Factors affecting acceptability and usability of technological approaches to diabetes self-management: a case study

Usability and Quality Evaluation of the "E- Midwife" Mobile Application for Nurse-Midwives in Obstetric Complications: A Randomized Controlled Trial

Background

Obstetric complications are illnesses that develop during childbirth. Smartphones, which facilitate the use of prompt features in the early diagnosis of challenges and quick delivery of respectful maternity care, are one of the most recent advances in health technology. The key objective of this project is to evaluate the usability and quality of the "E-Midwife" mobile application for nurse-midwives, which focuses on obstetric complications.

Methods

This study is a component of a randomized controlled trial on nurse-midwives. This project followed a four-step approach: content development phase, app design phase, app development phase, and usability testing phase. The app was developed using extensive flowcharts, a definition of the navigational framework, a structured database, and user-friendly software. 140 out of the 196 nurse-midwives were allocated to the intervention (n=70) and control group (n=70), using random allocation. The intervention group used the application for 8 weeks. Usability and quality of the application were assessed using the system usability scale and the mobile application rating scale, respectively. SPSS statistical software, version 17, was used to analyze the dat.

Results

The overall score of the usability testing of E-Midwife was 82.75±0.68. The total mean score of quality was 3.77±0.86. Therefore, it was shown to have good usability and quality.

Conclusion

The E-midwife mobile application has a high usability and quality which makes its usage effective and efficient. It is recommended that these similar mobile apps should be used along with other educational methods for educating the nurse-midwives.Trial Registration Number: CTRI/2022/03/040857.

Digital Interventions Supporting Self-care in People With Type 2 Diabetes Across Greater Manchester (Greater Manchester Diabetes My Way): Protocol for a Mixed Methods Evaluation

BACKGROUND

Type 2 Diabetes (T2D) is common, with a prevalence of approximately 7% of the population in the United Kingdom. The quality of T2D care is inconsistent across the United Kingdom, and Greater Manchester (GM) does not currently achieve the National Institute for Health and Care Excellence treatment targets. Barriers to delivery of care include low attendance and poor engagement with local T2D interventions, which tend to consist of programs of education delivered in traditional, face-to-face clinical settings. Thus, a flexible approach to T2D management that is accessible to people from different backgrounds and communities is needed. Diabetes My Way (DMW) is a digital platform that offers a comprehensive self-management and educational program that should be accessible to a wide range of people through mobile apps and websites. Building on evidence generated by a Scotland-wide pilot study, DMW is being rolled out and tested across GM.

OBJECTIVE

The overarching objectives are to assess whether DMW improves outcomes for patients with T2D in the GM area, to explore the acceptability of the DMW intervention to stakeholders, and to assess the cost-effectiveness of the intervention.

METHODS

A mixed methods approach will be used. We will take a census approach to recruitment in that all eligible participants in GM will be invited to participate. The primary outcomes will be intervention-related changes compared with changes observed in a matched group of controls, and the secondary outcomes will be within-person intervention-related changes. The cost-effectiveness analysis will focus on obtaining reliable estimates of how each intervention affects risk factors such as HbA1c and costs across population groups. Qualitative data will be collected via semistructured interviews and focus groups and organized using template analysis.

RESULTS

As of May 10, 2021, a total of 316 participants have been recruited for the quantitative study and have successfully enrolled. A total of 278 participants attempted to register but did not have appropriate permissions set by the general practitioners to gain access to their data. In total, 10 participants have been recruited for the qualitative study (7 practitioners and 3 patients). An extension to recruitment has been granted for the quantitative element of the research, and analysis should be complete by December 2022. Recruitment and analysis for the qualitative study should be complete by December 2021.

CONCLUSIONS

The findings from this study can be used both to develop the DMW system and improve accessibility and usability in more deprived populations generally, thus improving equity in access to support for T2D self-management.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26237.

Developing and validating a new scale to measure the acceptability of health apps among adolescents

Background

The acceptability of health interventions is centrally important to achieving their desired health outcomes. The construct of acceptability of mobile health interventions among adolescents is neither well-defined nor consistently operationalized.

Objectives

Building on the theoretical framework of acceptability, these two studies developed and assessed the reliability and validity of a new scale to measure the acceptability of mobile health applications (“apps”) among adolescents.

Methods

We followed a structured scale development process including exploratory factor analyses (EFAs), confirmatory factor analyses (CFAs), and employed structural equation modeling (SEM) to assess the relationship between the scale and app usage. Adolescent participants used the Fooducate healthy eating app and completed the acceptability scale at baseline and one-week follow-up.

Results

EFA (n = 182) determined that the acceptability of health apps was a multidimensional construct with six latent factors: affective attitude, burden, ethicality, intervention coherence, perceived effectiveness, and self-efficacy. CFA (n = 161) from the second sample affirmed the six-factor structure and the unidimensional structures for each of the six subscales. However, CFA did not confirm the higher-order latent factor model suggesting that the six subscales reflect unique aspects of acceptability. SEM indicated that two of the subscales—ethicality and self-efficacy—were predictive of health app usage at one-week follow-up.

Conclusions

These results highlight the importance of ethicality and self-efficacy for health app acceptability. Future research testing and adapting this new acceptability scale will enhance measurement tools in the fields of mobile health and adolescent health.

Perceptions and Understanding of Diabetes Mellitus Technology in Adults with Type 1 or Type 2 DM: A Pilot Survey from Pakistan

INTRODUCTION

Diabetes mellitus technology (DMT) is increasingly used for routine management in developed countries, yet its uptake in developing countries is not as consistent. Multiple factors may influence this, including country specific patient perception regarding DMT. We conducted a pilot study in Pakistan to understand this important question which has not been studied yet.

METHODS

A cross-sectional pilot study was conducted in Pakistan. An anonymous survey exploring perceptions of diabetes technology was circulated on social media platforms, collecting responses over 2 weeks. Target population included adults (≥18 years) living in Pakistan, with DM1 or 2.

RESULTS

A total of 40 responses were received. The majority (36/40) reported using conventional glucometers. Nine used continuous glucose monitoring (CGM). Thirty-two of 40 patients believed DMT improved diabetes care, 22 felt it helped decreased risk of Diabetes-related complications. 15/40 stated that DMT results in increased cost of care. Sixteen reported their diabetes care teams had never discussed wearable DMT options whereas 11 disliked them because they did not want a device on their self.

CONCLUSION

In our pilot study we have identified broad themes of opportunity and challenges to DMT use in Pakistan. Patients' perceptions regarding DMT were generally positive but significant barriers to its acceptance included high cost, lack of discussion between doctor and patient about available technology and personal hesitation. Limitations of our study include sampling bias (online survey) and small sample size, but this data can help inform larger studies, to look at this important topic in greater detail.

Application of the National Institute for Health and Care Excellence Evidence Standards Framework for Digital Health Technologies in Assessing Mobile-Delivered Technologies for the Self-Management of Type 2 Diabetes Mellitus: Scoping Review

BACKGROUND

There is a growing role of digital health technologies (DHTs) in the management of chronic health conditions, specifically type 2 diabetes. It is increasingly important that health technologies meet the evidence standards for health care settings. In 2019, the National Institute for Health and Care Excellence (NICE) published the NICE Evidence Standards Framework for DHTs. This provides guidance for evaluating the effectiveness and economic value of DHTs in health care settings in the United Kingdom.

OBJECTIVE

The aim of this study is to assess whether scientific articles on DHTs for the self-management of type 2 diabetes mellitus report the evidence suggested for implementation in clinical practice, as described in the NICE Evidence Standards Framework for DHTs.

METHODS

We performed a scoping review of published articles and searched 5 databases to identify systematic reviews and primary studies of mobile device-delivered DHTs that provide self-management support for adults with type 2 diabetes mellitus. The evidence reported within articles was assessed against standards described in the NICE framework.

RESULTS

The database search yielded 715 systematic reviews, of which, 45 were relevant and together included 59 eligible primary studies. Within these, there were 39 unique technologies. Using the NICE framework, 13 technologies met best practice standards, 3 met minimum standards only, and 23 technologies did not meet minimum standards.

CONCLUSIONS

On the assessment of peer-reviewed publications, over half of the identified DHTs did not appear to meet the minimum evidence standards recommended by the NICE framework. The most common reasons for studies of DHTs not meeting these evidence standards included the absence of a comparator group, no previous justification of sample size, no measurable improvement in condition-related outcomes, and a lack of statistical data analysis. This report provides information that will enable researchers and digital health developers to address these limitations when designing, delivering, and reporting digital health technology research in the future.

Scoping Review of Healthcare Literature on Mobile, Wearable, and Textile Sensing Technology for Continuous Monitoring

Remote monitoring of health can reduce frequent hospitalisations, diminishing the burden on the healthcare system and cost to the community. Patient monitoring helps identify symptoms associated with diseases or disease-driven disorders, which makes it an essential element of medical diagnoses, clinical interventions, and rehabilitation treatments for severe medical conditions. This monitoring can be expensive and time-consuming and provide an incomplete picture of the state of the patient. In the last decade, there has been a significant increase in the adoption of mobile and wearable devices, along with the introduction of smart textile solutions that offer the possibility of continuous monitoring. These alternatives fuel a technology shift in healthcare, one that involves the continuous tracking and monitoring of individuals. This scoping review examines how mobile, wearable, and textile sensing technology have been permeating healthcare by offering alternate solutions to challenging issues, such as personalised prescriptions or home-based secondary prevention. To do so, we have selected 222 healthcare literature articles published from 2007 to 2019 and reviewed them following the PRISMA process under the schema of a scoping review framework. Overall, our findings show a recent increase in research on mobile sensing technology to address patient monitoring, reflected by 128 articles published in journals and 19 articles in conference proceedings between 2014 and 2019, which represents 57.65% and 8.55% respectively of all included articles.

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 Review of Technology-based Interventions in Improving Type 2 Diabetes Management in Chinese Americans

Health disparities of type 2 diabetes (DM2) in America is an ongoing crisis. Despite this, technology has been helpful in managing DM2 in the non-Hispanic White, Hispanic, and African American populations and has been proven effective. Furthermore, it may be used to supplement health provider DM2 care through telemedicine to lower hemoglobin A1c (A1c), a gold standard DM2 measurement, and other DM2-related outcomes, such as glycated hemoglobin. The purpose of this study was to review current literature on the use of telemedicine in assisting DM2 management in racial ethnic minorities and to discuss how to adjust the telemedicine DM2 management program to be applied to Chinese Americans. In addition, it is worthy to note that the role of nurses makes a substantial difference in the effectiveness of technological management of DM2 from being culturally sensitive and sending catered messages to address specific patient needs.

A multi-level usability evaluation of mobile health applications: A case study

OBJECTIVE

To report a methodological approach for the development of a usable mHealth application (app).

MATERIALS AND METHODS

This work was guided by a 3-level stratified view of health information technology (IT) usability evaluation framework. We first describe a number of methodologies for operationalizing each level of the framework. Following the description of each methodology, we present a case study which illustrates the use of our preferred methodologies for the development of a mHealth app. At level 1 (user-task), we applied a card sorting technique to guide the information architecture of a mobile HIV symptom self-management app, entitled mVIP. At level 2 (user-task-system), we conducted a usability evaluation of mVIP in a laboratory setting through end-user usability testing and heuristic evaluation with informatics experts. At level 3 (user-task-system-environment), usability of mVIP was evaluated in a real-world setting following the use of the app during a 3-month trial.

RESULTS

The 3-level usability evaluation guided our work exploring in-depth interactions between the user, task, system, and environment. Integral to the findings from the 3-level usability evaluation, we iteratively refined the app's content, functionality, and interface to meet the needs of our intended end-users.

DISCUSSION AND CONCLUSION

The stratified view of the health IT usability evaluation framework is a useful methodological approach for the design, development, and evaluation of mHealth apps. The methodological recommendations for using the theoretical framework can inform future usability studies of mHealth apps.

Sustainability of improvements in medication adherence through a mobile health intervention

Context-Very few patient-centered, theory-guided programs for medication adherence and blood pressure control have been conducted in kidney transplant recipients. Objective-To evaluate preliminary indications of sustainability of improved blood pressure in kidney transplant recipients 12 months after completion of a 3-month randomized controlled trial of a mobile health pilot program to improve blood pressure and medication adherence. Participants and Design-A total of 18 of the 19 trial participants were contacted and all consented to inclusion in the retrospective analysis of their medical records showing their clinic-recorded systolic blood pressures at 3, 6, and 12 months following participation in the 3-month trial of a medical regimen self-management intervention. Results-A significant group difference in systolic blood pressure was observed longitudinally, indicating that the intervention group, as compared with the standard-care group, exhibited lower clinic-measured systolic blood pressures at the 12-month posttrial follow-up visit (P= .01). At 12-month follow-up, success in establishing and sustaining control of systolic blood pressure (<131 mm Hg) was greater in the intervention group (50%) than in the control group (11%). Conclusion-Patients in the intervention group continued to exhibit lower systolic blood pressure than did patients in the control group 12 months after the trial ended, suggesting that the intervention may have a durable impact on blood pressure control that most likely reflects sustained medication adherence. These findings will aid in the development of an adequately powered randomized controlled trial to address the sustainable impact of the intervention program on medication adherence and blood pressure control.

Distal technologies and type 1 diabetes management

Type 1 diabetes requires intensive self-management to avoid acute and long-term health complications. In the past two decades, substantial advances in technology have enabled more effective and convenient self-management of type 1 diabetes. Although proximal technologies (eg, insulin pumps, continuous glucose monitors, closed-loop and artificial pancreas systems) have been the subject of frequent systematic and narrative reviews, distal technologies have received scant attention. Distal technologies refer to electronic systems designed to provide a service remotely and include heterogeneous systems such as telehealth, mobile health applications, game-based support, social platforms, and patient portals. In this Review, we summarise the empirical literature to provide current information about the effectiveness of available distal technologies to improve type 1 diabetes management. We also discuss privacy, ethics, and regulatory considerations, issues of global adoption, knowledge gaps in distal technology, and recommendations for future directions.

Towards Usable E-Health. A Systematic Review of Usability Questionnaires

BACKGROUND

The use of e-health can lead to several positive outcomes. However, the potential for e-health to improve healthcare is partially dependent on its ease of use. In order to determine the usability for any technology, rigorously developed and appropriate measures must be chosen.

OBJECTIVES

To identify psychometrically tested questionnaires that measure usability of e-health tools, and to appraise their generalizability, attributes coverage, and quality.

METHODS

We conducted a systematic review of studies that measured usability of e-health tools using four databases (Scopus, PubMed, CINAHL, and HAPI). Non-primary research, studies that did not report measures, studies with children or people with cognitive limitations, and studies about assistive devices or medical equipment were systematically excluded. Two authors independently extracted information including: questionnaire name, number of questions, scoring method, item generation, and psychometrics using a data extraction tool with pre-established categories and a quality appraisal scoring table.

RESULTS

Using a broad search strategy, 5,558 potentially relevant papers were identified. After removing duplicates and applying exclusion criteria, 35 articles remained that used 15 unique questionnaires. From the 15 questionnaires, only 5 were general enough to be used across studies. Usability attributes covered by the questionnaires were: learnability (15), efficiency (12), and satisfaction (11). Memorability (1) was the least covered attribute. Quality appraisal showed that face/content (14) and construct (7) validity were the most frequent types of validity assessed. All questionnaires reported reliability measurement. Some questionnaires scored low in the quality appraisal for the following reasons: limited validity testing (7), small sample size (3), no reporting of user centeredness (9) or feasibility estimates of time, effort, and expense (7).

CONCLUSIONS

Existing questionnaires provide a foundation for research on e-health usability. However, future research is needed to broaden the coverage of the usability attributes and psychometric properties of the available questionnaires.

Patients' Perceptions and Experiences of a mHealth Diabetes Self-management System

Chronic diseases, including diabetes, constitute a substantial disease burden around the world. Mobile self-management systems now play a significant and increasingly important role in patients' disease management. Yet, patients' perceptions of these systems after longer-term use are largely unexplored. A random sample of 10 diabetes patients was assessed immediately after they exited a larger, 6-month randomized controlled trial on the use of a mHealth system called Care4Life. This descriptive, exploratory study assessed patients' perceptions and experiences of mHealth using a questionnaire and semistructured interview whose development was guided by the Technology Acceptance Model. Results indicated that patients saw clear benefits in using the technology and had favorable behavioral disease outcomes after using Care4Life. Suggestions for improving the system were highly individual despite the apparent homogeneity of the patient group. The study begins to fill the gap about the longer-term use of mHealth systems in chronic disease management and reflects the significance of individual needs for mHealth systems.

A Systematic and Integrated Review of Mobile-Based Technology to Promote Active Lifestyles in People With Type 2 Diabetes

AIM

The aim was to review studies examining the effectiveness, acceptability, and feasibility of mobile-based technology for promoting active lifestyles in people with type 2 diabetes (T2D).

BACKGROUND

Benefits of leading an active lifestyle following a diagnosis of T2D, including improved glycemic control, have been reported. Studies examining the specific use of mobile-based technologies to promote an active lifestyle in T2D have not previously been reviewed.

METHODS

Research studies examining effectiveness, feasibility or acceptability of mobile-based technology for active lifestyle promotion for T2D management were included (n = 9). The databases searched included PubMed, Medline, ScienceDirect, and ACM Digital Library (January 2005 to October 2015). Studies were categorized as (1) informing, (2) monitoring, (3) provoking, or (4) sustaining behavior change.

RESULTS

Technologies used included smartphone or tablet apps, diabetes personal digital assistant, continuous glucose monitor and accelerometer, pedometer, and a website delivered by a smartphone. No articles examined the effectiveness of mobile-based technology in monitoring health behaviors and behavior change. Four of the studies found mobile-based technology to be motivational and supportive for behavior change. The visual reinforcement was identified as motivational. The feasibility and acceptability of using mobile-based technology to provide sustained lifestyle change and the effectiveness of mobile-based technology in monitoring health behaviors and behavior change have not been investigated. No studies examined all 3 of the outcomes or focused decreasing the participants' sedentary behavior.

CONCLUSIONS

Limited research has examined the feasibility, acceptability, and effectiveness of mobile-based technology to promote active lifestyles and subsequently good diabetes management in people with T2D.

Instrument for assessing mobile technology acceptability in diabetes self-management: a validation and reliability study

BACKGROUND

Nowadays, mobile technologies are part of everyday life, but the lack of instruments to assess their acceptability for the management of chronic diseases makes their actual adoption for this purpose slow.

OBJECTIVE

The objective of this study was to develop a survey instrument for assessing patients' attitude toward and intention to use mobile technology for diabetes mellitus (DM) self-management, as well as to identify sociodemographic characteristics and quality of life factors that affect them.

METHODS

We first conducted the documentation and instrument design phases, which were subsequently followed by the pilot study and instrument validation. Afterward, the instrument was administered 103 patients (median age: 37 years; range: 18-65 years) diagnosed with type 1 or type 2 DM, who accepted to participate in the study. The reliability and construct validity were assessed by computing Cronbach's alpha and using factor analysis, respectively.

RESULTS

The instrument included statements about the actual use of electronic devices for DM management, interaction between patient and physician, attitude toward using mobile technology, and quality of life evaluation. Cronbach's alpha was 0.9 for attitude toward using mobile technology and 0.97 for attitude toward using mobile device applications for DM self-management. Younger patients (Spearman's ρ=-0.429; P<0.001) with better glycemic control (Spearman's ρ=-0.322; P<0.001) and higher education level (Kendall's τ=0.51; P<0.001) had significantly more favorable attitude toward using mobile assistive applications for DM control. Moreover, patients with a higher quality of life presented a significantly more positive attitude toward using modern technology (Spearman's ρ=0.466; P<0.001).

CONCLUSION

The instrument showed good reliability and internal consistency, making it suitable for measuring the acceptability of mobile technology for DM self-management. Additionally, we found that even if most of the patients showed positive attitude toward mobile applications, only a moderate level of intention to indeed use them was observed. Moreover, the study indicated that barriers were truthfulness and easiness to use.

Content Analysis of Mobile Health Applications on Diabetes Mellitus

Diabetes self-management offers an opportunity to patients to be actively involved in managing their conditions and modifying lifestyle behaviors to attain positive health outcomes. With the unprecedented growth of mobile technology, smartphone plays a role in supporting diabetes self-management. Nonetheless, selecting appropriate mobile applications (apps) is challenging for patients. Thus, this study aimed to evaluate and compare the contents and features of mobile medical apps for diabetes self-management. Of 346 commercial apps, 16 (16%) and 19 (7.72%) of the diabetes apps found in Apple and Google Play stores, respectively, were included based on the selection criteria and individually scored for the availability of 8 main features of diabetes self-management. The apps supported self-management by offering features such as free installation, less than 50 MB space used, offline use, automated data entry, data export and sharing, educational tool, and advice. Of the 8 evaluated features, only 11 (31.4%) apps had a score of 5 whereas 7 (20%) apps scored the lowest, with a score of 3. The majority of apps were free, required no Internet connectivity to use and were less than 50 MB in size. Our findings showed that the design of diabetes mobile apps focused on reporting and setting reminders, rather than providing personalized education or therapeutic support. In the future, the design of apps could be improved to integrate patients' needs, usability for disease management, and lifestyle modifications.

Stroke patients and their attitudes toward mHealth monitoring to support blood pressure control and medication adherence

BACKGROUND

Mobile health, or mHealth, has increasingly been signaled as an effective means to expedite communication and improve medical regimen adherence, especially for patients with chronic health conditions such as stroke. However, there is a lack of data on attitudes of stroke patients toward mHealth. Such information will aid in identifying key indicators for feasibility and optimal implementation of mHealth to prevent and/or decrease rates of secondary stroke. Our objective was to ascertain stroke patients' attitudes toward using mobile phone enabled blood pressure (BP) monitoring and medication adherence and identify factors that modulate these attitudes.

METHODS

Sixty stroke patients received a brief demonstration of mHealth devices to assist with BP control and medication adherence and a survey to evaluate willingness to use this technology.

RESULTS

The 60 participants had a mean age of 57 years, were 43.3% male, and 53.3% were White. With respect to telecommunication prevalence, 93.3% owned a cellular device and 25% owned a smartphone. About 70% owned a working computer. Regarding attitudes, 85% felt comfortable with a doctor or nurse using mHealth technologies to monitor personal health information, 78.3% believed mHealth would help remind them to follow doctor's directions, and 83.3% were confident that technology could effectively be used to communicate with health care providers for medical needs.

CONCLUSIONS

Mobile device use is high in stroke patients and they are amenable to mHealth for communication and assistance in adhering to their medical regimens. More research is needed to explore usefulness of this technology in larger stroke populations.

Metabolic Diet App Suite for inborn errors of amino acid metabolism

BACKGROUND

An increasing number of rare inborn errors of metabolism (IEMs) are amenable to targeted metabolic nutrition therapy. Daily adherence is important to attain metabolic control and prevent organ damage. This is challenging however, given the lack of information of disorder specific nutrient content of foods, the limited availability and cost of specialty products as well as difficulties in reliable calculation and tracking of dietary intake and targets.

OBJECTIVES

To develop apps for all inborn errors of amino acid metabolism for which the mainstay of treatment is a medical diet, and obtain patient and family feedback throughout the process to incorporate this into subsequent versions.

METHODS & RESULTS

The Metabolic Diet App Suite was created with input from health care professionals as a free, user-friendly, online tool for both mobile devices and desktop computers (http://www.metabolicdietapp.org) for 15 different IEMs. General information is provided for each IEM with links to useful online resources. Nutrient information is based on the MetabolicPro™, a North American food database compiled by the Genetic Metabolic Dietitians International (GMDI) Technology committee. After user registration, a personalized dashboard and management plan including specific nutrient goals are created. Each Diet App has a user-friendly interface and the functions include: nutrient intake counts, adding your own foods and homemade recipes and, managing a daily food diary. Patient and family feedback was overall positive and specific suggestions were used to further improve the App Suite.

DISCUSSION

The Metabolic Diet App Suite aids individuals affected by IEMs to track and plan their meals. Future research should evaluate its impact on patient adherence, metabolic control, quality of life and health-related outcomes. The Suite will be updated and expanded to Apps for other categories of IEMs. Finally, this Suite is a support tool only, and does not replace medical/metabolic nutrition professional advice.

eHealth technologies to support nutrition and physical activity behaviors in diabetes self-management

Diabetes is a chronic, complex condition requiring sound knowledge and self-management skills to optimize glycemic control and health outcomes. Dietary intake and physical activity are key diabetes self-management (DSM) behaviors that require tailored education and support. Electronic health (eHealth) technologies have a demonstrated potential for assisting individuals with DSM behaviors. This review provides examples of technologies used to support nutrition and physical activity behaviors in the context of DSM. Technologies covered include those widely used for DSM, such as web-based programs and mobile phone and smartphone applications. In addition, examples of novel tools such as virtual and augmented reality, video games, computer vision for dietary carbohydrate monitoring, and wearable devices are provided. The challenges to, and facilitators for, the use of eHealth technologies in DSM are discussed. Strategies to support the implementation of eHealth technologies within practice and suggestions for future research to enhance nutrition and physical activity behaviors as a part of broader DSM are provided.

Factors influencing the adoption of self-management solutions: an interpretive synthesis of the literature on stakeholder experiences

Background

In a research context, self-management solutions, which may range from simple book diaries to complex telehealth packages, designed to facilitate patients in managing their long-term conditions, have often shown cost-effectiveness, but their implementation in practice has frequently been challenging.

Methods

We conducted an interpretive qualitative synthesis of relevant articles identified through systematic searches of bibliographic databases in July 2014. We searched PubMed (Medline/NLM), Web of Science, LISTA (EBSCO), CINAHL, Embase and PsycINFO. Coding and analysis was inductive, using the framework method to code and to categorise themes. We took a sensemaking approach to the interpretation of findings.

Results

Fifty-eight articles were selected for synthesis. Results showed that during adoption, factors identified as facilitators by some were experienced as barriers by others, and facilitators could change to barriers for the same adopter, depending on how adopters rationalise the solutions within their context when making decisions about (retaining) adoption. Sometimes, when adopters saw and experienced benefits of a solution, they continued using the solution but changed their minds when they could no longer see the benefits. Thus, adopters placed a positive value on the solution if they could constructively rationalise it (which increased adoption) and attached a negative rationale (decreasing adoption) if the solution did not meet their expectations. Key factors that influenced the way adopters rationalised the solutions consisted of costs and the added value of the solution to them and moral, social, motivational and cultural factors.

Conclusions

Considering ‘barriers’ and ‘facilitators’ for implementation may be too simplistic. Implementers could instead iteratively re-evaluate how potential facilitators and barriers are being experienced by adopters throughout the implementation process, to help adopters to retain constructive evaluations of the solution. Implementers need to pay attention to factors including (a) cost: how much resource will the intervention cost the patient or professional; (b) moral: to what extent will people adhere because they want to be ‘good’ patients and professionals; (c) social: the expectations of patients and professionals regarding the interactive support they will receive; (d) motivational: motivations to engage with the intervention and (e) cultural: how patients and professionals learn and integrate new skills into their daily routines, practices and cultures.

The Use of an Adapted Health IT Usability Evaluation Model (Health-ITUEM) for Evaluating Consumer Reported Ratings of Diabetes mHealth Applications: Implications for Diabetes Care and Management

Background:

The aim of this paper is to present a usability analysis of the consumer ratings of key diabetes mHealth applications using an adapted Health IT Usability Evaluation Model (Health-ITUEM).

Methods:

A qualitative content analysis method was used to analyze publicly available consumer reported data posted on the Android Market and Google Play for four leading diabetes mHealth applications. Health-ITUEM concepts including information needs, flexibility/customizability, learnability, performance speed, and competency guided the categorization and analysis of the data. Health impact was an additional category that was included in the study. A total of 405 consumers’ ratings collected from January 9, 2014 to February 17, 2014 were included in the study.

Results:

Overall, the consumers’ ratings of the leading diabetes mHealth applications for both usability and health impacts were positive. The performance speed of the mHealth application and the information needs of the consumers were the primary usability factors impacting the use of the diabetes mHealth applications. There was also evidence on the positive health impacts of such applications.

Conclusions:

Consumers are more likely to use diabetes related mHealth applications that perform well and meet their information needs. Furthermore, there is preliminary evidence that diabetes mHealth applications can have positive impact on the health of patients.

A Mobile Health Intervention for Self-Management and Lifestyle Change for Persons With Type 2 Diabetes, Part 2: One-Year Results From the Norwegian Randomized Controlled Trial RENEWING HEALTH

Background

Self-management is crucial in the daily management of type 2 diabetes. It has been suggested that mHealth may be an important method for enhancing self-management when delivered in combination with health counseling.

Objective

The objective of this study was to test whether the use of a mobile phone–based self-management system used for 1 year, with or without telephone health counseling by a diabetes specialist nurse for the first 4 months, could improve glycated hemoglobin A_1c (HbA_1c) level, self-management, and health-related quality of life compared with usual care.

Methods

We conducted a 3-arm prospective randomized controlled trial involving 2 intervention groups and 1 control group. Eligible participants were persons with type 2 diabetes with an HbA_1c level ≥7.1% (≥54.1 mmol/mol) and aged ≥18 years. Both intervention groups received the mobile phone–based self-management system Few Touch Application (FTA). The FTA consisted of a blood glucose–measuring system with automatic wireless data transfer, diet manual, physical activity registration, and management of personal goals, all recorded and operated using a diabetes diary app on the mobile phone. In addition, one intervention group received health counseling based on behavior change theory and delivered by a diabetes specialist nurse for the first 4 months after randomization. All groups received usual care by their general practitioner. The primary outcome was HbA_1c level. Secondary outcomes were self-management (heiQ), health-related quality of life (SF-36), depressive symptoms (CES-D), and lifestyle changes (dietary habits and physical activity). Data were analyzed using univariate methods (t test, ANOVA) and multivariate linear and logistic regression.

Results

A total of 151 participants were randomized: 51 to the FTA group, 50 to the FTA-health counseling (FTA-HC) group, and 50 to the control group. Follow-up data after 1 year were available for 120 participants (79%). HbA_1c level decreased in all groups, but did not differ between groups after 1 year. The mean change in the heiQ domain skills and technique acquisition was significantly greater in the FTA-HC group after adjusting for age, gender, and education (P=.04). Other secondary outcomes did not differ between groups after 1 year. In the FTA group, 39% were substantial users of the app; 34% of the FTA-HC group were substantial users. Those aged ≥63 years used the app more than their younger counterparts did (OR 2.7; 95% CI 1.02-7.12; P=.045).

Conclusions

The change in HbA_1c level did not differ between groups after the 1-year intervention. Secondary outcomes did not differ between groups except for an increase in the self-management domain of skill and technique acquisition in the FTA-HC group. Older participants used the app more than the younger participants did.

Are patients with diabetes mellitus satisfied with technologies used to assist with diabetes management and coping?: A structured review

Modern technological devices supporting coping and management for patients with diabetes are increasingly popular and could be important healthcare tools. This review aimed to evaluate patient satisfaction and perceptions regarding these devices, examples of which include short message service reminder systems, online educational programs, and clinician-patient electronic communication. Therapy devices such as continuous glucose monitors and continuous subcutaneous insulin infusion pumps are not included in this review. Embase, Psychinfo, Medline, CINAHL, and gray literature databases were searched for "diabetes mellitus," "technical device," "patient satisfaction," and their synonyms. This review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. The search produced 1,902 studies, 26 of which were included in the review: type 1 diabetes mellitus (eight studies), type 2 diabetes mellitus (nine studies), and both (nine studies). High satisfaction was seen with almost all devices and correlated strongly with ease of use and improved diabetes management. Satisfaction was not affected by participant age, and the effect of diabetes type was not assessed. Web devices were reported as easiest to use. Increased support was valued and resulted from devices facilitating interaction with healthcare professionals (HCPs) or peers. Technical difficulties were barriers to both use and satisfaction. Overall, patients enjoyed supplementing their usual therapy with these devices. Perceived support from HCPs or peers formed an important aspect of patient satisfaction and should be considered for future interventions.

Getting a technology-based diabetes intervention ready for prime time: a review of usability testing studies

Consumer health technologies can educate patients about diabetes and support their self-management, yet usability evidence is rarely published even though it determines patient engagement, optimal benefit of any intervention, and an understanding of generalizability. Therefore, we conducted a narrative review of peer-reviewed articles published from 2009 to 2013 that tested the usability of a web- or mobile-delivered system/application designed to educate and support patients with diabetes. Overall, the 23 papers included in our review used mixed (n = 11), descriptive quantitative (n = 9), and qualitative methods (n = 3) to assess usability, such as documenting which features performed as intended and how patients rated their experiences. More sophisticated usability evaluations combined several complementary approaches to elucidate more aspects of functionality. Future work pertaining to the design and evaluation of technology-delivered diabetes education/support interventions should aim to standardize the usability testing processes and publish usability findings to inform interpretation of why an intervention succeeded or failed and for whom.

Predictors of eHealth usage: insights on the digital divide from the Health Information National Trends Survey 2012

Background

Recent eHealth developments have elevated the importance of assessing the extent to which technology has empowered patients and improved health, particularly among the most vulnerable populations. With noted disparities across racial and social groups in chronic health outcomes, such as cancer, obesity, and diabetes, it is essential that researchers examine any differences in the implementation, uptake, and impact of eHealth strategies across groups that bear a disproportionate burden of disease.

Objective

The goal was to examine eHealth use by sociodemographic factors, such as race/ethnicity, socioeconomic status (SES), age, and sex.

Methods

We drew data from National Cancer Institute’s 2012 Health Information National Trends Survey (HINTS) (N=3959) which is publicly available online. We estimated multivariable logistic regression models to assess sociodemographic predictors of eHealth use among adult Internet users (N=2358) across 3 health communication domains (health care, health information–seeking, and user-generated content/sharing).

Results

Among online adults, we saw no evidence of a digital use divide by race/ethnicity. However, there were significant differences in use by SES, particularly for health care and health information–seeking items. Patients with lower levels of education had significantly lower odds of going online to look for a health care provider (high school or less: OR 0.50, 95% CI 0.33-0.76) using email or the Internet to communicate with a doctor (high school or less: OR 0.46, 95% CI 0.29-0.72), tracking their personal health information online (high school or less: OR 0.53, 95% CI 0.32-0.84), using a website to help track diet, weight, and physical activity (high school or less: OR 0.64, 95% CI 0.42-0.98; some college: OR 0.67, 95% CI 0.49-0.93), or downloading health information to a mobile device (some college: OR 0.54, 95% CI 0.33-0.89). Being female was a consistent predictor of eHealth use across health care and user-generated content/sharing domains, whereas age was primarily influential for health information–seeking.

Conclusions

This study illustrates that lower SES, older, and male online US adults were less likely to engage in a number of eHealth activities compared to their counterparts. Future studies should assess issues of health literacy and eHealth literacy and their influence on eHealth engagement across social groups. Clinical care and public health communication efforts attempting to leverage Web 2.0 and 3.0 platforms should acknowledge differential eHealth usage to better address communication inequalities and persistent disparities in health.

Can chronic disease management programs for patients with type 2 diabetes reduce productivity-related indirect costs of the disease? Evidence from a randomized controlled trial

The objective was to assess the impacts of diabetes self-management programs on productivity-related indirect costs of the disease. Using an employer's perspective, this study estimated the productivity losses associated with: (1) employee absence on the job, (2) diabetes-related disability, (3) employee presence on the job, and (4) early mortality. Data were obtained from electronic medical records and survey responses of 376 adults aged ≥18 years who were enrolled in a randomized controlled trial of type 2 diabetes self-management programs. All study participants had uncontrolled diabetes and were randomized into one of 4 study arms: personal digital assistant (PDA), chronic disease self-management program (CDSMP), combined PDA and CDSMP, and usual care (UC). The human-capital approach was used to estimate lost productivity resulting from 1, 2, 3, and 4 above, which are summed to obtain total productivity loss. Using robust regression, total productivity loss was modeled as a function of the diabetes self-management programs and other identified demographic and clinical characteristics. Compared to subjects in the UC arm, there were no statistically significant differences in productivity losses among persons undergoing any of the 3 diabetes management interventions. Males were associated with higher productivity losses (+$708/year; P<0.001) and persons with greater than high school education were associated with additional productivity losses (+$758/year; P<0.001). Persons with more than 1 comorbid condition were marginally associated with lower productivity losses (-$326/year; P=0.055). No evidence was found that the chronic disease management programs examined in this trial affect indirect productivity losses.

Effects of diabetes self-management programs on time-to-hospitalization among patients with type 2 diabetes: a survival analysis model

OBJECTIVE

This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization.

METHODS

Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization.

RESULTS

Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm.

CONCLUSION

CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM.

PRACTICE IMPLICATIONS

Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients.

Behavioral and technological interventions targeting glycemic control in a racially/ethnically diverse population: a randomized controlled trial

BACKGROUND

Diabetes self-care by patients has been shown to assist in the reduction of disease severity and associated medical costs. We compared the effectiveness of two different diabetes self-care interventions on glycemic control in a racially/ethnically diverse population. We also explored whether reductions in glycated hemoglobin (HbA1c) will be more marked in minority persons.

METHODS

We conducted an open-label randomized controlled trial of 376 patients with type 2 diabetes aged ≥18 years and whose last measured HbA1c was ≥7.5% (≥58 mmol/mol). Participants were randomized to: 1) a Chronic Disease Self-Management Program (CDSMP; n = 101); 2) a diabetes self-care software on a personal digital assistant (PDA; n = 81); 3) a combination of interventions (CDSMP + PDA; n = 99); or 4) usual care (control; n = 95). Enrollment occurred January 2009-June 2011 at seven regional clinics of a university-affiliated multi-specialty group practice. The primary outcome was change in HbA1c from randomization to 12 months. Data were analyzed using a multilevel statistical model.

RESULTS

Average baseline HbA1c in the CDSMP, PDA, CDSMP + PDA, and control arms were 9.4%, 9.3%, 9.2%, and 9.2%, respectively. HbA1c reductions at 12 months for the groups averaged 1.1%, 0.7%, 1.1%, and 0.7%, respectively and did not differ significantly from baseline based on the model (P = .771). Besides the participants in the PDA group reporting eating more high-fat foods compared to their counterparts (P < .004), no other significant differences were observed in participants' diabetes self-care activities. Exploratory sub-analysis did not reveal any marked reductions in HbA1c for minority persons but rather modest reductions for all racial/ethnic groups.

CONCLUSIONS

Although behavioral and technological interventions can result in some modest improvements in glycemic control, these interventions did not fare significantly better than usual care in achieving glycemic control. More research is needed to understand how these interventions can be most effective in clinical practice. The reduction in HbA1c levels found in our control group that received usual care also suggests that good routine care in an integrated healthcare system can lead to better glycemic control.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01221090.

Mobile Health Medication Adherence and Blood Pressure Control in Renal Transplant Recipients: A Proof-of-Concept Randomized Controlled Trial

Background

Mobile phone based programs for kidney transplant recipients are promising tools for improving long-term graft outcomes and better managing comorbidities (eg, hypertension, diabetes). These tools provide an easy to use self-management framework allowing optimal medication adherence that is guided by the patients’ physiological data. This technology is also relatively inexpensive, has an intuitive interface, and provides the capability for real-time personalized feedback to help motivate patient self-efficacy. Automated summary reports of patients’ adherence and blood pressure can easily be uploaded to providers’ networks helping reduce clinical inertia by reducing regimen alteration time.

Objective

The aim of this study was to assess the feasibility, acceptability, and preliminary outcomes of a prototype mobile health (mHealth) medication and blood pressure (BP) self-management system for kidney transplant patients with uncontrolled hypertension.

Methods

A smartphone enabled medication adherence and BP self-management system was developed using a patient and provider centered design. The development framework utilized self-determination theory with iterative stages that were guided and refined based on patient/provider feedback. A 3-month proof-of-concept randomized controlled trial was conducted in 20 hypertensive kidney transplant patients identified as non-adherent to their current medication regimen based on a month long screening using an electronic medication tray. Participants randomized to the mHealth intervention had the reminder functions of their electronic medication tray enabled and received a bluetooth capable BP monitor and a smartphone that received and transmitted encrypted physiological data and delivered reminders to measure BP using text messaging. Controls received standard of care and their adherence continued to be monitored with the medication tray reminders turned off. Providers received weekly summary reports of patient medication adherence and BP readings.

Results

Participation and retention rates were 41/55 (75%) and 31/34 (91%), respectively. The prototype system appears to be safe, highly acceptable, and useful to patients and providers. Compared to the standard care control group (SC), the mHealth intervention group exhibited significant improvements in medication adherence and significant reductions in clinic-measured systolic blood pressures across the monthly evaluations. Physicians made more anti-hypertensive medication adjustments in the mHealth group versus the standard care group (7 adjustments in 5 patients versus 3 adjustments in 3 patients) during the 3-month trial based on the information provided in the weekly reports.

Conclusions

These data support the acceptability and feasibility of the prototype mHealth system. Further trials with larger sample sizes and additional biomarkers (eg, whole blood medication levels) are needed to examine efficacy and effectiveness of the system for improving medication adherence and blood pressure control after kidney transplantation over longer time periods.

Trial Registration

Clinicaltrials.gov NCT01859273; http://clinicaltrials.gov/ct2/show/NCT01859273 (Archived by WebCite at http://www.webcitation.org/6IqfCa3A3).

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.

Patient attitudes toward mobile phone-based health monitoring: questionnaire study among kidney transplant recipients

Background

Mobile phone based remote monitoring of medication adherence and physiological parameters has the potential of improving long-term graft outcomes in the recipients of kidney transplants. This technology is promising as it is relatively inexpensive, can include intuitive software and may offer the ability to conduct close patient monitoring in a non-intrusive manner. This includes the optimal management of comorbidities such as hypertension and diabetes. There is, however, a lack of data assessing the attitudes of renal transplant recipients toward this technology, especially among ethnic minorities.

Objective

To assess the attitudes of renal transplant recipients toward mobile phone based remote monitoring and management of their medical regimen; and to identify demographic or clinical characteristics that impact on this attitude.

Methods

After a 10 minute demonstration of a prototype mobile phone based monitoring system, a 10 item questionnaire regarding attitude toward remote monitoring and the technology was administered to the participants, along with the 10 item Perceived Stress Scale and the 7 item Morisky Medication Adherence Scale.

Results

Between February and April 2012, a total of 99 renal transplant recipients were identified and agreed to participate in the survey. The results of the survey indicate that while 90% (87/97) of respondents own a mobile phone, only 7% (7/98) had any prior knowledge of mobile phone based remote monitoring. Despite this, the majority of respondents, 79% (78/99), reported a positive attitude toward the use of a prototype system if it came at no cost to themselves. Blacks were more likely than whites to own smartphones (43.1%, 28/65 vs 20.6%, 7/34; P=.03) and held a more positive attitude toward free use of the prototype system than whites (4.25±0.88 vs 3.76±1.07; P=.02).

Conclusions

The data demonstrates that kidney transplant recipients have a positive overall attitude toward mobile phone based health technology (mHealth). Additionally, the data demonstrates that most kidney transplant recipients own and are comfortable using mobile phones and that many of these patients already own and use smart mobile phones. The respondents felt that mHealth offers an opportunity for improved self-efficacy and improved provider driven medical management. Respondents were comfortable with the idea of being monitored using mobile technology and are confident that their privacy can be protected. The small subset of kidney transplant recipients who are less interested in mHealth may be less technologically adept as reflected by their lower mobile phone ownership rates. As a whole, kidney transplant recipients are receptive to the technology and believe in its utility.