Evaluating the Implementation of the GREAT4Diabetes WhatsApp Chatbot to Educate People With Type 2 Diabetes During the COVID-19 Pandemic: Convergent Mixed Methods Study

Application of Chatbots to Help Patients Self-Manage Diabetes: Systematic Review and Meta-Analysis

BACKGROUND

The number of people with diabetes is on the rise globally. Self-management and health education of patients are the keys to control diabetes. With the development of digital therapies and artificial intelligence, chatbots have the potential to provide health-related information and improve accessibility and effectiveness in the field of patient self-management.

OBJECTIVE

This study systematically reviews the current research status and effectiveness of chatbots in the field of diabetes self-management to support the development of diabetes chatbots.

METHODS

A systematic review and meta-analysis of chatbots that can help patients with diabetes with self-management was conducted. PubMed and Web of Science databases were searched using keywords around diabetes, chatbots, conversational agents, virtual assistants, and more. The search period was from the date of creation of the databases to January 1, 2023. Research articles in English that fit the study topic were selected, and articles that did not fit the study topic or were not available in full text were excluded.

RESULTS

In total, 25 studies were included in the review. In terms of study type, all articles could be classified as systematic design studies (n=8, 32%), pilot studies (n=8, 32%), and intervention studies (n=9, 36%). Many articles adopted a nonrandomized controlled trial design in intervention studies (n=6, 24%), and there was only 1 (4%) randomized controlled trial. In terms of research strategy, all articles can be divided into quantitative studies (n=10, 40%), mixed studies (n=6, 24%), and qualitative studies (n=1, 4%). The evaluation criteria for chatbot effectiveness can be divided into technical performance evaluation, user experience evaluation, and user health evaluation. Most chatbots (n=17, 68%) provided education and management focused on patient diet, exercise, glucose monitoring, medications, and complications, and only a few studies (n=2, 8%) provided education on mental health. The meta-analysis found that the chatbot intervention was effective in lowering blood glucose (mean difference 0.30, 95% CI 0.04-0.55; P=.02) and had no significant effect in reducing weight (mean difference 1.41, 95% CI -2.29 to 5.11; P=.46) compared with the baseline.

CONCLUSIONS

Chatbots have potential for the development of self-management for people with diabetes. However, the evidence level of current research is low, and higher level research (such as randomized controlled trials) is needed to strengthen the evidence base. More use of mixed research in the research strategy is needed to fully use the strengths of both quantitative and qualitative research. Appropriate and innovative theoretical frameworks should be used in the research to provide theoretical support for the study. In addition, researchers should focus on the personalized and user-friendly interactive features of chatbots, as well as improvements in study design.

Traditional and Online Health Information Seeking Among Individuals With Limited English Proficiency in the United States: Cross-Sectional Study

PURPOSE

We investigate how individuals with Limited English Proficiency (LEP) seek, access, and evaluate traditional and online sources they rely on for health information.

DESIGN

Retrospective cross-sectional survey analysis from the United States.

SETTING

Pooled Health Information National Trends Survey surveys (2013-2019).

SUBJECTS

The sample was comprised 15,316 respondents; 236/15,316 (1.54%) completed the survey in Spanish and 1727/14,734 (11.72%) had LEP (did not speak English "very well"). The sample was nationally representative across demographic categories.

MEASURES

Independent and dependent variables were self-reported using validated measures.

ANALYSIS

Multivariable logistic regression models using jackknife replicate weights for population estimates.

RESULTS

Adults with LEP were less confident in their capacity to access health information (aOR = 0.59, CI: 0.47-0.75) and had less trust in health information from medical professionals (aOR = 0.57,CI: 0.46-0.72) than English proficient (EP) adults. Although LEP and EP adults were both most likely to use the internet as their first source of information, LEP adults were more likely than EP adults to consult health professionals, print sources like books, news or brochures, family and friends, television and radio. Spanish language survey respondents were more likely to trust health information from government agencies (aOR = 1.99, CI: 1.09-3.62) and watch health-related videos on the internet than respondents who took the survey in English (aOR = 2.51, CI: 1.23-5.12).

CONCLUSION

Our results show how language barriers may contribute to health disparities experienced by linguistic minorities. Government agencies and health care organizations need to promote health information dissemination in underserved communities and may need to embrace the use of alternative information sources such as television, radio, and the internet to reach LEP populations.

Digital Health Solutions for Community-Based Control of Diabetes During COVID-19 Pandemic: A Scoping Review of Implementation Outcomes

BACKGROUND

The COVID-19 pandemic has added to the pre-existing challenges of diabetes management in many countries. It has accelerated the wider use of digital health solutions which have tremendous potential to improve health outcomes for people with diabetes. However, little is known about the attributes and the implementation of these solutions.

OBJECTIVE

To identify and describe digital health solutions for community-based diabetes management and to highlight their key implementation outcomes.

METHODS

We searched Ovid Medline, CINAHL, Embase, PsycINFO, and Web of Science for relevant articles. A purposive search was also used to identify grey literature. Articles that described digital health solutions that aimed to improve community-based diabetes management were included in this review. We applied a thematic synthesis of evidence to describe the characteristics of digital health solutions, and to summarize their key implementation outcomes.

RESULTS

We included 15 articles that reported digital health solutions that primarily focused on community-based diabetes management. Nine of the 15 innovations involved were mobile applications and/or web-based platforms, and five were based on social media platforms. The majority of the digital health solutions were used for diabetes education and support. High engagement, utilization, and satisfaction rates with digital health solutions were observed. The use of digital health solutions was also associated with improvement in self-management, taking medication, and reduction in glycated hemoglobin (HbA1c) levels.

CONCLUSION

COVID-19 triggered digital health solutions have tremendous potential to improve health outcomes for people with diabetes. Further studies are needed to evaluate the sustainability and scale-up of these solutions.

The first AI-based Chatbot to promote HIV self-management: A mixed methods usability study

BACKGROUND

We developed MARVIN, an artificial intelligence (AI)-based chatbot that provides 24/7 expert-validated information on self-management-related topics for people with HIV. This study assessed (1) the feasibility of using MARVIN, (2) its usability and acceptability, and (3) four usability subconstructs (perceived ease of use, perceived usefulness, attitude towards use, and behavioural intention to use).

METHODS

In a mixed-methods study conducted at the McGill University Health Centre, enrolled participants were asked to have 20 conversations within 3 weeks with MARVIN on predetermined topics and to complete a usability questionnaire. Feasibility, usability, acceptability, and usability subconstructs were examined against predetermined success thresholds. Qualitatively, randomly selected participants were invited to semi-structured focus groups/interviews to discuss their experiences with MARVIN. Barriers and facilitators were identified according to the four usability subconstructs.

RESULTS

From March 2021 to April 2022, 28 participants were surveyed after a 3-week testing period, and nine were interviewed. Study retention was 70% (28/40). Mean usability exceeded the threshold (69.9/68), whereas mean acceptability was very close to target (23.8/24). Ratings of attitude towards MARVIN's use were positive (+14%), with the remaining subconstructs exceeding the target (5/7). Facilitators included MARVIN's reliable and useful real-time information support, its easy accessibility, provision of convivial conversations, confidentiality, and perception as being emotionally safe. However, MARVIN's limited comprehension and the use of Facebook as an implementation platform were identified as barriers, along with the need for more conversation topics and new features (e.g., memorization).

CONCLUSIONS

The study demonstrated MARVIN's global usability. Our findings show its potential for HIV self-management and provide direction for further development.

Mapping Digital Public Health Interventions Among Existing Digital Technologies and Internet-Based Interventions to Maintain and Improve Population Health in Practice: Scoping Review

BACKGROUND

The rapid progression and integration of digital technologies into public health have reshaped the global landscape of health care delivery and disease prevention. In pursuit of better population health and health care accessibility, many countries have integrated digital interventions into their health care systems, such as web-based consultations, electronic health records, and telemedicine. Despite the increasing prevalence and relevance of digital technologies in public health and their varying definitions, there has been a shortage of studies examining whether these technologies align with the established definition and core characteristics of digital public health (DiPH) interventions. Hence, the imperative need for a scoping review emerges to explore the breadth of literature dedicated to this subject.

OBJECTIVE

This scoping review aims to outline DiPH interventions from different implementation stages for health promotion, primary to tertiary prevention, including health care and disease surveillance and monitoring. In addition, we aim to map the reported intervention characteristics, including their technical features and nontechnical elements.

METHODS

Original studies or reports of DiPH intervention focused on population health were eligible for this review. PubMed, Web of Science, CENTRAL, IEEE Xplore, and the ACM Full-Text Collection were searched for relevant literature (last updated on October 5, 2022). Intervention characteristics of each identified DiPH intervention, such as target groups, level of prevention or health care, digital health functions, intervention types, and public health functions, were extracted and used to map DiPH interventions. MAXQDA 2022.7 (VERBI GmbH) was used for qualitative data analysis of such interventions' technical functions and nontechnical characteristics.

RESULTS

In total, we identified and screened 15,701 records, of which 1562 (9.94%) full texts were considered relevant and were assessed for eligibility. Finally, we included 185 (11.84%) publications, which reported 179 different DiPH interventions. Our analysis revealed a diverse landscape of interventions, with telemedical services, health apps, and electronic health records as dominant types. These interventions targeted a wide range of populations and settings, demonstrating their adaptability. The analysis highlighted the multifaceted nature of digital interventions, necessitating precise definitions and standardized terminologies for effective collaboration and evaluation.

CONCLUSIONS

Although this scoping review was able to map characteristics and technical functions among 13 intervention types in DiPH, emerging technologies such as artificial intelligence might have been underrepresented in our study. This review underscores the diversity of DiPH interventions among and within intervention groups. Moreover, it highlights the importance of precise terminology for effective planning and evaluation. This review promotes cross-disciplinary collaboration by emphasizing the need for clear definitions, distinct technological functions, and well-defined use cases. It lays the foundation for international benchmarks and comparability within DiPH systems. Further research is needed to map intervention characteristics in this still-evolving field continuously.

TRIAL REGISTRATION

PROSPERO CRD42021265562; https://tinyurl.com/43jksb3k.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33404.

Evaluating the implementation of group empowerment and training (GREAT) for diabetes in South Africa: convergent mixed methods

OBJECTIVE

Type 2 diabetes is a leading contributor to the burden of disease in South Africa. Primary care is struggling to support self-management and lifestyle change. Group empowerment and training (GREAT) for diabetes is a feasible and cost-effective intervention in our setting. This study aimed to evaluate the implementation of GREAT for diabetes.

DESIGN

A convergent mixed-methods study evaluated a range of implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, reach and cost.

SETTING

Ten primary care facilities from a district in all nine provinces of South Africa.

PARTICIPANTS

Descriptive exploratory individual semistructured interviews were conducted with 34 key stakeholders from national policy-makers to primary care providers. Three focus group interviews were held with 35 patients.

RESULTS

The National Department of Health saw GREAT as an acceptable and appropriate intervention, but only five of the nine provinces adopted GREAT. District-level and facility-level managers also saw GREAT as an acceptable and appropriate intervention. Factors related to feasibility included physical space, sufficient staff numbers, availability of resource materials, the health information system, adaptation to the model of care (selection of facilities, patients, adjustment of patient flow and appointment systems, leadership from local managers and the whole clinical team) and inclusion in systems for quality improvement. No major changes were made to the design of GREAT and fidelity to the session content ranged from 66% to 94%. Incremental costs were US$494 per facility. Due to disruption from the COVID-19 pandemic, only 14 facilities implemented and reached 588 patients at the time of evaluation.

CONCLUSION

Key lessons were learnt on how to implement GREAT for diabetes in a middle-income country setting. The findings informed the design of a programme theory using a health system framework. The programme theory will guide further scale-up in each province and scale-out to provinces that have not yet implemented.

QUESTION

This study focused on evaluating how to implement GREAT for type 2 diabetes in primary care and to take it to scale in South Africa.

FINDING

The findings led to a programme theory on how to successfully implement GREAT for diabetes in the South African context.

MEANING

The study demonstrates relevant contextual factors that need to be considered in the implementation of group diabetes education programme in a middle-income country.

Indonesian COVID-19 lesson: A mixed-methods study on adolescent health status and health services during pandemic

TOPIC

The COVID-19 pandemic affected adolescents' physical and psychological health. There must be specific services to cater to the needs of adolescents during COVID-19 in Indonesia. Lessons learned from previous pandemics will be beneficial for nurses and other health professionals to prepare services for future pandemics.

PURPOSE

This mixed-method study aimed to examine 459 Indonesian adolescents' health, literacy, preventive measures, and preferred health services during the COVID-19 pandemic. This study also examines sociodemographics, respondent characteristics, health information sources, and media choices.

RESULTS

A total of 47.5% of adolescents knew about COVID-19, 26.8% experienced physical health changes, and 61.7% considered wearing masks. Adolescent health information came from teachers (26.6%) and the Internet (32.9%). Psychological changes showed 67.8% irritation. Indonesians preferred online counseling (53.8%) and WhatsApp (45.8%) for pandemic health services. COVID-19 literacy did not affect physical or mental health (p > 0.05).

CONCLUSIONS

Most adolescents reported mental and physical health changes during COVID-19. Our data suggest that adolescents' strong COVID-19 knowledge did not prevent anxiety and other psychological difficulties. The longitudinal studies could be utilized if pandemic demands social and physical distance. The government, as well as nurses, might utilize WhatsApp-based remote online treatment for health services.

Exploring the characteristics of conversational agents in chronic disease management interventions: A scoping review

Objective

With the increasing global burden of chronic diseases, there is the potential for conversational agents (CAs) to assist people in actively managing their conditions. This paper reviews different types of CAs used for chronic condition management, delving into their characteristics and the chosen study designs. This paper also discusses the potential of these CAs to enhance the health and well-being of people with chronic conditions.

Methods

A search was performed in February 2023 on PubMed, ACM Digital Library, Scopus, and IEEE Xplore. Studies were included if they focused on chronic disease management or prevention and if systems were evaluated on target user groups.

Results

The 42 selected studies explored diverse types of CAs across 11 health conditions. Personalization varied, with 25 CAs not adapting message content, while others incorporated user characteristics and real-time context. Only 12 studies used medical records in conjunction with CAs for conditions like diabetes, mental health, cardiovascular issues, and cancer. Despite measurement method variations, the studies predominantly emphasized improved health outcomes and positive user attitudes toward CAs.

Conclusions

The results underscore the need for CAs to adapt to evolving patient needs, customize interventions, and incorporate human support and medical records for more effective care. It also highlights the potential of CAs to play a more active role in helping individuals manage their conditions and notes the value of linguistic data generated during user interactions. The analysis acknowledges its limitations and encourages further research into the use and potential of CAs in disease-specific contexts.

Social Media-Delivered Lifestyle Interventions Among Individuals Living with Diabetes and Prediabetes: A Scoping Review

PURPOSE OF REVIEW

There is a lack of synthesized evidence on social media-delivered lifestyle interventions for managing and preventing diabetes. This scoping review aims to evaluate recently reported lifestyle interventions delivered on social media for individuals with diabetes and prediabetes.

RECENT FINDINGS

Twelve studies were included in this review. A team of multidisciplinary healthcare professionals coordinated most interventions, half of which lasted for 6 months, and used a combination of videos, texts, images or audio to deliver the educational materials. The glycosylated hemoglobin (HbA1c) level improved in most of the studies, followed by diabetes self-care and fasting plasma glucose. The dietary intakes were only assessed in two interventions among the individuals with prediabetes and showed promising improvements. This scoping review provides a holistic overview of the recent designs of lifestyle interventions for diabetes management and prevention on social media. This is essential for various healthcare professionals and stakeholders to formulate and implement population-based, cost-effective interventions in combating diabetes using social media.

[ChatGPT: curse or blessing in nursing care?]

Artificial intelligence (AI) has been used in healthcare for some years for risk detection, diagnostics, documentation, education and training and other purposes. A new open AI application is ChatGPT, which is accessible to everyone. The application of ChatGPT as AI in education, training or studies is currently being discussed from many perspectives. It is questionable whether ChatGPT can and should also support nursing professions in health care. The aim of this review article is to show and critically discuss possible areas of application of ChatGPT in theory and practice with a focus on nursing practice, pedagogy, nursing research and nursing development.

Chatbot Artificial Intelligence for Genetic Cancer Risk Assessment and Counseling: A Systematic Review and Meta-Analysis

PURPOSE

Most individuals with a hereditary cancer syndrome are unaware of their genetic status to underutilization of hereditary cancer risk assessment. Chatbots, or programs that use artificial intelligence to simulate conversation, have emerged as a promising tool in health care and, more recently, as a potential tool for genetic cancer risk assessment and counseling. Here, we evaluated the existing literature on the use of chatbots in genetic cancer risk assessment and counseling.

METHODS

A systematic review was conducted using key electronic databases to identify studies which use chatbots for genetic cancer risk assessment and counseling. Eligible studies were further subjected to meta-analysis.

RESULTS

Seven studies met inclusion criteria, evaluating five distinct chatbots. Three studies evaluated a chatbot that could perform genetic cancer risk assessment, one study evaluated a chatbot that offered patient counseling, and three studies included both functions. The pooled estimated completion rate for the genetic cancer risk assessment was 36.7% (95% CI, 14.8 to 65.9). Two studies included comprehensive patient characteristics, and none involved a comparison group. Chatbots varied as to the involvement of a health care provider in the process of risk assessment and counseling.

CONCLUSION

Chatbots have been used to streamline genetic cancer risk assessment and counseling and hold promise for reducing barriers to genetic services. Data regarding user and nonuser characteristics are lacking, as are data regarding comparative effectiveness to usual care. Future research may consider the impact of chatbots on equitable access to genetic services.

Factors influencing insulin initiation in primary care facilities in Cape Town, South Africa

BACKGROUND

Type 2 diabetes (T2DM) is a leading cause of mortality in South Africa and resistance to the use of insulin is common. This study aimed to explore factors that influence the initiation of insulin in patients with T2DM in primary care facilities in Cape Town, South Africa.

METHODS

An exploratory descriptive qualitative study was conducted. Seventeen semi-structured interviews were held with patients eligible for insulin, on insulin and primary care providers. Participants were selected by maximum variation purposive sampling. Data were analysed using the framework method in Atlas-ti.

RESULTS

Factors related to the health system, service delivery, clinical care and patients. Systemic issues related to the required inputs of workforce, educational materials, and supplies. Service delivery issues related to workload, poor continuity and parallel coordination of care. Clinical issues related to adequate counselling. Patient factors included a lack of trust, concerns about injections, impact on lifestyle and disposal of needles.

CONCLUSION

Although resource constraints are likely to remain, district and facility managers can improve supplies, educational materials, continuity and coordination. Counselling must be improved and may require innovative alternative approaches to support clinicians who face high number of patients. Alternative approaches using group education, telehealth and digital solutions should be considered.Contribution: This study identified key factors influencing insulin initiation in patients with T2DM in primary care. These can be addressed by those responsible for clinical governance, service delivery and in further research.

Comprehensive patient education and counselling for non-communicable diseases in primary care, Western Cape

BACKGROUND

Treatment of non-communicable diseases (NCD) requires patient education and counselling (PEC). Initiatives have focused on Group Empowerment and Training (GREAT) for diabetes and Brief behaviour change counselling (BBCC). However, the implementation of comprehensive PEC in primary care remains a challenge. The aim of this study was to explore how such PEC could be implemented.

METHODS

This was a descriptive, exploratory, qualitative study at the end of the first year of a participatory action research project to implement comprehensive PEC for NCDs at two primary care facilities in the Western Cape. Focus group interviews were held with healthcare workers and reports from co-operative inquiry group meetings were used as qualitative data.

RESULTS

Staff were trained in GREAT for diabetes and BBCC. There were problems with training appropriate staff and sufficient numbers and a need for ongoing support. Implementation was limited by poor internal sharing of information, staff turnover and leave, rotation of staff, lack of space and fears of disrupting the efficiency of service delivery. Facilities had to embed the initiatives into appointment systems and fast track patients who attended GREAT. For those patients that were exposed to PEC, there were reported benefits.

CONCLUSION

Group empowerment was feasible to introduce, while BBCC was more challenging as it required extra time in the consultation.Contribution: Implementation of PEC requires alternative approaches that do not extend consultations (such as GREAT and maybe digital solutions) as well as commitment to facility organisation for PEC from managers.

Piloting of virtual group education for diabetes in Cape Town: An exploratory qualitative study

BACKGROUND

Diabetes is a major public health problem. During the coronavirus disease 2019 (COVID-19) pandemic, patient education and counselling (PEC) for diabetes were curtailed. This project explored the possibility of offering group empowerment and training (GREAT) for diabetes via computer or tablets and Zoom video conferencing. The aim was to explore whether this was feasible in the low-income community context of primary health care in Cape Town, South Africa.

METHODS

Three dieticians facilitated four sessions of GREAT for diabetes with a group of five patients with type-2 diabetes. Once the programme was completed, focus group interviews were held with the facilitators and the patients to explore their experience. Interviews were recorded and analysed using a simplified framework method.

RESULTS

Usual primary care was not offering PEC and service delivery was brief and mechanistic. The content, resources and group processes were successfully translated into the virtual environment. The guiding style of communication was more difficult. Patients reported changes in their self-management and appreciated being able to save time and money while participating from home. Patients required considerable support and training to use the technology. All participants were concerned about safety and crime with the hardware.

CONCLUSION

It was feasible to conduct GREAT for diabetes via tablets and Zoom video conferencing in this low-income community. To implement at scale, a number of concerns need to be addressed. The feasibility of conducting the sessions via smartphone technology should be evaluated.Contribution: Demonstrates how digital technology could be used to develop new ways of empowering people with type 2 diabetes.