Mobile intervention design in diabetes: review and recommendations

Predictors of self-management in pediatric type 1 diabetes: individual, family, systemic, and technologic influences

Type 1 diabetes (T1D) is a complex chronic disease that has many facets for successful management. The burden of this management falls largely on the individual and their family members. Self-management has a major influence on T1D health outcomes, and with successful management, children and adolescents with T1D can lead long and healthy lives. We discuss how various individual, family, and systemic/technologic factors influence T1D self-management, providing research that supports interventions targeting each of these factors. With this information, health care practitioners and researchers can better understand the role of T1D self-management and bolster this important aspect of T1D care.

Review of innovations in digital health technology to promote weight control

Advances in technology have contributed to the obesity epidemic and worsened health by reducing opportunities for physical activity and by the proliferation of inexpensive calorie-dense foods. However, much of the same technology can be used to counter these troublesome trends by fostering the development and maintenance of healthy eating and physical activity habits. In contrast to intensive face-to-face treatments, technology-based interventions also have the potential to reach large numbers of individuals at low cost. The purpose of this review is to discuss studies in which digital technology has been used for behavioral weight control, report on advances in consumer technology that are widely adopted but insufficiently tested, and explore potential future directions for both. Web-based, mobile (eg, smartphone), virtual reality, and gaming technologies are the focus of discussion. The best evidence exists to support the use of digital technology for self-monitoring of weight-related behaviors and outcomes. However, studies are underway that will provide additional, important information regarding how best to apply digital technology for behavioral weight control.

Diabetes self-management smartphone application for adults with type 1 diabetes: randomized controlled trial

Background

Persistently poor glycemic control in adult type 1 diabetes patients is a common, complex, and serious problem initiating significant damage to the cardiovascular, renal, neural, and visual systems. Currently, there is a plethora of low-cost and free diabetes self-management smartphone applications available in online stores.

Objective

The aim of this study was to examine the effectiveness of a freely available smartphone application combined with text-message feedback from a certified diabetes educator to improve glycemic control and other diabetes-related outcomes in adult patients with type 1 diabetes in a two-group randomized controlled trial.

Methods

Patients were recruited through an online type 1 diabetes support group and letters mailed to adults with type 1 diabetes throughout Australia. In a 6-month intervention, followed by a three-month follow-up, patients (n=72) were randomized to usual care (control group) or usual care and the use of a smartphone application (Glucose Buddy) with weekly text-message feedback from a Certified Diabetes Educator (intervention group). All outcome measures were collected at baseline and every three months over the study period. Patients’ glycosylated hemoglobin levels (HbA1c) were measured with a blood test and diabetes-related self-efficacy, self-care activities, and quality of life were measured with online questionnaires.

Results

The mean age of patients was 35.20 years (SD 10.43) (28 male, 44 female), 39% (28/72) were male, and patients had been diagnosed with type 1 diabetes for a mean of 18.94 years (SD 9.66). Of the initial 72 patients, 53 completed the study (25 intervention, 28 control group). The intervention group significantly improved glycemic control (HbA1c) from baseline (mean 9.08%, SD 1.18) to 9-month follow-up (mean 7.80%, SD 0.75), compared to the control group (baseline: mean 8.47%, SD 0.86, follow-up: mean 8.58%, SD 1.16). No significant change over time was found in either group in relation to self-efficacy, self-care activities, and quality of life.

Conclusions

In adjunct to usual care, the use of a diabetes-related smartphone application combined with weekly text-message support from a health care professional can significantly improve glycemic control in adults with type 1 diabetes.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12612000132842; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612000132842 (Archived by WebCite at http://www.webcitation.org/6Kl4jqn5u).

Improving diabetes management with mobile health technology

Diabetes affects 25.8 million persons in the United States, and these persons make more than 35 million ambulatory care visits annually. Yet, less than half of persons with diabetes meet the recommended levels of A1C, blood pressure and lipid control. One innovative approach is to use mobile health technologies to help patients better manage their diabetes and related conditions, and 85% to 90% of patients have access to mobile health technology. A brief review of the guidelines for diabetes care and mobile health technology that can support the guidelines are reported related to (1) glycemic control and self-monitoring of blood glucose, (2) pharmacological approaches and medication management, (3) medical nutrition therapy, (4) physical activity and resistance training, (5) weight loss, (6) diabetes self-management education and (7) blood pressure control and hypertension. The patient and provider are encouraged to explore possibilities for mobile health technologies that can support behavior change.

Development and feasibility of a text messaging and interactive voice response intervention for low-income, diverse adults with type 2 diabetes mellitus

Low-income, racial/ethnic minorities are often nonadherent to diabetes medications, have uncontrolled glycemia, and have high rates of diabetes-related morbidity. Cell phones provide a viable modality to support medication adherence, but few cell phone-based interventions have been designed for low-income persons, a population with more feature phone penetration than smartphone penetration. In an effort to reach the broadest range of patients, we leveraged the voice and text messaging capabilities shared by all cell phones to design the MEssaging for Diabetes intervention. We specifically advanced and adapted an existing tailored text messaging system to include interactive voice response functionality and support the medication adherence barriers of low-income, diverse adults with type 2 diabetes mellitus. We report on the design process and feasibility testing results (i.e., technical use patterns and subjective user experiences) from patients from the target population who used the intervention in one of three user-centered design iterations. The types of challenges encountered in design were related to providing text message content with valued information and support that engages patients. The design process also highlighted the value of obtaining mixed methods data to provide insight into legitimate versus illegitimate missing data, patterns of use, and subjective user experiences. The iterative testing process and results outlined here provide a potential template for other teams seeking to design technology-based self-care support solutions for comparable patient populations.

Long-term engagement with a mobile self-management system for people with type 2 diabetes

Background

In a growing number of intervention studies, mobile phones are used to support self-management of people with Type 2 diabetes mellitus (T2DM). However, it is difficult to establish knowledge about factors associated with intervention effects, due to considerable differences in research designs and outcome measures as well as a lack of detailed information about participants’ engagement with the intervention tool.

Objective

To contribute toward accumulating knowledge about factors associated with usage and usability of a mobile self-management application over time through a thorough analysis of multiple types of investigation on each participant’s engagement.

Methods

The Few Touch application is a mobile-phone–based self-management tool for patients with T2DM. Twelve patients with T2DM who have been actively involved in the system design used the Few Touch application in a real-life setting from September 2008 until October 2009. During this period, questionnaires and semistructured interviews were conducted. Recorded data were analyzed to investigate usage trends and patterns. Transcripts from interviews were thematically analyzed, and the results were further analyzed in relation to the questionnaire answers and the usage trends and patterns.

Results

The Few Touch application served as a flexible learning tool for the participants, responsive to their spontaneous needs, as well as supporting regular self-monitoring. A significantly decreasing (P<.05) usage trend was observed among 10 out of the 12 participants, though the magnitude of the decrease varied widely. Having achieved a sense of mastery over diabetes and experiences of problems were identified as reasons for declining motivation to continue using the application. Some of the problems stemmed from difficulties in integrating the use of the application into each participant’s everyday life and needs, although the design concepts were developed in the process where the participants were involved. The following factors were identified as associated with usability and/or usage over time: Integration with everyday life; automation; balance between accuracy and meaningfulness of data with manual entry; intuitive and informative feedback; and rich learning materials, especially about foods.

Conclusion

Many grounded design implications were identified through a thorough analysis of results from multiple types of investigations obtained through a year-long field trial of the Few Touch application. The study showed the importance and value of involving patient-users in a long-term trial of a tool to identify factors influencing usage and usability over time. In addition, the study confirmed the importance of detailed analyses of each participant’s usage of the provided tool for better understanding of participants’ engagement over time.

Quality of life and technology: impact on children and families with diabetes

Ensuring quality of life (QOL) while maintaining glycemic control within targets is an important challenge in type 1 and type 2 diabetes treatment. For children with diabetes, QOL includes enjoying meals, feeling safe in school, and perceiving positive, supportive relationships with parents, siblings, and friends. Yet many treatment-related and psychosocial barriers can interfere with a child's QOL and their ability to manage diabetes effectively. Diabetes management also imposes considerable lifestyle demands that are difficult and often frustrating for children to negotiate at a young age. Recent advances in diabetes medications and technologies have improved glycemic control in children with diabetes. Two widely used technologies are the insulin pump and continuous glucose monitoring (CGM) system. These technologies provide patients with more flexibility in their daily life and information about glucose fluctuations. Several studies report improvements in glycemic control in children with type 1 diabetes using the insulin pump or sensor-augmented pump therapy. Importantly, these technologies may impact QOL for children and families with diabetes, although they are rarely used or studied in the treatment of children with type 2 diabetes. Further, emerging closed loop and web- and phone-based technologies have great potential for supporting diabetes self-management and perhaps QOL. A deeper understanding and appreciation of the impact of diabetes technology on children's and parents' QOL is critical for both the medical and psychological care of diabetes. Thus, the purpose of this review is to discuss the impact of new diabetes technologies on QOL in children, adolescents and families with type 1 diabetes.

Pumpers, skypers, surfers and texters: technology to improve the management of diabetes in teenagers

A variety of innovative technologies are available to assist with the management of diabetes in teenagers. Technologies include devices that assist with the direct day-to-day management of diabetes including insulin pumps and continuous glucose monitors. These devices are being used more and more with teenagers as a means of improving treatment adherence and glycaemic control. In addition, telehealth is being used to deliver care and support around diabetes management issues for teens with diabetes. Telehealth used in diabetes care for teens includes cell phones and video-conferencing. The goal of this telehealth technology is to support health behaviours and implement behavioural change strategies in a way that is more integrated into the everyday lives of patients and even in the context in which the behaviours occur in 'real time'. Finally, information and support via the Internet are gaining acceptance and use among teens with diabetes as an effective means of strategies for improved diabetes self-care. All three of these broad uses of technology in diabetes in teens represent flexible, innovative, and accessible approaches to improving both diabetes management and glycaemic control in this 'at risk' population.

A pilot test of a tailored mobile and web-based diabetes messaging system for adolescents

We conducted a pilot trial of a new mobile and web-based intervention to improve diabetes adherence. The text messaging system was designed to motivate and remind adolescents about diabetes self-care tasks. Text messages were tailored according to individually-reported barriers to diabetes self-care. A total of 23 adolescents with type 1 diabetes used the system for a period of three months. On average, they received 10 text messages per week (range 8-12). A matched historical control group from the same clinic was used for comparison. After three months, system users rated the content, usability and experiences with the system, which were very favourable. Comparison of the intervention and control groups indicated a significant interaction between group and time. Both groups had similar HbA(1c) levels at baseline. After three months, the mean HbA(1c) level in the intervention group was unchanged (8.8%), but the mean level in the control group was significantly higher (9.9%), P = 0.006. The results demonstrate the feasibility of the messaging system, user acceptance and a promising effect on glycaemic control. Integrating this type of messaging system with online educational programming could prove to be beneficial.