UMMS Affiliation

Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences

Publication Date


Document Type



Endocrine System Diseases | Endocrinology, Diabetes, and Metabolism | Epidemiology | Health Communication | Health Services Research | Nutritional and Metabolic Diseases | Telemedicine


BACKGROUND: Rural patients with diabetes have difficulty accessing care and are at higher risk for poor diabetes management. Sustained use of patient portal features such as secure messaging (SM) can provide accessible support for diabetes self-management.

OBJECTIVE: This study explored whether rural patients' self-management and glycemic control was associated with the use of SM.

METHODS: This secondary, cross-sectional, mixed methods analysis of 448 veterans with diabetes used stratified random sampling to recruit a diverse sample from the United States (rural vs urban and good vs poor glycemic control). Administrative, clinical, survey, and interview data were used to determine patients' rurality, use of SM, diabetes self-management behaviors, and glycemic control. Moderated mediation analyses assessed these relationships.

RESULTS: The sample was 51% (n=229) rural and 49% (n=219) urban. Mean participant age was 66.4 years (SD 7.7 years). More frequent SM use was associated with better diabetes self-management (P=.007), which was associated with better glycemic control (P < .001). Among rural patients, SM use was indirectly associated with better glycemic control through improved diabetes self-management (95% CI 0.004-0.927). These effects were not observed among urban veterans with diabetes (95% CI -1.039 to 0.056). Rural patients were significantly more likely than urban patients to have diabetes-related content in their secure messages (P=.01).

CONCLUSIONS: More frequent SM use is associated with engaging in diabetes self-management, which, in turn, is associated with better diabetes control. Among rural patients with diabetes, SM use is indirectly associated with better diabetes control. Frequent patient-team communication through SM about diabetes-related content may help rural patients with diabetes self-management, resulting in better glycemic control.


access, accessible, cross-sectional, data, diabetes, digital health, eHealth, messaging, patient portal, portal, risk, rural, secure messaging, self-management, support, urban, veteran

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Copyright © Stephanie A Robinson, Dane Netherton, Mark Zocchi, Carolyn Purington, Arlene S Ash, Stephanie L Shimada. Originally published in JMIR Diabetes (, 19.11.2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Diabetes, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.

DOI of Published Version



Robinson SA, Netherton D, Zocchi M, Purington C, Ash AS, Shimada SL. Differences in Secure Messaging, Self-management, and Glycemic Control Between Rural and Urban Patients: Secondary Data Analysis. JMIR Diabetes. 2021 Nov 19;6(4):e32320. doi: 10.2196/32320. PMID: 34807834; PMCID: PMC8663667. Link to article on publisher's site

Journal/Book/Conference Title

JMIR diabetes

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Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.