Users' acceptability of a mobile application for persons with type 2 diabetes: a qualitative study

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

Participatory Development of an Integrated, eHealth-Supported, Educational Care Pathway (Diabetes Box) for People With Type 2 Diabetes: Development and Usability Study

BACKGROUND

Type 2 diabetes (T2D) tremendously affects patient health and health care globally. Changing lifestyle behaviors can help curb the burden of T2D. However, health behavior change is a complex interplay of medical, behavioral, and psychological factors. Personalized lifestyle advice and promotion of self-management can help patients change their health behavior and improve glucose regulation. Digital tools are effective in areas of self-management and have great potential to support patient self-management due to low costs, 24/7 availability, and the option of dynamic automated feedback. To develop successful eHealth solutions, it is important to include stakeholders throughout the development and use a structured approach to guide the development team in planning, coordinating, and executing the development process.

OBJECTIVE

The aim of this study is to develop an integrated, eHealth-supported, educational care pathway for patients with T2D.

METHODS

The educational care pathway was developed using the first 3 phases of the Center for eHealth and Wellbeing Research roadmap: the contextual inquiry, the value specification, and the design phase. Following this roadmap, we used a scoping review about diabetes self-management education and eHealth, past experiences of eHealth practices in our hospital, focus groups with health care professionals (HCPs), and a patient panel to develop a prototype of an educational care pathway. This care pathway is called the Diabetes Box (Leiden University Medical Center) and consists of personalized education, digital educational material, self-measurements of glucose, blood pressure, activity, and sleep, and a smartphone app to bring it all together.

RESULTS

The scoping review highlights the importance of self-management education and the potential of telemonitoring and mobile apps for blood glucose regulation in patients with T2D. Focus groups with HCPs revealed the importance of including all relevant lifestyle factors, using a tailored approach, and using digital consultations. The contextual inquiry led to a set of values that stakeholders found important to include in the educational care pathway. All values were specified in biweekly meetings with key stakeholders, and a prototype was designed. This prototype was evaluated in a patient panel that revealed an overall positive impression of the care pathway but stressed that the number of apps should be restricted to one, that there should be no delay in glucose value visualization, and that insulin use should be incorporated into the app. Both patients and HCPs stressed the importance of direct automated feedback in the Diabetes Box.

CONCLUSIONS

After developing the Diabetes Box prototype using the Center for eHealth and Wellbeing Research roadmap, all stakeholders believe that the concept of the Diabetes Box is useful and feasible and that direct automated feedback and education on stress and sleep are essential. A pilot study is planned to assess feasibility, acceptability, and usefulness in more detail.

Barriers and Enablers to the Adoption of a Healthier Diet Using an App: Qualitative Interview Study With Patients With Type 2 Diabetes Mellitus

BACKGROUND

Adopting a healthy diet is one of the cornerstones of type 2 diabetes (T2D) management. Apps are increasingly used in diabetes self-management, but most studies to date have focused on assessing their impact in terms of weight loss or glycemic control, with limited evidence on the behavioral factors that influence app use to change dietary habits.

OBJECTIVE

The main objectives of this study were to assess the enablers and barriers to adopting a healthier diet using the Gro Health app in 2 patient groups with T2D (patients with recently diagnosed and long-standing T2D) and to identify behavior change techniques (BCTs) to enhance enablers and overcome barriers.

METHODS

Two semistructured qualitative interview studies were conducted; the first study took place between June and July 2021, with a sample of 8 patients with recently diagnosed (<12 mo) T2D, whereas the second study was conducted between May and June 2022 and included 15 patients with long-standing (>18 mo) T2D. In both studies, topic guides were informed by the Capability, Opportunity, Motivation, and Behavior model and the Theoretical Domains Framework. Transcripts were analyzed using a combined deductive framework and inductive thematic analysis approach. The Behavior Change Wheel framework was applied to identify appropriate BCTs that could be used in future iterations of apps for patients with diabetes. Themes were compared between the patient groups.

RESULTS

This study identified similarities and differences between patient groups in terms of enablers and barriers to adopting a healthier diet using the app. The main enablers for recently diagnosed patients included the acquired knowledge about T2D diets and skills to implement these, whereas the main barriers were the difficulty in deciding which app features to use and limited cooking skills. By contrast, for patients with long-standing T2D, the main enablers included knowledge validation provided by the app, along with app elements to help self-regulate food intake; the main barriers were the limited interest paid to the content provided or limited skills engaging with apps in general. Both groups reported more enablers than barriers to performing the target behavior when using the app. Consequently, BCTs were selected to address key barriers in both groups, such as simplifying the information hierarchy in the app interface, including tutorials demonstrating how to use the app features, and redesigning the landing page of the app to guide users toward these tutorials.

CONCLUSIONS

Patients with recently diagnosed and long-standing T2D encountered similar enablers but slightly different barriers when using an app to adopting a healthier diet. Consequently, the development of app-based approaches to adopt a healthier diet should account for these similarities and differences within patient segments to reduce barriers to performing the target behavior.

A mixed-methods study on the implementation of a mobile health application (mHealth app) for stroke caregivers in Malaysia: healthcare providers' perspective

Introduction

Recognizing the burden experienced by caregivers of stroke survivors, an intervention using mobile health applications (mHealth apps) has been proposed to support and empower stroke caregivers. This study aimed to assess the acceptability and expectations of healthcare providers, who play a vital role as gatekeepers in the healthcare system, to ensure the effectiveness and sustainability of the intervention.

Methods

This was a concurrent mixed-method study design, with healthcare providers involved in stroke care management in the northeast regions of Malaysia as study participants. The qualitative component of the study was conducted using a phenomenological approach that involved in-depth interviews to explore the acceptability and expectations of healthcare providers regarding the adoption of mHealth apps in the context of stroke caregiving. The study was complemented by quantitative data collected through an online survey using an adjusted version of the technology acceptance model tool.

Results

In total, 239 participants from diverse backgrounds and professions were enrolled in the study, with 12 in the qualitative component and 227 in the quantitative component. The findings from the quantitative survey showed that over 80% of the participants expressed their intention to use mHealth apps. The qualitative component generated two themes related to the acceptability and expectations of mHealth apps, which were integrated with the quantitative findings. Additionally, in-depth interviews revealed a new theme, namely the key features of mHealth, with three sub-themes: availability of services for caregivers, provision of knowledge skills, and supporting caregivers in managing stroke patients.

Conclusion

Healthcare providers demonstrated excellent acceptability of this mHealth intervention as part of caregiving assistance, particularly with the inclusion of essential key features. However, future investigations are necessary to establish the feasibility of integrating the mHealth app into the healthcare system and to ensure its long-term sustainability.

Efficacy of a basal insulin dose management smartphone application for controlling fasting blood glucose in patients with type-2 diabetes mellitus: A single-centre, randomised clinical study

OBJECTIVE

To explore the efficacy and safety of the 'Walk with you' application for titrating basal insulin (BI) doses in type-2 diabetes mellitus (T2DM) hospitalised patients.

METHODS

This was a randomised, single-centre, open-label, controlled clinical trial to compare the changes in fasting blood glucose (FBG) and postprandial blood glucose (PBG), time to reach target FBG (FBG-TRT), incidence of hypoglycaemia events and FBG coefficient of variation in the application group (weight-based titration of BI dose regimen) and control group (typical adjustment regimen).

PATIENTS

This study selected 173 patients with T2DM using basal-prandial insulin therapy who were admitted to Binhaiwan Central Hospital of Dongguan between December 2021 and December 2022. Patients were randomised to the control group or the application group (App group) and then titrated to achieve an FBG concentration of less than 7.0 mmol/L.

RESULTS

There were 86 patients in the control group and 87 patients in the App group. The FBG concentrations in the control and App groups were decreased by 6.77 ± 4.75 and 5.95 ± 4.06 mmol/L, respectively. The FBG-TRTs in the control and App groups were 3.80 ± 1.52 and 2.82 ± 1.34 days, respectively (p < .001). Fewer patients in the control group reached the FBG-TRT within 3 days than in the App group, with 46.5% and 71.3% of patients reaching that target, respectively. There was no significant between-group difference in hypoglycaemia incidence.

CONCLUSION

The use of this weight-based insulin dose titration protocol for BI app is effective and safe for achieving the target FBG in noncritically ill patients with T2DM and is free, easy to use and user friendly.

Opening the Black Box of an mHealth Patient-Reported Outcome Tool for Diabetes Self-Management: Interview Study Among Patients With Type 2 Diabetes

BACKGROUND

Mobile health (mHealth) tools are used to collect data on patient-reported outcomes (PROs) and facilitate the assessment of patients' self-management behaviors outside the clinic environment. Despite the high availability of mHealth diabetes tools, there is a lack of understanding regarding the underlying reasons why these mHealth PRO tools succeed or fail in terms of changing patients' self-management behaviors.

OBJECTIVE

This study aims to identify the factors that drive engagement with an mHealth PRO tool and facilitate patients' adoption of self-management behaviors, as well as elicit suggestions for improvement.

METHODS

This qualitative study was conducted within the context of a randomized controlled trial designed to evaluate the efficacy of an mHealth PRO tool (known as i-Matter) versus usual care regarding reduction in glycated hemoglobin (HbA1c) levels and adherence to self-management behaviors at 12 months among patients with uncontrolled type 2 diabetes. Patients randomized to i-Matter participated in semistructured interviews about their experiences at the 3-, 6-, 9-, and 12-month study visits. A qualitative analysis of the interviews was conducted by 2 experienced qualitative researchers using conventional qualitative content analysis.

RESULTS

The sample comprised 71 patients, of whom 67 (94%) completed at least one interview (n=48, 72% female patients; n=25, 37% identified as African American or Black; mean age 56.65 [SD 9.79] years). We identified 4 overarching themes and 6 subthemes. Theme 1 showed that the patients' reasons for engagement with i-Matter were multifactorial. Patients were driven by internal motivating factors that bolstered their engagement and helped them feel accountable for their diabetes (subtheme 1) and external motivating factors that helped to serve as reminders to be consistent with their self-management behaviors (subtheme 2). Theme 2 revealed that the use of i-Matter changed patients' attitudes toward their disease and their health behaviors in 2 ways: patients developed more positive attitudes about their condition and their ability to effectively self-manage it (subtheme 3), and they also developed a better awareness of their current behaviors, which motivated them to adopt healthier lifestyle behaviors (subtheme 4). Theme 3 showed that patients felt more committed to their health as a result of using i-Matter. Theme 4 highlighted the limitations of i-Matter, which included its technical design (subtheme 5) and the need for more resources to support the PRO data collected and shared through the tool (subtheme 6).

CONCLUSIONS

This study isolated internal and external factors that prompted patients to change their views about their diabetes, become more engaged with the intervention and their health, and adopt healthy behaviors. These behavioral mechanisms provide important insights to drive future development of mHealth interventions that could lead to sustained behavior change.

Overcoming the struggle of living with type 2 diabetes - diabetes specialist nurses' and patients' perspectives on digital interventions

BACKGROUND

Diabetes self-management education and support (DSMES) is a cornerstone in the treatment of type 2 diabetes mellitus (T2DM). It is unclear whether delivering DSMES as a digital health intervention (DHI) might meet the needs experienced by patients with T2DM and diabetes specialist nurses (DSN) of the primary health care system in Sweden.

METHODS

Fourteen patients with T2DM and four DSN participated in three separate focus groups: two groups comprised patients and one group comprised DSN. The patients discussed the questions: "What needs did you experience after your T2DM diagnosis?" and "How might these needs be met with a DHI?" The DSN discussed the questions: "What needs do you experience when treating a patient with newly diagnosed T2DM?" and "How might these needs be met with a DHI?". Furthermore, data were collected in the form of field notes from group discussions at a meeting including 18 DSNs working with T2DM in PHCCs. The discussions from focus groups were transcribed verbatim and analyzed together with the field notes from the meeting using inductive content analysis.

RESULTS

The analysis yielded the overall theme: "Overcoming the struggle of living with T2DM", which was summarized in two categories: "learning and being prepared" and "giving and receiving support". Important findings were that, for success, a DHI for DSMES must be integrated into routine care, provide structured, high-quality information, suggest tasks to stimulate behavioral changes, and provide feedback from the DSN to the patient.

CONCLUSION

This study highlighted several important aspects, from the perspectives of both the patient with T2DM and the DSN, which should be taken into consideration for the successful development and use of a DHI for DSMES.

Aplicaciones móviles dirigidas a personas mayores para la autogestión del cuidado: revisión del alcances

Introducción: el uso de aplicaciones móviles puede facilitar la autogestión en salud y brindar oportunidades para la autonomía de las personas mayores en su autocuidado. Objetivo: mapear la producción científica en aplicaciones móviles para la autogestión del cuidado dirigido a las personas mayores. Materiales y Métodos: revisión de alcance realizada desde septiembre de 2020 a enero de 2021, con base en las siguientes bases de datos: MEDLINE, SciELO, Scopus, Web of Science y Science Direct, utilizando la estrategia de búsqueda: (“Self-management” OR “Self-care”) AND (Elderly OR “Old man”) AND (“Mobile Applications” OR Smartphone OR “Cell phone”), con la inclusión de artículos que tratan sobre el uso de aplicaciones móviles por parte de los ancianos para la autogestión de cuidado, sin limitaciones de tiempo e idioma. Resultados: la muestra final constó de 14 artículos, categorizados en tres aspectos del manejo, a saber: medicamentos, comorbilidades y prácticas saludables. En la mayoría de los estudios, las aplicaciones estuvieron dirigidas al autocontrol de los medicamentos, seguido de la atención de las condiciones crónicas y finalmente la autoevaluación del riesgo de caídas y los tratamientos no farmacológicos del dolor. Discusión: esta revisión contribuye a la práctica clínica y la investigación en enfermería, ya que sus resultados apuntan a lo publicado sobre el desarrollo y uso de aplicaciones móviles por parte de los ancianos para la autogestión del cuidado. Conclusiones: el uso de aplicaciones móviles facilita el autocuidado de la población anciana, especialmente en el manejo de la medicación para enfermedades crónicas. Como citar este artículo: Gomes, Manoelise Linhares Ferreira; Fernandes, Cristina da Silva; Sousa, Maria Gabrieli Aguiar de; Silva, Raimunda Leandra Bráz da; Silva, Illeanne de Jesus Manhiça da Costa; Barros, Lívia Moreira. Aplicativos móveis direcionados aos idosos para autogerenciamento do cuidado: revisão de escopo. Revista Cuidarte. 2023;14(1):e2594. http://dx.doi.org/10.15649/cuidarte.2594

What drives patients' acceptance of Digital Therapeutics? Establishing a new framework to measure the interplay between rational and institutional factors

BACKGROUND

The rising incidence of chronic diseases among the population, further exacerbated by the phenomenon of aging, is a primary concern and a serious challenge for the healthcare systems worldwide. Among the wide realm of health digital technologies, the rise of Digital Therapeutics (DTx), which are medical devices able to deliver evidence-based treatments to manage and treat diseases, opens new opportunities. However, their diffusion and usage are still fragmented among countries. As the diffusion results from the adoption of technology from a social system and individual acceptance, this study aims to design and test a theoretical model that investigates the intention to use DTx, with a particular focus on the treatment of obesity, as a widespread and burdensome chronic condition.

METHODS

This research is built on 336 answers coming from a survey to test the proposed model, which consists of a combination of organizational mechanisms, derived from Institutional Theory, and rational factors, derived from the Technology Acceptance Model (TAM). The survey has been delivered to patients and former patients of Istituto Auxologico Italiano, a hospital with several locations in northern Italy, recognized as a center of excellence for the treatment of obesity.

RESULTS

The analyses of the answers, performed through the Structural Equation Modelling (SEM) technique, confirmed the influence of the Perceived Usefulness on Intention To Use, and of the Perceived Ease Of Use on the Perceived Usefulness, confirming the validity of the assumptions derived from the TAM. On the other hand, institutional factors were introduced as antecedents of the Perceived Usefulness, and the Perceived Ease Of Use. Results show that the Regulative Pillar influences both the TAM constructs, the Normative Pillar (peer influence) has a positive effect only on the Perceived Usefulness, and finally, the Cultural Pillar impacts the Perceived Ease Of Use.

CONCLUSION

This study allows filling the knowledge gap regarding the usage of the Institutional as a means to predict individuals' intentions. Moreover, managerial contributions are available as the results have been operationalized into practical advice to managers and healthcare professionals to foster the adoption, and thus the diffusion, of Digital Therapeutics.

Participants' and Health Care Providers' Insights Regarding a Web-Based and Mobile-Delivered Healthy Eating Program for Disadvantaged People With Type 2 Diabetes: Descriptive Qualitative Study

BACKGROUND

Healthy eating is a key element of type 2 diabetes (T2D) self-management. Digital interventions offer new avenues to reach broad audiences to promote healthy eating behaviors. However, acceptance of these interventions by socioeconomically disadvantaged people (eg, those with lower levels of education and income or from ethnic minority groups) has not yet been fully evaluated.

OBJECTIVE

This study aimed to investigate the acceptability and usability of EatSmart, a 12-week web-based and mobile-delivered healthy eating behavior change support program, from the perspective of intervention participants living with T2D and health care providers (HCPs) involved in diabetes care.

METHODS

This study used a qualitative descriptive design. Overall, 60 disadvantaged adults with T2D, as determined by receipt of either a HealthCare Card or a pension or benefit as the main source of income, were recruited. Data from participants regarding their experiences with and perceptions of the program and longer-term maintenance of any behavior or attitudinal changes were collected through a web-based self-report survey with open-ended questions administered 12 weeks after baseline (54/60, 90%) and semistructured telephone interviews administered 36 weeks after baseline (16/60, 27%). Supplementary semistructured interviews with 6 HCPs involved in diabetes care (endocrinologists, accredited practicing dietitians, and diabetes nurse educators) were also conducted 36 weeks after baseline. These interviews aimed to understand HCPs' views on successful and unsuccessful elements of EatSmart as a technology-delivered intervention; any concerns or barriers regarding the use of these types of interventions; and feedback from their interactions with patients on the intervention's content, impact, or observed benefits. All data from the surveys and interviews were pooled and thematically analyzed.

RESULTS

In total, 5 key themes emerged from the data: program impact on food-related behaviors and routines, satisfaction with the program, reasons for low engagement and suggestions for future programs, benefits and challenges of digital interventions, and cultural considerations. Results showed that EatSmart was acceptable to participants and contributed positively to improving food-related behaviors. Most participants (27/43, 63%) mentioned that they enjoyed their experience with EatSmart and expressed high satisfaction with its content and delivery. The educational and motivational content was considered the most useful part of the program. Benefits discussed by intervention participants included gaining health knowledge and skills, positive changes in their food purchasing and cooking, and eating greater quantities and varieties of fruits and vegetables. HCPs also described the intervention as beneficial and persuasive for the target audience and had specific suggestions for future tailoring of such programs.

CONCLUSIONS

The findings suggested that this digitally delivered intervention with supportive educational modules and SMS text messages was generally appealing for both participants and HCPs. This intervention medium shows promise and could feasibly be rolled out on a broader scale to augment usual diabetes care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19488.

A Mobile Application to Improve Diabetes Self-Management Using Rapid Prototyping: Iterative Co-Design Approach in Asian Settings

BACKGROUND

Diabetes is a global public health issue, causing burden on healthcare system and increasing risk of mortality. Mobile applications (apps) can be a promising approach to facilitate diabetes self-management. An increasingly utilized approach to facilitate engagement with mobile health (mHealth) technology is to involve potential users in the creation of the technology.

OBJECTIVE

The aim of this study was to use co-design for type 2 diabetes mellitus (T2DM) self-management mHealth development.

METHODS

Three rounds of iterative rapid prototyping panel sessions were conducted with a total of 9 T2DM participants in an Asian setting between Oct 2020 and April 2021. The participants were recruited through convenience sampling. For each round, feedback was gathered through qualitative interviews, and the feedback was used as a reference by the development team to develop and test a more refined version of the app in the next round. Transcribed semi-structured interview data was analyzed thematically using an inductive approach.

RESULTS

Participants' ages ranged from 40 to 69 years. Data saturation was reached, with no new themes emerging from the data. During the sessions, the participants expressed a variety of concerns and feedback on T2DM self-management using EMPOWER app and raised suggestions on the features of ideal T2DM self-management app. Important features include 1) reminders and notifications for medications, 2) Bluetooth integration with glucometers and blood pressure machines to minimize manual entry, 3) enlarged local food database including information on sugar content and recommendations for healthier options, 4) one touch for logging of routine medications and favorite foods, 5) export function for data sharing with physicians. Overall inputs concerned aspects such as user-friendliness of the app, customization possibilities, and educational content for the features in the mobile app.

CONCLUSION

In this study, we explored users' opinions on a T2DM self-management mobile app using co-design approach. This study adds to the growing body of literature on co-designing behavioral mHealth interventions and can potentially guide researchers in mobile app design for other chronic conditions.

User experience of a self-management WeChat applet for patients with neurogenic bladder: A qualitative approach

Objectives

This study aimed to determine patients' perceived benefits of a WeChat applet for self-management of patients with neurogenic bladder (NGB) and identify the key factors hindering their adoption.

Methods

In the qualitative study, 19 NGB patients were invited for semi-structured interviews. They were hospitalized in the rehabilitation departments of two tertiary hospitals in Shenzhen and tried out the self-management applet for two weeks. Data were analyzed using the content analysis method.

Results

The results indicated that the WeChat applet of self-management was helpful and embraced by the NGB patients. Three perceived benefits were identified 1) being accessible, flexible, and intuitive to users, 2) driving bladder self-management, and 3) directing the way for care partners and family members. Challenges hindering the adoption of the applet included 1) negative attitudes of patients towards bladder self-management and patient characteristics, 2) concerns about the risks of mHealth, and 3) the necessity of applet upgrading.

Conclusion

This study showed feasibility of the WeChat applet for self-management among NGB patients to meet their needs for access to information during hospitalization and after discharge. The study also identified facilitators and barriers to patient use, providing valuable information for healthcare providers to implement mHealth interventions to promote self-management among NGB patients.

Performance and usability evaluation of a mobile health data capture application in clinical cancer trials follow-up

•

A mobile health data capture application can improve quality of data collection in clinical cancer trials.

•

The use of a mobile health data capture application optimizes the efficiency and effectivity of a trial participant’s visit to a clinic.

•

A mobile health data capture application relieves participants from instant recall on possible health changes during visits.

•

The use of a mobile health data capture application helps a healthcare provider in preparing a participant’s visit.

Mobile health data capture applications (mHDA’s) may improve communication between healthcare providers and patients. However, there is limited literature about the use of mHDA’s facilitating clinical trials. In this study, the effectiveness of an application, supporting follow-up visits of cancer trial participants was investigated. Twenty participants were provided with an e-questionnaire via the mHDA. Participants rated the usability of the application as high performing (mean Systems Usability Scale 87 points). The research team rated the mHDA as highly applicable and efficient in preparing visits. Anamnesis, physical examination and agreement on further policy were performed within an average of 31 min.

Use of a Smart-Phone Mobile Application is Associated With Improved Compliance and Reduced Length of Stay in Patients Undergoing Primary Total Joint Arthroplasty of the Hip and Knee

BACKGROUND

Patient compliance with perioperative protocols is paramount to improving outcomes and reducing adverse events in total joint arthroplasty (TJA) of the hip and knee. Given the widespread use of smartphones, mobile applications (MAs) may present an opportunity to improve outcomes in TJA. We aim to determine whether the use of a mobile application platform improves compliance with standardized pre-operative protocols and outcomes in TJA.

METHODS

A non-randomized, prospective cohort study was conducted in adult patients undergoing primary elective TJA to determine whether the use of an MA with timed reminders starting 5 days pre-operatively, to perform a chlorhexidine gluconate (CHG) shower and oral hydration protocol improves compliance with these protocols.

OUTCOME MEASURES

compliance, length of stay (LOS), surgical site infection (SSI), 90-day readmission.

RESULTS

App-users had increased adherence to the hydration protocol (odds ratio [OR] = 3.17 [95% confidence interval {CI} = 1.42, 7.09: P = .003]). App-use was associated with shorter LOS (Median Interquartile ranges [IQR] 2.0 days [1.0, 2.0 days]) for App-users vs 2.0 days ([1.0, 3.0] for non-App users, P = .031), younger age, (63.3 vs 67.9 years, P = .0001), Caucasian race (OR = 3.32 [95% CI = 1.59, 6.94 P = .0009]) and male gender (48.2% vs 35.0%, P = .02). There was no difference in adherence to chlorhexidine gluconate (CHG), readmission, or surgical site infection (SSI) (2.2% App-users vs 2.9% non-App users; P = .74).

CONCLUSION

Use of a mobile application was associated with increased compliance with a hydration protocol and reduced LOS. App-users were more likely to be younger, male and Caucasian. These disparities may reflect inequity of access to the requisite technology and warrant further study.

Diabetes Self-management Apps: Systematic Review of Adoption Determinants and Future Research Agenda

BACKGROUND

Most diabetes management involves self-management. Effective self-management of the condition improves diabetes control, reduces the risk of complications, and improves patient outcomes. Mobile apps for diabetes self-management (DSM) can enhance patients' self-management activities. However, they are only effective if clinicians recommend them, and patients use them.

OBJECTIVE

This study aimed to explore the determinants of DSM apps' use by patients and their recommendations by health care professionals (HCPs). It also outlines the future research agenda for using DSM apps in diabetes care.

METHODS

We systematically reviewed the factors affecting the adoption of DSM apps by both patients and HCPs. Searches were performed using PubMed, Scopus, CINAHL, Cochrane Central, ACM, and Xplore digital libraries for articles published from 2008 to 2020. The search terms were diabetes, mobile apps, and self-management. Relevant data were extracted from the included studies and analyzed using a thematic synthesis approach.

RESULTS

A total of 28 studies met the inclusion criteria. We identified a range of determinants related to patients' and HCPs' characteristics, experiences, and preferences. Young female patients were more likely to adopt DSM apps. Patients' perceptions of the benefits of apps, ease of use, and recommendations by patients and other HCPs strongly affect their intention to use DSM apps. HCPs are less likely to recommend these apps if they do not perceive their benefits and may not recommend their use if they are unaware of their existence or credibility. Young and technology-savvy HCPs were more likely to recommend DSM apps.

CONCLUSIONS

Despite the potential of DSM apps to improve patients' self-care activities and diabetes outcomes, HCPs and patients remain hesitant to use them. However, the COVID-19 pandemic may hasten the integration of technology into diabetes care. The use of DSM apps may become a part of the new normal.

Design and Development of a Mobile-Based Self-Care Application for Patients with Type 2 Diabetes

INTRODUCTION

Mobile-based applications play a leading role in changes in life-style, improve medication adherence, and provide a unique opportunity to aid patients with type 2 diabetes mellitus (T2DM) elevate their healthcare level. Therefore, we aim to design and develop a mobile-based self-care application for patients with T2DM.

METHODS

The present study was an applied and developmental study to design and develop a mobile-based self-care application for people living with T2DM conducted in 2020. The design and development of the T2DM self-care application were done in 2 main phases of determining the key features and capabilities, and design and development of the T2DM self-care mobile app.

RESULTS

We identified the main model and a set of capabilities and features for the T2DM self-care application. By content analysis on 32 different applications and a previous study by the author, 18 features were extracted for the T2DM self-care mobile app. JAVA programming languages were used to design T2DM applications. Moreover, because of the cost-effectiveness, the Android operating system (AOS) was selected as a platform, and because of the widespread use of smartphones; these phones were chosen as the format of T2DM self-care application.

CONCLUSIONS

In this study, we design and develop a mobile-based self-care application for patients with type 2 diabetes that shows potential in solving the shortcomings of mobile apps for diabetes care. By utilizing the T2DM self-care mobile app we are able to deploy a self-care application with a wide range of functionality such as text messaging, blood glucose monitoring, insulin dose suggestions, educational messaging, metabolic management, pedometer counts, and reporting. Future studies are needed to develop self-care applications for a different type of diabetes with different functions of diabetes care.

A Smartphone-Based Application to Assist Insulin Titration in Patients Undergoing Basal Insulin-Supported Oral Antidiabetic Treatment

INTRODUCTION

INSULIA is an insulin-titration app developed for patients with type 2 diabetes treated with basal insulin as part of a basal insulin-supported oral therapy (BOT). The app uses patient-logged fasting blood glucose (FBG) values and a titration plan defined by the treating physician to provide basal insulin dosing recommendations. Physicians use the web portal to monitor their patients' therapy progress and, if necessary, adjust therapy. The aim of this study was to assess the app, specifically its features, handling and impact on diabetes treatment and self-management in Germany.

METHODS

This German retrospective pilot study included physicians (diabetologists, general practitioners, and internists) and patients with type 2 diabetes who either receive or start BOT using the app. Both groups completed group-specific questionnaires between December 2018 and June 2019.

RESULTS

Overall, 10 physicians and 34 patients with type 2 diabetes completed their respective questionnaires. Physicians perceived their app-using patients to be more involved and more confident in managing their insulin therapy than patients not using the app. The majority of patients considered the app as a tool that assists with safer insulin treatment. The physicians perceived that due to the app use, FBG and HbA_1c target values were achieved more often than patients not using the app and the number and severity of hypoglycemic episodes was reduced.

CONCLUSION

The titration app seems to have a positive impact on BOT patients' FBG and HbA_1c target achievement and was highly appreciated by both physicians and patients alike.

Using the Stay Strong App for the Well-being of Indigenous Australian Prisoners: Feasibility Study

Background

The gap between mental health needs and resources for Aboriginal and Torres Strait Islander people, the Indigenous people of Australia, is most marked in the prison population. Indigenous people are overrepresented in Australian prisons. In prison, this group experiences mental disorders to a greater degree than non-Indigenous prisoners. This group has also been found to experience mental disorder at a higher rate than Indigenous people in the community. In addition to pre-existing determinants of poor mental health, these high prevalence rates may reflect poor engagement in mainstream interventions or the efficacy of available interventions. In community populations, the use of digital mental health resources may help to increase access to well-being support. However, culturally appropriate digital tools have not been available to Indigenous people in prisons. The absence of feasibility and efficacy studies of these tools needs to be addressed.

Objective

The aim of this study is to determine the feasibility of the Stay Strong app as a digital well-being and mental health tool for use by Indigenous people in prison.

Methods

Dual government agency (health and corrective services) precondition requirements of implementation were identified and resolved. This was essential given that the Stay Strong app was to be delivered by an external health agency to Indigenous prisoners. Then, acceptability at a practice level was tested using postuse qualitative interviews with clients and practitioners of the Indigenous Mental Health Intervention Program. All Indigenous Mental Health Intervention Program practitioners (10/37, 27%) and client participants who had completed their second follow-up (review of the Stay Strong app; 27/37, 73%) during the study period were invited to participate.

Results

Owing to the innovative nature of this project, identifying and resolving the precondition requirements of implementation was challenging but provided support for the implementation of the app in practice. Acceptability of the app by clients and practitioners at a practice level was demonstrated, with nine themes emerging across the interviews: satisfaction with the current Stay Strong app, supported client goal setting, increased client self-insight, improved client empowerment, cultural appropriateness, enhanced engagement, ease of use, problems with using an Android emulator, and recommendations to improve personalization.

Conclusions

The Stay Strong Custody Project is a pioneering example of digital mental health tools being implemented within Australian prisons. Using the app within high-security prison settings was found to be feasible at both strategic and practice levels. Feedback from both clients and practitioners supported the use of the app as a culturally safe digital mental health and well-being tool for Aboriginal and Torres Strait Islander people in prison.

Suitability of the Unified Theory of Acceptance and Use of Technology 2 Model for Predicting mHealth Acceptance Using Diabetes as an Example: Qualitative Methods Triangulation Study

Background

In recent years, the use of mobile health (mHealth) apps to manage chronic diseases has increased significantly. Although mHealth apps have many benefits, their acceptance is still low in certain areas and groups. Most mHealth acceptance studies are based on technology acceptance models. In particular, the Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) model was developed to predict technology acceptance in a consumer context. However, to date, only a few studies have used the UTAUT2 model to predict mHealth acceptance and confirm its suitability for the health sector. Thus, it is unclear whether the UTAUT2 model is suitable for predicting mHealth acceptance and whether essential variables for a health-related context are missing.

Objective

This study aims to validate the suitability of UTAUT2 for predicting mHealth acceptance.

Methods

In this study, diabetes was used as an example as mHealth apps are a significant element of diabetes self-management. In addition, diabetes is one of the most common chronic diseases affecting young and older people worldwide. An explorative literature review and guided interviews with 11 mHealth or technology acceptance experts and 8 mHealth users in Austria and Germany were triangulated to identify all relevant constructs for predicting mHealth acceptance. The interview participants were recruited by purposive sampling until theoretical saturation was reached. Data were analyzed using structured content analysis based on inductive and deductive approaches.

Results

This study was able to confirm the relevance of all exogenous UTAUT2 constructs. However, it revealed two additional constructs that may also need to be considered to better predict mHealth acceptance: trust and perceived disease threat.

Conclusions

This study showed that the UTAUT2 model is suitable for predicting mHealth acceptance. However, the model should be extended to include 2 additional constructs for use in the mHealth context.

A qualitative evidence synthesis of users' experience of mobile health applications in the self-management of type 2 diabetes

AIM

The aim of this qualitative evidence synthesis was to identify and synthesise qualitative research relating to experiences of using mobile health (mHealth) applications to aid self-management of Type 2 Diabetes.

METHODS

Using a systematic search strategy, 11 databases were searched (Medline, CINAHL, PsychInfo, PubMed, Web of Science, Embase, Cochrane Library, Scopus, ProQuest A&1, ProQuest UK & Ireland, Mednar). "Best fit" framework synthesis was used guided by the Health Information Technology Acceptance Model (HITAM). Assessment of methodological limitations was conducted using Critical Appraisal Skills Programme (CASP) and confidence in the review findings were guided by GRADE-CERQual.

RESULTS

Fourteen eligible studies were included in the synthesis (7 qualitative and 5 mixed methods). Key themes identified under the health, information and technology zones of the HITAM revealed the benefits of mHealth apps, barriers to their use, their perceived usefulness and ease of use.

DISCUSSION

Most people used the apps for feedback on their self-management and found them helpful in their communication with health care providers. Some embraced the technology and found it easy to use while others found mHealth apps to be counterintuitive.

Barriers and Drivers Regarding the Use of Mobile Health Apps Among Patients With Type 2 Diabetes Mellitus in the Netherlands: Explanatory Sequential Design Study

Background

Self-monitoring of blood glucose levels, food intake, and physical activity supports self-management of patients with type 2 diabetes mellitus (T2DM). There has been an increase in the development and availability of mobile health apps for T2DM.

Objective

The aim of this study is to explore the actual use of mobile health apps for diabetes among patients with T2DM and the main barriers and drivers among app users and nonusers.

Methods

An explanatory sequential design was applied, starting with a web-based questionnaire followed by semistructured in-depth interviews. Data were collected between July and December 2020. Questionnaire data from 103 respondents were analyzed using IBM SPSS Statistics (version 25.0). Descriptive statistics were performed for the actual use of apps and items of the Unified Theory of Acceptance and Use of Technology (UTAUT). The UTAUT includes 4 key constructs: performance expectancy (the belief that an app will help improve health performance), effort expectancy (level of ease associated with using an app), social influence (social support), and facilitating conditions (infrastructural support). Differences between users and nonusers were analyzed using chi-square tests for individual items. Independent 2-tailed t tests were performed to test for differences in mean scores per the UTAUT construct. In total, 16 respondents participated in the interviews (10 users and 6 nonusers of apps for T2DM). We performed content analysis using a deductive approach on all transcripts, guided by the UTAUT.

Results

Regarding actual use, 55.3% (57/103) were nonusers and 44.7% (46/103) were users of apps for T2DM. The main driver for the use of apps was the belief that using apps for managing diabetes would result in better personal health and well-being. The time and energy required to keep track of the data and understand the app were mentioned as barriers. Mean scores were significantly higher among users compared with nonusers of apps for T2DM for the constructs performance expectancy (4.06, SD 0.64 vs 3.29, SD 0.89; P<.001), effort expectancy (4.04, SD 0.62 vs 3.50, SD 0.82; P<.001), social influence (3.59, SD 0.55 vs 3.29, SD 0.54; P=.007), and facilitating conditions (4.22, SD 0.48 vs 3.65, SD 0.70; P<.001). On the basis of 16 in-depth interviews, it was recognized that health care professionals play an important role in supporting patients with T2DM in using apps. However, respondents noticed that their health care professionals were often not supportive of the use of apps for managing diabetes, did not show interest, or did not talk about apps. Reimbursement by insurance companies was mentioned as a missing facilitator.

Conclusions

Empowering health care professionals’ engagement is of utmost importance in supporting patients with T2DM in the use of apps. Insurance companies can play a role in facilitating the use of diabetes apps by ensuring reimbursement.

The good, the bad, and the poorly designed: The mobile app stores are not a user-friendly experience for health and medical purposes

The utilization of mobile health applications to help manage health conditions have grown in utilization within the past decade. However, the application stores (i.e. Google and Apple) are not designed in a user-friendly manner that allows consumers to identify high-quality health and medical-related mobile applications. Researchers have been interested in identifying applications that may be recommended for patient care but have found the ability to quantify and assess these applications to be difficult due to the current layout and organization of applications. We explain here in this brief communication our own research experience in the identification of mobile health applications on the application stores, along with trends noted in other mobile health research, and make suggestions on how the application store experience could be improved for both patients and health professionals. These include collaboration between developers, medical professionals and organizations, and technology companies to facilitate a better means of categorizing health applications for patient use, alongside other current endeavors being pursued such as application review organizations and the creation of digital health formulary databases.

Usability and Acceptability of JAGA SEHAT: Mobile Application to Improve Knowledge About Healthy Lifestyle

Purpose

The use of mHealth has great potential to overcome many barriers in healthcare and become powerful tools to promote health. We developed Jaga Sehat (“Stay Healthy”), an Indonesian version of the mHealth app which was created as a form of health education for the general population. The current study aimed to test the usability and acceptability of the Jaga Sehat mHealth app.

Patients and Methods

A total of 113 dentistry students who participated in the first-year initiation program at a state university in West Java, Indonesia were recruited. Participants were asked to download, use the app and complete an online questionnaire. Open response questions explored participants’ recommendations for future improvement. Descriptive statistics were used to analyze participants responses, and content analysis was carried out to analyze open-ended responses.

Results

In general, participants perceived that Jaga Sehat mHealth app was useful, well-designed app, functional, and easy to use. We found that most of participants gave positive feedback and considered it as having high usability and acceptability.

Conclusion

Participants reported that Jaga Sehat mHealth app was functional, easy to use and have a good design. The language and material were clear and easy to understand. The app could encourage and help them lead a healthy lifestyle; therefore, they would recommend this app for others.

Usability and Acceptability of a Mobile App for Behavior Change and to Improve Immunization Coverage among Children in Pakistan: A Mixed-Methods Study

Background: Pakistan’s immunization uptake rates are still significantly lower than anticipated despite several initiatives. Lack of awareness, forgetting about vaccination schedule, and vaccine misconception/misinformation are a few of the major drivers that mitigate the rates of immunization. The current COVID-19 pandemic emphasizes the importance of immunization. The significant reductions in regular childhood vaccination during pandemic have increased the risk of outbreaks of vaccine-preventable diseases. Concerns among parents over possibly exposing their children to COVID-19 during child visits may have contributed to the reported declines. Innovative and cost-effective mHealth interventions must be implemented in order to address the problem of inadequate immunization rates. In addition, it is also critical to understand the end user needs in order to reflect on the highly relevant essence of the customized healthcare experience. Objective: The aim of this study was to learn about caregivers’ attitudes toward the usability and acceptability of behavior-change smartphone applications (mobile phones) for improving immunization coverage in Pakistan. Methods: A mixed-method design was employed for this study. The study was conducted at Aga Khan University, Hospital. Parents visiting the Community Health Center for 6-week vaccination of their children were recruited. The study was conducted in two stages. Stage 1 consisted of qualitative interviews that grasped the parent’s attitudes and challenges to immunization, as well as their acceptability and accessibility of the smartphone-based behavior-change application to increase vaccine uptake. Stage 1 was followed by stage 2, in which data were collected through a questionnaire designed by using data from qualitative interviews. Results: The majority of participants agreed that immunization serves an important role in protecting their child from illnesses that cause morbidity and mortality. Almost all of them emphasized the importance of using a pre-appointment method at vaccination center in order to reduce the waiting time. Furthermore, participants were also interested in AI-based behavior modification applications related to immunization. They also wanted to have applications in their native language for better understanding and communication of related information. In our study, approximately 95.2 percent of participants agreed to accept SMS immunization updates, which was also reasonably high. Lastly, the majority of them identified forgetfulness as a significant contributor to regular immunization. Conclusion: To enhance the uptake of childhood vaccines, overall vaccination rates, and overcome barriers related to vaccination coverage, cost-effective and user-friendly mHealth AI-based smart phone applications are required to raise awareness regarding the continuation of vaccination service and the importance of timely vaccination. Parents’ experiences and attitudes must be considered while designing and evaluating the efficacy of mHealth-based interventions.

Applying Mobile Technology to Sustain Physical Activity After Completion of Cardiac Rehabilitation: Acceptability Study

BACKGROUND

Many patients do not meet the recommended levels of physical activity after completing a cardiac rehabilitation (CR) program. Wearable activity trackers and mobile phone apps are promising potential self-management tools for maintaining physical activity after CR completion.

OBJECTIVE

This study aims to evaluate the acceptability of a wearable device, mobile app, and push messages to facilitate physical activity following CR completion.

METHODS

We used semistructured interviews to assess the acceptability of various mobile technologies after participation in a pilot randomized controlled trial. Intervention patients in the randomized controlled trial wore the Fitbit Charge 2, used the Movn mobile app, and received push messages on cardiovascular disease prevention and physical activity for over 2 months. We asked 26 intervention group participants for feedback about their experience with the technology and conducted semistructured individual interviews with 7 representative participants. We used thematic analysis to create the main themes from individual interviews.

RESULTS

Our sample included participants with a mean age of 66.7 (SD 8.6) years; 23% (6/26) were female. Overall, there were varying levels of satisfaction with different technology components. There were 7 participants who completed the satisfaction questionnaires and participated in the interviews. The Fitbit and Movn mobile app received high satisfaction scores of 4.86 and 4.5, respectively, whereas push messages had a score of 3.14 out of 5. We identified four main themes through the interviews: technology use increased motivation to be physically active, technology use served as a reminder to be physically active, recommendations for technology to improve user experience, and desire for personal feedback.

CONCLUSIONS

By applying a wearable activity tracker, mobile phone app, and push messages, our study showed strong potential for the adoption of new technologies by older adults to maintain physical activity after CR completion. Future research should include a larger sample over a longer period using a mixed methods approach to assess the efficacy of technology use for promoting long-term physical activity behavior in older adults.

A Digital Lifestyle Program in Outpatient Treatment of Type 2 Diabetes: A Randomized Controlled Study

BACKGROUND

Lifestyle is important in type 2 diabetes mellitus (T2DM). This study's aim was to investigate whether a healthy-lifestyle-supporting smartphone application could affect treatment outcomes at an endocrinology outpatient clinic.

METHODS

Consecutively invited patients were randomly assigned to an intervention or control group after age and gender stratification. In addition to standard care, intervention group participants used a smartphone application to access a lifestyle program (SidekickHealth) through which they received personalized recommendations and education about healthy lifestyles. Tests at baseline and every other month for six months included body weight and blood tests for glycated hemoglobin (HbA1c) and blood lipids, as well as questionnaires about distress related to diabetes, health-related quality of life, depression, and anxiety. Statistics included comparisons both within and between groups.

RESULTS

A total of 37 patients (23 women) were included, whereof 30 finished, 15 in each group (19% dropout); the average age was 51.2 ± 10.6 (25-70) years. No significant differences emerged between groups, but within the intervention group, there was a significant decrease in HbA1c from 61 ± 21.4 to 52.7 ± 15.2 mmol/mol, in disease-specific distress from 19.5 ± 16.5 to 11.7 ± 13.4, and in anxiety symptoms from 5.4 ± 4.0 to 4.1 ± 3.8. No significant changes occurred within the control group. The application usage was most frequent during the first months and differed interpersonally.

CONCLUSIONS

Our results indicate that the SidekickHealth digital lifestyle program could potentially enhance outpatient treatment in T2DM, in terms of both glycemic control and psychological well-being but larger confirmative studies are needed.

The Challenge of Sustainable Access to Telemonitoring Tools for People with Diabetes in Europe: Lessons from COVID-19 and Beyond

Telemedicine in diabetes care has been evolving over several years, particularly since the advent of cloud-connected technologies for diabetes management, such as glucose monitoring devices, including continuous glucose monitoring (CGM) systems, that facilitate sharing of glucose data between people with diabetes and their healthcare professionals in near-real time. Extreme social distancing and shielding in place for vulnerable patients during the COVID-19 pandemic has created both the challenge and the opportunity to provide care at a distance on a large scale. Available evidence suggests that glucose control has in fact improved during this period for people with diabetes who are able to use CGM devices for remote glucose monitoring. The development of telemedicine as part of the standard of care in diabetes faces significant challenges in the European context, particularly in terms of providing consistent and effective care at a distance to large populations of patients while using robust systems that can be supported by large regional and national healthcare services. These challenges include a fragmented approach to healthcare technology assessment and reimbursement, lack of eHealth education and literacy, particularly amongst healthcare professionals, lack of data integration, as well as concerns about electronic health records, patient consent and privacy. Here we review the benefits of and challenges to wider application of telemedicine and telemonitoring in the post-pandemic future, with the aim to ensure that the value of these eHealth services is provided to patients, healthcare providers and health systems.

Technology in the management of type 2 diabetes: Present status and future prospects

The growing incidence of type 2 diabetes (T2D) is a significant health concern, representing 90% of diabetes cases worldwide. As the disease progresses, resultant insulin deficiency and hyperglycaemia necessitates insulin therapy in many cases. It has been recognized that a significant number of people who have a clinical requirement for insulin therapy, as well as their healthcare professionals, are reluctant to intensify treatment with insulin due to fear of hypoglycaemia, poor understanding of treatment regimens or lack of engagement, and are therefore at higher risk of developing complications from poor glycaemic control. Over the past decade, the rise of diabetes technologies, including dosing advisors, continuous glucose monitoring systems, insulin pumps and automated insulin delivery systems, has led to great improvements in the therapies available, particularly to those requiring insulin. Although the focus has largely been on delivering these therapies to the type 1 diabetes population, it is becoming increasingly recognized that people with T2D face similar challenges to achieve recommended glycaemic standards and also have the potential to benefit from these advances. In this review, we discuss diabetes technologies that are currently available for people with T2D and the evidence supporting their use, as well as future prospects. We conclude that there is a clinical need to extend the use of these technologies to the T2D population to curb the consequences of suboptimal disease management in this group.

Preferences for mHealth Technology and Text Messaging Communication in Patients With Type 2 Diabetes: Qualitative Interview Study

Background

Individuals with diabetes need regular support to help them manage their diabetes on their own, ideally delivered via mechanisms that they already use, such as their mobile phones. One reason for the modest effectiveness of prior technology-based interventions may be that the patient perspective has been insufficiently incorporated.

Objective

This study aims to understand patients’ preferences for mobile health (mHealth) technology and how that technology can be integrated into patients’ routines, especially with regard to medication use.

Methods

We conducted semistructured qualitative individual interviews with patients with type 2 diabetes from an urban health care system to elicit and explore their perspectives on diabetes medication–taking behaviors, daily patterns of using mobile technology, use of mHealth technology for diabetes care, acceptability of text messages to support medication adherence, and preferred framing of information within text messages to support diabetes care. The interviews were digitally recorded and transcribed. The data were analyzed using codes developed by the study team to generate themes, with representative quotations selected as illustrations.

Results

We conducted interviews with 20 participants, of whom 12 (60%) were female and 9 (45%) were White; in addition, the participants’ mean glycated hemoglobin A_1c control was 7.8 (SD 1.1). Overall, 5 key themes were identified: patients try to incorporate cues into their routines to help them with consistent medication taking; many patients leverage some form of technology as a cue to support adherence to medication taking and diabetes self-management behaviors; patients value simplicity and integration of technology solutions used for diabetes care, managing medications, and communicating with health care providers; some patients express reluctance to rely on mobile technology for these diabetes care behaviors; and patients believe they prefer positively framed communication, but communication preferences are highly individualized.

Conclusions

The participants expressed some hesitation about using mobile technology in supporting diabetes self-management but have largely incorporated it or are open to incorporating it as a cue to make medication taking more automatic and less burdensome. When using technology to support diabetes self-management, participants exhibited individualized preferences, but overall, they preferred simple and positively framed communication. mHealth interventions may be improved by focusing on integrating them easily into daily routines and increasing the customization of content.

Use of Virtual Care for Glycemic Management in People With Types 1 and 2 Diabetes and Diabetes in Pregnancy: A Rapid Review

Our objective in this study was to answer the main research question: In patients with diabetes, does virtual care vs face-to-face care provide different clinical, patient and practitioner experience or quality outcomes? Articles (2012 to 2020) describing interventions using virtual care with the capability for 2-way, individualized interactions compared with usual care were included. Studies involving any patients with diabetes and outcomes of glycated hemoglobin (A1C), quality of care and/or patient or health-care practitioner experience were included. Systematic reviews, randomized controlled studies, quasi-experimental trials, implementation trials, observational studies and qualitative analyses were reviewed. MEDLINE and McMaster Health Evidence databases searched in June 2020 identified 59 articles. Virtual care, in particular telemonitoring, combined with a means of 2-way communications provided improvement in A1C similar or superior to usual care, with the strongest evidence for type 2 diabetes. Virtual care was generally acceptable to patients, who expressed satisfaction with their care. Health-care providers recognized benefits but raised issues of technical support, workflow and compensation.

User Engagement and Clinical Impact of the Manage My Pain App in Patients With Chronic Pain: A Real-World, Multi-site Trial

Background

Chronic pain imposes a large burden on individuals and society. A patient-centric digital chronic pain management app called Manage My Pain (MMP) can be used to enhance communication between providers and patients and promote self-management.

Objective

The purpose of this study was to evaluate the real-world engagement of patients in urban and rural settings in Ontario, Canada with the MMP app alongside their standard of care and assess the impact of its usage on clinical outcomes of pain and related mental health.

Methods

A total of 246 participants with chronic pain at a rural and 2 urban pain clinics were recruited into this prospective, open-label, exploratory study that compared the use of MMP, a digital health app for pain that incorporates validated questionnaires and provides patients with summarized reports of their progress in combination with standard care (app group), against data entered on paper-based questionnaires (nonapp group). Participants completed validated questionnaires on anxiety, depression, pain catastrophizing, satisfaction, and daily opioid consumption up to 4.5 months after the initial visit (short-term follow-up) and between 4.5 and 7 months after the initial visit (long-term follow-up). Engagement and clinical outcomes were compared between participants in the two groups.

Results

A total of 73.6% (181/246) of the participants agreed to use the app, with 63.4% (111/175) of them using it for at least one month. Individuals who used the app rated lower anxiety (reduction in Generalized Anxiety Disorder 7-item questionnaire score by 2.10 points, 95% CI –3.96 to –0.24) at short-term follow-up and had a greater reduction in pain catastrophizing (reduction in Pain Catastrophizing Scale score by 5.23 points, 95% CI –9.55 to –0.91) at long-term follow-up relative to patients with pain who did not engage with the MMP app.

Conclusions

The use of MMP by patients with chronic pain is associated with engagement and improvements in self-reported anxiety and pain catastrophizing. Further research is required to understand factors that impact continued engagement and clinical outcomes in patients with chronic pain.

Trial Registration

ClinicalTrials.gov NCT04762329; https://clinicaltrials.gov/ct2/show/NCT04762329

Patient Preference and Satisfaction with the Use of Telemedicine for Glycemic Control in Patients with Type 2 Diabetes: A Review

BACKGROUND

Telemedicine has the potential to improve patient care and management for various chronic diseases such as type 2 diabetes. To ensure the success of any telemedicine program, there is a need to understand the patients' satisfaction and their preferences. This review aims to collate and provide evidence related to practices that may influence the performance of telemedicine for patients with type 2 diabetes.

METHODS

We searched three electronic databases for studies examining patients' satisfaction and preferences for using telemedicine in type 2 diabetes. An evaluation matrix was developed to collect the data from the included articles. A total of 20 articles were identified and data on the key outcomes identified were narratively synthesized.

RESULTS

Patients were generally satisfied with the use of telemedicine for management of type 2 diabetes. Users reported that telemedicine was beneficial as it provided constant monitoring, improved access to healthcare providers, and reduced waiting time. When adopting a telemedicine platform, most patients expressed preference for mobile health (mHealth) as the telemedicine modality, especially if it has been endorsed by their physician. To improve usability and sustainability, patients suggested that modules related to diabetes education be enhanced, together with sufficient technical and physician support when adopting telemedicine. Patients also expressed the importance of having a sufficiently flexible platform that could be adapted to their needs.

CONCLUSION

Personalized telemedicine strategies coupled with appropriate physician endorsement greatly influences a patient's decision to undertake telemedicine. Future work should focus on improving telemedicine infrastructure and increasing physician's involvement, especially during the implementation phase.

Assessing acceptability and patient experience of a behavioral lifestyle intervention using fitbit technology in older adults to manage type 2 diabetes amid COVID-19 pandemic: A focus group study

Type 2 diabetes (T2D) contributes to reduced quality of life in older adults, especially in those with comorbidities such as being overweight or obese. Personal fitness technology (Fitbit ®) has the potential to improve the management of T2D. Using a semi-structured interview guide, focus groups were conducted to explore participants' acceptability and experiences following a behavioral lifestyle intervention that integrated Fitbit in overweight/obese older adults with T2D amid the COVID-19 pandemic which began during the time of this study. Focus group transcripts were transcribed and analyzed using thematic analysis. Eighteen (18) of the 20 participants completed the program and focus group interviews. Overall, we observed high acceptability of the program, and participants reported favorable experiences such as increased knowledge of health behaviors, improved diabetes management, and improved quality of life following the behavioral lifestyle intervention, even under stressful life circumstances from COVID-19.

Identifying features of a mobile-based application for self-care of people living with T2DM

INTRODUCTION

Diabetes self-care requires support to empower patients to improve self-monitoring and maintain the necessary self-care behaviors. We aimed to identify features of a mobile-based application as a technology-based device for self-care of people living with T2DM.

METHOD

This study was conducted in two main phases in 2020. In the first phase, a literature review study was performed to identify the data elements and technical features of the T2DM self-care application. In the second phase, using the information obtained from the review of similar articles, a questionnaire was designed to validate identified requirements. The statistical population of the present study consisted of 22 endocrinologists and metabolic specialists.

RESULTS

Identification of 55 data elements and technical features for mobile-based self-care application for people with T2DM, and according to the statistical population, 15data elements for demographic requirements, 16 data elements for clinical requirements, and 17 features for the technical capability of this app were selected.

CONCLUSION

Blood sugar monitoring, exercise, nutrition, weight monitoring, and educational capabilities were the most highlighted technical features of the T2DM self-care application. Software designers can use these requirements to design a self-care app for people with type-2 diabetes that can help manage and improve patients' health status.

EatSmart, a Web-Based and Mobile Healthy Eating Intervention for Disadvantaged People With Type 2 Diabetes: Protocol for a Pilot Mixed Methods Intervention Study

Background

People of low socioeconomic position (SEP) are disproportionately affected by type 2 diabetes (T2D), partly due to unhealthy eating patterns that contribute to inadequate disease self-management and prognosis. Digital technologies have the potential to provide a suitable medium to facilitate diabetes education, support self-management, and address some of the barriers to healthy eating, such as lack of nutritional knowledge or shopping or cooking skills, in this target group.

Objective

This study aims to test the feasibility, appeal, and potential effectiveness of EatSmart, a 12-week, evidence-based, theoretically grounded, fully automated web-based and mobile-delivered healthy eating behavior change program to help disadvantaged people living with T2D to eat healthily on a budget and improve diabetes self-management.

Methods

EatSmart is a mixed methods (quantitative and qualitative) pre-post design pilot study. Sixty socioeconomically disadvantaged people with T2D aged 18 to 75 years will be recruited. Participants will complete self-reported baseline assessments of their basic demographic and clinical data, dietary intake, dietary self-efficacy, and barriers to healthy eating. They will be provided with login access to the EatSmart web program, which includes six progressive skill-based modules covering healthy eating planning; smart food budgeting and shopping; time-saving meal strategies, healthy cooking methods, modifying recipes; and a final reinforcement and summary module. Over the 3-month intervention, participants will also receive 3 text messages weekly, encouraging them to review goals, continue to engage with different components of the EatSmart web program, and eat healthily. Participants will undertake follow-up assessments directly following the intervention 3 months post baseline and again after a 6-month postintervention follow-up period (9 months post baseline). Feasibility will be evaluated using the number of participants recruited and retained and objective indicators of engagement with the website. Program appeal and potential effects on primary and secondary outcomes will be assessed via the same surveys used at baseline, with additional questions asking about experience with and perceptions of the program. In-depth qualitative interviews will also be conducted 6 months post intervention to provide deeper insight into experiences with EatSmart and a more comprehensive description of the program’s appeal.

Results

The EatSmart website has been developed, and all participants have viewed the modules as of May 2020. Results are expected to be submitted for publication in December 2020.

Conclusions

This study will provide data to address the currently limited evidence regarding whether disadvantaged populations with T2D may benefit from digitally delivered behavior change programs that facilitate eating healthily on a budget.

Trial Registration

Australian New Zealand Clinical Trials Registry, ACTRN12619001111167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001111167

International Registered Report Identifier (IRRID)

DERR1-10.2196/19488

Effect of the Pregnant+ Smartphone App on the Dietary Behavior of Women With Gestational Diabetes Mellitus: Secondary Analysis of a Randomized Controlled Trial

Background

The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide. A healthy diet and stable blood glucose levels during pregnancy can prevent adverse health outcomes for the mother and the newborn child. Mobile health may be a useful supplement to prenatal care, providing women with targeted dietary information concerning GDM.

Objective

We analyzed secondary data from a two-arm, multicentered, nonblinded randomized controlled trial to determine if a smartphone app with targeted dietary information and blood glucose monitoring had an effect on the dietary behavior of women with GDM.

Methods

Women with a 2-hour oral glucose tolerance test level of ≥9 mmol/L were individually randomized to either the intervention group receiving the Pregnant+ app and usual care or the control group receiving usual care only. Eligible women were enrolled from 5 diabetes outpatient clinics in the Oslo region, Norway, between October 2015 and April 2017. The Pregnant+ app promoted 10 GDM-specific dietary recommendations. A healthy dietary score for Pregnant+ (HDS-P+) was constructed from a 41-item food frequency questionnaire and used to assess the intervention effect on the dietary behavior completed at trial entry and at around gestation week 36. Dietary changes from baseline to week 36 were examined by a paired sample two-tailed t test. Between-group dietary differences after the intervention were estimated with analysis of covariance, with adjustment for baseline diet.

Results

A total of 238 women participated: 115 were allocated to the intervention group and 123 to the control group. Of the 238 women, 193 (81.1%) completed the food frequency questionnaire both at baseline and around gestational week 36. All the participants showed improvements in their HDS-P+ from baseline. However, the Pregnant+ app did not have a significant effect on their HDS-P+. The control group reported a higher weekly frequency of choosing fish meals (P=.05). No other significant differences were found between the intervention and control groups. There were no significant demographic baseline differences between the groups, except that more women in the intervention group had a non-Norwegian language as their first language (61 vs 46; P=.02).

Conclusions

Our findings do not support the supplementation of face-to-face follow-up of women with GDM with a smartphone app in the presence of high-standard usual care, as the Pregnant+ app did not have a beneficial effect on pregnant women’s diet.

Trial Registration

ClinicalTrials.gov NCT02588729; https://clinicaltrials.gov/ct2/show/NCT02588729

User Perception of a Smartphone App to Promote Physical Activity Through Active Transportation: Inductive Qualitative Content Analysis Within the Smart City Active Mobile Phone Intervention (SCAMPI) Study

Background

Physical inactivity is globally recognized as a major risk factor for morbidity, particularly the incidence of noncommunicable diseases. Increasing physical activity (PA) is therefore a public health priority. Engaging in active transportation (AT) is a viable approach for promoting daily PA levels. Mobile health interventions enable the promotion of AT to a larger population. The Smart City Active Mobile Phone Intervention (SCAMPI) study was a randomized controlled trial designed to evaluate the ability of a behavior change program delivered via a smartphone app to motivate participants to increase their PA by engaging in AT.

Objective

This qualitative study aims to examine the acceptance and user experience of the app promoting AT that was used in the SCAMPI trial (the TRavelVU Plus app).

Methods

A total of 17 residents of Stockholm County (13 women; age range 25-61 years) who completed the 3-month app-based behavioral change program (delivered through the TRavelVU Plus app) in the SCAMPI randomized controlled trial during 2018 agreed to participate in a semistructured telephone-based interview. These participants were well representative of the whole intervention group (n=127) in terms of baseline characteristics such as age, sex, and area of residence. The interviews were audiorecorded, transcribed verbatim, and analyzed using an inductive qualitative content analysis.

Results

The content analysis revealed 2 themes and 4 subcategories. The first theme, “main motivators: monitoring and messages,” highlighted that monitoring AT and being able to set weekly goals using the app were the primary motivators reported by study participants. The second theme, “acceptable but modifiable,” reflects that the app was well accepted and effectively encouraged many participants to use more AT. Nevertheless, there were functions in the app that require modification. For example, while the semiautomated travel tracking feature was appreciated, participants found it time-consuming and unreliable at times.

Conclusions

This study contributes novel insight into adults’ experiences of using a mobile app to promote the use of AT. The results showed that the app was well accepted and that self-monitoring and goal setting were the main motivators to engage in more AT. The semiautomated tracking of AT was appreciated; however, it was also reported to be energy- and time-consuming when it failed to work. Thus, this feature should be improved going forward.

Trial Registration

ClinicalTrials.gov NCT03086837; https://clinicaltrials.gov/ct2/show/NCT03086837

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-018-5658-4

A Companion App to Support Rheumatology Patients Treated with Certolizumab Pegol: Results From a Usability Study

Background

Certolizumab pegol (CZP) is an anti-tumor necrosis factor drug approved for the treatment of multiple moderate to severe chronic inflammatory diseases. In the European Union, CZP is approved for administration by subcutaneous self-injection using a prefilled syringe, prefilled pen, or reusable electromechanical auto-injector (electronic device). CimplyMe is a companion app for use alongside CZP self-injection devices, designed to support CZP-treated patients self-managing their treatment and disease.

Objective

This study aimed to validate the usability of the companion app by demonstrating that tasks required for use can be performed successfully by intended end users.

Methods

We recruited 15 patients with moderate to severe rheumatoid arthritis, currently prescribed biologic treatment, and using apps on a smart phone. Patients were assessed on their ability to use the companion app in a setting designed to simulate a location where patients regularly administer biologic treatment. To assess the usability of the key features of the app, 8 critical and 3 noncritical tasks were designed. Patients’ success on each task was recorded through observations or knowledge-based questions. Successes with difficulty and use errors were also recorded. If a patient made a use error at the first attempt, a second attempt was allowed. Second-attempt use errors were recorded as a task failure.

Results

A total of 207 first attempts at the 14 components of the 8 critical tasks were evaluated (3 patients failed to complete one component); 178 (86.0%) critical tasks were successfully completed at the first attempt. The remaining first attempts comprised 16 (7.7%) successes with difficulty and 13 (6.3%) use errors, which had to be repeated. One critical task was not re-attempted by one patient due to time constraints; however, there were no use errors in the 12 completed second attempts. A total of 107 first attempts at the 3 noncritical tasks were made, all of which (107/107, 100.0%) were completed without use errors.

Conclusions

In simulated testing, patients were able to successfully use the companion app without formal training. This study suggests the companion app is easy to use and could help patients prescribed CZP better manage their treatment and disease.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

People with type 2 diabetes struggling for self-management: A part study from the randomized controlled trial in RENEWING HEALTH

AIM

To develop a theoretical explanation for the daily life problems and challenges perceived by those living with type 2 diabetes.

DESIGN AND METHODS

We used a grounded theory approach with a constant comparative method to discover a framework with the core concept of struggling between "ought to do" and "want to do" and related concepts.

RESULTS

The struggle to self-manage and maintain new habits can be more or less difficult depending on the patient's perceived conditions. We identified three situations illustrated in a diagram: one where there is less struggle to let go of old habits, a second where there is more of a struggle to balance between what individuals want to do and what they ought to do and a third where they are giving up struggling. Study findings show that healthcare personnel must consciously seek to understand how patients perceive their own situation.