Diabetes Self-management Apps Research Articles

A randomized controlled study on the effectiveness of a diabetes self-management app in Bangladesh

Introduction: The smart phone application concept is widely recognized as a tool to support patients’ adherence. Using different types of reminder-based materials combined with traditional health education has demonstrated its effectiveness in enhancing knowledge and fostering adherence to diabetes management. Very few studies found to identify the effectiveness of smartphone application for the diabetes seven self-management components. This study was aimed to assess this issue among Bangladeshi patients. Methods: A randomized controlled trial was performed from July 2022 to June 2023 in two diabetic hospitals affiliated with the Diabetic Association of Bangladesh located in Dhaka district among the 400 diabetic patients. The smartphone Application ‘Diabetes Self-Care’ was installed on the smartphone of each patient of the intervention group and instructed them to use it. Data were collected using a semi-structured questionnaire through face-to-face interview. Knowledge and adherence were measured and compared in the different groups before and after the intervention using t-test, McNemar’s test, and logistic regression technique. Results: The endline status of the intervention group reflected significant (P<0.01) improvement in knowledge and adherence to self-management compared to the baseline status. Knowledge (regarding seven self-management components, basic and technical components of diabetes) improved significantly (P<0.01) in the intervention group. Adherence to self-management components improved significantly(P<0.01) more in the intervention group than in the control group. Conclusions: The m-Health intervention, using smartphone application, demonstrated a noteworthy enhancement and positive impact on patients’ knowledge and adherence. This successful model of intervention holds the potential for nationwide replication, offering a viable approach for self-managing diabetes and other non-communicable diseases to enhance patient outcomes and reduce healthcare burdens.

Mobile apps for diabetes self-management: An updated review of app features and effectiveness.

Self-management of diabetes is extremely challenging and non-adherence is common. Health consequences are significant for those unable to adhere to the complex treatment regimen, which includes regular oral medication and/or insulin use, frequent blood sugar checks, strict dietary management, and regular physical activity. Mobile applications (apps) present a tremendous opportunity to help patients improve adherence to these behaviors. The availability of commercial diabetes self-management apps is increasing exponentially, making it difficult for patients and providers to stay informed about app options and benefits. Previous reviews have described commercial diabetes apps and their features and usability for patients with diabetes. A smaller number have reviewed the effectiveness of these apps in improving blood glucose as well as other aspects of diabetes management. The aim of this article is to update our 2016 review, summarize the results of new reviews, review outcomes of diabetes apps described in the literature, and offer recommendations for app features, effectiveness research, and marketing in apps for diabetes self-management. Although higher-quality research is needed, current reviews suggest that many diabetes apps are effective in lowering HbA1c. Recommendations for future research include reporting critical details such as patient demographics and intervention elements and designing studies to identify the most effective components of diabetes management apps. Furthermore, clearly labeling apps that have data supporting clinical efficacy in app stores would allow both providers and patients to easily identify apps that might be most beneficial. Future research should explore the use of apps for the prevention of diabetes in individuals diagnosed with prediabetes.

Factors influencing patients' adoption and use of mobile health applications for diabetes self-management: a systematic review

Mobile health (mHealth) apps can facilitate diabetes self-management (DSM) and assist in reducing the risk of complications, enhancing diabetes control and improving patient outcomes. The objectives of this systematic review were to (1) determine the adoption level of DSM apps among diabetes patients, (2) identify the factors associated with the adoption and use of DSM apps, and (3) explore patients’ perspectives of DSM apps and the predominant preferred features. A comprehensive literature search was performed in four electronic databases: PubMed, Scopus, PsychNet, and IEEE Xplore digital library using the PRISMA guidelines. Relevant data and information were collected from studies published between 2016 and 2023, fulfilling the inclusion criteria (n = 26), and thematic analysis was performed. The adoption level of mHealth apps for DSM among diabetic patients ranged from 7.0% to 47.0%, and diverse factors relating to patients’ demographics, preferences and experiences were identified. Overall, older, male and less educated patients were less likely to adopt DSM apps, while the intention to use these apps was influenced by patients’ perceived benefits, recommendations by patients and healthcare professionals, and ease of use. Given that most of the reviewed studies were conducted in developed countries, the present patients’ adoption level of mHealth apps for DSM is relatively low, thereby highlighting the need for improvement. The factors identified in this study may be considered when attempting to encourage patients to use these apps. More research is needed to elucidate how mobile health apps can be effectively integrated into diabetes care and management pathways.

A multisectoral and multidisciplinary endeavor: a review of diabetes self-management apps in China

BackgroundWhile the use of self-management apps has considerable promise to efficiently reduce the diabetes burden that disproportionally affects low- and middle-income countries (LMICs), and the multisectoral and multidisciplinary approaches have been encouraged to be used in diabetes management, little is known about the status of the integration of these approaches in the existing diabetes self-management apps. This review examines the diabetes apps in China as an indication of the current status of integrating multisectoral and multidisciplinary approaches in diabetes mHealth care in LMICs. MethodsEligible diabetes apps were searched on major Chinese app stores up to December 23, 2022. The app comprehensiveness index (ranging 0–80) regarding the app functions and diabetes management domains was created. The multisectoral and multidisciplinary features were summarized using indices derived from current guidance. ResultsSixty-six apps were reviewed, all developed by private companies. The average comprehensiveness score was 16, with many major self-management domains and functions not represented among the reviewed apps. Forty apps (61%) involved multiple sectoral entities, with public/private and private/private collaborations being the most common collaborative combinations. Thirty-seven apps (56%) involved multiple disciplines, among which endocrinology/metabolism, nutrition, and cardiovascular medicine were the top three most common disciplines. Compared to non-multidisciplinary apps, multidisciplinary apps tended to provide more comprehensive services in apps (6.14 vs. 5.18, p = 0.0345). Different sectors and disciplines tended to work independently, without robust interactions, in providing diabetes management services in the reviewed apps.ConclusionMultisectoral and multidisciplinary features has presented in the current diabetes self-management apps in China; however, it is still in its infancy and significant limitations existed. More engagement of civil society organizations and community groups and innovative collaborations between sectors and disciplines are needed to provide comprehensive, continuous, and patient-centered mHealth care for patients with diabetes in LMICs like China. Clear guidance for integrating and evaluating the multisectoral and multidisciplinary efforts in self-management apps is necessary to ensure the effective use of mHealth solutions for diabetes management in LMICs.

Mobile Health Apps for the Control and Self-management of Type 2 Diabetes Mellitus: Qualitative Study on Users’ Acceptability and Acceptance

Mobile health apps are promising tools to help patients with type 2 diabetes mellitus (T2DM) improve their health status and thereby achieve diabetes control and self-management. Although there is a wide array of mobile health apps for T2DM available at present, apps are not yet integrated into routine diabetes care. Acceptability and acceptance among patients with T2DM is a major challenge and prerequisite for the successful implementation of apps in diabetes care. This study provides an in-depth understanding of the perceptions of patients with T2DM before use (acceptability) and after use (acceptance) regarding 4 different mobile health apps for diabetes control and self-management. A descriptive qualitative research design was used in this study. Participants could choose 1 of the 4 selected apps for diabetes control and self-management (ie, Clear.bio in combination with FreeStyle Libre, mySugr, MiGuide, and Selfcare). The selection was based on a systematic analysis of the criteria for (functional) requirements regarding monitoring, data collection, provision of information, coaching, privacy, and security. To explore acceptability, 25 semistructured in-depth interviews were conducted with patients with T2DM before use. This was followed by 4 focus groups to discuss the acceptance after use. The study had a citizen science approach, that is, patients with T2DM collaborated with researchers as coresearchers. All coresearchers actively participated in the preparation of the study, data collection, and data analysis. Data were collected between April and September 2021. Thematic analysis was conducted using a deductive approach using AtlasTi9. In total, 25 coresearchers with T2DM participated in this study. Of them, 12 coresearchers tested Clear, 5 MiGuide, 4 mySugr, and 4 Selfcare. All coresearchers participated in semistructured interviews, and 18 of them attended focus groups. Personal health was the main driver of app use. Most coresearchers were convinced that a healthy lifestyle would improve blood glucose levels. Although most coresearchers did not expect that they need to put much effort into using the apps, the additional effort to familiarize themselves with the app use was experienced as quite high. None of the coresearchers had a health care professional who provided suggestions on using the apps. Reimbursement from insurance companies and the acceptance of apps for diabetes control and self-management by the health care system were mentioned as important facilitating conditions. The research showed that mobile health apps provide support for diabetes control and self-management in patients with T2DM. Integrating app use in care as usual and guidelines for health care professionals are recommended. Future research is needed on how to increase the implementation of mobile health apps in current care pathways. In addition, health care professionals need to improve their digital skills, and lifelong learning is recommended.

A fuzzy-set qualitative comparative analysis exploration of multiple paths to users’ continuous use behavior of diabetes self-management apps

BackgroundDespite the obvious potential benefits of diabetes self-management apps, users’ continuous use of diabetes self-management apps is still not widespread. Influential factors coexisted in information ecologies are likely to have a synthetic effect on users’ continuous use behavior. However, it is less clear how factors in information ecologies combine to influence users’ continuous use behavior. ObjectiveThe objectives of this study are to explore combinations of factors (perceived severity, information quality, service quality, system quality, and social influence) in information ecologies that lead to users’ continuous use behavior of diabetes self-management apps and which combination is the most important. MethodsPurpose sampling was used to recruit diabetes self-management app users from July 1, 2021 to January 31, 2022. Fuzzy-set qualitative comparative analysis (fsQCA) was then employed by conducting necessity and sufficiency analysis. ResultsIn total 280 diabetes self-management app users participated. The necessity analysis indicated that no single factor was necessary to cause users’ continuous use behavior, and the sufficiency analysis identified five different combinations of factors that lead to users’ continuous use behavior. Of these five, the combination of high information quality, high service quality, and high social influence was found to be the most important path. ConclusionsUsers’ continuous use behavior of diabetes self-management apps results from the synergistic effects of factors in information ecologies. The five paths that directly contribute to users’ continuous use, as well as the four user types preliminarily identified in this study may provide a reference for healthcare providers and app developers.

Integrated Diabetes Self-Management (IDSM) mobile application to improve self-management and glycemic control among patients with Type 2 Diabetes Mellitus (T2DM) in Indonesia: A mixed methods study protocol.

The number of patients with diabetes in Indonesia reach 19,47 million in 2021, mostly is caused by the adoption of sedentary and unhealthy lifestyles. Continuous self-management is important in diabetes care. It requires optimal coordination and communication between patients, families, and health care provider. The use of communication technology could be solution to the problem. This study aims to initiate an android-based mobile apps technology as a tool for patient, family, and healthcare provider to optimize patient with T2DM treatment. This study will be conducted in Public Health Centers (PHCs) in Yogyakarta using an exploratory sequential mixed-methods design which is divided into three phases. The first phase will use qualitative descriptive methods. Patients with T2DM, families, nurses, physicians and Health Social Security Agency officers in Indonesia will be involved in a focus group discussion (FGD) and in-depth interviews to understand their needs in optimizing the treatment. The second phase will be the development of an android-based application on the first phase results. The apps will be usability tested by involving experts (heuristic evaluation) and users (think aloud method) to ensure that the apps really meet targeted user's need. In the third phase, we will collect feedback from user after using this apps for three months. The effectiveness of the apps will be measured by self-management improvement and glycemic control of patients with T2DM. The non-equivalent control group design will be applied using a pre-repeated post-test control group. The result of this study will be an Android-based Application which will be called Integrated Diabetes Self-Management (IDSM) app to optimize the implementation of diabetes self-management which can improve glycemic control of patients with T2DM as one of the indicators of the Indonesian Chronic Disease Management Program at PHCs.

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

BackgroundMost 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.ObjectiveThis 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.MethodsWe 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.ResultsA 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.ConclusionsDespite 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.

Use and Trends of Diabetes Self-Management Technologies: A Correlation-Based Study.

Applications and systems for diabetes self-management are growing and involve a vast majority of factors to consider. This study was aimed at examining the integration of portable technologies for diabetes self-management, as well as benefits and issues arising of its use. From a web-based study on several groups of people with diabetes, most of them accustomed to the daily use of devices and applications for self-control, a deeper analysis based on correlations and inference was conducted considering information about the disease, technology knowledge and devices handling, use of technologies for diabetes control and management, and training with devices from a clinical and educational viewpoint. In this study, more than 70% of participants use Continuous Glucose Systems and additional devices (41.85% also use insulin pumps) which impacts positively on the knowledge of incoming technologies. The “easy to use” factor of current apps for diabetes self-management is the most valuable feature. Also, 88.98% of participants did not use gamification-based methods during the initial training sessions, although gamification is a useful technique in learning stages. An inference analysis shows how specific characteristics of diabetes devices and apps should improve. On the basis of the results, we discuss about benefits, shortcomings, and the state of these technologies and patient needs for the future.

Physician-Authored Feedback in a Type 2 Diabetes Self-management App: Acceptability Study.

BackgroundType 2 diabetes (T2D) is increasingly prevalent in society, in part because of behavioral issues, with sedentary behavior, reduced exercise, and the consumption of foods with a high glycemic index being major contributors. There is evidence for the efficacy of mobile apps in promoting behavior change and lifestyle improvements in people with T2D. Many mobile phone apps help to monitor the condition of people with T2D and inform them about their health. Some of these digital interventions involve patients using apps on their own or in conjunction with health care professionals.ObjectiveThis study aimed to test the acceptability of receiving app-based, daily physician feedback for patients with T2D that is informed by the continuous monitoring of their activity, food choices, and glucose profiles, with the aim of encouraging healthier behavior. The GLOOK! app was designed and developed by an academic research team and pilot-tested at an Australian public hospital.MethodsA total of 15 patients diagnosed with T2D wore a glucose monitor and an Apple Watch for 12 days. The uploaded data were integrated into the GLOOK! app on the patients’ smartphones, which also enabled the recording of activity and consumed food. A physician provided daily feedback to each individual through the app based on their data from each of the 12 days. At the beginning and end of the study, data were collected on vital signs, anthropometry, hemoglobin A1c level, fructosamine level, and fasting lipids level. Participants were also interviewed at the beginning and end of the study to assess the acceptability of the intervention and its potential impact on promoting positive behavior change.ResultsOver the 12 days of the study, there was a significant reduction of 0.22% (P=.004) in hemoglobin A1c level. There were favorable changes in fructosamine and lipid fractions; however, none reached significance. There was also a fall of 0.65 kg in body weight and falls in blood pressure and pulse rate that did not reach significance. Patient feedback on the GLOOK! system was positive. Of the 15 participants, 13 (87%) were enthusiastic about continuing to use the app system if some usability and reliability aspects were improved. All participants regarded the personalized physician feedback as supportive and helpful in understanding their own health behavior. Of the 15 participants, 4 (27%) felt that using the system encouraged long-term behavior changes.ConclusionsA mobile app system that provides people with T2D daily, physician-generated, personalized feedback can produce favorable changes in glycemic and cardiovascular risk parameters—even in the short term—and encourage better self-management of their condition. Study participants found the experience of using the mobile app system acceptable and were motivated to establish longer-term lifestyle improvements through behavior changes.

Standardized evaluation of the quality and persuasiveness of mobile health applications for diabetes management

This study evaluates diabetes self-management mobile health applications available from European app stores with respect to quality, concordance with recommended self-management tasks and implementation of persuasive system design principles. The European Play Store and Apple App Store were systematically searched and relevant apps were tested. Two raters independently assessed app quality using the Mobile Application Rating Scale and conducted a content analysis of provided persuasive system design principles and self-management tasks. A total of 2,269 mobile health applications were identified and 120 could be included in the evaluation. The overall quality was rated as moderate M = 3.20 (SD = 0.39, min = 2.31, max = 4.62), with shortcomings in the subcategories of engagement (M = 2.80, SD = 0.67) and information quality (M = 2.26, SD = 0.48). Scientific evidence is available for 8% of the apps. The reviewed apps implemented a median of three persuasive system design principles (range 0–15) and targeted a median of 4.5 (range 1–8) self-management tasks, however, with a lack of information about psychosocial coping strategies. Most available diabetes self-management apps lack a scientific evidence base. Persuasive system design features are underrepresented and may form a promising tool to improve app quality. Furthermore, the interaction of physical and behavioral health should be improved in existing diabetes self-management mobile health applications.

A fsQCA Exploration of Multiple Paths to Users' Continued Use of Diabetes Self-Management Apps

A fsQCA Exploration of Multiple Paths to Users' Continued Use of Diabetes Self-Management Apps

Eliciting Requirements for a Diabetes Self-Management Application for Underserved Populations: A Multi-Stakeholder Analysis

Medically underserved communities have limited access to effective disease management resources in the U.S. Mobile health applications (mHealth apps) offer patients a cost-effective way to monitor and self-manage their condition and to communicate with providers; however, current diabetes self-management apps have rarely included end-users from underserved communities in the design process. This research documents key stakeholder-driven design requirements for a diabetes self-management app for medically underserved patients. Semi-structured survey interviews were carried out on 97 patients with diabetes and 11 healthcare providers from medically underserved counties in South Texas, to elicit perspectives and preferences regarding a diabetes self-management app, and their beliefs regarding such an app’s usage and utility. Patients emphasized the need for accessible educational content and for quick access to guidance on regulating blood sugar, diet, and exercise and physical activity using multimedia rather than textual forms. Healthcare providers indicated that glucose monitoring, educational content, and the graphical visualization of diabetes data were among the top-rated app features. These findings suggest that specific design requirements for the underserved can improve the adoption, usability, and sustainability of such interventions. Designers should consider health literacy and numeracy, linguistic barriers, data visualization, data entry complexity, and information exchange capabilities.

Heuristic Evaluation of a Top-Rated Diabetes Self-Management App.

The purpose of this study was to evaluate the usability of a top-rated diabetes app. Such apps are intended to markedly support the achievement of optimal health and financial outcomes by providing patients with substantive and continual support for self-management of their disease between periodic clinician visits. Poor usability can deter use which is especially concerning in patients with diabetes due to prevalence of the disease and impact of self-management on long-term prognosis. A diabetes app was selected due to the prevalence and seriousness of the disease. A heuristic evaluation was then performed to collect and analyze data on the usability of the app based on Nielsen's heuristics. Pareto analysis was used to illustrate the contribution of each type of heuristic violation, augmented by a stacked bar chart illuminating associated severity. There were 51 heuristic violations on the opening screen, violating 6 of Nielsen's 10 heuristics. Pareto analysis revealed 29 (57%) of the heuristic violations involved a match between system and real world and 8 (16%) aesthetic and minimalist design. Severity ratings ranged from 1.0 to 4.0 (mean: 3.01) with 80% comprising a major usability problem and 6% a usability catastrophe. Studies show that people with diabetes are more likely to receive greater benefit from a diabetes app if they are easy to use. The number and severity of heuristic violations in this study suggest that the commercialization of mobile health apps may play a factor in bypassing experts in clinical informatics during the design phase of development. Usability and associated benefits received from mobile health apps can be enhanced by debugging the user interface of identified heuristic violations during design. Waiting to correct ongoing usability issues while apps are in production can result in patients disengaging from use of digital health tools engendering poorer outcomes.

Evaluating the Potential Use of Smartphone Apps for Diabetes Self-Management in an Underserved Population: A Qualitative Approach.

Health disparities cause a higher rate of diabetes development in poor and minority groups and also limit the care these people receive. Smartphone applications (apps) may be a low-cost, accessible resource to patients with diabetes who experience barriers to traditional health care. Currently, little is known about using health apps to help underserved patients in the United States. This study aimed to investigate the willingness to use diabetes apps in patients with limited access to primary care providers. Fifteen personal interviews were collected and analyzed according to the interpretative phenomenological analysis framework. The interviews produced three overall themes: (1) Despite having little previous knowledge about health apps, patients were all willing to try at least one diabetes-related app; (2) app functions should be individualized to each patient’s needs for maximum benefit; and (3) barriers to app use were varied but commonly included knowledge and technological challenges and security issues. Underserved patients with diabetes expressed a willingness to try health apps, despite limited experience with the technology. Choosing apps individualized to each patient’s needs, instead of a blanket multifunctional app, would provide the greatest benefit for patient-driven diabetes management. Smartphone apps may be a feasible, low-cost resource for patients with limited access to traditional healthcare.

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

BackgroundAs 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.ObjectiveThis 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.MethodsThe 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.ResultsThe 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.ConclusionsMobile- 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.

Perspectives From Underserved African Americans and Their Health Care Providers on the Development of a Diabetes Self-Management Smartphone App: Qualitative Exploratory Study.

BackgroundType 2 diabetes mellitus (T2DM) affects approximately 10% of the US population, disproportionately afflicting African Americans. Smartphone apps have emerged as promising tools to improve diabetes self-management, yet little is known about the use of this approach in low-income minority communities.ObjectiveThe goal of the study was to explore which features of an app were prioritized for people with T2DM in a low-income African American community.MethodsBetween February 2016 and May 2018, we conducted formative qualitative research with 78 participants to explore how a smartphone app could be used to improve diabetes self-management. Information was gathered on desired features, and app mock-ups were presented to receive comments and suggestions of improvements from smartphone users with prediabetes and T2DM, their friends and family members, and health care providers; data were collected from six interactive forums, one focus group, and 15 in-depth interviews. We carried out thematic data analysis using an inductive approach.ResultsAll three types of participants reported that difficulty with accessing health care was a main problem and suggested that an app could help address this. Participants also indicated that an app could provide information for diabetes education and self-management. Other suggestions included that the app should allow people with T2DM to log and track diabetes care–related behaviors and receive feedback on their progress in a way that would increase engagement in self-management among persons with T2DM.ConclusionsWe identified educational and tracking smartphone features that can guide development of diabetes self-management apps for a low-income African American population. Considering those features in combination gives rise to opportunities for more advanced support, such as determining self-management recommendations based on data in users’ logs.

Acceptability of an Embodied Conversational Agent for Type 2 Diabetes Self-Management Education and Support via a Smartphone App: Mixed Methods Study.

BackgroundEmbodied conversational agents (ECAs) are increasingly used in health care apps; however, their acceptability in type 2 diabetes (T2D) self-management apps has not yet been investigated.ObjectiveThis study aimed to evaluate the acceptability of the ECA (Laura) used to deliver diabetes self-management education and support in the My Diabetes Coach (MDC) app.MethodsA sequential mixed methods design was applied. Adults with T2D allocated to the intervention arm of the MDC trial used the MDC app over a period of 12 months. At 6 months, they completed questions assessing their interaction with, and attitudes toward, the ECA. In-depth qualitative interviews were conducted with a subsample of the participants from the intervention arm to explore their experiences of using the ECA. The interview questions included the participants’ perceptions of Laura, including their initial impression of her (and how this changed over time), her personality, and human character. The quantitative and qualitative data were interpreted using integrated synthesis.ResultsOf the 93 intervention participants, 44 (47%) were women; the mean (SD) age of the participants was 55 (SD 10) years and the baseline glycated hemoglobin A1c level was 7.3% (SD 1.5%). Overall, 66 of the 93 participants (71%) provided survey responses. Of these, most described Laura as being helpful (57/66, 86%), friendly (57/66, 86%), competent (56/66, 85%), trustworthy (48/66, 73%), and likable (40/66, 61%). Some described Laura as not real (18/66, 27%), boring (26/66, 39%), and annoying (20/66, 30%). Participants reported that interacting with Laura made them feel more motivated (29/66, 44%), comfortable (24/66, 36%), confident (14/66, 21%), happy (11/66, 17%), and hopeful (8/66, 12%). Furthermore, 20% (13/66) of the participants were frustrated by their interaction with Laura, and 17% (11/66) of the participants reported that interacting with Laura made them feel guilty. A total of 4 themes emerged from the qualitative data (N=19): (1) perceived role: a friendly coach rather than a health professional; (2) perceived support: emotional and motivational support; (3) embodiment preference acceptability of a human-like character; and (4) room for improvement: need for greater congruence between Laura’s words and actions.ConclusionsThese findings suggest that an ECA is an acceptable means to deliver T2D self-management education and support. A human-like character providing ongoing, friendly, nonjudgmental, emotional, and motivational support is well received. Nevertheless, the ECA can be improved by increasing congruence between its verbal and nonverbal communication and accommodating user preferences.Trial RegistrationAustralian New Zealand Clinical Trials Registry CTRN12614001229662; https://tinyurl.com/yxshn6pd

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

BackgroundDiabetes 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.ObjectiveThis study aims to explore users’ real-world experiences with the My Diabetes Coach (MDC) self-management app.MethodsWe 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.ResultsA 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.ConclusionsUser 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 RegistrationAustralia New Zealand Clinical Trials Registry CTRN126140012296; URL https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366925&isReview=true

Quality, Functionality, and Features of Chinese Mobile Apps for Diabetes Self-Management: Systematic Search and Evaluation of Mobile Apps.

BackgroundThe emergence and advancement of mobile technologies offer a promising opportunity for people with diabetes to improve their self-management. Despite the proliferation of mobile apps, few studies have evaluated the apps that are available to the millions of people with diabetes in China.ObjectiveThis study aimed to conduct a systematic search of Chinese mobile apps for diabetes self-management and to evaluate their quality, functionality, and features by using validated rating scales.MethodsA systematic search was conducted to identify Chinese apps for diabetes self-management in the four most popular Chinese language mobile app stores. Apps were included if they were designed for diabetes self-management and contained at least one of the following components: blood glucose management, dietary and physical activity management, medication taking, and prevention of diabetes-related comorbidities. Apps were excluded if they were unrelated to health, not in Chinese, or the targeted users are health care professionals. Apps meeting the identified inclusion criteria were downloaded and evaluated by a team of 5 raters. The quality, functionalities, and features of these apps were assessed by using the Mobile App Rating Scale (MARS), the IMS Institute for Healthcare Informatics Functionality score, and a checklist of self-management activities developed based on the Chinese diabetes self-management guideline, respectively.ResultsAmong 2072 apps searched, 199 were eligible based on the inclusion criteria, and 67 apps were successfully downloaded for rating. These 67 apps had an average MARS score of 3.42 out of 5, and 76% (51/67) of the apps achieved an acceptable quality (MARS score >3.0). The scores for the four subdomains of MARS were 3.97 for functionality, 3.45 for aesthetics, 3.21 for information, and 3.07 for engagement. On average, reviewed apps applied five out of the 19 examined behavior change techniques, whereas the average score on the subjective quality for the potential impact on behavior change is 3 out of 5. In addition, the average score on IMS functionality was 6 out of 11. Functionalities in collecting, recording, and displaying data were mostly presented in the reviewed apps. Most of the apps were multifeatured with monitoring blood glucose and tracking lifestyle behaviors as common features, but some key self-management activities recommended by clinical guidelines, such as stress and emotional management, were rarely presented in these apps.ConclusionsThe general quality of the reviewed apps for diabetes self-management is suboptimal, although the potential for improvement is significant. More attention needs to be paid to the engagement and information quality of these apps through co-design with researchers, public health practitioners, and consumers. There is also a need to promote the awareness of the public on the benefit and potential risks of utilizing health apps for self-management.