Improving diabetes management with mobile health technology

"Internet+Nursing Service" Mobile Apps in China App Stores: Functionality and Quality Assessment Study

Background

As the Chinese society ages and the concern for health and quality of life grows, the demand for care services in China is increasing. The widespread use of internet technology has greatly improved the convenience and efficiency of web-based services. As a result, the Chinese government has been implementing "Internet+Nursing Services" since 2019, with mobile apps being the primary tools for users to access these services. The quality of these apps is closely related to user experience and the smooth use of services.

Objective

This study aims to evaluate the functionality, services, and quality of "Internet+Nursing Service" apps; identify weaknesses; and provide suggestions for improving service programs and the research, development, improvement, and maintenance of similar apps.

Methods

In December 2022, two researchers searched for "Internet+Nursing Service" apps by applying the search criteria on the Kuchuan mobile app monitoring platform. After identifying the apps to be included based on ranking criteria, they collected information such as the app developer, app size, version number, number of downloads, user ratings, and number and names of services. Afterward, 5 trained researchers independently evaluated the quality of the apps by using the Chinese version of the user version of the Mobile App Rating Scale (uMARS-C). The total uMARS-C score was based on the average of the five evaluators' ratings.

Results

A total of 17 "Internet+Nursing Service" apps were included. Among these, 12 (71%) had been downloaded more than 10,000 times, 11 (65%) had user ratings of 4 or higher, the median app size was 62.67 (range 22.71-103; IQR 37.51-73.47) MB, 16 (94%) apps provided surgical wound dressing change services, 4 (24%) covered first-tier cities, and only 1 (6%) covered fourth-tier cities. The median total uMARS-C score was 3.88 (range 1.92-4.92; IQR 3.71-4.05), which did not correlate with app store user ratings (r=0.003; P=.99). The quality of most apps (11/17, 65%) was average. Most apps (12/17, 71%) were rated as "good" or above (≥4 points) in terms of information quality, layout, graphics, performance, and ease of use; however, the vast majority of apps were rated as "fair" or even "poor" (<4 points) in terms of credibility (14/17, 82%) and demand (16/17, 94%).

Conclusions

"Internet+Nursing Service" apps need to broaden their service coverage, increase service variety, and further optimize their service structure. The overall quality of these apps is generally poor. App developers should collaborate with medical professionals and communicate with target users before launching their products to ensure accurate content, complete functionality, and good operation that meets user needs.

Dominican Adolescents' Preferences for Content, Design, and Functionality of a Mobile Application for Type 1 Diabetes Mellitus Self-management

OBJECTIVE

The purpose of this interdisciplinary study was to determine Dominican adolescents' preferences for the content, functionality (i.e. food's glycemic index list, and amount of insulin based on foods' carbohydrate count), and design of a culturally and linguistically relevant mobile application (app) for type 1 diabetes mellitus (T1DM) self-management. The app would facilitate T1DM self-management education and support by addressing providers' challenges in monitoring patients' disease progression and promoting patient adherence to recommended lifestyle changes. Findings inform an app development process that considers the linguistic and cultural values, norms, and structures of people with T1DM and their providers in the Dominican Republic.

METHODS

Phone interviews were conducted with 23 adolescents (14 to 18 years of age), using a semistructured questionnaire. The research team conducted the data analysis using NVivo through a deductive and inductive approach.

RESULTS

The findings suggest that, regardless of the context, adolescents with T1DM desire similar features and functionalities in a self-management app. Overall, participants preferred an app with a graphic format that has accessible information, a straightforward design, and instructional videos. Participants also desired that an app provide information and reminders about proper eating and insulin administration timing and be a vehicle to access a social network to foster mutual support and encouragement.

CONCLUSIONS

Our study highlights adolescents' perspectives on components for inclusion in an app for T1DM self-management. Participants' recommendations for the app's potential usability, contents, and design features will be used to guide the development of a new app to promote engagement and foster better health outcomes.

Using a Hybrid Neural Network and a Regularized Extreme Learning Machine for Human Activity Recognition with Smartphone and Smartwatch

Mobile health (mHealth) utilizes mobile devices, mobile communication techniques, and the Internet of Things (IoT) to improve not only traditional telemedicine and monitoring and alerting systems, but also fitness and medical information awareness in daily life. In the last decade, human activity recognition (HAR) has been extensively studied because of the strong correlation between people's activities and their physical and mental health. HAR can also be used to care for elderly people in their daily lives. This study proposes an HAR system for classifying 18 types of physical activity using data from sensors embedded in smartphones and smartwatches. The recognition process consists of two parts: feature extraction and HAR. To extract features, a hybrid structure consisting of a convolutional neural network (CNN) and a bidirectional gated recurrent unit GRU (BiGRU) was used. For activity recognition, a single-hidden-layer feedforward neural network (SLFN) with a regularized extreme machine learning (RELM) algorithm was used. The experimental results show an average precision of 98.3%, recall of 98.4%, an F₁-score of 98.4%, and accuracy of 98.3%, which results are superior to those of existing schemes.

Role of Internet of things in diabetes healthcare: Network infrastructure, taxonomy, challenges, and security model

The Internet of things (IoT) is an emerging technology that enables ubiquitous devices to connect with the Internet. IoT technology has revolutionized the medical and healthcare industry by interconnecting smart devices and sensors. IoT-based devices and biosensors are ideal to detect diabetes disease by collecting the accurate value of glucose continuously. Diabetes is one of the well-known and major chronic diseases that has a worldwide social impact on community life. Blood glucose monitoring is a challenging task, and there is a need to propose a proper architecture of the noninvasive glucose sensing and monitoring mechanism, which could make diabetic people aware of self-management techniques. This survey presents a rigorous discussion of diabetes types and presents detection techniques based on IoT technology. In this research, an IoT-based healthcare network infrastructure has been proposed for monitoring diabetes disease based on big data analytics, cloud computing, and machine learning. The proposed infrastructure could handle the symptoms of diabetes, collect data, analyze it, and then transmit the results to the server for the next action. Besides, presented an inclusive survey on IoT-based diabetes monitoring applications, services, and proposed solutions. Furthermore, based on IoT technology the diabetes disease management taxonomy has also been presented. Finally, presented the attacks taxonomy as well as discussed challenges, and proposed a lightweight security model in order to secure the patient's health data.

Effectiveness of Smartphone-Based Lifestyle Interventions on Women with Gestational Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Gestational diabetes mellitus (GDM) is a condition that causes poor glucose tolerance during pregnancy and usually resolves after birth. Having GDM impacts the mother and baby. Smartphone-based lifestyle interventions may offer innovative solutions.

Aim

To examine the effects of smartphone-based lifestyle interventions on compliance, Hemoglobin A1c (HbA1c), maternal outcomes, infant outcomes, psychological status, satisfaction, and cost effectiveness among women with GDM.

Methods

Randomized controlled trials (RCTs) of smartphone-based lifestyle interventions for women with GDM aged over 18 years were included. A systematic search of PubMed, Embase, Web of Science, CINAHL, and Cochrane Library for articles published from January 2007 to March 2022 and updated on 12 October 2022. Data were extracted independently by two researchers, and the risk of bias in individual trials was rated using the Cochrane risk-of-bias tool (RoB 2). Meta-analysis was conducted by using RevMan 5.3.

Results

Ten studies were included involving 1626 participants. The mean ages of the women were 32.42 ±4.68 years. Eight out of 10 studies were conducted in developed countries. Meta-analysis found that smartphone-based lifestyle interventions statistically improved compliance [SMD = 7.36, 95% CI = (4.05 to 10.68), P < 0.0001] and decreased the incidences of neonatal intensive care unit (NICU) admission [RR = 0.64, 95% CI = (0.47,0.86), P = 0.003], compared with controls. However, intervention effects on HbA1c, maternal outcomes, neonatal hypoglycemia, and infant birth weight were non significant. Moreover, the satisfaction of intervention is high in this review. Contrastingly, no significant effects were observed for psychological status and cost-effectiveness.

Conclusion

Smartphone-based lifestyle interventions may improve patient compliance and reduce NICU admissions. These findings may aid in developing future intervention strategies, help elucidate future research directions, and guide clinical practice for women with GDM. Future high-quality RCTs must be further studied at larger scales to examine smartphone-based lifestyle interventions' long-term effects and cost-effectiveness.

Artificial Intelligence-Based Teleopthalmology Application for Diagnosis of Diabetics Retinopathy

Diabetic Retinopathy (DR) is one of the leading causes of blindness for people who have diabetes in the world. However, early detection of this disease can essentially decrease its effects on the patient. The recent breakthroughs in technologies, including the use of smart health systems based on Artificial intelligence, IoT and Blockchain are trying to improve the early diagnosis and treatment of diabetic retinopathy. In this study, we presented an AI-based smart teleopthalmology application for diagnosis of diabetic retinopathy. The app has the ability to facilitate the analyses of eye fundus images via deep learning from the Kaggle database using Tensor Flow mathematical library. The app would be useful in promoting mHealth and timely treatment of diabetic retinopathy by clinicians. With the AI-based application presented in this paper, patients can easily get supports and physicians and researchers can also mine or predict data on diabetic retinopathy and reports generated could assist doctors to determine the level of severity of the disease among the people.

Development and implementation of an interprofessional digital platform to increase therapeutic adherence: a mixed design (Preprint)

Background

Adherence to care plans is a major issue in health care systems. Improved adherence has several potential benefits such as ensuring treatment effectiveness and control of chronic diseases. There is currently a lack of tools to maximize treatment adherence in an integrated manner, that is, covering multiple aspects of patients’ health continuously throughout their medical care. To ensure better adherence, such tools must meet the needs of patients with chronic conditions as well as those of health care professionals. Acknowledging the health issues associated with nonadherence to treatment, an industry-research-clinical partnership aims to adapt a digital platform—facilitating patient-health care professional interactions—to improve therapeutic adherence in patients with chronic illnesses. The platform allows for exchanges between patients and health care professionals to facilitate the timing of medication use or chronic disease management and maximize patient adherence.

Objective

This study aims to (1) identify the needs of patients living with a chronic condition and their health professionals concerning their interactions regarding treatment; (2) codevelop an adaptation of an interactive patient-professional platform that meets the needs identified; and (3) then test the platform and document its effects and acceptability in a clinical setting.

Methods

The study will use a creative design thinking process based on the needs expressed by users (patients and health professionals) concerning treatment adherence for chronic diseases (eg, diabetes, asthma, high blood pressure, depression and anxiety, chronic obstructive pulmonary disease). A mixed method evaluation research design will be used to develop and evaluate the platform. Qualitative data will be used to assess user needs and acceptability of the platform, and quantitative data will provide the necessary insights to document its effects.

Results

Technological development of the platform has been completed. Recruitment for the first part of Phase 1 started in May 2022. The results of this project to codevelop an interprofessional digital platform to increase therapeutic adherence will be relevant to clinicians and managers seeking contemporary solutions that support patient adherence to treatment for chronic diseases. These results will enable optimal use of the platform and identify areas for improvement in interactive patient-health care professional apps.

Conclusions

The adoption of an interactive digital platform to facilitate effective exchanges between patients and health care professionals in primary care settings could improve adherence to treatment. The platform tested in this project takes a first step in this direction by ensuring that the technological product is developed according to the needs of patients as well as the health professionals who are likely to use it.

International Registered Report Identifier (IRRID)

DERR1-10.2196/34463

Towards Developing a Voice-activated Self-monitoring Application (VoiS) for Adults with Diabetes and Hypertension

The integration of motivational strategies and self-management theory with mHealth tools is a promising approach to changing the behavior of patients with chronic disease. In this manuscript, we describe the development and current architecture of a prototype voice-activated self-monitoring application (VoiS) which is based on these theories. Unlike prior mHealth applications which require textual input, VoiS app relies on the more convenient and adaptable approach of asking users to verbally input markers of diabetes and hypertension control through a smart speaker. The VoiS app can provide real-time feedback based on these markers; thus, it has the potential to serve as a remote, regular, source of feedback to support behavior change. To enhance the usability and acceptability of the VoiS application, we will ask a diverse group of patients to use it in real-world settings and provide feedback on their experience. We will use this feedback to optimize tool performance, so that it can provide patients with an improved understanding of their chronic conditions. The VoiS app can also facilitate remote sharing of chronic disease control with healthcare providers, which can improve clinical efficacy and reduce the urgency and frequency of clinical care encounters. Because the VoiS app will be configured for use with multiple platforms, it will be more robust than existing systems with respect to user accessibility and acceptability.

Deep learning in multimedia healthcare applications: a review

The increase in chronic diseases has affected the countries' health system and economy. With the recent COVID-19 virus, humanity has experienced a great challenge, which has led to make efforts to detect it and prevent its spread. Hence, it is necessary to develop new solutions that are based on technology and low cost, to satisfy the citizens' needs. Deep learning techniques is a technological solution that has been used in healthcare lately. Nowadays, with the increase in chips processing capabilities, increase size of data, and the progress in deep learning research, healthcare applications have been proposed to provide citizens' health needs. In addition, a big amount of data is generated every day. Development in Internet of Things, gadgets, and phones has allowed the access to multimedia data. Data such as images, video, audio and text are used as input of applications based on deep learning methods to support healthcare system to diagnose, predict, or treat patients. This review pretends to give an overview of proposed healthcare solutions based on deep learning techniques using multimedia data. We show the use of deep learning in healthcare, explain the different types of multimedia data, show some relevant deep learning multimedia applications in healthcare, and highlight some challenges in this research area.

Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review

BACKGROUND

Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities.

OBJECTIVE

This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities.

METHODS

A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study.

RESULTS

PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information.

CONCLUSIONS

Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.

A Novel Mobile Health App to Educate and Empower Young People With Type 1 Diabetes to Exercise Safely: Prospective Single-Arm Mixed Methods Pilot Study

BACKGROUND

Empowering young people with type 1 diabetes (T1D) to manage their blood glucose levels during exercise is a complex challenge faced by health care professionals due to the unpredictable nature of exercise and its effect on blood glucose levels. Mobile health (mHealth) apps would be useful as a decision-support aid to effectively contextualize a blood glucose result and take appropriate action to optimize glucose levels during and after exercise. A novel mHealth app acT1ve was recently developed, based on expert consensus exercise guidelines, to provide real-time support for young people with T1D during exercise.

OBJECTIVE

Our aim was to pilot acT1ve in a free-living setting to assess its acceptability and functionality, and gather feedback on the user experience before testing it in a larger clinical trial.

METHODS

A prospective single-arm mixed method design was used. Ten participants with T1D (mean age 17.7 years, SD 4.2 years; mean HbA_1c, 54 mmol/mol, SD 5.5 mmol/mol [7.1%, SD 0.5%]) had acT1ve installed on their phones, and were asked to use the app to guide their exercise management for 6 weeks. At the end of 6 weeks, participants completed both a semistructured interview and the user Mobile Application Rating Scale (uMARS). All semistructured interviews were transcribed. Thematic analysis was conducted whereby interview transcripts were independently analyzed by 2 researchers to uncover important and relevant themes. The uMARS was scored for 4 quality subscales (engagement, functionality, esthetics, and information), and a total quality score was obtained from the weighted average of the 4 subscales. Scores for the 4 objective subscales were determined by the mean score of each of its individual questions. The perceived impact and subjective quality of acT1ve for each participant were calculated by averaging the scores of their related questions, but were not considered in the total quality score. All scores have a maximal possible value of 5, and they are presented as medians, IQRs, and ranges.

RESULTS

The main themes arising from the interview analysis were "increased knowledge," "increased confidence to exercise," and "suitability" for people who were less engaged in exercise. The uMARS scores for acT1ve were high (out of 5) for its total quality (median 4.3, IQR 4.2-4.6), engagement (median 3.9, IQR 3.6-4.2), functionality (median 4.8, IQR 4.5-4.8), information (median 4.6, IQR 4.5-4.8), esthetics (median 4.3, IQR 4.0-4.7), subjective quality (median 4.0, IQR 3.8-4.2), and perceived impact (median 4.3, IQR 3.6-4.5).

CONCLUSIONS

The acT1ve app is functional and acceptable, with a high user satisfaction. The efficacy and safety of this app will be tested in a randomized controlled trial in the next phase of this study.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001414101; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378373.

Perceptions of Using Multiple Mobile Health Devices to Support Self-Management Among Adults With Type 2 Diabetes: A Qualitative Descriptive Study

PURPOSE

This study identified facilitators and barriers pertaining to the use of multiple mobile health (mHealth) devices (Fitbit Alta® fitness tracker, iHealth® glucometer, BodyTrace® scale) that support self-management behaviors in individuals with type 2 diabetes mellitus (T2DM).

DESIGN

This qualitative descriptive study presents study participants' perceptions of using multiple mobile devices to support T2DM self-management. Additionally, this study assessed whether participants found visualizations, generated from each participant's health data as obtained from the three separate devices, useful and easy to interpret.

METHODS

Semistructured interviews were completed with a convenience sample of participants (n = 20) from a larger randomized control trial on T2DM self-management. Interview questions focused on participants' use of three devices to support T2DM self-management. A study team member created data visualizations of each interview participant's health data using RStudio.

RESULTS

We identified two themes from descriptions of study participants: feasibility and usability. We identified one theme about visualizations created from data obtained from the mobile devices. Despite some challenges, individuals with T2DM found it feasible to use multiple mobile devices to facilitate engagement in T2DM self-management behaviors.

DISCUSSION

As mHealth devices become increasingly popular for diabetes self-management and are integrated into care delivery, we must address issues associated with the use of multiple mHealth devices and the use of aggregate data to support T2DM self-management.

CLINICAL RELEVANCE

Real-time patient-generated health data that are easily accessible and readily available can assist T2DM self-management and catalyze conversations, leading to better self-management. Our findings lay an important groundwork for understanding how individuals with T2DM can use multiple mHealth devices simultaneously to support self-management.

Digital Interventions for Psychological Comorbidities in Chronic Diseases-A Systematic Review

Chronic diseases represent one of the main causes of death worldwide. The integration of digital solutions in clinical interventions is broadly diffused today; however, evidence on their efficacy in addressing psychological comorbidities of chronic diseases is sparse. This systematic review analyzes and synthesizes the evidence about the efficacy of digital interventions on psychological comorbidities outcomes of specific chronic diseases. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of PubMed, PsycInfo, Scopus and Web of Science databases was conducted. Only Randomized Controlled Trials (RCTs) were considered and either depression or anxiety had to be assessed to match the selection criteria. Of the 7636 identified records, 17 matched the inclusion criteria: 9 digital interventions on diabetes, 4 on cardiovascular diseases, 3 on Chronic Obstructive Pulmonary Disease (COPD) and one on stroke. Of the 17 studies reviewed, 14 found digital interventions to be effective. Quantitative synthesis highlighted a moderate and significant overall effect of interventions on depression, while the effect on anxiety was small and non-significant. Design elements making digital interventions effective for psychological comorbidities of chronic diseases were singled out: (a) implementing a communication loop with patients and (b) providing disease-specific digital contents. This focus on “how” to design technologies can facilitate the translation of evidence into practice.

Evaluating the Impact of Mobile Phone Technology on Health Outcomes for Latinos with Type 2 Diabetes

OBJECTIVES

To assess whether a Spanish-language text messaging program helps Latinos with diabetes better manage their disease.

METHODS

Spanish-speaking Latinos with type 2 diabetes and HbA1c ≥ 8% (N = 38) were recruited January 1, 2016-May 31, 2016, at a large integrated healthcare delivery system. Participants received 1-3 Spanish-language text messages about diabetes self-care per day for 3 months with an optional 3-month extension. The Wilcoxon signed-rank test for paired data was used to compare pre-post intervention HbA1c. The Wilcoxon-Mann-Whitney nonparametric test was used to compare changes in HbA1c across groups.

RESULTS

After 3 months, the median HbA1c reduction overall was 1.4 percentage points (IQR: 0.5-3.3, p < 0.01). Latinos having pre-intervention HbA1c > 10.0% had a greater reduction in median HbA1c (3.8, IQR: 0.5-5.3) compared with those having pre-intervention HbA1c ≤ 10.0% (0.9, IQR: 0.1-1.9, p < 0.05). This reduction in median HbA1c persisted after 6 months (1.3, IQR: 0.2-2.9, p < 0.01).

CONCLUSION

A Spanish-language text messaging program was an effective way to improve glycemic control for Latinos with type 2 diabetes.

POLICY IMPLICATIONS

Culturally and linguistically tailored text messaging programs for managing diabetes should be considered.

Mobile Phone-Based Behavioral Interventions in Pregnancy to Promote Maternal and Fetal Health in High-Income Countries: Systematic Review

Background

Chronic diseases have recently had an increasing effect on maternal-fetal health, especially in high-income countries. However, there remains a lack of discussion regarding health management with technological approaches, including mobile health (mHealth) interventions.

Objective

This study aimed to systematically evaluate mHealth interventions used in pregnancy in high-income countries and their effects on maternal health behaviors and maternal-fetal health outcomes.

Methods

This systematic review identified studies published between January 1, 2000, and November 30, 2018, in MEDLINE via PubMed, Cochrane Library, EMBASE, CINAHL, PsycINFO, Web of Science, and gray literature. Studies were eligible for inclusion if they included only pregnant women in high-income countries and evaluated stand-alone mobile phone interventions intended to promote healthy maternal beliefs, behaviors, and/or maternal-fetal health outcomes. Two researchers independently reviewed and categorized aspects of full-text articles, including source, study design, intervention and control, duration, participant age, attrition rate, main outcomes, and risk of bias. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and the study was registered in PROSPERO before initiation.

Results

Of the 2225 records examined, 28 studies were included and categorized into 4 themes: (1) gestational weight gain, obesity and physical activity (n=9); (2) smoking cessation (n=9); (3) influenza vaccination (n=2); and (4) general prenatal health, preventive strategies, and miscellaneous topics (n=8). Reported sample sizes ranged from 16 to 5243 with a median of 91. Most studies were performed in the United States (18/28, 64%) and were randomized controlled trials (21/28, 75%). All participants in the included studies were pregnant at the time of study initiation. Overall, 14% (4/28) of studies showed association between intervention use and improved health outcomes; all 4 studies focused on healthy gestational weight. Among those, 3 studies showed intervention use was associated with less overall gestational weight gain. These 3 studies involved interventions with text messaging or an app in combination with another communication strategy (Facebook or email). Regarding smoking cessation, influenza vaccination, and miscellaneous topics, there was some evidence of positive effects on health behaviors and beliefs, but very limited correlation with improved health outcomes. Data and interventions were heterogeneous, precluding a meta-analysis.

Conclusions

In high-income countries, utilization of mobile phone–based health behavior interventions in pregnancy demonstrates some correlation with positive beliefs, behaviors, and health outcomes. More effective interventions are multimodal in terms of features and tend to focus on healthy gestational weight gain.

Wave of Wearables: Clinical Management of Patients and the Future of Connected Medicine

The future of connected health care will involve the collection of patient data or enhancement of clinician workflows through various biosensors and displays found on wearable electronic devices, many of which are marketed directly to consumers. The adoption of wearables in health care is being driven by efforts to reduce health care costs, improve care quality, and increase clinician efficiency. Wearables have significant potential to achieve these goals but are currently limited by lack of widespread integrations into electronic health records, biosensor data collection types, and a lack of scientifically rigorous literature showing benefit.

Nutrition-Related Mobile Apps in the China App Store: Assessment of Functionality and Quality

BACKGROUND

There are an increasing number of mobile apps that provide dietary guidance to support a healthy lifestyle and disease management. However, the characteristics of these nutrition-related apps are not well analyzed.

OBJECTIVE

This study aimed to evaluate the functionality and quality of nutrition-related apps in China.

METHODS

Mobile apps providing dietary guidance were screened in the Chinese iOS and Android app stores in November 2017, using stepwise searching criteria. The first screening consisted of extracting information from the app descriptions. Apps that (1) were free, (2) contain information on diet and nutrition, and (3) were last updated after January 1, 2016, were downloaded for further analysis. Nutritional functionalities were determined according to the Chinese Dietary Guidelines framework. Market-related functionalities were developed from previous studies and tailored to downloaded apps. The quality of apps was assessed with the user version of the Mobile App Rating Scale (uMARS).

RESULTS

Out of 628 dietary guidance apps screened, 44 were nutrition-related. Of these, guidance was provided on diet exclusively (11/44, 25%), fitness (17/44, 39%), disease management (11/44, 25%), or maternal health (5/44, 11%). Nutritional functionalities included nutritional information inquiry (40/44, 91%), nutrition education (35/44, 80%), food record (34/44, 77%), diet analysis (34/44, 77%), and personalized recipes (21/44, 48%). Dietary analysis and suggestions mainly focused on energy intake (33/44, 75%) and less on other factors such as dietary structure (10/44, 23%). Social communication functionalities were available in 42 apps (96%), user incentives were supported in 26 apps (59%), and intelligent recognition technology was available in 8 apps (18%). The median score for the quality of the 44 apps, as determined on a 5-point uMARS scale, was 3.6 (interquartile range 0.7).

CONCLUSIONS

Most nutrition-related apps are developed for health management rather than for dietary guidance exclusively. Although basic principles of energy balance are used, their nutritional functionality was relatively limited and not individualized. More efforts should be made to develop nutrition-related apps with evidence-based nutritional knowledge, comprehensive and personalized dietary guidance, and innovative technology.

Effect of mobile learning (application) on self-care behaviors and blood glucose of type 2 diabetic patients

Purpose

More than 70% of the health expenditure is related to chronic diseases. Therefore, an efficient managerial program can markedly reduce medical and administrative costs and benefit both patients and service providers. The use of mobile technologies can be very helpful in this regard. This study was conducted to determine the effect of mobile learning (application) on self-care behaviors and blood glucose control of type 2 diabetic patients attending the Diabetes Clinic of Imam Khomeini Hospital Complex.

Methods

This interventional, quasi-experimental study was conducted on 51 diabetic patients. The patients were randomly assigned to case and control groups, and a specifically designed application was used in the case group for three months. Self-care behavior, FBS, and HbA₁C were assessed in both groups before and three months after the intervention, and the results were analyzed after the intervention. The Summary of Diabetes Self-Care Activities (SDSCA) measure and medical records was used for data collection. Descriptive and inferential statics (paired t test, ANCOVA analysis) were used for data analysis.

Results

The Mean ± SD of the self-care posttest score, FBS, and HbA₁C was 76.95 ± 7.94 vs. 43.4 ± 9.74 (P = 0.001), 143.58 ± 23.39 vs. 171.81 ± 36.98 (P = 0.001), and 6.84 ± 0.63 vs. 8.10 ± 0.10 (P = 0,001), in the case and control group respectively, indicating a difference in all cases.

Conclusions

The results indicated the positive effect of the mobile application on self-care behavior, FBS, and HbA₁C.

Promoting Relational Agent for Health Behavior Change in Low and Middle - Income Countries (LMICs): Issues and Approaches

The use of contemporary technologies in healthcare systems to improve quality of care and to promote behavioral healthcare outcomes are prevalent in high-income countries. However, low and middle-income countries (LMICs) are not receiving the same advantages of technology, which may be due to inadequate technological infrastructure and financial resources, lack of interest among policy makers and healthcare service providers, lack of skills and capacity among healthcare professionals in using technology based interventions, and resistance of the public to the use of technologies for healthcare or health promotion activities. Technology-based interventions offer considerable promise to develop entirely new models of healthcare both within and outside of formal systems of care and offer the opportunity to have a large public health impact. Such technology-based interventions could be used to address targeted global health problems in LMICs, including the chronic non-communicable diseases (NCDs) - a growing health system burden in LMICs. Major preventable behavioral risk factors of chronic NCDs are increasing in LMICs, and innovative interventions are essential to address these risk factors. Computer-based or mobile-based virtual coaches or Relational Agents (RAs) are increasingly being explored for counseling patients to change their health behavior in high-income countries; however, the use of RAs in LMICs has not been studied. In this paper, we summarize the growing application of RA technology in behavior change interventions in high-income countries and describe the potential of its use in LMICs. Finally, we review the potential barriers and challenges in promoting RAs in LMICs.

Defining Adherence to Mobile Dietary Self-Monitoring and Assessing Tracking Over Time: Tracking at Least Two Eating Occasions per Day Is Best Marker of Adherence within Two Different Mobile Health Randomized Weight Loss Interventions

BACKGROUND

Mobile dietary self-monitoring methods allow for objective assessment of adherence to self-monitoring; however, the best way to define self-monitoring adherence is not known.

OBJECTIVE

The objective was to identify the best criteria for defining adherence to dietary self-monitoring with mobile devices when predicting weight loss.

DESIGN

This was a secondary data analysis from two 6-month randomized trials: Dietary Intervention to Enhance Tracking with Mobile Devices (n=42 calorie tracking app or n=39 wearable Bite Counter device) and Self-Monitoring Assessment in Real Time (n=20 kcal tracking app or n=23 photo meal app).

PARTICIPANTS/SETTING

Adults (n=124; mean body mass index=34.7±5.6) participated in one of two remotely delivered weight-loss interventions at a southeastern university between 2015 and 2017.

INTERVENTION

All participants received the same behavioral weight loss information via twice-weekly podcasts. Participants were randomly assigned to a specific diet tracking method.

MAIN OUTCOME MEASURES

Seven methods of tracking adherence to self-monitoring (eg, number of days tracked, and number of eating occasions tracked) were examined, as was weight loss at 6 months.

STATISTICAL ANALYSES PERFORMED

Linear regression models estimated the strength of association (R²) between each method of tracking adherence and weight loss, adjusting for age and sex.

RESULTS

Among all study completers combined (N=91), adherence defined as the overall number of days participants tracked at least two eating occasions explained the most variance in weight loss at 6 months (R²=0.27; P<0.001). Self-monitoring declined over time; all examined adherence methods had fewer than half the sample still tracking after Week 10.

CONCLUSIONS

Using the total number of days at least two eating occasions are tracked using a mobile self-monitoring method may be the best way to assess self-monitoring adherence during weight loss interventions. This study shows that self-monitoring rates decline quickly and elucidates potential times for early interventions to stop the reductions in self-monitoring.

A mobile health monitoring-and-treatment system based on integration of the SSN sensor ontology and the HL7 FHIR standard

BACKGROUND

Mobile health (MH) technologies including clinical decision support systems (CDSS) provide an efficient method for patient monitoring and treatment. A mobile CDSS is based on real-time sensor data and historical electronic health record (EHR) data. Raw sensor data have no semantics of their own; therefore, a computer system cannot interpret these data automatically. In addition, the interoperability of sensor data and EHR medical data is a challenge. EHR data collected from distributed systems have different structures, semantics, and coding mechanisms. As a result, building a transparent CDSS that can work as a portable plug-and-play component in any existing EHR ecosystem requires a careful design process. Ontology and medical standards support the construction of semantically intelligent CDSSs.

METHODS

This paper proposes a comprehensive MH framework with an integrated CDSS capability. This cloud-based system monitors and manages type 1 diabetes mellitus. The efficiency of any CDSS depends mainly on the quality of its knowledge and its semantic interoperability with different data sources. To this end, this paper concentrates on constructing a semantic CDSS based on proposed FASTO ontology.

RESULTS

This realistic ontology is able to collect, formalize, integrate, analyze, and manipulate all types of patient data. It provides patients with complete, personalized, and medically intuitive care plans, including insulin regimens, diets, exercises, and education sub-plans. These plans are based on the complete patient profile. In addition, the proposed CDSS provides real-time patient monitoring based on vital signs collected from patients' wireless body area networks. These monitoring include real-time insulin adjustments, mealtime carbohydrate calculations, and exercise recommendations. FASTO integrates the well-known standards of HL7 fast healthcare interoperability resources (FHIR), semantic sensor network (SSN) ontology, basic formal ontology (BFO) 2.0, and clinical practice guidelines. The current version of FASTO includes 9577 classes, 658 object properties, 164 data properties, 460 individuals, and 140 SWRL rules. FASTO is publicly available through the National Center for Biomedical Ontology BioPortal at https://bioportal.bioontology.org/ontologies/FASTO .

CONCLUSIONS

The resulting CDSS system can help physicians to monitor more patients efficiently and accurately. In addition, patients in rural areas can depend on the system to manage their diabetes and emergencies.

Effect of Health Information Technologies on Cardiovascular Risk Factors among Patients with Diabetes

PURPOSE OF REVIEW

To identify a common effect of health information technologies (HIT) on the management of cardiovascular disease (CVD) risk factors among people with type 2 diabetes (T2D) across randomized control trials (RCT).

RECENT FINDINGS

CVD is the most frequent cause of morbidity and mortality among patients with diabetes. HIT are effective in reducing HbA1c; however, their effect on cardiovascular risk factor management for patients with T2D has not been evaluated. We identified 21 eligible studies (23 estimates) with measurement of SBP, 20 (22 estimates) of DBP, 14 (17 estimates) of HDL, 14 (17 estimates) of LDL, 15 (18 estimates) of triglycerides, and 10 (12 estimates) of weight across databases. We found significant reductions in SBP, DBP, LDL, and TG, and a significant improvement in HDL associated with HIT. As adjuvants to standard diabetic treatment, HIT can be effective tools for improving CVD risk factors among patients with T2D, especially in those whose CVD risk factors are not at goal.

The Changing Paradigm of Health and Mobile Phones

This article describes how widespread adoption of mobile technology in healthcare is an innovation that is inevitable today in both developed and emerging markets around the world. Mobile health services (m-Health) act as an effective, accessible and affordable means of providing healthcare knowledge to users directly from providers. Despite such benefits of m-Health services, rapid adoption is not yet occurring, particularly in emerging markets. The main barrier is mostly the cynical behavior of users regarding this medium of healthcare services. The aim of this article is to examine underlying factors that can influence future use intentions of m-Health services. Conceptual model of the study identifies service qualities like reliability, privacy, responsiveness, empathy and information quality along with facilitating conditions, trust, effort expectancy and performance expectancy as significant constructs that influences users' overall perceptions of m-Health services, along with moderating effects of age and gender. Limitations and implications for practice and research are also discussed.

Uncovering the invisible patient work system through a case study of breast cancer self-management

As patients transition from passive recipients to actors in their health management, there is an opportunity to enhance theoretical frameworks describing the patient work system. Previous macroergonomic frameworks depict how patients manage health outside the institutional healthcare system, though none formally integrate the concept of invisible work - self-management practices undervalued or unseen by healthcare providers. This article overlays invisible work onto the patient work system through a case study of breast cancer self-management. Thirty breast cancer survivors were interviewed about positive and negative experiences post-diagnosis. Invisible and visible components of participants' work systems were explicated through qualitative content analysis. The results demonstrate that all participants had invisible work system components, and based on these findings, this article theorises the existence of an 'invisible patient work system.' Future research and design to support self-management practices should explicitly address the invisible characteristics of the work systems in which patients are embedded.Practitioner Summary: This article seeks to enhance the healthcare human factors literature by integrating the concept of invisible work into preexisting patient work system models. Through a secondary analysis of an interview study with 30 breast cancer survivors, we found that all participants recalled invisible components of their respective work systems. Abbreviations CHIT Consumer Health Information Technology SEIPS Systems Engineering Initiative for Patient Safety IRB Institutional Review Board SES Socioeconomic Status mHealth Mobile Health PHR Patient Health Record ICAN Instrument for Patient Capacity Assessment HIPAA Health Insurance Portability and Accoutability Act.

Effectiveness of SMS Technology on Timely Community Health Worker Follow-Up for Childhood Malnutrition: A Retrospective Cohort Study in sub-Saharan Africa

BACKGROUND

The Millennium Villages Project facilitated technology-based health interventions in rural under-resourced areas of sub-Saharan Africa. Our study examined whether data entry using SMS compared with paper forms by community health workers (CHWs) led to higher proportion of timely follow-up visits for malnutrition screening in under-5 children in Ghana, Rwanda, Senegal, and Uganda.

METHODS

Children under 5 years were screened for malnutrition every 90 days by CHWs using mid-upper arm circumference (MUAC) readings. CHWs used either SMS texts or paper forms to enter MUAC data. Reminder texts were sent at 15 days before follow-up was needed. Chi-square tests assessed proportion of timely follow-up visits within 90 days between SMS and paper groups. Logistic regression analysis was conducted in a step-wise multivariate model. Post-hoc power calculations were conducted to verify strength of associations.

RESULTS

SMS data entry was associated with a higher proportion of timely malnutrition follow-up visits compared with paper forms across all sites. The association was strongest with consistent SMS use over consecutive visits. SMS use at the first of 2 consecutive visits was most effective, highlighting the importance of SMS reminder alerts.

CONCLUSIONS

SMS technology with reminders increased timely CHW malnutrition screening visits for under-5 children in Ghana, Rwanda, Senegal, and Uganda, highlighting the importance of such technology for improving health worker behavior in low-resource settings.

The Health-e Babies App for antenatal education: Feasibility for socially disadvantaged women

Background

The use of mobile technology such as phone applications (apps) has been proposed as an efficient means of providing health and clinical information in a variety of healthcare settings. We developed the Health-e Babies app as an Android smart phone application for pregnant women attending a tertiary hospital in a low socio-economic community, with the objective of providing health information about early pregnancy that would increase maternal confidence and reduce anxiety. Based on our earlier research, this form of health communication was viewed as a preferred source of information for women of reproductive age. However, the pilot study had a poor participation rate with 76% (n = 94) not completing the study requirements. These initial findings raised some very important issues in relation to the difficulties of engaging women with a pregnancy app. This paper analyses the characteristics of the participants who did not complete the study requirements in an attempt to identify potential barriers associated with the implementation of a pregnancy app.

Methods

This retrospective review of quantitative and qualitative data collected at the commencement of the Health-e Babies App trial, related to the participant’s communication technology use, confidence in knowing where to seek help and mental health status, maternal-fetal attachment and parenting confidence. Engagement and use of the Health-e Babies App was measured by the completion of a questionnaire about the app and downloaded data from participant’s phones. Mental health status, confidence and self-efficacy were measured by questionnaires.

Results

All women were similar in terms of age, race, marital status and level of education. Of the 94 women (76%) who did not complete the trial, they were significantly more anxious as indicated by State Trait Anxiety Inventory (p = 0.001 Student T-test) and more likely to be unemployed (50% vs 31%, p = 0.012 Student T-Test).

Conclusion

This study provides important information about the challenges associated with the implementation of a pregnancy app in a socially disadvantaged community. The data suggests that factors including social and mental health issues, financial constraints and technological ability can affect women’s engagement with a mobile phone app.

Readmissions Among Sepsis Survivors: Risk Factors and Prevention

Hospital readmissions are common and result in increased mortality and cost while reducing quality of life. Readmission rates have been subjected to increasing scrutiny in recent years as part of a larger effort to improve the quality and value of healthcare in the United States. Emerging evidence suggests that sepsis survivors are at high risk for hospital readmission and experience readmission rates comparable to survivors of congestive heart failure, acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease, diseases whose readmission rates determine reimbursement penalties from the federal government. In this article, we review the unique challenges that sepsis survivors face as well as the patient-level and hospital-level risk factors that are known to be associated with hospital readmission after sepsis survival. Additionally, we identify the causes and outcomes of readmissions in this population before concluding with a discussion of readmission prevention strategies and future directions.

How can clinical practices pragmatically increase physical activity for patients with type 2 diabetes? A systematic review

Although regular physical activity (PA) is a cornerstone of treatment for type 2 diabetes (T2D), most adults with T2D are sedentary. Randomized controlled trials (RCTs) have proven the effectiveness of PA behavioral interventions for adults with T2D but have rarely been conducted in healthcare settings. We sought to identify PA interventions that are effective and practical to implement in clinical practice settings. Our first aim was to use the valid Pragmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool to assess the potential for future implementation of PA interventions in clinical practice settings. Our second aim was to identify interventions that effectively increased PA and glycemic control among the interventions in the top tertile of PRECIS-2 scores. We searched PubMed MEDLINE from January 1980 through May 2015 for RCTs of behavioral PA interventions coordinated by clinical practices for patients with T2D. Dual investigators assessed pragmatism by PRECIS-2 scores, and study effectiveness was extracted from original RCT publications. The PRECIS-2 scores of the 46 behavioral interventions (n = 13,575 participants) ranged from 3.0 to 4.8, where 5 is the most pragmatic score. In the most pragmatic tertile of interventions (n = 16) by PRECIS-2 scores, 30.8 and 31.3% of interventions improved PA outcomes and hemoglobin A1c, respectively. A minority of published evidence-based PA interventions for adults with T2D were both effective and pragmatic for clinical implementation. These should be tested for dissemination using implementation trial designs.

Exploring the Use of Personal Technology in Type 2 Diabetes Management Among Ethnic Minority Patients: Cross-Sectional Analysis of Survey Data from the Lifestyle Intervention for the Treatment of Diabetes Study (LIFT Diabetes)

Background

Minority populations have higher morbidity from chronic diseases and typically experience worse health outcomes. Internet technology may afford a low-cost method of ongoing chronic disease management to promote improved health outcomes among minority populations.

Objective

The objective of our study was to assess the feasibility of capitalizing on the pervasive use of technology as a secondary means of delivering diabetic counseling though an investigation of correlates to technology use within the context of an ongoing diabetes intervention study.

Methods

The Lifestyle Intervention for the Treatment of Diabetes study (LIFT Diabetes) randomly assigned 260 overweight and obese adults with type 2 diabetes mellitus to 2 intervention arms. At baseline, we administered a survey evaluating access to and use of various technologies and analyzed the responses using descriptive statistics and logistic regression.

Results

The sample population had a mean age of 56 (SD 11) years; 67.3% (175/260) were female and 54.6% (n=142) self-identified as being from ethnic minority groups (n=125, 88.0% black; n=6, 4.3% Hispanic; and n=11, 7.7% other). Minority participants had higher baseline mean body mass index (P=.002) and hemoglobin A_1c levels (P=.003). Minority participants were less likely to have a home computer (106/142, 74.7% vs 110/118, 93.2%; P<.001) and less likely to have email access at home (P=.03). Ownership of a home computer was correlated to higher income (P<.001), higher educational attainment (P<.001), full-time employment (P=.01), and ownership of a smartphone (P=.001). Willingness to complete questionnaires online was correlated to higher income (P=.001), higher education (P<.001), full-time employment (P=.01), and home access to a computer, internet, and smartphone (P≤.05). Racial disparities in having a home computer persisted after controlling for demographic variables and owning a smartphone (adjusted OR 0.26, 95% CI 0.10-0.67; P=.01). Willingness to complete questionnaires online was driven by ownership of a home computer (adjusted OR 3.87, 95% CI 1.14-13.2; P=.03).

Conclusions

Adults who self-identified as being part of a minority group were more likely to report limited access to technology than were white adults. As ownership of a home computer is central to a willingness to use online tools, racial disparities in access may limit the potential of Web-based interventions to reach this population.

Trial Registration

ClinicalTrials.gov NCT01806727; https://clinicaltrials.gov/ct2/show/NCT01806727 (Archived by WebCite at http://www.webcitation.org/6xOq2b7Tv)

Effective behavioral intervention strategies using mobile health applications for chronic disease management: a systematic review

Background

Mobile health (mHealth) has continuously been used as a method in behavioral research to improve self-management in patients with chronic diseases. However, the evidence of its effectiveness in chronic disease management in the adult population is still lacking. We conducted a systematic review to examine the effectiveness of mHealth interventions on process measures as well as health outcomes in randomized controlled trials (RCTs) to improve chronic disease management.

Methods

Relevant randomized controlled studies that were published between January 2005 and March 2016 were searched in six databases: PubMed, CINAHL, EMBASE, the Cochrane Library, PsycINFO, and Web of Science. The inclusion criteria were RCTs that conducted an intervention using mobile devices such as smartphones or tablets for adult patients with chronic diseases to examine disease management or health promotion.

Results

Of the 12 RCTs reviewed, 10 of the mHealth interventions demonstrated statistically significant improvement in some health outcomes. The most common features of mHealth systems used in the reviewed RCTs were real-time or regular basis symptom assessments, pre-programed reminders, or feedbacks tailored specifically to the data provided by participants via mHealth devices. Most studies developed their own mHealth systems including mobile apps. Training of mHealth systems was provided to participants in person or through paper-based instructions. None of the studies reported the relationship between health outcomes and patient engagement levels on the mHealth system.

Conclusions

Findings from mHealth intervention studies for chronic disease management have shown promising aspects, particularly in improving self-management and some health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0591-0) contains supplementary material, which is available to authorized users.

Conceptual Framework for Developing a Diabetes Information Network

Objective:

To provide a conceptual framework for managing diabetic patient care, and creating an information network for clinical research.

Background:

A wide range of information technology (IT) based interventions such as distance learning, diabetes registries, personal or electronic health record systems, clinical information systems, and clinical decision support systems have so far been used in supporting diabetic care. Previous studies demonstrated that IT could improve diabetes care at its different aspects. There is however no comprehensive conceptual framework that defines how different IT applications can support diverse aspects of this care. Therefore, a conceptual framework that combines different IT solutions into a wide information network for improving care processes and for research purposes is widely lacking. In this study we describe the theoretical underpin of a big project aiming at building a wide diabetic information network namely DIANET.

Research design and methods:

A literature review and a survey of national programs and existing regulations for diabetes management was conducted in order to define different aspects of diabetic care that should be supported by IT solutions. Both qualitative and quantitative research methods were used in this study. In addition to the results of a previous systematic literature review, two brainstorming and three expert panel sessions were conducted to identify requirements of a comprehensive information technology solution. Based on these inputs, the requirements for creating a diabetes information network were identified and used to create a questionnaire based on 9-point Likert scale. The questionnaire was finalized after removing some items based on calculated content validity ratio and content validity index coefficients. Cronbach’s alpha reliability coefficient was also calculated (αTotal= 0.98, P<0.05, CI=0.95). The final questionnaire was containing 45 items. It was sent to 13 clinicians at two diabetes clinics of endocrine and metabolism research institute in order to assess the necessity level of the requirements for diabetes information network conceptual framework. The questionnaires were returned by 10 clinicians. Each requirement item was labeled as essential, semi-essential, or non-essential based on the mean of its scores.

Results:

All requirement items were identified as essential or semi-essential. Thus, all of them were used to build the conceptual framework. The requirements were allocated into 11 groups each one representing a module in the conceptual framework. Each module was described separately.

Conclusion:

We proposed a conceptual framework for supporting diabetes care and research. Integrating different and heterogeneous clinical information systems of healthcare facilities and creating a comprehensive diabetics data warehouse for research purposes, would be possible by using the DIANET framework.

What do we know about mobile applications for diabetes self-management? A review of reviews

Diabetes is a chronic illness with significant health consequences, especially for those who are unable to adhere to the complex treatment regimen. Self-management tasks such as regular medication and insulin use, frequent blood sugar checks, strict diet management, and consistent exercise can be quite challenging. Mobile technologies, specifically mobile applications (apps), present a unique opportunity to help patients improve adherence to these behaviors. The availability of commercial diabetes self-management apps is increasing rapidly, making it difficult for patients and providers to stay informed about app options. A number of reviews have described commercial app technology and use for patients with diabetes. The aims of this article are to summarize the results and themes of those reviews, to review outcomes of apps described in the research literature, and to identify areas for further consideration in the use of mobile apps for diabetes self-management.

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.

The two faces of miR-29

Diabetes mellitus is a metabolic homeostasis disease that contributes to additional comorbidities such as cardiovascular disease (CVD) and cancer. It has a long undiagnosed latent period during which there can be irreparable damage to the pancreas and cardiovascular tissues. Recent studies have highlighted the roles of several microRNAs in CVD. Determining the microRNAs that link diabetes mellitus and CVD is an important topic to be explored. In the present review, we discuss the microRNAs that contribute to the progression of diabetes mellitus and CVD and focus on the miR-29 family microRNAs whose expression is upregulated by hyperglycemia and proinflammatory cytokines, the hallmarks of diabetes mellitus. Upregulation of miR-29 expression is a key factor in the loss of pancreatic β cells and development of the first stage of type 1 diabetes mellitus (T1DM). Additionally, miR-29-mediated suppression of myeloid cell leukemia 1 (MCL-1), an important prosurvival protein, underlies Marfan's syndrome, abdominal aortic aneurysm, and diabetes mellitus-associated cardiomyocyte disorganization. Suppression of miR-29 expression and subsequent increase in the prosurvival MCL-1, however, promotes tumor development. Therefore, miR-29 mimics that suppress MCL-1 are hailed as tumor suppressors. The critical question is whether an increase in miR-29 levels is well tolerated in conditions of comorbidities in which insulin resistance is an underlying disease. In light of increasing awareness of the interconnection of diabetes mellitus, CVD, and cancer, it is of utmost importance to understand the mechanism of action of current treatment options on all of the comorbidities and careful evaluation of cardiovascular toxicity must accompany any treatment paradigm that increases miR-29 levels.

The Assessment of the Readiness of Molecular Biomarker-Based Mobile Health Technologies for Healthcare Applications

Mobile health technologies to detect physiological and simple-analyte biomarkers have been explored for the improvement and cost-reduction of healthcare services, some of which have been endorsed by the US FDA. Advancements in the investigations of non-invasive and minimally-invasive molecular biomarkers and biomarker candidates and the development of portable biomarker detection technologies have fuelled great interests in these new technologies for mhealth applications. But apart from the development of more portable biomarker detection technologies, key questions need to be answered and resolved regarding to the relevance, coverage, and performance of these technologies and the big data management issues arising from their wide spread applications. In this work, we analyzed the newly emerging portable biomarker detection technologies, the 664 non-invasive molecular biomarkers and the 592 potential minimally-invasive blood molecular biomarkers, focusing on their detection capability, affordability, relevance, and coverage. Our analysis suggests that a substantial percentage of these biomarkers together with the new technologies can be potentially used for a variety of disease conditions in mhealth applications. We further propose a new strategy for reducing the workload in the processing and analysis of the big data arising from widespread use of mhealth products, and discuss potential issues of implementing this strategy.

An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act

The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability.

Diabetic patients' willingness to use tele-technology to manage their disease - A descriptive study

Objectives: Diabetes mellitus is a public health concern worldwide. TeleHealth technology may be an effective tool for empowering patients in the self-management of diabetes mellitus. However despite the great impact of diabetes on healthcare in Saudi Arabia, no research has investigated diabetic patients' willingness to use this technology. This study investigates diabetic patients' willingness to use tele-technology as a tool to monitor their disease.

Methods: Data were collected from diabetic patients attending the diabetes education clinic at the Ministry of National Guard Health Affairs (MNGHA) in the Eastern region of Saudi Arabia over a three month period. A survey was developed which measured patients' willingness to use tele-technology in the self-management of their diabetes as well as their perceived expectations from the technology.

Results: The study found that the majority of patients were willing to use tele-technology to self- monitor their diabetes. However, a minority (11.3%) indicated willingness to use the system daily and only half indicated preference to use it once a week (53.8%). Patients who were younger, had higher education levels, were employed, had internet access and had Type II diabetes were significantly more likely to report willingness to use the technology.

Conclusions: Diabetic patients could be ready to play a more active role in their care if given the opportunity. Results from this study could serve as a baseline for future studies to develop targeted interventions by trialing tele-technology on a sample of the diabetic population. Patients with diabetes need to be in charge of their own care in order to improve health outcomes across the country.

Out-of-office hours nurse-driven acute telephone counselling service in a large diabetes outpatient clinic: A mixed methods evaluation

OBJECTIVE

To map the usage of out-of-office hours acute telephone counselling (ATC) provided by diabetes specialist nurses (n=18) for diabetes patients to explore potentials for improvement.

METHODS

A mixed methods study involved mapping of ATC-usage during 6 months and a retrospective audit of frequent users.

RESULTS

Altogether, 3197 calls were registered that were related to 592 individual patients, corresponding to 10% of the population. Proportionally more users suffered from type 1 diabetes (p<0.001). ATC-users' mean HbA1c was 8.8% (73 mmol/mol) compared to 8.1% (65 mmol/mol) for all patients attending the clinic (p<0.001). Hyperglycaemia was the most frequent reason for calling. The use of ATC likely prevented 15 admissions. More than half of the calls came from general nurses based in the community (n=619) and general nurses and nursing assistants based in care homes (n=1018). The majority (75%) of patients called less than five times. However, 8% called 16 times or more accounting for 52% of all calls. A retrospective audit identified them as physically and/or psychologically fragile patients.

CONCLUSION

Hyperglycaemia was the most frequent reason for calling, and insulin dose adjustment the most frequent advice given.

PRACTICE IMPLICATIONS

Frequent users identified need additional support.

Use of and interest in mobile health for diabetes self-care in vulnerable populations

Objective

We aimed to assess use of and interest in mobile health (mHealth) technology and in-person services for diabetes self-care in vulnerable populations.

Methods

We delivered a self-administered cross-sectional survey. Participants were recruited at two primary care practices (P1 and P2) with P1 located in a medically underserved area and P2 in an affluent suburb. Two-sample t-tests and chi-square tests were used with p < 0.05 significant. In addition, a secondary analysis was performed to analyse differences in use and interest in mHealth by age.

Results

Of 75 eligible patients, 60 completed the survey (80% response rate). P1 patients had significantly higher interest in three of five categories of in-person diabetes support services, one of four categories of health-related text messages (TM), and three of eight categories of mHealth applications ( p < 0.05). Smartphone users reported higher interest in TM ( p = 0.004) and mHealth applications for diabetes self-care ( p = 0.004). Younger patients were more likely to have a smartphone ( p < 0.006), use the Internet ( p < 0.0012), use smartphone applications ( p < 0.0004), and to be interested in using applications to manage their diabetes ( p < 0.004).

Discussion

This study shows substantial patient interest in TM and mHealth applications for diabetes self-care and suggests that patients in underserved areas may have particularly high interest in using mHealth solutions in primary care. Younger patients and smartphone users were more likely to be interested in using applications to manage their diabetes. As more patients use smartphones, interest in using mHealth to support patient self-care and strengthen primary care infrastructure will continue to grow.

Public health guidelines for physical activity: is there an app for that? A review of android and apple app stores

BACKGROUND

Physical activity participation is an important behavior for modifying lifestyle-related disease risk. Mobile health apps for chronic disease management and prevention are being developed at a rapid rate. However, it is unclear whether these apps are evidence-based. Current public health recommendations for physical activity participation for adults highlight the importance of engaging in 150 minutes weekly of purposeful exercise, and muscle strengthening activities on at least 2 days of the week.

OBJECTIVE

The aims of the present review were to (1) identify available evidence-based physical activity apps, and (2) identify technological features that could be leveraged to improve health outcomes.

METHODS

iTunes and Google Play mobile app stores were searched using keyword and category searching during a single day (February 18, 2014) for physical activity apps available in English. The description pages of eligible apps were reviewed by 4 independent reviewers for evidence-based content, technological, and descriptive features. An a priori subset of apps was downloaded for further review (n=6 affiliated with a non-commercial agency; n=10 top rated; n=10 random selection), and developers were contacted for information regarding evidence-informed content.

RESULTS

The initial search yielded 2400 apps, of which 379 apps (n=206 iTunes; n=173 Google Play) were eligible. Primary results demonstrated no apps (n=0) adhering to evidence-based guidelines for aerobic physical activity, and 7 out of 379 implementing evidence-based guidelines for resistance training physical activity. Technological features of apps included social networking (n=207), pairing with a peripheral health device (n=61), and measuring additional health parameters (n=139). Secondary results revealed 1 app that referenced physical activity guidelines (150 minutes/weekly of exercise), and demonstrated that apps were based on various physical activity reports (n=4) or personal expertise (n=2).

CONCLUSIONS

The present study demonstrated a shortage of evidence-based physical activity apps. This gap underscores the need for development of evidence-informed mobile apps. Results highlight the opportunity to develop evidence-informed mobile apps that can be used clinically to enhance health outcomes.

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.

Tackling the growing diabetes burden in Sub-Saharan Africa: a framework for enhancing outcomes in stroke patients

According to the World Health Organization (WHO), more than 80% of worldwide diabetes (DM)-related deaths presently occur in low- and middle-income countries (LMIC), and left unchecked these DM-related deaths will likely double over the next 20 years. Cardiovascular disease (CVD) is the most prevalent and detrimental complication of DM: doubling the risk of CVD events (including stroke) and accounting for up to 80% of DM-related deaths. Given the aforementioned, interventions targeted at reducing CVD risk among people with DM are integral to limiting DM-related morbidity and mortality in LMIC, a majority of which are located in Sub-Saharan Africa (SSA). However, SSA is contextually unique: socioeconomic obstacles, cultural barriers, under-diagnosis, uncoordinated care, and shortage of physicians currently limit the capacity of SSA countries to implement CVD prevention among people with DM in a timely and sustainable manner. This article proposes a theory-based framework for conceptualizing integrated protocol-driven risk factor patient self-management interventions that could be adopted or adapted in future studies among hospitalized stroke patients with DM encountered in SSA. These interventions include systematic health education at hospital discharge, use of post-discharge trained community lay navigators, implementation of nurse-led group clinics and administration of health technology (personalized phone text messaging and home tele-monitoring), all aimed at increasing patient self-efficacy and intrinsic motivation for sustained adherence to therapies proven to reduce CVD event risk.

Health education via mobile text messaging for glycemic control in adults with type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Diabetes type 2 is an increasing problem worldwide that may be managed through education. Text-messaging using a cell phone can assist with self-care. The aim of this study was to systematically review the impact of education through mobile text-messaging on glycemic control.

METHODS

The design was a systematic review with meta-analysis. Five electronic databases were searched to access English studies involving a randomized controlled trial design that used text-messaging educational interventions in patients with type 2 diabetes during an 11-year period (2003-2013). Studies were evaluated using a quality assessment scale adapted from Jadad scale and Cochrane handbook. Extraction of data was carried out by two reviewers. A random-effect model with a standardized mean difference and Hedges's g indices was used for conducting the meta-analysis. Subgroup analyses were conducted and a Funnel plot was used to examine publication bias.

RESULTS

Ten studies overall were identified that fulfilled inclusion criteria, involving a total of 960 participants. The mean age of the sample was 52.8 years and majority were females. Data were heterogeneous (I(2)=67.6). Analyses suggested a publication bias based on Egger's regression (P<0.05). HbA1c was reduced significantly in experimental groups compared to control groups (P<0.001). The effect size for glycemic control in studies that used text-messaging only was 44%. For studies that used both text-messaging and Internet, the effect size was 86%.

CONCLUSION

Mobile text-messaging for educating Type 2 diabetics appears to be effective on glycemic control. Further investigations on mobile applications to achieve educational goals involving other diseases are recommended.