Mobile intervention design in diabetes: review and recommendations

Association between glucose levels of children with type 1 diabetes and parental economic status in mobile health application

BACKGROUND

The glycemic control of children with type 1 diabetes (T1D) may be influenced by the economic status of their parents.

AIM

To investigate the association between parental economic status and blood glucose levels of children with T1D using a mobile health application.

METHODS

Data from children with T1D in China's largest T1D online community, Tang-TangQuan^®. Blood glucose levels were uploaded every three months and parental economic status was evaluated based on annual household income. Children were divided into three groups: Low-income (< 30000 Yuan), middle-income (30000-100000 Yuan), and high-income (> 100000 yuan) (1 Yuan = 0.145 United States Dollar approximately). Blood glucose levels were compared among the groups and associations were explored using Spearman’s correlation analysis and multivariable logistic regression.

RESULTS

From September 2015 to August 2022, 1406 eligible children with T1D were included (779 female, 55.4%). Median age was 8.1 years (Q1-Q3: 4.6-11.6) and duration of T1D was 0.06 years (0.02-0.44). Participants were divided into three groups: Low-income (n = 320), middle-income (n = 724), and high-income (n = 362). Baseline hemoglobin A1c (HbA1c) levels were comparable among the three groups (P = 0.072). However, at month 36, the low-income group had the highest HbA1c levels (P = 0.036). Within three years after registration, glucose levels increased significantly in the low-income group but not in the middle-income and high-income groups. Parental economic status was negatively correlated with pre-dinner glucose (r = -0.272, P = 0.012). After adjustment for confounders, parental economic status remained a significant factor related to pre-dinner glucose levels (odds ratio = 13.02, 95%CI: 1.99 to 126.05, P = 0.002).

CONCLUSION

The blood glucose levels of children with T1D were negatively associated with parental economic status. It is suggested that parental economic status should be taken into consideration in the management of T1D for children.

Patient Satisfaction with Telemedicine in Adults with Diabetes: A Systematic Review

Patient satisfaction assessment is essential for improving the quality of healthcare. Diabetes management using telemedicine technology is promising in the 21st century. However, the number of randomised controlled trials (RCTs) examining the effect of telemedicine on satisfaction in patients with diabetes is limited. This systematic review aimed to summarise the current evidence on patient satisfaction with telemedicine in adults with diabetes and discuss related issues and future directions of telemedicine in patients with diabetes. The author systematically searched PubMed/MEDLINE, Embase and The Cochrane Library, and a total of six RCTs were eligible for this review. Patient satisfaction with telemedicine was as high as conventional face-to-face care; however, telemedicine appeared not to significantly increase patient satisfaction compared with conventional face-to-face care in the included studies. Significant heterogeneity was noted between the studies, including participants’ age, study duration, the method of assessing patient satisfaction and types of telemedicine. Further studies are required to provide firm evidence to healthcare providers who are willing to use telemedicine in diabetes management. Telemedicine technology has been advancing and is a key tool in providing high-quality healthcare to patients with diabetes in the 21st century.

Supporting breast cancer survivors via text messages: reach, acceptability, and utility of EMPOWER-SMS

Purpose

This study aims to evaluate the reach, usefulness, acceptability, and factors influencing engagement with a lifestyle-focused text message intervention to support women’s mental and physical health after breast cancer treatment.

Methods

This study uses a mixed-methods process evaluation nested in the EMPOWER-SMS randomised controlled trial (n = 160; intervention n = 80, wait-list control n = 80). Data sources included screening logs, text message delivery software analytics, intervention feedback survey, and focus groups (n = 16), which were summarised thematically based on the framework approach.

Results

A total of 387 women met the inclusion criteria (mean_age ± SD = 59.3 ± 11.6 years). Participants who declined (n = 227) were significantly older than those who enrolled (n = 160; 62.2 ± 11.1 vs 55.1 ± 11.1 years, respectively, p < 0.001). Most intervention participants (64/80; 80%) completed the end-of-study survey, reporting the messages were easy to understand (64/64; 100%), useful (58/64; 91%), and motivating (43/64; 67%). The focus groups (n = 16) revealed five factors influencing engagement: (i) feelings of support/continued care, (ii) convenience/flexibility of message delivery, (iii) weblinks, (iv) information from a credible source, and (v) options to save or share messages.

Conclusion

A lifestyle-focused text message program was acceptable and useful for women after breast cancer treatment. However, text messaging may be a barrier for women aged over 68 years. Suggestions for program improvements included delivering the program to patients with other cancers, during all stages of treatment, and including more weblinks in text messages.

Implications for Cancer Survivors

Text message programs offer a low-cost way to deliver post-treatment health support to breast cancer survivors in a non-invasive way. Text messages can improve patient–health professional communication and were found to be acceptable and useful.

Efficacy of eHealth Interventions for Adults with Diabetes: A Systematic Review and Meta-Analysis

The aim is to provide meta-analytical evidence on eHealth interventions’ efficacy in supporting the psychosocial and physical well-being of adults with type 1 or type 2 Diabetes Mellitus (DM), and to investigate differences in interventions primarily targeted at providing glycemic control vs. psychosocial support. A PRISMA-guided systematic search was conducted. Randomized Controlled Trials (RCTs) regarding eHealth interventions for adults (18–65 years) with DM were included. Data were pooled using Standard Mean Difference (SMD); sub-group analysis and meta-regressions were performed when appropriate. Outcomes were Hemoglobin A1c (HbA1c), diabetes distress, quality of life, anxiety, stress, and depression. Intervention acceptability was assessed performing the Odds Ratio (OR) of drop-out rates. Thirteen RCTs comprising 1315 participants were included (52.09% females; M_age = 46.18, SD = 9.98). Analyses showed intervention efficacy on HbA1c (SMD = −0.40; 95% CI = −0.70, −0.12; k = 13) and depressive symptoms (SMD = −0.18; 95% CI = −0.33, −0.02; k = 6) at RCTs endpoint and were well accepted (OR = 1.43; 95% CI = 0.72, 2.81; k = 10). However, efficacy on HbA1c was not maintained at follow-up (SMD = −0.13; 95% CI = −0.31, 0.05; k = 6). eHealth interventions providing medical support were acceptable and effective in fostering glycemic control and decreasing depressive symptoms in the short-term only. Digital solutions should be developed on multiple levels to fully support the psychophysical well-being of people with DM.

Comparing Two Commercially Available Diabetes Apps to Explore Challenges in User Engagement: Randomized Controlled Feasibility Study

BACKGROUND

Diabetes apps represent a promising addition to face-to-face self-management interventions, which can be time and resource intensive. However, few randomized controlled trials have evaluated the efficacy of diabetes apps, in particular as a stand-alone intervention without additional clinical support.

OBJECTIVE

We used a feasibility randomized trial design to investigate differences in user engagement between 2 commercially available apps (free versions of Glucose Buddy and mySugr) over 2 weeks in adults with type 2 diabetes. Feasibility was assessed based on recruitment uptake, adherence to the diabetes apps, and follow-up rates. We also hypothesized that the diabetes app mySugr would demonstrate higher user engagement at follow-up due to its use of gamification. We also predicted higher user engagement would be associated with improved self-care behaviors and illness beliefs.

METHODS

Adults with type 2 diabetes attending outpatient diabetes clinics in Auckland were recruited and randomized (1:1 without blinding) to use either the Glucose Buddy or mySugr diabetes apps. User engagement, self-care behaviors, and illness beliefs were measured 2 weeks after baseline. Spearman rank correlations, Mann-Whitney tests, and Wilcoxon signed-rank tests were used to explore associations between the outcome measures and to investigate possible changes between and within groups. Six participants were interviewed to further explore acceptability and usability.

RESULTS

In total, 58 participants (29 per group) completed the 2-week follow-up, of whom only 38 reported using the apps (Glucose Buddy: n=20; mySugr: n=18). Both groups reported low engagement (Glucose Buddy: median 4 days; mySugr: median 6.5 days; P=.06; use for both groups: median 10 minutes). No changes were observed in self-care or illness beliefs in either group. Out of the self-care behaviors, only blood glucose testing was significantly associated with minutes of app use (P=.02). The interviews suggested that although both apps were deemed acceptable, they were generally viewed as time-consuming and too complicated to use.

CONCLUSIONS

Low engagement with both Glucose Buddy and mySugr reflect the challenges associated with engaging users with diabetes apps. Due to low engagement and loss to follow-up, the changes in outcome measures should be interpreted with caution. The results highlight the need for more clinical support as well as involvement from end users and behavior change specialists in order to incorporate evidence-based behavior change techniques to motivate and provide value to users.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12618000424202; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374671.

Clinical efficacy and plausibility of a smartphone-based integrated online real-time diabetes care system via glucose and diet data management: a pilot study

BACKGROUND

Smartphones have become novel healthcare tools for patients with diabetes. However, it is uncertain whether the smartphone application support system helps in glycaemic control in patients with type 2 diabetes.

AIMS

To evaluate the efficacy and plausibility of smartphone-based integrated online real-time diabetes care.

METHODS

Forty patients with type 2 diabetes were randomly assigned to the smartphone-based care (SC) (n = 20) and conventional care (CC) (n = 20) groups for 12 weeks. The SC group was instructed to use smartphone application (Noom Coach) and a glucose meter, and was provided medical supervision based on blood glucose level and food intake information sent to the central database server. The efficacy was evaluated by glycated haemoglobin (A1C ≤ 6.5%). The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire was collected at baseline and at week 12.

RESULTS

Seventeen and 18 patients of the SC and CC groups completed the study respectively. In the SC group, more patients achieved target A1C compared with the CC group (47.1% vs 11.1%, P = 0.019). In both group, SDSCA scores excluding the exercise item showed overall improvement (general diet, 1.4 ± 2.0 → 2.6 ± 2.3 vs 0.4 ± 1.1 → 1.8 ± 2.2; specific diet, 4.2 ± 1.7 → 5.4 ± 1.2 vs 3.8 ± 1.6 → 5.1 ± 1.1; blood glucose test, 3.3 ± 2.8 → 4.9 ± 2.3 vs 1.0 ± 2.2 → 4.7 ± 2.3; foot care, 1.5 ± 1.6 → 3.6 ± 2.8 vs 1.4 ± 1.9 → 6.1 ± 1.4; all P < 0.05). There was no difference between both groups other than the aspect of foot care (P = 0.008).

CONCLUSIONS

The smartphone-based integrated online real-time diabetes care system through glucose and diet data management showed clinical plausibility in glucose control in real clinical practice.

A reinforcement learning based algorithm for personalization of digital, just-in-time, adaptive interventions

Suboptimal health related behaviors and habits; and resulting chronic diseases are responsible for majority of deaths globally. Studies show that providing personalized support to patients yield improved results by preventing and/or timely treatment of these problems. Digital, just-in-time and adaptive interventions are mobile phone-based notifications that are being utilized to support people wherever and whenever necessary in coping with their health problems. In this research, we propose a reinforcement learning-based mechanism to personalize interventions in terms of timing, frequency and preferred type(s). We simultaneously employ two reinforcement learning models, namely intervention-selection and opportune-moment-identification; capturing and exploiting changes in people's long-term and momentary contexts respectively. While the intervention-selection model adapts the intervention delivery with respect to type and frequency, the opportune-moment-identification model tries to find the most opportune moments to deliver interventions throughout a day. We propose two accelerator techniques over the standard reinforcement learning algorithms to boost learning performance. First, we propose a customized version of eligibility traces for rewarding past actions throughout an agent's trajectory. Second, we utilize the transfer learning method to reuse knowledge across multiple learning environments. We validate the proposed approach in a simulated experiment where we simulate four personas differing in their daily activities, preferences on specific intervention types and attitudes towards the targeted behavior. Our experiments show that the proposed approach yields better results compared to the standard reinforcement learning algorithms and successfully capture the simulated variations associated with the personas.

Fall prevention education for people with multiple sclerosis: a randomized clinical trial

BACKGROUND

Online spaced education (OSE) is a method recognized for promoting long-term knowledge retention, changing behaviors and improving outcomes for students and healthcare professionals. However, there is little evidence about its impacts on patient education.

OBJECTIVES

The aim of this research was to compare knowledge retention using educational brochure and OSE on individuals with multiple sclerosis (MS) and to verify the impact of educational methods on fall outcome.

METHODS

Individuals with MS (n = 230) were randomly assigned to two types of patient education-educational brochure (control) and OSE (intervention). During 12 weeks, the intervention group received multiple-choice tests on fall prevention. Knowledge retention, behavior change and fall incidence were assessed before intervention and after 3 and 6 months. The participants' satisfaction with the education method was also evaluated.

RESULTS

Knowledge retention was similar between groups, and behavior change was observed in both groups. There was a significant reduction in fall rate in the intervention group, from 0.60 to 0.27 at 6 months (P < 0.001). Participants' satisfaction achieved an average of 8.75, with no differences between groups.

CONCLUSION

Individuals demonstrated significant improvement in fall rate outcome in both groups with no significant difference. In regard to test scores and satisfaction, results were similar between groups.

Type 1 Doing Well: Pilot Feasibility and Acceptability Study of a Strengths-Based mHealth App for Parents of Adolescents with Type 1 Diabetes

Background: We evaluated the feasibility and acceptability of a pilot behavioral intervention delivered to parents of adolescents with type 1 diabetes (T1D) via mobile-friendly web app. The Type 1 Doing Well app aimed to promote supportive family diabetes management by helping parents recognize and reinforce teens' positive diabetes-related behaviors ("strengths"). Methods: Parents (n = 80, 74% recruitment) of adolescents (age range = 12-17 years, M = 15.3 ± 1.5 years, 59% female, 56% insulin pump, M hemoglobin A1c (HbA1c) = 9.0% ± 2.1%) were randomized 2:1 to intervention or control (i.e., usual medical care with or without app) for 3-4 months between diabetes appointments. The app prompted parents daily to track adolescents' strengths and generated weekly summaries of their teen's top strengths. Parents could access a library of text messages to praise their teens. Exploratory pre/post data included questionnaires (98% completed) and HbA1c. Results: Parents used the app for M = 106.1 ± 37.1 days, logging in ≥once/day on 80% of days. Ninety-one percent of parents used the app ≥2 days/week on average. Parents viewed M = 5.6 ± 4.7 weekly summaries and "favorited" 15 praise texts in the library. App acceptability ratings (7-point scale) were high: Satisfaction 5.0 ± 1.5, Usefulness 4.8 ± 1.5, Ease of Use 6.2 ± 0.8, and Ease of Learning 6.5 ± 0.8. Parents (n = 48) and adolescents (n = 47) gave positive feedback and suggestions via qualitative interviews. There were no significant between-group differences for change in exploratory outcomes (HbA1c, questionnaires). Conclusions: Type 1 Doing Well was feasible to deliver and highly acceptable and engaging for parents of adolescents with T1D. It may have a larger impact on behavioral or clinical outcomes as part of a multicomponent intervention protocol. Trial Registration: ClinicalTrials.gov NCT02877680.

User Experiences With a Type 2 Diabetes Coaching App: Qualitative Study

BACKGROUND

Diabetes self-management apps have the potential to improve self-management in people with type 2 diabetes (T2D). Although efficacy trials provide evidence of health benefits, premature disengagement from apps is common. Therefore, it is important to understand the factors that influence engagement in real-world settings.

OBJECTIVE

This study aims to explore users' real-world experiences with the My Diabetes Coach (MDC) self-management app.

METHODS

We conducted telephone-based interviews with participants who had accessed the MDC self-management app via their smartphone for up to 12 months. Interviews focused on user characteristics; the context within which the app was used; barriers and facilitators of app use; and the design, content, and delivery of support within the app.

RESULTS

A total of 19 adults with T2D (8/19, 42% women; mean age 60, SD 14 years) were interviewed. Of the 19 interviewees, 8 (42%) had T2D for <5 years, 42% (n=8) had T2D for 5-10 years, and 16% (n=3) had T2D for >10 years. In total, 2 themes were constructed from interview data: (1) the moderating effect of diabetes self-management styles on needs, preferences, and expectations and (2) factors influencing users' engagement with the app: one size does not fit all.

CONCLUSIONS

User characteristics, the context of use, and features of the app interact and influence engagement. Promoting engagement is vital if diabetes self-management apps are to become a useful complement to clinical care in supporting optimal self-management.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry CTRN126140012296; URL https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366925&isReview=true.

A Facilitated Web-Based Self-Management Tool for People With Type 1 Diabetes Using an Insulin Pump: Intervention Development Using the Behavior Change Wheel and Theoretical Domains Framework

BACKGROUND

Type 1 diabetes (T1D) requires intensive self-management (SM). An insulin pump is designed to better support personal T1D management, but at the same time, it exacerbates the complexity and requirements of SM. Research shows that people with diabetes are likely to benefit from navigating and connecting to local means of social support and resources through web-based interventions that offer flexible, innovative, and accessible SM. However, questions remain as to which behavior change mechanisms within such resources benefit patients most and how to foster engagement with and endorsement of SM interventions.

OBJECTIVE

The aim of this study was to evaluate the perspectives and experiences of people with T1D using an insulin pump and specialist health care professionals (HCPs) and determine what behavior change characteristics and strategies are required to inform the optimization of an existing web-based social network (SN) intervention to support SM.

METHODS

Focus groups with insulin pump users (n=19) and specialist HCPs (n=20) in 6 National Health Service (NHS) trusts across the south of England examined the barriers and enablers to incorporating and self-managing an insulin pump. An analysis was undertaken using the Behavior Change Wheel and Theoretical Domains Framework, followed by a taxonomy of behavior change techniques (BCTs) to identify the contents of and strategies for the implementation of a complex health intervention.

RESULTS

A total of 4 themes represent the SM perspectives and experiences of stakeholders: (1) a desire for access to tailored and appropriate resources and information-the support and information required for successful SM are situational and contextual, and these vary according to time and life circumstances, and therefore, these need to be tailored and appropriate; (2) specific social support preferences-taking away isolation as well as providing shared learnings and practical tips, but limitations included the fear of judgment from others and self-pity from peers; (3) the environmental context, that is, capacity and knowledge of pump clinic HCPs-HCPs acknowledge the patient's need for holistic support but lack confidence in providing it; and (4) professional responsibility and associated risks and dangers, whereas HCPs are fearful of the consequences of promoting non-NHSSM support, and they question whether SM support fits into their role. BCTs were identified to address these issues.

CONCLUSIONS

The use of behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers and enablers of self-managing T1D with an insulin pump. A web-based SN intervention appears to offer additional forms of SM support while complementing NHS services. However, for intervention implementation, HCPs' apprehensions about responsibility when signposting to non-NHS SM support would need to be addressed, and opportunistic features would need to be added, through which pump users could actively engage with other people living with T1D.

Text Message Intervention for Teens with Type 1 Diabetes Preserves HbA1c: Results of a Randomized Controlled Trial

Aims: Teens with type 1 diabetes (T1D) often struggle with diabetes self-management, which may lead to suboptimal self-care and worsening hemoglobin A1c (HbA1c). Innovative strategies are needed to improve self-care and protect against glycemic decline, especially during adolescence. We aimed to assess the impact on HbA1c of two interventions, problem-solving and text messaging, in teens with T1D. Methods: In a two-site randomized controlled trial, teens (N = 301) 13-17 years of age with T1D were randomized to one of the four groups using a 2 × 2 factorial design: Teenwork (TW), Text Messaging (Text), TW+Text, or Usual Care. TW intervention included problem-solving aimed at improving T1D self-care for blood glucose (BG) monitoring and insulin bolus dosing. Text intervention involved text reminders to check BG. The primary outcome was change in HbA1c from baseline to 12 months. Results: At baseline, teens (51% female, 78% white, 59% pump-treated) were (mean ± SD) 15.0 ± 1.3 years, had diabetes duration of 6.5 ± 3.7 years, and HbA1c 8.5% ± 1.1%. There was no significant difference in HbA1c over time by study group. Responsiveness to text reminders by teens in the TEXT and TW+TEXT predicted glycemic benefit; TW did not. Conclusions: Despite no HbA1c difference by study group, greater response to text message reminders to check BG led to better glycemic control and no deterioration in HbA1c; the problem-solving intervention did not. Given the high penetration of mobile phones and the wide acceptance of text messaging among teens in general, it is encouraging that a text messaging intervention can preserve HbA1c, thus preventing the expected deterioration in glycemic control often seen in teens with T1D.

Prescription of individual therapeutic exercises via smartphone app for patients suffering from non-specific back pain : A qualitative feasibility and quantitative pilot study

Background

The purpose of this qualitative study was the assessment of the feasibility and acceptance of orthopedists prescribing individualized therapeutic exercises via a smartphone app to patients suffering from non-specific back pain.

Methods

A total of 27 patients (mean age 44.8 ± 13.2 years) diagnosed with acute non-specific back pain were prescribed individually chosen therapy exercises via a smartphone app. Before the patients started and after 4 weeks of exercising all participants went through an assessment protocol consisting of questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], International Physical Activity Questionnaire [IPAQ], Work Ability Index [WAI], Visual Analogue Scale [VAS] back pain, sociodemographic parameters), assessment of functional parameters (handgrip strength, timed up and go test). With 16 randomly chosen patients semi-structured interviews were undertaken at the end of the intervention period. Interview transcripts were analyzed using thematic analysis. Power analysis and a priori sample size calculations were undertaken with the quantitative data.

Results

From the interviews four thematic categories emerged: prior exercise experience, evaluation of exercise intensity, communication with physician via smartphone app, and variability of exercise location. Quantitative analysis of secondary data showed significant improvements in back pain (ODI) as well as quality of life domains “physical functioning”, “bodily pain” and “vitality” (SF-36) of which “bodily pain” was sufficiently powered with the current sample size.

Conclusion

The prescription of therapeutic exercises via smartphone app to patients suffering from non-specific back pain is feasible and well-accepted in patients at all ages. Pilot data additionally pointed towards efficacy of the intervention.

Sociodemographic Factors Associated with Participation in Diabetes Education among Community-Dwelling Adults with Diabetes

PURPOSE

This study investigated the sociodemographic factors associated with participation in diabetes self-management education (DSME) among community-dwelling adults with diabetes.

MATERIALS AND METHODS

Data from 23400 people aged ≥30 years who were diagnosed with diabetes from the nationwide 2016 Korea Community Health Survey were analyzed. The relationship between sociodemographic factors and participation in DSME was examined by logistic regression analysis. The study sample was classified according to the type of institution providing DSME: hospitals/medical clinics (HMCs) and/or public health institutions (PHIs).

RESULTS

Of the total sample population with diabetes, 27.2% had attended DSME programs, including 21.9% at HMCs, 4.0% at PHIs, and 1.3% at both types of institutions. As age increased and educational level and monthly household income decreased, the odds ratios (ORs) of participation in DSME decreased in a fully adjusted model. Respondents living in rural areas had lower ORs for attending DSME compared to those living in urban areas [OR, 0.85; 95% confidence interval (CI), 0.80-0.91]. Service/sales workers and mechanical/manual workers had lower ORs for attending DSME (OR, 0.84; 95% CI, 0.71-0.99; and OR, 0.81; 95% CI, 0.69-0.94, respectively) compared to professional/managerial workers. However, in the subgroup of participants receiving education at PHIs, the likelihood of participation in DSME increased as age increased, and respondents living in rural areas had higher ORs compared to those living in urban areas (OR, 1.73; 95% CI, 1.51-1.98).

CONCLUSION

Customized DSME programs targeting socioeconomically vulnerable groups, including residential region and reimbursement of DSME by public insurance, are needed to resolve the inequalities in participation in DSME.

Achieving Effective and Efficient Basal Insulin Optimal Management by Using Mobile Health Application (APP) for Type 2 Diabetes Patients in China

AIM

To evaluate the effectiveness of the mobile health application (APP) education in basal insulin optimal management program for insulin-naive type 2 diabetes (T2D) patients in China.

METHODS

The basal insulin optimal management program was launched in 297 hospitals in China, throughout the six main regions of China. A total of 17,208 insulin-naive patients with T2D who started to use basal insulin were screened. The mobile health APP was downloaded in each recruited patient's mobile phone and the doctor's mobile phone. Then, according to the instructions and education materials in the APP, these patients began their self-management of insulin dosage titrations and contacted their doctors by APP if they need help.

RESULTS

Overall, 12,530 patients with T2D were finally included in the analysis. The average age was 51.97±12.76 years, and 58% of them were males. The average body mass index is 24.46±3.83 kg/m², and the average HbA1c at baseline was 8.33±2.11% with 24% of the subjects reaching the target of HbA1c<7.0% at baseline. After 3 months of treatment and educations through the APP, HbA1c decreased significantly from baseline (-1.02±1.72%), with 59% of the patients reaching HbA1c<7.0%. After 6 months, the glycemic control of HbA1c also decreased from baseline significantly (-1.01±1.67%). Dosage of insulin daily was 0.23±0.09 IU/kg at baseline, and 0.23±0.23 IU/kg after 6 months of treatment. Regarding the profiles of hypoglycemia treatment, 3145 patients received basal insulin in combination with mono oral anti-diabetic drug (OAD), 1204 patients with dual OADs, 208 patients with triple OADs, and 17 patients with quarter OADs.

CONCLUSION

Patients could benefit from the basal insulin optimal management program in self-management by using mobile health APP educations. For T2D patients who are going to start insulin treatment, mobile health APP can help them to reach the target of glycemic control with appropriate dosage of insulin.

mHealth Family Adaptation Intervention for Families of Young Children with Down Syndrome: A Feasibility Study

PURPOSE

The aim of this study was to explore the feasibility of using the mHealth Family Adaptation Intervention (FamilyAdapt-DS), with families of young children with Down syndrome (DS), and to assess the effect of participating in this mHealth intervention on family adaptation.

DESIGN AND METHODS

A one-group pre-test post-test design was employed. Sixteen parents from eight families of young children with DS (under the age of three years) participated in this study between September 2015 and September 2016. A Wilcoxon signed rank test was used to identify the difference between the pre-test and post-test scores.

RESULTS

All parents perceived that the program was feasible to use and they were willing to recommend the intervention to other families. Improvements were noted between pre-test and post-test scores. For fathers, views of their child's daily life became more positive, their child's condition became more manageable, their problem-solving communication became more affirming and their family functioning scores improved. Mothers reported less difficulty managing their child's condition.

CONCLUSIONS

These findings suggest that FamilyAdapt-DS is a feasible m-Health intervention for families of young children with DS; however, scaling up of this program with larger and more diverse samples is needed to test its effectiveness.

PRACTICE IMPLICATIONS

Nurses and other healthcare providers may find it helpful to use therapeutic conversations and mHealth interventions such as the one described in this paper to tailor the care they provide to families of young children with DS.

THRIVE study protocol: a randomized controlled trial evaluating a web-based app and tailored messages to improve adherence to adjuvant endocrine therapy among women with breast cancer

Background

Long-term use of adjuvant endocrine therapy (AET) among women with early-stage, hormone receptor-positive breast cancer significantly reduces the risk of hospitalizations, cancer recurrence, and mortality. AET is associated with adverse symptoms that often result in poor adherence. A web-enabled app offers a novel way to communicate and manage symptoms for women on AET. In a region with significant racial disparities in breast cancer outcomes, our study tests the impact of a web-enabled app that collects and transmits patient-reported symptoms to healthcare teams to facilitate timely and responsive symptom management on medication adherence.

Methods

In this randomized controlled trial, we randomize 300 patients initiating AET to one of three arms: 1) an “App” group (n = 100) that receives weekly reminders to use the THRIVE study app; 2) an “App+Feedback” group (n = 100) that receives weekly reminders and tailored feedback based on their use of the app; or 3) a “Usual Care” group (n = 100) that receives usual care only. Participants are stratified by race: 50% White and 50% Black. The duration of the intervention is six months following enrollment, and outcomes are assessed at 12-months. The primary outcome is adherence, which is captured using an electronic monitoring pillbox. Secondary outcomes include symptom burden, quality of life, self-efficacy for managing symptoms, and healthcare costs. We also evaluate the impact of the intervention on racial disparities in adherence. Data are derived from three sources: electronic health record data to capture treatment changes, healthcare utilization, and health outcomes; self-report survey data related to adherence, symptom burden, and quality of life; and an electronic medication monitoring device that captures adherence.

Discussion

A successful web-enabled intervention could be disseminated across systems, conditions, and populations. By evaluating the impact of this intervention on a comprehensive set of measures, including AET adherence, patient outcomes, and costs, our study will provide valuable and actionable results for providers, policy makers, and insurers who strive to achieve the “Triple Aim” – reduce costs while improving health outcomes and the patient care experience.

Trial registration

NCT03592771. Prospectively registered on July 19, 2018.

Improving HbA1c with Glucose Self-Monitoring in Diabetic Patients with EpxDiabetes, a Phone Call and Text Message-Based Telemedicine Platform: A Randomized Controlled Trial

Background: We conducted a randomized controlled trial of EpxDiabetes, a novel digital health intervention as an adjunct therapy to reduce HbA_1c and fasting blood glucose (FBG) among patients with type 2 diabetes mellitus (T2DM). In addition, we examined the effect of social determinants of health on our system. Methods: Sixty-five (n = 65) patients were randomized at a primary care clinic. Self-reported FBG data were collected by EpxDiabetes automated phone calls or text messages. Only intervention group responses were shared with providers, facilitating follow-up and bidirectional communication. ΔHbA_1c and ΔFBG were analyzed after 6 months. Results: There was an absolute HbA_1c reduction of 0.69% in the intervention group (95% confidence interval [CI], -1.41 to 0.02) and an absolute reduction of 0.03% in the control group (95% CI, -0.88 to 0.82). For those with baseline HbA_1c >8%, HbA_1c decreased significantly by 1.17% in the intervention group (95% CI, -1.90 to -0.44), and decreased by 0.02% in the control group (95% CI, -0.99 to 0.94). FBG decreased in the intervention group by 21.6 mg/dL (95% CI, -37.56 to -5.639), and increased 13.0 mg/dL in the control group (95% CI, -47.67 to 73.69). Engagement (proportion responding to ≥25% of texts or calls over 4 weeks) was 58% for the intervention group (95% CI, 0.373-0.627) and 48% for the control group (95% CI, 0.296-0.621). Smoking, number of comorbidities, and response rate were significant predictors of ΔHbA_1c. Conclusions: EpxDiabetes helps to reduce HbA_1c in patients with uncontrolled T2DM and fosters patient-provider communication; it has definite merit as an adjunct therapy in diabetes management. Future work will focus on improving the acceptability of the system and implementation on a larger scale trial.

Association Between User Engagement of a Mobile Health App for Gout and Improvements in Self-Care Behaviors: Randomized Controlled Trial

Background

Mobile health (mHealth) apps represent a promising approach for improving health outcomes in patients with chronic illness, but surprisingly few mHealth interventions have investigated the association between user engagement and health outcomes. We aimed to examine the efficacy of a recommended, commercially available gout self-management app for improving self-care behaviors and to assess self-reported user engagement of the app in a sample of adults with gout.

Objective

Our objective was to examine differences in self-reported user engagement between a recommended gout app (treatment group) and a dietary app (active control group) over 2 weeks as well as to examine any differences in self-care behaviors and illness perceptions.

Methods

Seventy-two adults with gout were recruited from the community and three primary and secondary clinics. Participants were randomized to use either Gout Central (n=36), a self-management app, or the Dietary Approaches to Stop Hypertension Diet Plan (n=36), an app based on a diet developed for hypertension, for 2 weeks. The user version of the Mobile Application Rating Scale (uMARS, scale: 1 to 5) was used after the 2 weeks to assess self-reported user engagement, which included an open-ended question. Participants also completed a self-report questionnaire on self-care behaviors (scale: 1-5 for medication adherence and diet and 0-7 for exercise) and illness perceptions (scale: 0-10) at baseline and after the 2-week trial. Independent samples t tests and analysis of covariance were used to examine differences between groups at baseline and postintervention.

Results

Participants rated the gout app as more engaging (mean difference –0.58, 95% CI –0.96 to –0.21) and more informative (mean difference –0.34, 95% CI –0.67 to –0.01) than the dietary app at the 2-week follow-up. The gout app group also reported a higher awareness of the importance of gout (mean difference –0.64, 95% CI –1.27 to –0.003) and higher knowledge/understanding of gout (mean difference –0.70, 95% CI –1.30 to –0.09) than the diet app group at follow-up. There were no significant differences in self-care behaviors between the two groups postintervention. The gout app group also demonstrated stronger negative beliefs regarding the impact of gout (mean difference –2.43, 95% CI –3.68 to –1.18), stronger beliefs regarding the severity of symptoms (mean difference –1.97, 95% CI –3.12 to –0.82), and a stronger emotional response to gout (mean difference –2.38, 95% CI –3.85 to –0.90) at follow-up. Participant feedback highlighted the importance of tracking health-related information, customizing to the target group/individual, providing more interactive features, and simplifying information.

Conclusions

Participants found the commercially available gout app more engaging. However, these findings did not translate into differences in self-care behaviors. The gout app group also demonstrated stronger negative illness perceptions at the follow-up. Overall, these findings suggest that the development of gout apps would benefit from a user-centered approach with a focus on daily, long-term self-care behaviors as well as modifying illness beliefs.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12617001052325; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373217.

Designing Online and Mobile Diabetes Education for Fathers of Children With Type 1 Diabetes: Mixed Methods Study

BACKGROUND

Fathers make unique and central contributions to the health of their children. However, research in type 1 diabetes (T1D) education largely ignores the needs of fathers, including during the development of online and mobile educational materials.

OBJECTIVE

The purpose of this study was to solicit and incorporate input from fathers of children with T1D into the design, content, and infrastructure of a suite of online diabetes self-management education and support (DSMES) resources.

METHODS

The study took part in three phases: (1) exploratory research, (2) website and subdomain development, and (3) evaluation. Fathers of children with T1D (n=30) completed surveys and semistructured qualitative interviews. Thematic content analysis was used to identify fathers' content and design preferences. An online DSMES website (T1DToolkit.org) and a separate mobile subdomain targeting fathers (Mobile Diabetes Advice for Dads, or mDAD) were developed. A prototype of the site for fathers was evaluated by 33 additional father participants. End user feedback was elicited via survey.

RESULTS

Participants in the exploratory phase were enthusiastic about the online diabetes resources. Preferences included high-quality design, availability via mobile phone and tablet, brief text content supplemented with multimedia and interactive features, reminders via text or email, endorsement by medical professionals, and links to scientific evidence. The mDAD subdomain received high usability and acceptability ratings, with 100% of participants very likely or likely to use the site again.

CONCLUSIONS

The development of eHealth educational platforms for fathers of children with T1D remains an unmet need in optimizing diabetes management. This study incorporated fathers' feedback into the development of a suite of online diabetes education resources. The findings will serve as the basis for future research to assess the clinical efficacy of the website, its subdomain targeting fathers, and additional subdomains targeting unique populations.

Text-message responsiveness to blood glucose monitoring reminders is associated with HbA1c benefit in teenagers with Type 1 diabetes

AIMS

To evaluate an 18-month text-messaging intervention in teenagers with Type 1 diabetes and to assess factors associated with text responsiveness and glycaemic benefit.

METHODS

Teenagers with diabetes (N = 147), aged 13-17 years, received two-way text reminders at self-selected times to check blood glucose levels and reply with blood glucose results.

RESULTS

At baseline, the participants (48% boys, 78% white, 63% pump-treated) had a mean ± sd age of 14.9 ± 1.3 years, diabetes duration of 7.1 ± 3.9 years and HbA_1c concentration of 69 ± 12 mmol/mol (8.5 ± 1.1%). The mean proportion of days with ≥1 blood glucose response declined over time (0-6 months, 60 ± 26% of days, 7-12 months, 53 ± 31% of days, 13-18 months, 43 ± 33% of days). Over 18 months, 49% responded with ≥1 blood glucose result on ≥50% of days (high responders). Regression analysis controlling for baseline HbA_1c revealed no significant change in HbA_1c from baseline to 18 months in high responders (P = 0.54) compared with a significant HbA_1c increase in low responders (+0.3%, P = 0.01). In participants with baseline HbA_1c ≥64 mmol/mol (≥8%), high responders were 2.5 times more likely than low responders to have a clinically significant [≥5.5 mmol/mol (≥0.5%)] HbA_1c decrease over 18 months (P < 0.05). In participants with baseline HbA_1c <64 mmol/mol(<8%), high responders were 5.7 times more likely than low responders to have an 18-month HbA_1c <58 mmol/mol (<7.5%; P < 0.05).

CONCLUSIONS

Teenagers with Type 1 diabetes who responded to text reminders on ≥50% of days over 18 months experienced clinically significant glycaemic benefit. There remains a need to tailor interventions to maintain teenager engagement and optimize improvements.

Sociodemographic Factors Associated With Engagement in Diabetes Self-management Education Among People With Diabetes in the United States

OBJECTIVE

Research outside the United States shows that certain subgroups of patients (eg, those who are older, male, of low socioeconomic status, and uninsured) are less likely than others to report receiving diabetes self-management education (DSME); however, less is known about DSME uptake in the United States. We examined sociodemographic, patient, and behavioral characteristics associated with DSME in a nationally representative sample.

METHODS

We analyzed data from the 2011-2013 Behavioral Risk Factor Surveillance System for 84 179 adults who self-identified receiving a diagnosis of diabetes. We constructed weighted, multivariate logistic regression models to examine the associations between DSME and sociodemographic characteristics (age, sex, race/ethnicity, marital status, education, and annual household income), patient characteristics (body mass index, having a regular provider, health insurance status, health status, and insulin use), and self-management behaviors (home foot examination, home blood glucose testing, and physical activity).

RESULTS

More than half (n = 45 557, 53.7% [weighted]) of respondents reported engaging in DSME. Compared with non-Hispanic white adults, non-Hispanic black adults were more likely to engage in DSME (adjusted odds ratio [aOR] = 1.17; 95% confidence interval [CI], 1.07-1.29). Respondents were less likely to engage in DSME if they were male (aOR = 0.85; 95% CI, 0.80-0.91) or Hispanic (aOR = 0.81; 95% CI, 0.71-0.92), were a high school graduate (but no college; aOR = 0.71; 95% CI, 0.66-0.78) or less than a high school graduate (aOR = 0.51; 95% CI, 0.45-0.59), had an annual household income of $15 000-$24 999 (aOR = 0.81; 95% CI, 0.73-0.89) or <$15 000 (aOR = 0.70; 95% CI, 0.62-0.78), or had no health insurance (aOR = 0.87; 95% CI, 0.76-0.98). DSME was significantly associated with all 3 self-management behaviors.

CONCLUSIONS

Increasing public health interventions aimed at educating people with diabetes about self-management could improve outcomes.

Return of the JITAI: Applying a Just-in-Time Adaptive Intervention Framework to the Development of m-Health Solutions for Addictive Behaviors

PURPOSE

Lapses are strong indicators of later relapse among individuals with addictive disorders, and thus are an important intervention target. However, lapse behavior has proven resistant to change due to the complex interplay of lapse triggers that are present in everyday life. It could be possible to prevent lapses before they occur by using m-Health solutions to deliver interventions in real-time.

METHOD

Just-in-time adaptive intervention (JITAI) is an intervention design framework that could be delivered via mobile app to facilitate in-the-moment monitoring of triggers for lapsing, and deliver personalized coping strategies to the user to prevent lapses from occurring. An organized framework is key for successful development of a JITAI.

RESULTS

Nahum-Shani and colleagues (2014) set forth six core elements of a JITAI and guidelines for designing each: distal outcomes, proximal outcomes, tailoring variables, decision points, decision rules, and intervention options. The primary aim of this paper is to illustrate the use of this framework as it pertains to developing a JITAI that targets lapse behavior among individuals following a weight control diet.

CONCLUSION

We will detail our approach to various decision points during the development phases, report on preliminary findings where applicable, identify problems that arose during development, and provide recommendations for researchers who are currently undertaking their own JITAI development efforts. Issues such as missing data, the rarity of lapses, advantages/disadvantages of machine learning, and user engagement are discussed.

Importance of Patient-Provider Communication to Adherence in Adolescents with Type 1 Diabetes

Effective communication between pediatric diabetes patients and their providers has the potential to enhance patient satisfaction and health outcomes, as well as improve diabetes-related self-management. In this review, we highlight the importance of communication between patients and providers, focusing on the effect of communication on adherence in the high-risk population of adolescents with type 1 diabetes. We synthesize the literature describing patient-provider communication in pediatric populations and provide implications for practice that focus on the most relevant, modifiable factors for improving self-management in adolescents with type 1 diabetes.

Strengths-Based Behavioral Intervention for Parents of Adolescents With Type 1 Diabetes Using an mHealth App (Type 1 Doing Well): Protocol for a Pilot Randomized Controlled Trial

Background

Supportive parent involvement for adolescents’ type 1 diabetes (T1D) self-management promotes optimal diabetes outcomes. However, family conflict is common and can interfere with collaborative family teamwork. Few interventions have used explicitly strengths-based approaches to help reinforce desired management behaviors and promote positive family interactions around diabetes care.

Objective

The aim of this protocol was to describe the development of a new, strengths-based behavioral intervention for parents of adolescents with T1D delivered via a mobile-friendly Web app called Type 1 Doing Well.

Methods

Ten adolescent-parent dyads and 5 diabetes care providers participated in a series of qualitative interviews to inform the design of the app. The 3- to 4-month pilot intervention will involve 82 parents receiving daily prompts to use the app, in which they will mark the diabetes-related strength behaviors (ie, positive attitudes or behaviors related to living with or managing T1D) their teen engaged in that day. Parents will also receive training on how to observe diabetes strengths and how to offer teen-friendly praise via the app. Each week, the app will generate a summary of the teen’s most frequent strengths from the previous week based on parent reports, and parents will be encouraged to praise their teen either in person or from a library of reinforcing text messages (short message service, SMS).

Results

The major outcomes of this pilot study will include intervention feasibility and satisfaction data. Clinical and behavioral outcomes will include glycemic control, regimen adherence, family relationships and conflict, diabetes burden, and health-related quality of life.

Conclusions

This strengths-based, mobile health (mHealth) intervention aims to help parents increase their awareness of and efforts to support their adolescents’ engagement in positive diabetes-related behaviors. If efficacious, this intervention has the potential to reduce the risk of family conflict, enhance collaborative family teamwork, and ultimately improve diabetes outcomes.

Trial Registration

ClinicalTrials.gov NCT02877680; https://clinicaltrials.gov/ct2/show/NCT02877680 (Archived by WebCite at http://www.webcitation.org/6xTAMN5k2)

Use of self-monitoring tools in a clinic sample of adults with type 2 diabetes

Self-monitoring is an effective strategy for chronic disease management; many readily available mobile applications allow tracking of diabetes-related health behaviors but their use has not yet been integrated into routine clinical care. How patients engage with these applications in the real world is not well understood. The specific aim of this study is to survey adults with type 2 diabetes (T2D) regarding self-monitoring behaviors, including mobile application use. In 2015, we surveyed an adult diabetes clinic population (n = 96) regarding self-monitoring behaviors: diet, physical activity, weight, and blood glucose. Self-monitoring with any method ranged from 20-90 %. About half of the participants owned smartphones; few had mobile applications. The most common app-tracked behavior was physical activity, then weight and diet. Despite numerous available mobile health-tracking applications, few T2D adults from our sample used them, though many reported self-monitoring with other methods.

The effectiveness, reproducibility, and durability of tailored mobile coaching on diabetes management in policyholders: A randomized, controlled, open-label study

This randomized, controlled, open-label study conducted in Kangbuk Samsung Hospital evaluated the effectiveness, reproducibility, and durability of tailored mobile coaching (TMC) on diabetes management. The participants included 148 Korean adult policyholders with type 2 diabetes divided into the Intervention-Maintenance (I-M) group (n = 74) and Control-Intervention (C-I) group (n = 74). Intervention was the addition of TMC to typical diabetes care. In the 6-month phase 1, the I-M group received TMC, and the C-I group received their usual diabetes care. During the second 6-month phase 2, the C-I group received TMC, and the I-M group received only regular information messages. After the 6-month phase 1, a significant decrease (0.6%) in HbA1c levels compared with baseline values was observed in only the I-M group (from 8.1 ± 1.4% to 7.5 ± 1.1%, P < 0.001 based on a paired t-test). At the end of phase 2, HbA1c levels in the C-I group decreased by 0.6% compared with the value at 6 months (from 7.9 ± 1.5 to 7.3 ± 1.0, P < 0.001 based on a paired t-test). In the I-M group, no changes were observed. Both groups showed significant improvements in frequency of blood-glucose testing and exercise. In conclusion, addition of TMC to conventional treatment for diabetes improved glycemic control, and this effect was maintained without individualized message feedback.

E-health in inflammatory bowel diseases: More challenges than opportunities?

Patients with inflammatory bowel disease need close monitoring for an optimal disease management. For this, e-health technologies are promising tools. But the current evidence for the implementation of e-health in inflammatory bowel disease is weak. For this a critical evaluation of the existing evidence is presented. Furthermore some essential conditions need to be full-filled. We need a robust digital infrastructure that is workable for the patient and the healthcare provider. Important legal issues need to be solved to protect the patient. And the e-health technologies will have to proof their durability, feasibility and acceptance for the patient on the long term.

Efficacy of Mobile Apps to Support the Care of Patients With Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Diabetes Mellitus (DM) is a chronic disease that is considered a global public health problem. Education and self-monitoring by diabetic patients help to optimize and make possible a satisfactory metabolic control enabling improved management and reduced morbidity and mortality. The global growth in the use of mobile phones makes them a powerful platform to help provide tailored health, delivered conveniently to patients through health apps.

Objective

The aim of our study was to evaluate the efficacy of mobile apps through a systematic review and meta-analysis to assist DM patients in treatment.

Methods

We conducted searches in the electronic databases MEDLINE (Pubmed), Cochrane Register of Controlled Trials (CENTRAL), and LILACS (Latin American and Caribbean Health Sciences Literature), including manual search in references of publications that included systematic reviews, specialized journals, and gray literature. We considered eligible randomized controlled trials (RCTs) conducted after 2008 with participants of all ages, patients with DM, and users of apps to help manage the disease. The meta-analysis of glycated hemoglobin (HbA1c) was performed in Review Manager software version 5.3.

Results

The literature search identified 1236 publications. Of these, 13 studies were included that evaluated 1263 patients. In 6 RCTs, there were a statistical significant reduction (P<.05) of HbA1c at the end of studies in the intervention group. The HbA1c data were evaluated by meta-analysis with the following results (mean difference, MD −0.44; CI: −0.59 to −0.29; P<.001; I²=32%).The evaluation favored the treatment in patients who used apps without significant heterogeneity.

Conclusions

The use of apps by diabetic patients could help improve the control of HbA1c. In addition, the apps seem to strengthen the perception of self-care by contributing better information and health education to patients. Patients also become more self-confident to deal with their diabetes, mainly by reducing their fear of not knowing how to deal with potential hypoglycemic episodes that may occur.

Evidence-based behavioral interventions to promote diabetes management in children, adolescents, and families

As members of multidisciplinary diabetes care teams, psychologists are well-suited to support self-management among youth with Type 1 diabetes (T1D) and Type 2 diabetes (T2D) and their families. Psychological and behavioral interventions can promote adherence to the complex and demanding diabetes care regimen, with the goals of promoting high quality of life, achieving optimal glycemic control, and ultimately preventing disease-related complications. This article reviews well-researched contemporary behavioral interventions to promote optimal diabetes family- and self-management and health outcomes in youth with T1D, in the context of key behavioral theories. The article summarizes the evidence base for established diabetes skills training programs, family interventions, and multisystemic interventions, and introduces emerging evidence for technology and mobile health interventions and health care delivery system interventions. Next steps in behavioral T1D intervention research include tailoring interventions to meet individuals' and families' unique needs and strengths, and systematically evaluating cost-effectiveness to advocate for dissemination of well-developed interventions. Although in its infancy, this article reviews observational and intervention research for youth with T2D and their families and discusses lessons for future research with this population. Interventions for youth with T2D will need to incorporate family members, consider cultural and family issues related to health behaviors, and take into account competing priorities for resources. As psychologists and behavioral scientists, we must advocate for the integration of behavioral health into routine pediatric diabetes care in order to effectively promote meaningful change in the behavioral and medical well-being of youth and families living with T1D and T2D. (PsycINFO Database Record

The Use of Mobile Health to Deliver Self-Management Support to Young People With Type 1 Diabetes: A Cross-Sectional Survey

BACKGROUND

Young people living with type 1 diabetes face not only the challenges typical of adolescence, but also the challenges of daily management of their health and evolving understanding of the impact of their diagnosis on their future. Adolescence is a critical time for diabetes self-management, with a typical decline in glycemic control increasing risk for microvascular diabetes complications. To improve glycemic control, there is a need for evidence-based self-management support interventions that address the issues pertinent to this population, utilizing platforms that engage them. Increasingly, mobile health (mHealth) interventions are being developed and evaluated for this purpose with some evidence supporting improved glycemic control. A necessary step to enhance effectiveness of such approaches is to understand young people's preferences for this mode of delivery.

OBJECTIVE

A cross-sectional survey was conducted to investigate the current and perceived roles of mHealth in supporting young people to manage their diabetes.

METHODS

Young adults (16-24 years) with type 1 diabetes in Auckland, New Zealand, were invited to take part in a survey via letter from their diabetes specialist.

RESULTS

A total of 115 young adults completed the survey (mean age 19.5 years; male 52/115, 45%; European 89/115, 77%), with all reporting they owned a mobile phone and 96% (110/115) of those were smartphones. However, smartphone apps for diabetes management had been used by only 33% (38/115) of respondents. The most commonly reported reason for not using apps was a lack of awareness that they existed. Although the majority felt they managed their diabetes well, 63% (72/115) reported wanting to learn more about diabetes and how to manage it. A total of 64% (74/115) respondents reported that they would be interested in receiving diabetes self-management support via text message (short message service, SMS).

CONCLUSIONS

Current engagement with mHealth in this population appears low, although the findings from this study provide support for the use of mHealth in this group because of the ubiquity and convenience of mobile devices. mHealth has potential to provide information and support to this population, utilizing mediums commonplace for this group and with greater reach than traditional methods.

mHealth Intervention Elements and User Characteristics Determine Utility: A Mixed-Methods Analysis

BACKGROUND

Mobile health (mHealth) interventions are improving the medication adherence of adults with type 2 diabetes mellitus (T2DM), but few studies examine how users experience these interventions. Therefore, we used a mixed-methods approach to understand how T2DM users experience a text messaging and interactive voice response (IVR)-delivered medication adherence intervention called MEssaging for Diabetes (MED).

METHODS

Adults with T2DM used MED as part of a 3-month pilot study. MED sends daily tailored text messages addressing adherence barriers, daily assessment text messages asking about adherence, and weekly tailored IVR calls providing adherence feedback, encouragement, and questions to facilitate problem solving. Sixty participants completed feedback interviews. We used a mixed-methods approach to understand their experience, examining associations between participants' characteristics and their feedback.

RESULTS

Participants who completed feedback interviews were on average 50.0 ± 10.1 years old; 65% female, 62% non-white; 15% had less than a high school education, 70% had annual incomes less than $20K; and average hemoglobin A1c was 8.0% ± 1.9%. Participants rated each intervention element favorably; common reasons for MED's helpfulness included receiving novel information about diabetes medications, emotional support, and reminders to take medication. People who were younger and more recently diagnosed with T2DM had more favorable experiences using MED. In general, users valued text messages more than IVR calls.

CONCLUSIONS

Consideration of the user experience is critical for developing engaging mHealth interventions. User feedback reveals what mHealth elements have the most value and why, which users to target, and how to optimize an intervention's utility and appeal.

T2DM Self-Management via Smartphone Applications: A Systematic Review and Meta-Analysis

BACKGROUND

Mobile health interventions (mHealth) based on smartphone applications (apps) are promising tools to help improve diabetes care and self-management; however, more evidence on the efficacy of mHealth in diabetes care is needed. The objective of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effect of mHealth apps on changes in hemoglobin A1c (HbA1c), blood glucose, blood pressure, serum lipids, and body weight in type 2 diabetes mellitus (T2DM) patients.

METHODS

Two independent reviewers searched three online databases (PubMed, the Cochrane Library, and EMBASE) to identify relevant studies published between January 2005 and June 2016. Of the 2,596 articles retrieved, 13 RCTs were included. We used random effects model to estimate the pooled results.

RESULTS

Thirteen studies were selected for the systematic review, six of which with data available containing 1,022 patients were included for the meta-analysis. There was a moderate effect on glycemic control after the mHealth app-based interventions. The overall effect on HbA1c shown as mean difference (MD) was -0.40% (-4.37 mmol/mol) (95% confidence interval [CI] -0.69 to -0.11% [-7.54 to -1.20 mmol/mol]; p = 0.007) and standardized mean differences (SMD) was -0.40% (-4.37 mmol/mol) (95% confidence interval [CI] -0.69 to -0.10% [-7.54 to -1.09 mmol/mol]; p = 0.008). A subgroup analysis showed a similar effect with -0.33% (-3.61 mmol/mol) (95% CI -0.59 to -0.06% [-6.45 to -0.66 mmol/mol]; p = 0.02) in MD and -0.38% (-4.15 mmol/mol) (95% CI -0.71 to -0.05% [-7.76 to -0.55 mmol/mol]; p = 0.02) in SMD in studies where patients' baseline HbA1c levels were less than 8.0%. No effects of mHealth app interventions were found on blood pressure, serum lipids, or weight. Assessment of overall study quality and publication bias demonstrated a low risk of bias among the six studies.

CONCLUSIONS

Smartphone apps offered moderate benefits for T2DM self-management. However, more research with valid study designs and longer follow-up is needed to evaluate the impact of mHealth apps for diabetes care and self-management.

Effectiveness of short message service-based intervention (SMS) on self-care in type 2 diabetes: A feasibility study

AIM

The objective of the current study is to assess the effectiveness of Mobile Short Message Service (SMS) intervention on education of basic self-care skills in patients with type 2 diabetes. Moreover, we aimed to determine whether delivering individually-tailored educational messages can be more effective than general educational messages.

METHODS

A total of 150 patients with diabetes type 2 were randomized into three groups: tailored SMS group, non-tailored SMS group, and the control group. Biochemical parameters including HbA1c, FBS, lipid profile were evaluated for the three groups at baseline and after 12 weeks. Moreover, self-care Inventory (SCI), Diabetes Management Self-Efficacy Scale (DMSES) and Diabetes Self-Care Barriers assessment scale for Older Adults (DSCB-OA) were completed. In the tailored SMS group, each person received 75% of their messages based on the top two barriers to adherence that they had experienced and reported in their scale. In the non-tailored SMS group, random messages were sent to every patient.

RESULTS

After 12 weeks, although HgA1c levels did not significantly change, significant decline was observed in FBS and mean BMI in both intervention groups. Mean SCI-R scores significantly increased and mean DSCB and DMSES scores significantly decreased in both tailored and non-tailored SMS groups. In the control group, mean SCI-R scores decreased and mean DSCB and DMSES scores significantly increased (P<0.001).

CONCLUSION

Sending short text messages as a method of education in conjunction with conventional diabetes treatment can improve glycemic control and positively influence other aspects of diabetes self-care. According to our findings, sending SMS regularly in particular times appears to be as effective as sending individually tailored messages.

A systematic review on incentive-driven mobile health technology: As used in diabetes management

Introduction Mobile health (mHealth) technologies have been shown to improve self-management of chronic diseases, such as diabetes. However, mHealth tools, e.g. apps, often have low rates of retention, eroding their potential benefits. Using incentives is a common mechanism for engaging, empowering and retaining patients that is applied by mHealth tools. We conducted a systematic review aiming to categorize the different types of incentive mechanisms employed in mHealth tools for diabetes management, which we defined as incentive-driven technologies (IDTs). As an auxiliary aim, we also analyzed barriers to adoption of IDTs. Methods Literature published in English between January 2008-August 2014 was identified through searching leading publishers and indexing databases: IEEE, Springer, Science Direct, NCBI, ACM, Wiley and Google Scholar. Results A total of 42 articles were selected. Of these, 34 presented mHealth tools with IDT mechanisms; Education was the most common mechanism ( n = 21), followed by Reminder ( n = 11), Feedback ( n = 10), Social ( n = 8), Alert ( n = 5), Gamification ( n = 3), and Financial ( n = 2). Many of these contained more than one IDT ( n = 19). The remaining eight articles, from which we defined barriers for adoption, were review papers and a qualitative study of focus groups and interviews. Discussion While mHealth technologies have advanced over the last five years, the core IDT mechanisms have remained consistent. Instead, IDT mechanisms have evolved with the advances in technology, such as moving from manual to automatic content delivery and personalization of content. Conclusion We defined the concept of IDT to be core features designed to act as motivating mechanisms for retaining and empowering users. We then identified seven core IDT mechanisms that are used by mHealth tools for diabetes management and classified 34 articles into these categories.

Patterns of User Engagement with Mobile- and Web-Delivered Self-Care Interventions for Adults with T2DM: A Review of the Literature

Technology-delivered interventions can improve the health behaviors and clinical outcomes of persons with diabetes, but only if end users engage with these interventions. To summarize the current knowledge on engagement with technology-based interventions, we conducted a review of recent mobile- and web-delivered intervention studies for adults with type 2 diabetes published from 2011 to 2015. Among 163 identified studies, 24 studies satisfied our inclusion criteria. There was substantial variation in how intervention engagement was reported across studies. Engagement rates were lower among interventions with a longer duration, and engagement decreased over time. In several studies, older age and lower health literacy were associated with less engagement, and more engagement was associated with intervention improvement in at least one outcome, including glycemic control. Future technology-based intervention studies should report on engagement, examine and report on associations between user characteristics and engagement, and aim to standardize how this is reported, particularly in longer trials.

Sensor Monitoring of Physical Activity to Improve Glucose Management in Diabetic Patients: A Review

Diabetic individuals need to tightly control their blood glucose concentration. Several methods have been developed for this purpose, such as the finger-prick or continuous glucose monitoring systems (CGMs). However, these methods present the disadvantage of being invasive. Moreover, CGMs have limited accuracy, notably to detect hypoglycemia. It is also known that physical exercise, and even daily activity, disrupt glucose dynamics and can generate problems with blood glucose regulation during and after exercise. In order to deal with these challenges, devices for monitoring patients’ physical activity are currently under development. This review focuses on non-invasive sensors using physiological parameters related to physical exercise that were used to improve glucose monitoring in type 1 diabetes (T1DM) patients. These devices are promising for diabetes management. Indeed they permit to estimate glucose concentration either based solely on physical activity parameters or in conjunction with CGM or non-invasive CGM (NI-CGM) systems. In these last cases, the vital signals are used to modulate glucose estimations provided by the CGM and NI-CGM devices. Finally, this review indicates possible limitations of these new biosensors and outlines directions for future technologic developments.

Text message-based diabetes self-management support (SMS4BG): study protocol for a randomised controlled trial

Background

Addressing the increasing prevalence, and associated disease burden, of diabetes is a priority of health services internationally. Interventions to support patients to effectively self-manage their condition have the potential to reduce the risk of costly and debilitating complications. The utilisation of mobile phones to deliver self-management support allows for patient-centred care at the frequency and intensity that patients desire from outside the clinic environment. Self-Management Support for Blood Glucose (SMS4BG) is a novel text message-based intervention for supporting people with diabetes to improve self-management behaviours and achieve better glycaemic control and is tailored to individual patient preferences, demographics, clinical characteristics, and culture. This study aims to assess whether SMS4BG can improve glycaemic control in adults with poorly controlled diabetes. This paper outlines the rationale and methods of the trial.

Methods/design

A two-arm, parallel, randomised controlled trial will be conducted across New Zealand health districts. One thousand participants will be randomised at a 1:1 ratio to receive SMS4BG, a theoretically based and individually tailored automated text message-based diabetes self-management support programme (intervention) in addition to usual care, or usual care alone (control). The primary outcome is change in glycaemic control (HbA1c) at 9 months. Secondary outcomes include glycaemic control at 3 and 6 months, self-efficacy, self-care behaviours, diabetes distress, health-related quality of life, perceived social support, and illness perceptions. Cost information and healthcare utilisation will also be collected as well as intervention satisfaction and interaction.

Discussion

This study will provide information on the effectiveness of a text message-based self-management support tool for people with diabetes. If found to be effective it has the potential to provide individualised support to people with diabetes across New Zealand (and internationally), thus extending care outside the clinic environment.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12614001232628.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1305-5) contains supplementary material, which is available to authorized users.

Use of Commonly Available Technologies for Diabetes Information and Self-Management Among Adolescents With Type 1 Diabetes and Their Parents: A Web-Based Survey Study

BACKGROUND

For individuals with Type 1 diabetes (T1D), following a complicated daily medical regimen is critical to maintaining optimal health. Adolescents in particular struggle with regimen adherence. Commonly available technologies (eg, diabetes websites, apps) can provide diabetes-related support, yet little is known about how many adolescents with T1D use them, why they are used, or relationships between use and self-management.

OBJECTIVE

This study examined adolescent and parent use of 5 commonly available technologies for diabetes, including proportions who use each technology, frequency of use, and number of different technologies used for diabetes. Analyses also investigated the reasons adolescents reported for using or not using technologies for diabetes, and factors correlated with adolescents' technology use. Finally, this study examined relationships between the type and number of technologies adolescents use for diabetes and their self-management and glycemic control.

METHODS

Adolescents (12-17 years) and their parents (N=174 pairs), recruited from a pediatric diabetes clinic (n=134) and the Children with Diabetes community website (n=40), participated in this Web-based survey study. Glycosylated hemoglobin (A1C) values were obtained from medical records for pediatric clinic patients. Adolescents reported their use of 5 commonly available technologies for diabetes (ie, social networking, diabetes websites, mobile diabetes apps, text messaging, and glucometer/insulin pump software), reasons for use, and self-management behavior (Self-Care Inventory-Revised, SCI-R).

RESULTS

Most adolescents and parents used at least one of the 5 technologies for diabetes. Among adolescents, the most commonly used technology for diabetes was text messaging (53%), and the least commonly used was diabetes websites (25%). Most adolescents who used diabetes apps, text messaging, or pump/glucometer software did so more frequently (≥2 times per week), compared to social networking and website use (≤1 time per week). The demographic, clinical, and parent-technology use factors related to adolescents' technology use varied by technology. Adolescents who used social networking, websites, or pump/glucometer software for diabetes had better self-management behavior (SCI-R scores: beta=.18, P=.02; beta=.15, P=.046; beta=.15, P=.04, respectively), as did those who used several technologies for diabetes (beta=.23, P=.003). However, use of diabetes websites was related to poorer glycemic control (A1C: beta=.18, P=.01).

CONCLUSIONS

Adolescents with T1D may be drawn to different technologies for different purposes, as individual technologies likely offer differing forms of support for diabetes self-management (eg, tracking blood glucose or aiding problem solving). Findings suggest that technologies that are especially useful for adolescents' diabetes problem solving may be particularly beneficial for their self-management. Additional research should examine relationships between the nature of technology use and adolescents' T1D self-management over time.

Mobile Phone and Smartphone Technologies for Diabetes Care and Self-Management

Mobile and smartphone (mHealth) technologies have the potential to improve diabetes care and self-management, but little is known about their effectiveness and how patients, providers, and payers currently interact with them. We conducted a systematic review and found only 20 peer-reviewed articles, published since 2010, with robust evidence about the effectiveness of mHealth interventions for diabetes. The majority of these interventions showed improvement on primary endpoints, such as HbA1c; mHealth technologies that interacted with both patients and providers were more likely to be effective. There was little evidence about persistent use by patients, use by a patient's health care provider, or long-term effectiveness. None of the studies discussed regulatory oversight of mHealth technologies or payer reimbursement for them. No robust studies evaluated the more than 1100 publicly available smartphone apps for diabetes. More research with valid study designs and longer follow-up is needed to evaluate the impact of mHealth technologies for diabetes care and self-management.

Quantifying usability: an evaluation of a diabetes mHealth system on effectiveness, efficiency, and satisfaction metrics with associated user characteristics

OBJECTIVE

Mobile health (mHealth) systems are becoming more common for chronic disease management, but usability studies are still needed on patients' perspectives and mHealth interaction performance. This deficiency is addressed by our quantitative usability study of a mHealth diabetes system evaluating patients' task performance, satisfaction, and the relationship of these measures to user characteristics.

MATERIALS AND METHODS

We used metrics in the International Organization for Standardization (ISO) 9241-11 standard. After standardized training, 10 patients performed representative tasks and were assessed on individual task success, errors, efficiency (time on task), satisfaction (System Usability Scale [SUS]) and user characteristics.

RESULTS

Tasks of exporting and correcting values proved the most difficult, had the most errors, the lowest task success rates, and consumed the longest times on task. The average SUS satisfaction score was 80.5, indicating good but not excellent system usability. Data trends showed males were more successful in task completion, and younger participants had higher performance scores. Educational level did not influence performance, but a more recent diabetes diagnosis did. Patients with more experience in information technology (IT) also had higher performance rates.

DISCUSSION

Difficult task performance indicated areas for redesign. Our methods can assist others in identifying areas in need of improvement. Data about user background and IT skills also showed how user characteristics influence performance and can provide future considerations for targeted mHealth designs.

CONCLUSION

Using the ISO 9241-11 usability standard, the SUS instrument for satisfaction and measuring user characteristics provided objective measures of patients' experienced usability. These could serve as an exemplar for standardized, quantitative methods for usability studies on mHealth systems.

A case study in open source innovation: developing the Tidepool Platform for interoperability in type 1 diabetes management

Objective Develop a device-agnostic cloud platform to host diabetes device data and catalyze an ecosystem of software innovation for type 1 diabetes (T1D) management.

Materials and Methods An interdisciplinary team decided to establish a nonprofit company, Tidepool, and build open-source software.

Results Through a user-centered design process, the authors created a software platform, the Tidepool Platform, to upload and host T1D device data in an integrated, device-agnostic fashion, as well as an application (“app”), Blip, to visualize the data. Tidepool’s software utilizes the principles of modular components, modern web design including REST APIs and JavaScript, cloud computing, agile development methodology, and robust privacy and security.

Discussion By consolidating the currently scattered and siloed T1D device data ecosystem into one open platform, Tidepool can improve access to the data and enable new possibilities and efficiencies in T1D clinical care and research. The Tidepool Platform decouples diabetes apps from diabetes devices, allowing software developers to build innovative apps without requiring them to design a unique back-end (e.g., database and security) or unique ways of ingesting device data. It allows people with T1D to choose to use any preferred app regardless of which device(s) they use.

Conclusion The authors believe that the Tidepool Platform can solve two current problems in the T1D device landscape: 1) limited access to T1D device data and 2) poor interoperability of data from different devices. If proven effective, Tidepool’s open source, cloud model for health data interoperability is applicable to other healthcare use cases.

Participatory approach to the development of a knowledge base for problem-solving in diabetes self-management

OBJECTIVE

To develop an expandable knowledge base of reusable knowledge related to self-management of diabetes that can be used as a foundation for patient-centric decision support tools.

MATERIALS AND METHODS

The structure and components of the knowledge base were created in participatory design with academic diabetes educators using knowledge acquisition methods. The knowledge base was validated using scenario-based approach with practicing diabetes educators and individuals with diabetes recruited from Community Health Centers (CHCs) serving economically disadvantaged communities and ethnic minorities in New York.

RESULTS

The knowledge base includes eight glycemic control problems, over 150 behaviors known to contribute to these problems coupled with contextual explanations, and over 200 specific action-oriented self-management goals for correcting problematic behaviors, with corresponding motivational messages. The validation of the knowledge base suggested high level of completeness and accuracy, and identified improvements in cultural appropriateness. These were addressed in new iterations of the knowledge base.

DISCUSSION

The resulting knowledge base is theoretically grounded, incorporates practical and evidence-based knowledge used by diabetes educators in practice settings, and allows for personally meaningful choices by individuals with diabetes. Participatory design approach helped researchers to capture implicit knowledge of practicing diabetes educators and make it explicit and reusable.

CONCLUSION

The knowledge base proposed here is an important step towards development of new generation patient-centric decision support tools for facilitating chronic disease self-management. While this knowledge base specifically targets diabetes, its overall structure and composition can be generalized to other chronic conditions.

Technology Use for Diabetes Problem Solving in Adolescents with Type 1 Diabetes: Relationship to Glycemic Control

BACKGROUND

This study examines technology use for problem solving in diabetes and its relationship to hemoglobin A1C (A1C).

SUBJECTS AND METHODS

A sample of 112 adolescents with type 1 diabetes completed measures assessing use of technologies for diabetes problem solving, including mobile applications, social technologies, and glucose software. Hierarchical regression was performed to identify the contribution of a new nine-item Technology Use for Problem Solving in Type 1 Diabetes (TUPS) scale to A1C, considering known clinical contributors to A1C.

RESULTS

Mean age for the sample was 14.5 (SD 1.7) years, mean A1C was 8.9% (SD 1.8%), 50% were female, and diabetes duration was 5.5 (SD 3.5) years. Cronbach's α reliability for TUPS was 0.78. In regression analyses, variables significantly associated with A1C were the socioeconomic status (β = -0.26, P < 0.01), Diabetes Adolescent Problem Solving Questionnaire (β = -0.26, P = 0.01), and TUPS (β = 0.26, P = 0.01). Aside from the Diabetes Self-Care Inventory--Revised, each block added significantly to the model R(2). The final model R(2) was 0.22 for modeling A1C (P < 0.001).

CONCLUSIONS

Results indicate a counterintuitive relationship between higher use of technologies for problem solving and higher A1C. Adolescents with poorer glycemic control may use technology in a reactive, as opposed to preventive, manner. Better understanding of the nature of technology use for self-management over time is needed to guide the development of technology-mediated problem solving tools for youth with type 1 diabetes.

DialBetics With a Multimedia Food Recording Tool, FoodLog: Smartphone-Based Self-Management for Type 2 Diabetes

BACKGROUND

Diabetes self-management education is an essential element of diabetes care. Systems based on information and communication technology (ICT) for supporting lifestyle modification and self-management of diabetes are promising tools for helping patients better cope with diabetes. An earlier study had determined that diet improved and HbA1c declined for the patients who had used DialBetics during a 3-month randomized clinical trial. The objective of the current study was to test a more patient-friendly version of DialBetics, whose development was based on the original participants' feedback about the previous version of DialBetics.

METHOD

DialBetics comprises 4 modules: data transmission, evaluation, exercise input, and food recording and dietary evaluation. Food recording uses a multimedia food record, FoodLog. A 1-week pilot study was designed to determine if usability and compliance improved over the previous version, especially with the new meal-input function.

RESULTS

In the earlier 3-month, diet-evaluation study, HbA1c had declined a significant 0.4% among those who used DialBetics compared with the control group. In the current 1-week study, input of meal photos was higher than with the previous version (84.8 ± 13.2% vs 77.1% ± 35.1% in the first 2 weeks of the 3-month trial). Interviews after the 1-week study showed that 4 of the 5 participants thought the meal-input function improved; the fifth found input easier, but did not consider the result an improvement.

CONCLUSIONS

DialBetics with FoodLog was shown to be an effective and convenient tool, its new meal-photo input function helping provide patients with real-time support for diet modification.

Diabetes Text-Message Self-Management Support Program (SMS4BG): A Pilot Study

Background

The increasing prevalence of diabetes and costly long-term complications associated with poor glycemic control are issues facing health services worldwide. Diabetes self-management, with the support of health care providers, is critical for successful outcomes, however, frequent clinical contact is costly. Text messages via short message service (SMS) have the advantage of instant transmission at low cost and, given the ubiquity of mobile phones, may be the ideal platform for the delivery of diabetes self-management support. A tailored text message-based diabetes support intervention called Self-Management Support for Blood Glucose (SMS4BG) was developed. The intervention incorporates prompts around diabetes education, management, and lifestyle factors (healthy eating, exercise, and stress management), as well as blood glucose monitoring reminders, and is tailored to patient preferences and clinical characteristics.

Objective

To determine the usability and acceptability of SMS4BG among adults with poorly controlled diabetes.

Methods

Adults (aged 17 to 69 years) with type 1 (n=12) or type 2 diabetes (n=30), a hemoglobin A1c (HbA1c) over 70 mmol/mol (8.6%), and who owned a mobile phone (n=42) were recruited to take part in a 3-month pilot study of SMS4BG. At registration, participants selected the modules they would like to receive and, where appropriate, the frequency and timing of blood glucose monitoring reminders. Patient satisfaction and perceptions of the usability of the program were obtained via semistructured phone interviews conducted at completion of the pilot study. HbA1c was obtained from patient records at baseline and completion of the pilot study.

Results

Participants received on average 109 messages during the 3-month program with 2 participants withdrawing early from the study. Follow-up interviews were completed with 93% of participants with all reporting SMS4BG to be useful and appropriate to their age and culture. Participants reported a range of perceived positive impacts of SMS4BG on their diabetes and health behaviors. HbA1c results indicated a positive impact of the program on glycemic control with a significant decrease in HbA1c from baseline to follow-up.

Conclusions

A tailored text message-based intervention is both acceptable and useful in supporting self-management in people with poorly controlled diabetes. A randomized controlled trial of longer duration is needed to assess the efficacy and sustainability of SMS4BG.