Evaluation of a Behavioral Mobile Phone App Intervention for the Self-Management of Type 2 Diabetes: Randomized Controlled Trial Protocol

Empowering patients with comorbid diabetes and hypertension through a multi-component intervention of mobile app, health coaching and shared decision-making: Protocol for an effectiveness-implementation of randomised controlled trial

INTRODUCTION

Diabetes and hypertension are prevalent and costly to the health system. We have developed a mobile app (EMPOWER app) which enables remote monitoring and education through personalised nudges. We aim to study the effectiveness of a multi-component intervention comprising the EMPOWER mobile app with health coaching and shared decision-making for diabetes and hypertension.

METHODS

We will conduct a two-arm, open-label, pragmatic randomised controlled trial (RCT). Participants with comorbid diabetes and hypertension enrolled from public primary care clinics will be randomised to either intervention or control in a 1:1 ratio. The intervention group participants will have access to health coaching with shared decision-making interventions in addition to the EMPOWER app and their usual primary care. The control group participants will continue to receive usual primary care and will neither receive the EMPOWER app nor health coaching and shared decision-making interventions. Our primary outcome is change in HbA1c level over 9 months. Secondary outcomes include change in systolic blood pressure, quality of life, patient activation, medication adherence, physical activity level, diet, and healthcare cost (direct and indirect) over 9 months.

DISCUSSION

Our trial will provide key insights into clinical- and cost-effectiveness of a multi-component intervention comprising EMPOWER mobile app, health coaching and shared decision-making in diabetes and hypertension management. This trial will also offer evidence on cost-effective and sustainable methods for promoting behavioural changes among patients with comorbid diabetes and hypertension.

TRIAL REGISTRATION

This study was registered on clintrials.gov on August 3, 2022, with the trial registration number: NCT05486390.

EMPOWERing Patients With Diabetes Using Profiling and Targeted Feedbacks Delivered Through Smartphone App and Wearable (EMPOWER): Protocol for a Randomized Controlled Trial on Effectiveness and Implementation

Introduction

Type 2 diabetes mellitus (T2DM) poses huge burden and cost on the healthcare system. Mobile health (mHealth) interventions that incorporate wearables may be able to improve diabetes self-management. The aim of this randomized controlled trial (RCT) is to investigate the clinical and cost-effectiveness of personalized educational and behavioral interventions delivered through an EMPOWER mobile application (app) among patients with T2DM.

Methods

This is a parallel two-arm randomized controlled trial (RCT). Patients with T2DM recruited from primary care will be randomly allocated in a 1:1 ratio to either intervention or control group. The intervention group will receive personalized educational and behavioral interventions through the EMPOWER app in addition to their usual clinical care. The control group will receive the usual clinical care for their T2DM but will not have access to the EMPOWER app. Our primary outcome is patient activation score at 12 months. Secondary outcomes will include HbA1c, physical activity level and diet throughout 12 months; quality of life (QoL), medication adherence, direct healthcare cost and indirect healthcare cost at 6 and 12 months.

Discussion

This RCT will provide valuable insights into the effectiveness and implementation of personalized educational and behavioral interventions delivered through mobile application in T2DM management. Findings from this study can help to achieve sustainable and cost-effective behavioral change in patients with T2DM, and this can be potentially scaled to other chronic diseases such as hypertension and dyslipidemia.

The Feasibility and Efficiency of Remote Spirometry System on the Pulmonary Function for Multiple Ribs Fracture Patients

BACKGROUND

Multiple rib fractures is a common chest trauma with a significant and sustained impact on pulmonary function and quality of life. Continuous monitoring of the pulmonary function parameter was necessary to adjust the therapeutic goals in these patients. We developed an internet-based remote system for lung function monitoring with a remote spirometry and smart device application to follow up these patients consecutively.

METHOD

From Jan 2021 to April 2021, we conducted a prospective study that applied an intelligent spirometry system for patients with multiple rib fractures. With informed consent, we collected clinical data from them and introduced the remote spirometry system. We followed up with these patients for 12 weeks after trauma and compared the recovery of pulmonary function parameters and clinical outcomes.

RESULT

A total of 21 patients were enrolled in our study. We divided them into two groups by the compliance to this remote spirometry system. The improvement of forced vital capacity was better in the good compliance group than the poor compliance group (110% versus 21%, p value 0.049). Moreover, the complication rate was also lower in the good compliance group than the poor compliance group (10% versus 66.7% p value 0.017).

CONCLUSIONS

Remote spirometry system is a novel system that can help in lung rehabilitation in patients with multiple rib fractures. Patients that cooperate well with this system presented superior lung function improvement and inferior complication rate.

Comparing Two Commercially Available Diabetes Apps to Explore Challenges in User Engagement: Randomized Controlled Feasibility Study

BACKGROUND

Diabetes apps represent a promising addition to face-to-face self-management interventions, which can be time and resource intensive. However, few randomized controlled trials have evaluated the efficacy of diabetes apps, in particular as a stand-alone intervention without additional clinical support.

OBJECTIVE

We used a feasibility randomized trial design to investigate differences in user engagement between 2 commercially available apps (free versions of Glucose Buddy and mySugr) over 2 weeks in adults with type 2 diabetes. Feasibility was assessed based on recruitment uptake, adherence to the diabetes apps, and follow-up rates. We also hypothesized that the diabetes app mySugr would demonstrate higher user engagement at follow-up due to its use of gamification. We also predicted higher user engagement would be associated with improved self-care behaviors and illness beliefs.

METHODS

Adults with type 2 diabetes attending outpatient diabetes clinics in Auckland were recruited and randomized (1:1 without blinding) to use either the Glucose Buddy or mySugr diabetes apps. User engagement, self-care behaviors, and illness beliefs were measured 2 weeks after baseline. Spearman rank correlations, Mann-Whitney tests, and Wilcoxon signed-rank tests were used to explore associations between the outcome measures and to investigate possible changes between and within groups. Six participants were interviewed to further explore acceptability and usability.

RESULTS

In total, 58 participants (29 per group) completed the 2-week follow-up, of whom only 38 reported using the apps (Glucose Buddy: n=20; mySugr: n=18). Both groups reported low engagement (Glucose Buddy: median 4 days; mySugr: median 6.5 days; P=.06; use for both groups: median 10 minutes). No changes were observed in self-care or illness beliefs in either group. Out of the self-care behaviors, only blood glucose testing was significantly associated with minutes of app use (P=.02). The interviews suggested that although both apps were deemed acceptable, they were generally viewed as time-consuming and too complicated to use.

CONCLUSIONS

Low engagement with both Glucose Buddy and mySugr reflect the challenges associated with engaging users with diabetes apps. Due to low engagement and loss to follow-up, the changes in outcome measures should be interpreted with caution. The results highlight the need for more clinical support as well as involvement from end users and behavior change specialists in order to incorporate evidence-based behavior change techniques to motivate and provide value to users.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12618000424202; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374671.

Mobile-Based and Cloud-Based System for Self-management of People With Type 2 Diabetes: Development and Usability Evaluation

Background

As the use of smartphones and mobile apps is increasing, mobile health (mHealth) can be used as a cost-effective option to provide behavioral interventions aimed at educating and promoting self-management for chronic diseases such as diabetes. Although many mobile software apps have been developed for this purpose, they usually lack a theoretical foundation and do not follow the guidelines suggested for evidence-based practice. Therefore, this study aimed to develop a theory-based self-management app for people with type 2 diabetes and provide an app based on a needs assessment analysis.

Objective

This paper describes the development and usability evaluation of a cloud-based and mobile-based diabetes self-management app designed to help people with diabetes change their health behavior and also enable remote monitoring by health care providers.

Methods

The development of this mHealth solution comprises 3 phases. Phase I: feature extraction of the Android apps that had a user rating of 4 stars or more and review of papers related to mHealth for diabetes self-management were performed followed by seeking expert opinions about the extracted features to determine the essential features of the app. Phase II: design and implementation included selecting which behavioral change and structural theories were to be applied the app and design of the website. Phase III: evaluation of the usability and user experience of the mobile app by people with diabetes and the portal by health care providers using the User Experience Questionnaire.

Results

The developed mobile app includes modules that support several features. A person’s data were entered or collected and viewed in the form of graphs and tables. The theoretical foundation of behavioral intervention is the transtheoretical model. Users were able to receive customized messages based on the behavioral change preparation stage using the Kreuter algorithm. The clinician’s portal was used by health care providers to monitor the patients. The results of the usability evaluation revealed overall user satisfaction with the app.

Conclusions

Mobile- and cloud-based systems may be an effective tool for facilitating the modification of self-management of chronic care. The results of this study showed that the usability of mobile- and cloud-based systems can be satisfactory and promising. Given that the study used a behavioral model, assessment of the effectiveness of behavior change over time requires further research with long-term follow-up.

Diabetes management intervention studies: lessons learned from two studies

Introduction

Several clinical studies investigated improvements of patient outcomes due to diabetes management interventions. However, chronic disease management is intricate with complex multifactorial behavior patterns. Such studies thus have to be well designed in order to allocate all observed effects to the defined intervention and to exclude effects of other confounders as well as possible.

This article aims to provide challenges in interpreting diabetes management intervention studies and suggests approaches for optimizing study implementation and for avoiding pitfalls based on current experiences.

Main body

Lessons from the STeP and ProValue studies demonstrated the difficulty in medical device studies that rely on behavioral changes in intervention group patients. To successfully engage patients, priority should be given to health care professionals being engaged, operational support in technical issues being available, and adherence being assessed in detail.

Another difficulty is to avoid contamination of the control group with the intervention; therefore, strict allocation concealment should be maintained. However, randomization and blinding are not always possible. A limited effect size due to improvements regarding clinical endpoints in the control group is often caused by the Hawthorne effect. Improvements in the control group can also be caused with increased attention paid to the subjects. In order to reduce improvements in the control group, it is essential to identify the specific reasons and adjust study procedures accordingly. A pilot phase is indispensable for this. Another option is to include a third study arm to control for enhanced standard of care and study effects. Furthermore, retrospective data collection could be a feasible option. Adaptive study designs might reduce the necessity of a separate pilot study and combine the exploratory and confirmatory stages of an investigation in one single study.

Conclusion

There are several aspects to consider in medical device studies when using interventions that rely on changes in behavior to achieve an effective implementation and significant study results. Improvements in the control group may reduce effect sizes and limit statistical significance; therefore, alternatives to the traditional randomized controlled trials may be considered.

Web-Based Patient Self-Reported Outcome After Radiotherapy in Adolescents and Young Adults With Cancer: Survey on Acceptance of Digital Tools

BACKGROUND

eHealth and mobile health (mHealth) are an evolving trend in the medical field. The acceptance of digital tools is high, and the need is growing.

OBJECTIVE

Young adults (18-40 years) confronted with a cancer diagnosis present unique needs and require special care. They often have a strong affinity and are familiar with modern technology. On that account, we implemented a web-based symptom and quality of life (QoL) assessment to address patients' attitudes and willingness to use mHealth tools. The study also aims to evaluate sociodemographic parameters that could influence patients' opinions.

METHODS

A total of 380 young patients aged 18-40 treated with radiotherapy between 2002 and 2017 were included in the trial. We assessed QoL via the European Organization for Research and Treatment of Cancer-Core 30 (EORTC C30) questionnaire and added general questions about mHealth technology. The added questions inquired patients' opinions regarding general aspects, including technical advances in medicine, mobile and app assistance during cancer treatment, data transfer, and app-specific features. The survey was conducted for 12 months. Participation was voluntary and pseudonymized; prior written consent was obtained.

RESULTS

We achieved a participation rate of 57.6% (219/380) and a completion rate of 50.2% (110/219). The median age was 33 years (range 18-40). Of all participants, 89.1% (98/110) considered new technologies in medicine as positive; 10.9% (12/110) answered with neutral. Nearly all patients (96.4%, 106/110) stated that they would send further data via a web-based platform. Of all, 96.4% (106/110) considered the provided pseudonymization of their data as safe. We further asked the patients if they would use a mobile app for symptom and QoL assessment similar to the present web-based system: 74.5% (82/110) answered with yes and 25.5% (28/110) said they would not use a mobile app in the future. We tested the willingness to use an app on several sociodemographic parameters, such as age, gender, education, health insurance status, and cancer-related parameters: tumor stage, time since radiation treatment, and treatment intention. None of these parameters correlated with app use in this group of young adults. Patients who were generally positive regarding using an app rated several possible functions of a future app. The 3 most requested features were appointment reminders (89.0%, 73/82), contact overview of all involved clinics and physicians (87%, 71/82), and making an appointment via app (78%, 64/82).

CONCLUSIONS

eHealth and mHealth tools should be available as an integrated part of a comprehensive cancer care approach. It provides automated, thorough documentation of health parameters during therapy and follow-up for doctors, medical staff, and tumor patients to optimize treatment. With this study, we could show that young adults are the ideal patient population to use eHealth/mHealth tools. Such tools offer further digital support and improve the patients' need for constant QoL during cancer care.

An Image-Based Mobile Health App for Postdrainage Monitoring: Usability Study

Background

The application of mobile health (mHealth) platforms to monitor recovery in the postdischarge period has increased in recent years. Despite widespread enthusiasm for mHealth, few studies have evaluated the usability and user experience of mHealth in patients with surgical drainage.

Objective

Our objectives were to (1) develop an image-based smartphone app, SurgCare, for postdrainage monitoring and (2) determine the feasibility and clinical value of the use of SurgCare by patients with drainage.

Methods

We enrolled 80 patients with biliary or peritoneal drainage in this study. A total of 50 patients were assigned to the SurgCare group, who recorded drainage monitoring data with the smartphone app; and 30 patients who manually recorded the data were assigned to the conventional group. The patients continued to record data until drain removal. The primary aim was to validate feasibility for the user, which was defined as the proportion of patients using each element of the system. Moreover, the secondary aim was to evaluate the association of compliance with SurgCare and the occurrence of unexpected events.

Results

The average submission duration was 14.98 days, and the overall daily submission rate was 84.2%. The average system usability scale was 83.7 (SD 3.5). This system met the definition of “definitely feasible” in 34 patients, “possibly feasible” in 10 patients, and “not feasible” in 3 patients. We found that the occurrence rates of complications in the SurgCare group and the conventional group were 6% and 26%, respectively, with statistically significant differences P=.03. The rate of unexpected hospital return was lower in the SurgCare group (6%) than in the conventional groups (26%) (P=.03).

Conclusions

Patients can learn to use a smartphone app for postdischarge drainage monitoring with high levels of user satisfaction. We also identified a high degree of compliance with app-based drainage-recording design features, which is an aspect of mHealth that can improve surgical care.

Smartphone-Based Technology in Diabetes Management

Diabetes is a group of metabolic disorders characterized by elevated levels of blood glucose which leads over time to serious complications and significant morbidity and mortality worldwide. Self-management tasks in diabetes may be quite challenging because of lack of training, difficulties in sustaining lifestyle modifications, and limited access to specialized healthcare. Nowadays, the evolution of mobile technology provides a large number of health-related smartphone applications (apps), aiming to increase the self-management skills of the patient in chronic diseases, to facilitate the communication between the patient and healthcare providers, and to increase also the patient's compliance with the treatment. In the field of diabetes there are also many diabetes-related mobile apps mainly focusing on self-management of diabetes, lifestyle modification, and medication adherence motivation. The aim of this paper is to review the most important diabetes-related mobile smartphone applications, including only those supported by prospective randomized controlled trials.

Structure and Characteristics of Diabetes Self-management Applications: A Systematic Review of the Literature

Diabetes is one of the most common chronic conditions, and a good self-management regimen is needed in order to control the disease and prevent complications. In the last few years, the number of health information technologies has increased, and while there are many smartphone applications for diabetic patients, their effectiveness is still unclear. This systematic review aims to outline structure and characteristics that can make an application for diabetes management effective and safe and improve usability and the chances of success for a mobile health service. Applications found in the literature have been analyzed to evaluate the different features. Findings of the review suggest that patients seem to be more attracted by tools that are helpful in everyday management of diabetes, and that allow them to save time and increase safety. The personalization of the application is essential to obtain success in promoting use, and applications should be based upon patients' predisposition to use technological tools that will ensure better outcomes.

Development and Efficacy of an Electronic, Culturally Adapted Lifestyle Counseling Tool for Improving Diabetes-Related Dietary Knowledge: Randomized Controlled Trial Among Ethnic Minority Adults With Type 2 Diabetes Mellitus

Background

Ethnic minority populations exhibit disproportionately high rates of type 2 diabetes mellitus (T2DM). Electronic health tools have the potential to facilitate the cultural adaptation and tailoring of T2DM education to improve the knowledge and management of diabetes mellitus (DM).

Objective

This study aimed (1) to develop an adaptable Interactive Lifestyle Assessment, Counseling, and Education (I-ACE) software to support dietitian-delivered lifestyle counseling among low-socioeconomic status (SES) ethnic minority patients with T2DM and (2) to evaluate its effect on DM-related dietary knowledge and management compared with standard lifestyle advice (SLA) in a randomized controlled trial (RCT).

Methods

The I-ACE software, developed in consultation with clinical dieticians, incorporates evidence-based dietary and physical activity (PA) recommendations and educational materials. The features and behavioral change techniques include quantitative lifestyle (dietary intake and PA) assessment and simulation, individually tailored education and recommendations, motivational interviewing, and goal setting. For the unblinded pilot RCT, 50 overweight or obese Arab adults (aged 40-62 years) with poorly controlled T2DM were recruited from primary care clinics and randomly assigned to receive 4 in-person, dietician-delivered counseling sessions over 6 months using either (1) the I-ACE tool (experimental arm) or (2) the SLA methods (comparison arm). All outcome assessments were face-to-face. DM-related dietary knowledge (primary outcome) was measured at baseline, 3, 6, and 12 months. Lifestyle and other parameters were measured before, during, and after the intervention. Multiple linear regression and repeated measures linear mixed models were used to compare the changes in study outcomes and explore time trends in between-group and within-group changes.

Results

A total of 25 participants were enrolled in each arm, of whom 24 and 21 completed the final assessment of the primary outcome in the I-ACE and SLA arms, respectively. DM-related lifestyle knowledge increased more rapidly in the I-ACE arm than in the SLA arm (P value for study arm×time interaction=.02). Within the I-ACE arm, the mean (SE) differences in added sugar and dietary fiber intakes from baseline to 12 months were −2.6% (SE 1.0%) of total energy (P=.03) and 2.7 (SE 0.0) g/1000 kcal (P=.003), respectively. The odds of engaging in any leisure PA at 12 months tended to be higher in the I-ACE arm versus SLA arm, but did not reach statistical significance (odds ratio 2.8; 95% CI 0.7-11.6; P=.16). Both arms exhibited significant reductions in HbA_1c (P value for change over time <.001).

Conclusions

The use of the I-ACE software in a 6-month, 4-session dietician-delivered lifestyle counseling intervention improved the efficiency of lifestyle education, compared with SLA, among low-SES, ethnic minority patients with T2DM. This pilot trial provides justification for conducting a large-scale trial to evaluate its effectiveness and applicability in routine clinical care among ethnically diverse populations.

Trial Registration

ClinicalTrials.gov NCT01858506; https://clinicaltrials.gov/ct2/show/NCT01858506.

Determining minimum set of features for diabetes mobile apps

Purpose

Interest in mobile health applications (apps) for diabetes self-care is growing. Mobile health is a promising new treatment modality for diabetes, though few smartphone apps have been designed based on a proper study and prioritization. The aim of this study was to determine a minimum set of features for diabetes mobile apps.

Methods

This study was conducted in three steps: 1.A review of the literature to collect all available features, 2. Assessing the validity of suggested features by Content Validity Index (CVI) and Content Validity Ratio (CVR), 3. Examining the importance of features by Friedman test.

Results

We retrieved all features of available mobile apps for type 2 diabetes, which are suggested and discussed in literature and compiled as a single list comprising of 33 features. Then, a survey of expert's opinion produced a set of 23 final minimum features which includes all types of tracking, mealtime tagging, food database, diet management, educational materials, healthy coping, reducing risks, problem solving, Email, color coding, alerts, reminder, target range setting, trend chart view, logbook view, numerical indicators view, customizable theme, preset notes, and custom notes. According to the mean rank which indicates the priority of each feature, the most important one was blood glucose tracking (with 16.71 mean rank) and the least important feature was the numerical indicators like such as standard deviation or average (with 6.50 mean rank).

Conclusions

The present study is the first step towards the development of our mobile apps for people with type II diabetes, and highest the essential features that are required for an optimal self-care comprehensively.

Assessing the Quality of Mobile Phone Apps for Weight Management: User-Centered Study With Employees From a Lebanese University

Background

Evaluating the quality of mobile health apps for weight loss and weight management is important to understand whether these can be used for obesity prevention and treatment. Recent reviews call for more research on multidimensional aspects of app quality, especially involving end users, as there are already many expert reviews on this domain. However, no quantitative study has investigated how laypersons see popular apps for weight management and perceive different dimensions of app quality.

Objective

This study aimed to explore how laypersons evaluate the quality of 6 free weight management apps (My Diet Coach, SparkPeople, Lark, MyFitnessPal, MyPlate, and My Diet Diary), which achieved the highest quality ratings in a related and recent expert review.

Methods

A user-centered study was conducted with 36 employees of a Lebanese university. Participants enrolled in the study on a rolling basis between October 2016 and March 2017. Participants were randomly assigned an app to use for 2 weeks. App quality was evaluated at the end of the trial period using the Mobile App Rating Scale user version (uMARS). uMARS assesses the dimensions of engagement, functionality, aesthetics, information, and subjective quality on 5-point scales. Internal consistency and interrater agreement were examined. The associations between uMARS scores and users’ demographic characteristics were also explored using nonparametric tests. Analyses were completed in November 2017.

Results

Overall, the 6 apps were of moderately good quality (median uMARS score 3.6, interquartile range [IQR] 0.3). The highest total uMARS scores were achieved by Lark (mean 4.0 [SD 0.5]) and MyPlate (mean 3.8 [SD 0.4]), which also achieved the highest subjective quality scores (Lark: mean 3.3 [SD 1.4]; MyPlate: mean 3.3 [SD 0.8]). Functionality was the domain with the highest rating (median 3.9, IQR 0.3), followed by aesthetics (median 3.7, IQR 0.5), information (median 3.7, IQR 0.1), and engagement (median 3.3, IQR 0.2). Subjective quality was judged low (median 2.5, IQR 0.9). Overall, subjective quality was strongly and positively related (P<.001) with total uMARS score (ρ=.75), engagement (ρ=.68), information, and aesthetics (ρ=.60) but not functionality (ρ=.40; P=.02). Higher engagement scores were reported among healthy (P=.003) and obese individuals (P=.03), who also showed higher total uMARS (P=.04) and subjective quality (P=.05) scores.

Conclusions

Although the apps were considered highly functional, they were relatively weak in engagement and subjective quality scores, indicating a low propensity of using the apps in the future. As engagement was the subdomain most strongly associated with subjective quality, app developers and researchers should focus on creating engaging apps, holding constant the functionality, aesthetics, and information quality. The tested apps (in particular Lark and MyPlate) were perceived as more engaging and of higher quality among healthy, obese individuals, making them a promising mode of delivery for self-directed interventions promoting weight control among the sampled population or in similar and comparable settings.

Review of mobile applications for optimizing the follow-up care of patients with diabetes

BACKGROUND

Several smartphone applications aim at facilitating communication between patients and healthcare providers. In this review, we evaluate and compare the most promising applications in the field of diabetes mellitus (DM) and obesity. Most applications monitor body weight, fasting or postprandial blood glucose, glycosylated hemoglobin (Hgb) A1c (HgbA1c), and units and types of insulin used.

METHODS

Nine clinically tested applications and two Web platforms were grouped into three categories that were evaluated and compared. Group 1 included seven applications focusing mainly on monitoring DM, fitness and weight, blood glucose levels, and HbA1c. Group 2 included two applications that focus on insulin dosage calculators and glucose self-monitoring tests. Group 3 included two web-platforms that interact with patients via SMS (short message service) messaging.

RESULTS

A common feature of the applications examined was the limited number of clinical parameters tested, the small number of subjects taking part in the evaluation, and the fact that the controls were not randomized. Furthermore, the interfaces of the applications varied and were not standardized. Finally, another common characteristic across applications was the lack of standardization of the interface and the overall structure due to language barriers, the devices usually having been designed around a specific language. Lastly, most applications lacked a critical mass of evaluators and were thus not worthy of being considered of serious clinical relevance.

CONCLUSIONS

The current smartphone applications for DM are characterized by a limited number of participants, a small number of parameters, and a lack of standardization.

Psychological interventions for diabetes-related distress in adults with type 2 diabetes mellitus

BACKGROUND

Many adults with type 2 diabetes mellitus (T2DM) experience a psychosocial burden and mental health problems associated with the disease. Diabetes-related distress (DRD) has distinct effects on self-care behaviours and disease control. Improving DRD in adults with T2DM could enhance psychological well-being, health-related quality of life, self-care abilities and disease control, also reducing depressive symptoms.

OBJECTIVES

To assess the effects of psychological interventions for diabetes-related distress in adults with T2DM.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, BASE, WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was December 2014 for BASE and 21 September 2016 for all other databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on the effects of psychological interventions for DRD in adults (18 years and older) with T2DM. We included trials if they compared different psychological interventions or compared a psychological intervention with usual care. Primary outcomes were DRD, health-related quality of life (HRQoL) and adverse events. Secondary outcomes were self-efficacy, glycosylated haemoglobin A1c (HbA1c), blood pressure, diabetes-related complications, all-cause mortality and socioeconomic effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified publications for inclusion and extracted data. We classified interventions according to their focus on emotion, cognition or emotion-cognition. We performed random-effects meta-analyses to compute overall estimates.

MAIN RESULTS

We identified 30 RCTs with 9177 participants. Sixteen trials were parallel two-arm RCTs, and seven were three-arm parallel trials. There were also seven cluster-randomised trials: two had four arms, and the remaining five had two arms. The median duration of the intervention was six months (range 1 week to 24 months), and the median follow-up period was 12 months (range 0 to 12 months). The trials included a wide spectrum of interventions and were both individual- and group-based.A meta-analysis of all psychological interventions combined versus usual care showed no firm effect on DRD (standardised mean difference (SMD) -0.07; 95% CI -0.16 to 0.03; P = 0.17; 3315 participants; 12 trials; low-quality evidence), HRQoL (SMD 0.01; 95% CI -0.09 to 0.11; P = 0.87; 1932 participants; 5 trials; low-quality evidence), all-cause mortality (11 per 1000 versus 11 per 1000; risk ratio (RR) 1.01; 95% CI 0.17 to 6.03; P = 0.99; 1376 participants; 3 trials; low-quality evidence) or adverse events (17 per 1000 versus 41 per 1000; RR 2.40; 95% CI 0.78 to 7.39; P = 0.13; 438 participants; 3 trials; low-quality evidence). We saw small beneficial effects on self-efficacy and HbA1c at medium-term follow-up (6 to 12 months): on self-efficacy the SMD was 0.15 (95% CI 0.00 to 0.30; P = 0.05; 2675 participants; 6 trials; low-quality evidence) in favour of psychological interventions; on HbA1c there was a mean difference (MD) of -0.14% (95% CI -0.27 to 0.00; P = 0.05; 3165 participants; 11 trials; low-quality evidence) in favour of psychological interventions. Our included trials did not report diabetes-related complications or socioeconomic effects.Many trials were small and were at high risk of bias for incomplete outcome data as well as possible performance and detection biases in the subjective questionnaire-based outcomes assessment, and some appeared to be at risk of selective reporting. There are four trials awaiting further classification. These are parallel RCTs with cognition-focused and emotion-cognition focused interventions. There are another 18 ongoing trials, likely focusing on emotion-cognition or cognition, assessing interventions such as diabetes self-management support, telephone-based cognitive behavioural therapy, stress management and a web application for problem solving in diabetes management. Most of these trials have a community setting and are based in the USA.

AUTHORS' CONCLUSIONS

Low-quality evidence showed that none of the psychological interventions would improve DRD more than usual care. Low-quality evidence is available for improved self-efficacy and HbA1c after psychological interventions. This means that we are uncertain about the effects of psychological interventions on these outcomes. However, psychological interventions probably have no substantial adverse events compared to usual care. More high-quality research with emotion-focused programmes, in non-US and non-European settings and in low- and middle-income countries, is needed.

Mobile Health in Oncology: A Patient Survey About App-Assisted Cancer Care

Background

In the last decade, the health care sector has been enriched by numerous innovations such as apps and connected devices that assist users in weight reduction and diabetes management. However, only a few native apps in the oncological context exist, which support patients during treatment and aftercare.

Objective

The objective of this study was to analyze patients’ acceptance regarding app use and to investigate the functions of an oncological app that are most required, and the primary reasons for patients to refuse app-assisted cancer care.

Methods

We designed and conducted a survey with 23 questions, inquiring patients about their technical knowledge and equipment, as well as the possible advantages and disadvantages, data transfer, and general functionality of an app.

Results

A total of 375 patients participated; the participation rate was 60.7% (375/618). Gender distribution was about 3:4 (female:male) with a median age of 59 years (range 18-92 years). Whereas 69.6% (261/375) of patients used mobile devices, 16.3% (61/375) did not own one, and 9.1% (34/375) only used a personal computer (PC). About half of the patients rated their usability skills as very good and good (18.9% 71/375; 35.2% 132/375), 23.5% (88/375) described their skills as intermediate, and 14.4% (54/375) as bad. Of all patients, 182 (48.5%, 182/375) were willing to send data to their treating clinic via an app, that is, to a server (61.0% 111/182) or as email (33.5%, 61/182). About two-thirds (68.7%, 125/182) believed that additional and regularly sent data would be an ideal complement to the standard follow-up procedure. Additionally, 86.8% (158/182) wished to be contacted by a physician when entered data showed irregularities. Because of lack of skills (34.4%, 56/163), concerns about the use of data (35.0%, 57/163), lack of capable devices (25.8%, 42/163), and the wish for personal contact with the treating physician (47.2%, 77/163), a total of 163 (43.5%, 163/375) patients refused to use an app. Pearson correlation showed a significant but mild relationship between age and app use (P=.03, r=−.12), favoring younger age; male gender correlated as well (P=.04; r=−.11).

Conclusions

The results show that the introduction of mobile apps needs to follow different strategies depending on the patients’ attitude. Age and gender seem to be the strongest predictive factors. For oncology patients, our survey showed that about half of the patients were willing to send data via an app supporting their treatment. In the future, clinical data such as quality of life and treatment satisfaction recorded by mobile health (mHealth) devices could be used to evaluate and improve therapy workflow. Furthermore, apps could support classical visits, document adverse effects, and remind patients of treatment dates or drug intake.