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Kerr D, Ahn D, Waki K, Wang J, Breznen B, Klonoff DC. Digital Interventions for Self-Management of Type 2 Diabetes Mellitus: Systematic Literature Review and Meta-Analysis. J Med Internet Res 2024; 26:e55757. [PMID: 39037772 DOI: 10.2196/55757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The proliferation of digital technology has the potential to transform diabetes management. One of the critical aspects of modern diabetes management remains the achievement of glycemic targets to avoid acute and long-term complications. OBJECTIVE This study aims to describe the landscape of evidence pertaining to the relative effectiveness or efficacy and safety of various digital interventions for the self-management of type 2 diabetes mellitus (T2DM), with a primary focus on reducing glycated hemoglobin A1c (HbA1c) levels. METHODS A systematic literature review (SLR) was conducted by searching Embase, MEDLINE, and CENTRAL on April 5, 2022. Study selection, data extraction, and quality assessment were performed by 2 independent reviewers. Eligibility criteria for the SLR included randomized controlled trials (RCTs) and comparative observational studies evaluating interventions containing both human (eg, coaching) and digital components (eg, glucose meter) in adult patients with T2DM. The primary meta-analysis was restricted to studies that reported laboratory-measured HbA1c. In secondary analyses, meta-regression was performed with the intensity of coaching in the digital intervention as a categorical covariate. RESULTS In total, 28 studies were included in this analysis. Most studies (23/28, 82%) used the reduction of HbA1c levels as the primary end point, either directly or as a part of a multicomponent outcome. In total, 21 studies reported statistically significant results with this primary end point. When stratified into 3 intervention categories by the intensity of the intervention supporting the digital health technology (analyzing all 28 studies), the success rate appeared to be proportional to the coaching intensity (ie, higher-intensity studies reported higher success rates). When the analysis was restricted to RCTs using the comparative improvement of HbA1c levels, the effectiveness of the interventions was less clear. Only half (12/23, 52%) of the included RCTs reported statistically significant results. The meta-analyses were broadly aligned with the results of the SLR. The primary analysis estimated a greater reduction in HbA1c associated with digital interventions compared with usual care (-0.31%, 95% CI -0.45% to -0.16%; P<.001). Meta-regression estimated reductions of -0.45% (95% CI -0.81% to -0.09%; P=.02), -0.29% (95% CI -0.48% to -0.11%; P=.003), and -0.28% (95% CI -0.65% to 0.09%; P=.20) associated with high-, medium-, and low-intensity interventions, respectively. CONCLUSIONS These findings suggest that reducing HbA1c levels in individuals with T2DM with the help of digital interventions is feasible, effective, and acceptable. One common feature of effective digital health interventions was the availability of timely and responsive personalized coaching by a dedicated health care professional.
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Affiliation(s)
- David Kerr
- Center for Health Systems Research, Sutter Health, Walnut Creek, CA, United States
| | - David Ahn
- Mary & Dick Allen Diabetes Center at Hoag, Newport Beach, CA, United States
| | - Kayo Waki
- The University of Tokyo, Tokyo, Japan
| | - Jing Wang
- Florida State University College of Nursing, Tallahassee, FL, United States
| | - Boris Breznen
- Evidinno Outcomes Research Inc, Vancouver, BC, Canada
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, United States
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Jospe MR, Richardson KM, Saleh AA, Bohlen LC, Crawshaw J, Liao Y, Konnyu K, Schembre SM. Leveraging continuous glucose monitoring as a catalyst for behaviour change: a scoping review. Int J Behav Nutr Phys Act 2024; 21:74. [PMID: 38987796 PMCID: PMC11238504 DOI: 10.1186/s12966-024-01622-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/27/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Amidst the escalating prevalence of glucose-related chronic diseases, the advancements, potential uses, and growing accessibility of continuous glucose monitors (CGM) have piqued the interest of healthcare providers, consumers, and health behaviour researchers. Yet, there is a paucity of literature characterising the use of CGM in behavioural intervention research. This scoping review aims to describe targeted populations, health behaviours, health-related outcomes, and CGM protocols in randomised controlled trials (RCTs) that employed CGM to support health behaviour change. METHODS We searched Ovid MEDLINE, Elsevier Embase, Cochrane Central Register of Controlled Trials, EBSCOhost PsycINFO, and ProQuest Dissertations & Theses Global from inception to January 2024 for RCTs of behavioural interventions conducted in adults that incorporated CGM-based biological feedback. Citation searching was also performed. The review protocol was registered ( https://doi.org/10.17605/OSF.IO/SJREA ). FINDINGS Collectively, 5389 citations were obtained from databases and citation searching, 3995 articles were screened, and 31 were deemed eligible and included in the review. Most studies (n = 20/31, 65%) included adults with type 2 diabetes and reported HbA1c as an outcome (n = 29/31, 94%). CGM was most commonly used in interventions to target changes in diet (n = 27/31, 87%) and/or physical activity (n = 16/31, 52%). 42% (n = 13/31) of studies provided prospective CGM-based guidance on diet or activity, while 61% (n = 19/31) included retrospective CGM-based guidance. CGM data was typically unblinded (n = 24/31, 77%) and CGM-based biological feedback was most often provided through the CGM and two-way communication (n = 12/31, 39%). Communication typically occurred in-person (n = 13/31, 42%) once per CGM wear (n = 13/31; 42%). CONCLUSIONS This scoping review reveals a predominant focus on diabetes in CGM-based interventions, pointing out a research gap in its wider application for behaviour change. Future research should expand the evidence base to support the use of CGM as a behaviour change tool and establish best practices for its implementation. TRIAL REGISTRATION doi.org/10.17605/OSF.IO/SJREA.
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Affiliation(s)
- Michelle R Jospe
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA
| | - Kelli M Richardson
- School of Nutritional Sciences and Wellness, College of Agriculture, Life and Environmental Sciences, University of Arizona, Tucson, AZ, USA
| | - Ahlam A Saleh
- Arizona Health Sciences Library, University of Arizona, Tucson, AZ, USA
| | - Lauren C Bohlen
- Center for Health Promotion and Health Equity, Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Jacob Crawshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Yue Liao
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Kristin Konnyu
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
| | - Susan M Schembre
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington DC, USA.
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Shen Y, Wang S, Shen Y, Tan S, Dong Y, Qin W, Zhuang Y. Evaluating the Usability of mHealth Apps: An Evaluation Model Based on Task Analysis Methods and Eye Movement Data. Healthcare (Basel) 2024; 12:1310. [PMID: 38998845 PMCID: PMC11241497 DOI: 10.3390/healthcare12131310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Advancements in information technology have facilitated the emergence of mHealth apps as crucial tools for health management and chronic disease prevention. This research work focuses on mHealth apps for the management of diabetes by patients on their own. Given that China has the highest number of diabetes patients in the world, with 141 million people and a prevalence rate of 12.8% (mentioned in the Global Overview of Diabetes), the development of a usability research methodology to assess and validate the user-friendliness of apps is necessary. This study describes a usability evaluation model that combines task analysis methods and eye movement data. A blood glucose recording application was designed to be evaluated. The evaluation was designed based on the model, and the feasibility of the model was demonstrated by comparing the usability of the blood glucose logging application before and after a prototype modification based on the improvement suggestions derived from the evaluation. Tests showed that an improvement plan based on error logs and post-task questionnaires for task analysis improves interaction usability by about 24%, in addition to an improvement plan based on eye movement data analysis for hotspot movement acceleration that improves information access usability by about 15%. The results demonstrate that this study presents a usability evaluation model for mHealth apps that enables the effective evaluation of the usability of mHealth apps.
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Affiliation(s)
- Yichun Shen
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Shuyi Wang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Yuhan Shen
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Shulian Tan
- The Institute of Rehabilitation Engineering and Technology, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Yue Dong
- The Institute of Rehabilitation Engineering and Technology, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Wei Qin
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Yiwei Zhuang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
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Liu F, Li J, Li X, Yang Z, Wang W, Zhao L, Wu T, Huang C, Xu Y. Efficacy of telemedicine intervention in the self-management of patients with type 2 diabetes: a systematic review and meta-analysis. Front Public Health 2024; 12:1405770. [PMID: 38835608 PMCID: PMC11148367 DOI: 10.3389/fpubh.2024.1405770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/01/2024] [Indexed: 06/06/2024] Open
Abstract
Purpose We aimed to report the latest and largest pooled analyses and evidence updates to assess the effectiveness of telemedicine interventions for self-management (DSM) in patients with type 2 diabetes mellitus (T2DM). Methods A systematic literature search was conducted using PubMed, Cochrane, Embase, and Web of Science in December 2023. We included randomized controlled trials (RCTs) of adults (≥18 years of age) diagnosed with T2DM where the intervention was the application of telemedicine. The Cochrane Risk of Bias Assessment was used to evaluate quality. The study's main outcome indicators were glycosylated hemoglobin (HbA1c) and diabetes self-management (DSM) capacity. Results A total of 17 eligible articles, comprising 20 studies and 1,456 patients (734 in the intervention group and 722 in the control group), were included in the evidence synthesis. The baseline characteristics of both groups were similar in all outcomes. Comprehensive analyses showed post-intervention decreases in HbA1c, 2-h postprandial glucose, systolic and diastolic blood pressure, increases in Diabetes Self- Care activities, DSM competencies based on dietary and medication adherence, and improvements in overall DSM scores, all of which were statistically significant. While no statistically significant differences were observed in body mass index, lipids, and other DSM dimensions. Based on subgroup analyses, app-based experimental interventions targeting under 60 years old populations in Asia and North America were found to be more effective and less heterogeneity in the short term (<6 months of intervention). Conclusion Telemedicine interventions may assist patients with T2DM in enhancing their DSM and improving their HbA1c levels. Clinician can use various telemedicine interventions to enhance DSM in T2DM patients, considering local circumstances. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, CRD42024508522.
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Affiliation(s)
- Fengzhao Liu
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Jixin Li
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiangyu Li
- Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhenyu Yang
- Graduate School of Heilongjiang University of Chinese Medicine, Harbin, China
| | - Wenru Wang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lijuan Zhao
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Tao Wu
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Chengcheng Huang
- Department of Endocrinology, Shandong University of Traditional Chinese Medicine Affiliated Hospital, Jinan, China
| | - Yunsheng Xu
- Department of Endocrinology, Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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Zhang X, Zhang L, Lin Y, Liu Y, Yang X, Cao W, Ji Y, Chang C. Effects of E-health-based interventions on glycemic control for patients with type 2 diabetes: a Bayesian network meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1068254. [PMID: 37214251 PMCID: PMC10196691 DOI: 10.3389/fendo.2023.1068254] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/22/2023] [Indexed: 05/24/2023] Open
Abstract
The high disease burden of type 2 diabetes seriously affects the quality of life of patients, and with the deep integration of the Internet and healthcare, the application of electronic tools and information technology to has become a trend for disease management. The aim of this study was to evaluate the effectiveness of different forms and durations of E-health interventions in achieving glycemic control in type 2 diabetes patients. PubMed, Embase, Cochrane, and Clinical Trials.gov were searched for randomized controlled trials reporting different forms of E-health intervention for glycemic control in type 2 diabetes patients, including comprehensive measures (CM), smartphone applications (SA), phone calls (PC), short message service (SMS), websites (W), wearable devices (WD), and usual care. The inclusion criteria were as follows: (1) adults (age≥18) with type 2 diabetes mellitus; (2) intervention period ≥1 month; (3) outcome HbA1c (%); and (4) randomized control of E-health based approaches. Cochrane tools were used to assess the risk of bias. R 4.1.2 was used to conduct the Bayesian network meta-analysis. A total of 88 studies with 13,972 type 2 diabetes patients were included. Compared to the usual care group, the SMS-based intervention was superior in reducing HbA1c levels (mean difference (MD)-0.56, 95% confidence interval (CI): -0.82 to -0.31), followed by SA (MD-0.45, 95% CI: -0.61 to -0.30), CM (MD-0.41, 95% CI: -0.57 to -0.25), W (MD-0.39, 95% CI: -0.60 to -0.18) and PC (MD-0.32, 95% CI: -0.50 to -0.14) (p < 0.05). Subgroup analysis revealed that intervention durations of ≤6 months were most effective. All type of E-health based approaches can improve glycemic control in patients with type 2 diabetes. SMS is a high-frequency, low-barrier technology that achieves the best effect in lowering HbA1c, with ≤6 months being the optimal intervention duration. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42022299896.
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Bernabe-Ortiz A, Carrillo-Larco RM, Safary E, Vetter B, Lazo-Porras M. Use of continuous glucose monitors in low- and middle-income countries: A scoping review. Diabet Med 2023; 40:e15089. [PMID: 36929661 DOI: 10.1111/dme.15089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/21/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023]
Abstract
AIMS The use of continuous glucose monitors (CGMs) has been shown to have positive impact on diabetes management for people with type 1 diabetes (T1DM), type 2 diabetes (T2DM) and gestational diabetes (GDM) in high-income countries. However, as useful as CGMs are, the experience in low- and middle-income countries (LMICs) is limited and has not been summarized. METHODS A scoping review of the scientific literature was conducted. Medline, Embase, Global Health and Scopus were used to seek original research conducted in LMICs. The search results were screened by two reviewers independently. We included studies assessing health outcomes following the use of CGMs at the individual level (e.g. glycaemic control or complications) and at the health system level (e.g. barriers, facilitators and cost-effectiveness) in English, Portuguese, Spanish and French. Results were summarized narratively. RESULTS From 4772 records found in database search, 27 reports were included; most of them from China (n = 7), Colombia (n = 5) and India (n = 4). Thirteen reports studied T1DM, five T2DM, seven both T1DM and T2DM and two GDM. Seven reports presented results of experimental studies (five randomized trials and two quasi-experimental); two on cost-effective analysis and the remaining 18 were observational. Studies showed that CGMs improved surrogate glycaemic outcomes (HbA1c reduction), hard endpoints (lower hospitalization rates and diabetes complications) and patient-oriented outcomes (quality of life). However, several caveats were identified: mostly observational studies, few participants in trials, short follow-up and focused on surrogate outcomes. CONCLUSIONS The scoping review identified that studies about CGMs in LMICs have several limitations. Stronger study designs, appropriate sample sizes and the inclusion of patient-important outcomes should be considered to inform the evidence about CGMs for the management of people with diabetes in LMICs.
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Affiliation(s)
- Antonio Bernabe-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Universidad Científica del Sur, Lima, Peru
| | - Rodrigo M Carrillo-Larco
- Emory Global Diabetes Research Center, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | | | - María Lazo-Porras
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
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Xiao Z, Han X. Evaluation of the Effectiveness of Telehealth Chronic Disease Management System: A Systematic Review and Meta-Analysis (Preprint). J Med Internet Res 2022; 25:e44256. [PMID: 37103993 PMCID: PMC10176143 DOI: 10.2196/44256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/15/2022] [Accepted: 03/10/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Long-term daily health monitoring and management play a more significant role in telehealth management systems nowadays, which require evaluation indicators to present patients' general health conditions and become applicable to multiple chronic diseases. OBJECTIVE This study aims to evaluate the effectiveness of subjective indicators of telehealth chronic disease management system (TCDMS). METHODS We selected Web of Science, ScienceDirect, Scopus, Cochrane library, IEEE, and Chinese National Knowledge Infrastructure and Wanfang, a Chinese medical database, and searched papers published from January 1, 2015, to July 1, 2022, regarding randomized controlled trials on the effectiveness of the telehealth system on patients with chronic diseases. The narrative review summarized the questionnaire indicators presented in the selected studies. In the meta-analysis, Mean Difference (MD) and Standardized Mean Difference (SMD) with a 95% CI were pooled depending on whether the measurements were the same. Subgroup analysis was conducted if the heterogeneity was significant, and the number of studies was sufficient. RESULTS Twenty RCTs with 4153 patients were included in the qualitative review. Seventeen different questionnaire-based outcomes were found, within which quality of life, psychological well-being (including depression, anxiety, and fatigue), self-management, self-efficacy, and medical adherence were most frequently used. Ten RCTs with 2095 patients remained in meta-analysis. Compared to usual care, telehealth system can significantly improve the quality of life (SMD 0.44; 95% CI 0.16-0.73; P=.002), whereas no significant effects were found on depression (SMD -0.25; 95% CI -0.72 to 0.23; P=.30), anxiety (SMD -0.10; 95% CI -0.27 to 0.07; P=.71), fatigue (SMD -0.36; 95% CI -1.06 to 0.34; P<.001), and self-care (SMD 0.77; 95% CI -0.28-1.81; P<.001). In the subdomains of quality of life, telehealth statistically significantly improved physical functioning (SMD 0.15; 95% CI 0.02 to 0.29; P=.03), mental functioning (SMD 0.37; 95% CI 0.13-0.60; P=.002), and social functioning (SMD 0.64; 95% CI 0.00-1.29; P=.05), while there was no difference on cognitive functioning (MD 8.31; 95% CI -7.33 to 23.95; P=.30) and role functioning (MD 5.30; 95% CI -7.80 to 18.39; P=.43). CONCLUSIONS TCDMS positively affected patients' physical, mental, and social quality of life across multiple chronic diseases. However, no significant difference was found in depression, anxiety, fatigue, and self-care. Subjective questionnaires had the potential ability to evaluate the effectiveness of long-term telehealth monitoring and management. However, further well-designed experiments are warranted to validate TCDMS's effects on subjective outcomes, especially when tested among different chronically ill groups.
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Affiliation(s)
- Ziyan Xiao
- Research Center Intelligent Equipment and Technology, Yangtze Delta Region Institute of Tsinghua University, Jiaxing, Zhejiang, China
- Department of Statistics and Actuarial Science, Faculty of Science, The University of Hong Kong, Hong Kong, Hong Kong
| | - Xiuping Han
- Research Center Intelligent Equipment and Technology, Yangtze Delta Region Institute of Tsinghua University, Jiaxing, Zhejiang, China
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Holtz BE, Mitchell KM, Holmstrom AJ, Hershey DS, Cotten SR, Dunneback JK, Ellis DA, Wood MA. The effect of an mHealth intervention for adolescents with Type 1 diabetes and their parents. J Telemed Telecare 2022:1357633X221125835. [PMID: 36177538 DOI: 10.1177/1357633x221125835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Past research has demonstrated that adolescents with Type 1 diabetes (T1D) typically have a decline in health outcomes as they begin to assume more self-management activities. Mobile app interventions have been suggested as one possible way to improve this behavior. PURPOSE The primary aim of this study was to address declines in health outcomes by pilot testing the satisfaction, use and feasibility of an app-based family communication intervention aimed to assist in adolescent self-management of T1D. METHODS Thirty-three adolescent-parent pairs were enrolled in and completed the 12-week pilot study. Participants were randomized 2:1 to intervention (app use) or control group. Pre/post quantitative and qualitative data were collected, including HbA1c and surveys. Paired-sample t-tests and ANOVA statistics were conducted. RESULTS The parents and adolescents reported high satisfaction with the app, and that it was easy to use. Results showed HbA1c stability in the intervention group and significant worsening in the control group. There were also significant improvements in adherence to diabetes management and quality of life for the parents in the intervention group. The adolescents did not show any improvement in quality-of-life measures. CONCLUSION This study suggests that the app intervention is acceptable, shows promise for improving health outcomes for adolescents with T1D, and may improve family communication. The public health implications of this work are that app interventions have a potential role in positively influencing chronic disease outcomes. Additional research with a more extensive and diverse sample is needed to determine generalizability.
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Affiliation(s)
- Bree E Holtz
- Department of Advertising & Public Relations, Michigan State University, East Lansing, MI, USA
| | - Katharine M Mitchell
- Department of Advertising & Public Relations, Michigan State University, East Lansing, MI, USA
| | - Amanda J Holmstrom
- Department of Communication, Michigan State University, East Lansing, MI, USA
| | - Denise S Hershey
- College of Nursing, Michigan State University, East Lansing, MI, USA
| | | | | | - Deborah A Ellis
- Department of Family Medicine, 2954Wayne State University, Detroit, MI, USA
| | - Michael A Wood
- Pediatric Endocrinology, University of Michigan Medical School, Ann Arbor, MI, USA
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