementation Research Logic Model
mHealthMobile Health
PROMSPatient-Reported Outcome Measures
SMSShort Message Service
T2DMType 2 Diabetes Mellitus

Appendix A. Interview Guide

Objective: To explore the perceptions of decision-makers and other relevant actors of the Spanish Health Service regarding the DiabeText tool, and to identify barriers and facilitators for its implementation and routine use by health services.
  • Interviewer script:
  • Request for permission to record the interview
    • Could you describe your activity/functions?
    • How do you see the role of patient-oriented digital tools in the future of healthcare services?
  • Presentation of the project and the DiabeText tool
    • What do you think of DiabeText?
    • Do you know similar tools?
    • Do you think DiabeText can become a healthcare product?
    • Can you imagine DiabeText being applied in any system (public or private sector…, companies, health insurance) that you know of?
    • From your point of view, what would be the biggest difficulties in transferring this tool to other services/companies?
    • One of the biggest handicaps of DiabeText is keeping the patients’ health data in the servers where it is implemented. Do you see any problem when transferring the tool to the private sector? Any solution?
    • Can you think of any essential improvement for this type of tool?
    • Can you think of any potential client?
    • Any other comments or suggestions.

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Diabetology 07 00017 g001
Figure 1. Core components of the Implementation Research Logic Model for DiabeText.
Figure 1. Core components of the Implementation Research Logic Model for DiabeText.
Diabetology 07 00017 g001
Table 1. Characteristics and roles of key informants.
Table 1. Characteristics and roles of key informants.
CodeGenderAcademic BackgroundRole/Position and Years of ExperienceRegion
MITC-BIMaleTelecommunications engineerInformation Technology and Communications, 13 yearsBalearic Islands
MHS-MUMaleDoctorHealth Service (Projects & Innovation), 8 yearsMurcia
FMD-BIFemaleBiotechnologyBiotechnology and Biomedical Cluster of the Balearic Islands (BIOB), 2 months; EIT Health, 5 yearsBalearic Islands
FHS-BIFemaleFamily doctorHealth Service, 4 yearsBalearic Islands
MDHS-BIMaleDoctorDigital Health Strategy, 1 year (26 years as a doctor)Balearic Islands
MDHS-MAMaleIT technicianDigital Health Strategy, 7 yearsMadrid
MDP-BIMaleLawyerData Protection, 5 yearsBalearic Islands
MPHC-BIMaleFamily doctorPrimary Health Care, 8 yearsBalearic Islands
FID-CAFemaleBiologistInnovation Development, 3 yearsCatalonia
FPP-BIFemaleFamily doctorPatient Portal, 1 year (20 years as a doctor)Balearic Islands
MDS-BIMaleFamily doctorDiabetes Strategy, 15 yearsBalearic Islands
MHS-BIMaleFamily doctorHealth Service (Projects & Innovation), 7 yearsBalearic Islands
FHS-BIFemaleTourismHealth Service (Information Technology), 4 yearsBalearic Islands
MCIS-BIMaleFamily doctorClinical Information systems, 2 yearsBalearic Islands
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MDPI and ACS Style

Gervilla-García, E.; García-Pazo, P.; Guillén-Solà, M.; Leguizamo, F.; Ricci-Cabello, I.; Serrano-Ripoll, M.J.; Bennasar-Veny, M.; Fiol-deRoque, M.A.; Angullo-Martínez, E.; Zamanillo-Campos, R. Stakeholder Perspectives on Implementing DiabeText: Exploring Barriers and Facilitators for a Personalized Diabetes Self-Management SMS Intervention in Spain. Diabetology 2026, 7, 17. https://doi.org/10.3390/diabetology7010017

AMA Style

Gervilla-García E, García-Pazo P, Guillén-Solà M, Leguizamo F, Ricci-Cabello I, Serrano-Ripoll MJ, Bennasar-Veny M, Fiol-deRoque MA, Angullo-Martínez E, Zamanillo-Campos R. Stakeholder Perspectives on Implementing DiabeText: Exploring Barriers and Facilitators for a Personalized Diabetes Self-Management SMS Intervention in Spain. Diabetology. 2026; 7(1):17. https://doi.org/10.3390/diabetology7010017

Chicago/Turabian Style

Gervilla-García, Elena, Patricia García-Pazo, Mireia Guillén-Solà, Federico Leguizamo, Ignacio Ricci-Cabello, María Jesús Serrano-Ripoll, Miquel Bennasar-Veny, Maria Antònia Fiol-deRoque, Escarlata Angullo-Martínez, and Rocío Zamanillo-Campos. 2026. "Stakeholder Perspectives on Implementing DiabeText: Exploring Barriers and Facilitators for a Personalized Diabetes Self-Management SMS Intervention in Spain" Diabetology 7, no. 1: 17. https://doi.org/10.3390/diabetology7010017

APA Style

Gervilla-García, E., García-Pazo, P., Guillén-Solà, M., Leguizamo, F., Ricci-Cabello, I., Serrano-Ripoll, M. J., Bennasar-Veny, M., Fiol-deRoque, M. A., Angullo-Martínez, E., & Zamanillo-Campos, R. (2026). Stakeholder Perspectives on Implementing DiabeText: Exploring Barriers and Facilitators for a Personalized Diabetes Self-Management SMS Intervention in Spain. Diabetology, 7(1), 17. https://doi.org/10.3390/diabetology7010017

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