Diabetes self-management support using mHealth and enhanced informal caregiving

Social support via Internet communication technology for diabetes self-management: a scoping review

Background

The global prevalence of diabetes has been increasing over the past 30 years, leading to a rise in complications; diabetes is the leading cause of amputations, blindness, and kidney failure in developed countries. Diabetes self-management is challenging due to the complex lifestyle changes required. Social support from family and friends plays a crucial role in overcoming barriers to healthy behavior choices. Integrating Internet and communication technologies with social support interventions has the potential to improve diabetes self-management.

Methods

A scoping review was conducted by searching PubMed, Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Association for Computing Machinery (ACM) Digital Library databases for studies combining diabetes, Internet and communication technologies, and social support interventions. Inclusion criteria focused on adult patients with diabetes and primarily Internet and communication technologies-based strategies to initiate and enhance social support. Data abstraction included study population, design, outcomes, social support domains emphasized, support relationship intervention strategy, and Internet and communication technologies modality.

Results

The review identified 39 articles and 33 unique studies representing 27 unique interventions utilizing peer web forums, interactive voice recordings, messaging-based interventions (including Short Message Service and instant messaging), and email as Internet and communication technologies modalities. Various outcomes were reported, including improvements in perception of social support, psychosocial well-being, behavior changes, and clinical outcomes. Existing support relationships may be more effective in promoting behavior change and clinical outcomes compared to developing new relationships. Studies that explicitly measured patients' perception of support consistently showed improvements in psycho-social, behavioral, and clinical outcomes.

Conclusions

This scoping review highlights the pivotal role of social support in diabetes self-management. By integrating Internet and communication technologies into interventions, diverse modalities such as web forums and text messaging have shown promise in enhancing patients' perception of support and improving psychosocial well-being, behavior changes, and clinical outcomes. The emphasis on leveraging existing support relationships, rather than establishing new ones, underscores the effectiveness of personalized, patient-centered approaches. These findings provide essential insights for healthcare strategies, emphasizing the need to harness technology and existing social networks to empower individuals in managing diabetes effectively.

Diabetes distress in Veterans with type 2 diabetes mellitus: Qualitative descriptive study

Diabetes distress (DD) is a negative psychosocial response to living with type 2 diabetes mellitus (T2DM). We sought insight into Veterans' experiences with DD in the context of T2DM self-management. The four domains in the Diabetes Distress Scale (i.e. regimen, emotional, interpersonal, healthcare provider) informed the interview guide and analysis (structural coding using thematic analysis). The mean age of the cohort (n = 36) was 59.1 years (SD 10.4); 8.3% of patients were female and 63.9% were Black or Mixed Race; mean A1C was 8.8% (SD 2.0); and mean DDS score was 2.4 (SD 1.1), indicating moderate distress. Veterans described DD and challenges to T2DM self-management across the four domains in the Diabetes Distress Scale. We found that (1) Veterans' challenges with their T2DM self-management routines influenced DD and (2) Veterans experienced DD across a wide range of domains, indicating that clinical interventions should take a "whole-person" approach.Trial Registration: NCT04587336.

Health Outcomes Following Engagement With a Digital Health Tool Among People With Prediabetes and Type 2 Diabetes: Prospective Evaluation Study

BACKGROUND

Diabetes is a worldwide chronic condition causing morbidity and mortality, with a growing economic burden on health care systems. Complications from poorly controlled diabetes are associated with increased socioeconomic costs and reduced quality of life. Smartphones have become an influential platform, providing feasible tools such as health apps to deliver tailored support to enhance the ability of patients with diabetes for self-management. Gro Health is a National Health Service division X-certified digital health tool used to deliver educational and monitoring support to facilitate the development of skills and practices for maintaining good health.

OBJECTIVE

This study aims to assess self-reported outcomes of the Gro Health app among users with diabetes and prediabetes and identify the factors that determine engagement with the digital health tool.

METHODS

This was a service evaluation of self-reported data collected prospectively by the developers of the Gro Health app. The EQ-5D questionnaire is a standardized tool used to measure health status for clinical and economic appraisal. Gro Health users completed the EQ-5D at baseline and 6 months after using the app. Users provided informed consent for the use of their anonymized data for research purposes. EQ-5D index scores and visual analogue scale (VAS) scores were calculated at baseline and 6 months for individuals with prediabetes and type 2 diabetes. Descriptive statistics and multiple-regression models were used to assess changes in the outcome measures and determine factors that affected engagement with the digital tool.

RESULTS

A total of 84% (1767/2114) of Gro Health participants completed EQ-5D at baseline and 6 months. EQ-5D index scores are average values that reflect people's preferences about their health state (1=full health and 0=moribund). There was a significant and clinically meaningful increase in mean EQ-5D index scores among app users between baseline (0.746, SD 0.23) and follow-up (0.792, SD 0.22; P<.001). The greatest change was observed in the mean VAS score, with a percentage change of 18.3% improvement (61.7, SD 18.1 at baseline; 73.0, SD 18.8 at follow-up; P<.001). Baseline EQ-5D index scores, age, and completion of educational modules were associated with significant changes in the follow-up EQ-5D index scores, with baseline EQ-5D index scores, race and ethnicity, and completion of educational modules being significantly associated with app engagement (P<.001).

CONCLUSIONS

This study provides evidence of a significant positive effect on self-reported quality of life among people living with type 2 diabetes engaging with a digital health intervention. The improvements, as demonstrated by the EQ-5D questionnaire, are facilitated through access to education and monitoring support tools within the app. This provides an opportunity for health care professionals to incorporate National Health Service-certified digital tools, such as Gro Health, as part of the holistic management of people living with diabetes.

An mHealth Text Messaging Program Providing Symptom Detection Training and Psychoeducation to Improve Hypoglycemia Self-Management: Intervention Development Study

BACKGROUND

Hypoglycemia remains a challenge for roughly 25% of people with type 1 diabetes (T1D) despite using advanced technologies such as continuous glucose monitors (CGMs) or automated insulin delivery systems. Factors impacting hypoglycemia self-management behaviors (including reduced ability to detect hypoglycemia symptoms and unhelpful hypoglycemia beliefs) can lead to hypoglycemia development in people with T1D who use advanced diabetes technology.

OBJECTIVE

This study aims to develop a scalable, personalized mobile health (mHealth) behavioral intervention program to improve hypoglycemia self-management and ultimately reduce hypoglycemia in people with T1D who use advanced diabetes technology.

METHODS

We (a multidisciplinary team, including clinical and health psychologists, diabetes care and education specialists, endocrinologists, mHealth interventionists and computer engineers, qualitative researchers, and patient partners) jointly developed an mHealth text messaging hypoglycemia behavioral intervention program based on user-centered design principles. The following five iterative steps were taken: (1) conceptualization of hypoglycemia self-management processes and relevant interventions; (2) identification of text message themes and message content development; (3) message revision; (4) patient partner assessments for message readability, language acceptability, and trustworthiness; and (5) message finalization and integration with a CGM data-connected mHealth SMS text message delivery platform. An mHealth web-based SMS text message delivery platform that communicates with a CGM glucose information-sharing platform was also developed.

RESULTS

The mHealth SMS text messaging hypoglycemia behavioral intervention program HypoPals, directed by patients' own CGM data, delivers personalized intervention messages to (1) improve hypoglycemia symptom detection and (2) elicit self-reflection, provide fact-based education, and suggest practical health behaviors to address unhelpful hypoglycemia beliefs and promote hypoglycemia self-management. The program is designed to message patients up to 4 times per day over a 10-week period.

CONCLUSIONS

A rigorous conceptual framework, a multidisciplinary team (including patient partners), and behavior change techniques were incorporated to create a scalable, personalized mHealth SMS text messaging behavioral intervention. This program was systematically developed to improve hypoglycemia self-management in advanced diabetes technology users with T1D. A clinical trial is needed to evaluate the program's efficacy for future clinical implementation.

Characterising consumer engagement in virtual models of care: A systematic review and narrative synthesis

BACKGROUND

Widespread adoption of digital tools and technologies now support the delivery of virtual healthcare. Although, consumer engagement is central to care processes in virtual care models, there is paucity of evidence regarding the nature and outcomes of consumer engagement. This study aimed to determine the nature of consumer engagement used in virtual models of care, and its impact on quality and safety of care.

METHODS

A systematic review was undertaken with a narrative synthesis, with a search strategy applied to five electronic databases (CINAHL, EMBASE, MEDLINE, PsycINFO and Web of Science) RESULTS: Fifty-eight studies were included in the review that utilised a variety of virtual models of care across care services. Consumer engagement, such as patients' active involvement in monitoring, capturing and reporting their health data, was a common feature of the identified virtual models.

CONCLUSION

Increasing use of virtual models of care requires consideration of the role of patients and their support persons in the use of technology and in wider care processes that occur at a distance from health professionals. Ensuring consumers are equipped with necessary support to effectively engage in virtual care is important to ensure equity in access to, and outcomes of, virtual care models.

Prerandomization withdrawals from a Type 2 diabetes self-care support intervention trial are associated with lack of available support person coparticipant

OBJECTIVES

Dyadic interventions, involving two persons with a preexisting close relationship, offer the opportunity to activate support persons (SPs) to improve health for adults with chronic conditions. Requiring SP coparticipation can challenge recruitment and bias samples; however, the associations between voluntary SP coparticipation and recruitment outcomes across patient characteristics are unknown.

METHODS

The Family/Friend Activation to Motivate Self-care 2.0 randomized controlled trial (RCT) enrolled adults with Type 2 diabetes (T2D) from an academic health system. Participants were asked-but not required-to invite an SP to coenroll. Using data from the electronic health record we sought to describe RCT enrollment in the setting of voluntary SP coparticipation.

RESULTS

In a diverse sample of adults with (T2D) (48% female, 44% minoritized race/ethnicity), most participants (91%) invited SPs and (89%) enrolled with SPs. However, prerandomization withdrawal was significantly higher among participants who did not have consenting SPs than those who did. Females were less likely to invite SPs than males and more Black PWD were prerandomization withdrawals than randomized.

DISCUSSION

Voluntary SP coenrollment may benefit recruitment for dyadic sampling; however, more research is needed to understand if these methods systematically bias sampling and to prevent these unintended biases.

Factors Predicting Older People's Acceptance of a Personalized Health Care Service App and the Effect of Chronic Disease: Cross-Sectional Questionnaire Study

BACKGROUND

Mobile health (mHealth) services enable real-time measurement of information on individuals' biosignals and environmental risk factors; accordingly, research on health management using mHealth is being actively conducted.

OBJECTIVE

The study aims to identify the predictors of older people's intention to use mHealth in South Korea and verify whether chronic disease moderates the effect of the identified predictors on behavioral intentions.

METHODS

A cross-sectional questionnaire study was conducted among 500 participants aged 60 to 75 years. The research hypotheses were tested using structural equation modeling, and indirect effects were verified through bootstrapping. Bootstrapping was performed 10,000 times, and the significance of the indirect effects was confirmed through the bias-corrected percentile method.

RESULTS

Of 477 participants, 278 (58.3%) had at least 1 chronic disease. Performance expectancy (β=.453; P=.003) and social influence (β=.693; P<.001) were significant predictors of behavioral intention. Bootstrapping results showed that facilitating conditions (β=.325; P=.006; 95% CI 0.115-0.759) were found to have a significant indirect effect on behavioral intention. Multigroup structural equation modeling testing the presence or absence of chronic disease revealed a significant difference in the path of device trust to performance expectancy (critical ratio=-2.165). Bootstrapping also confirmed that device trust (β=.122; P=.039; 95% CI 0.007-0.346) had a significant indirect effect on behavioral intention in people with chronic disease.

CONCLUSIONS

This study, which explored the predictors of the intention to use mHealth through a web-based survey of older people, suggests similar results to those of other studies that applied the unified theory of acceptance and use of technology model to the acceptance of mHealth. Performance expectancy, social influence, and facilitating conditions were revealed as predictors of accepting mHealth. In addition, trust in a wearable device for measuring biosignals was investigated as an additional predictor in people with chronic disease. This suggests that different strategies are needed, depending on the characteristics of users.

Examining factors affecting self-care-self-regulation among registered nurses using path analysis

BACKGROUND

Practicing self-care is a requisite for nurses as they face the extreme physical, mental, and emotional challenges presented by the pandemic era. This study aimed to examine factors that contribute to self-care-self-regulation (SCSR) and investigate the mediation effect of psychological and physical health in the relationship between work stress and SCSR among registered nurses in the United States.

MATERIALS AND METHODS

This cross-sectional study was conducted on the data collected from 386 registered nurses who completed an online survey over a 3-week period during the COVID-19 pandemic (April 19 to May 6, 2020). The survey assessed demographic and work-related characteristics, work stress, depressive mood, self-rated health, and SCSR. The model was tested with depressive mood as the first mediator and self-rated health as the second mediator. The potential serial mediation effect was analyzed using PROCESS macros adjusting for covariates.

RESULTS

The sequential indirect effect of work stress on SCSR through depressive mood and self-rated health in series was significant, while its direct effect was not.

CONCLUSION

The findings of the path analysis demonstrate that psychological and physical health status is important to promote self-care behaviors when nurses experience high work stress.

Intensive, telemedicine-based, self-management program for rural, underserved patients with diabetes mellitus: Re-entry of retired endocrinologists into practice

INTRODUCTION

Endocrinology workforce data demonstrate a substantial gap in the number of practicing endocrinologists, a phenomenon particularly affecting patients with diabetes in rural, financially challenged, underserved areas. We evaluated the concept that retired endocrinologists could re-enter practice part time and utilize telemedicine in collaboration with personnel in Federally Qualified Community Health Center clinics to conduct an intensive self-management program and provide 6-month concurrent care for patients with diabetes.

METHODS

The program involved intensive glucose control measures and education in diabetes, nutrition, and lifestyle changes over a 6-month period. Key elements included comprehensive initial telehealth evaluations, frequent phone calls, and collaboration with certified diabetes care and education specialists, referring providers, referring-clinic staff, and the University of Virginia Telehealth Center.

RESULTS

The mean A1C in the 139 patients completing the 6-month self-management program decreased from 10.3 ± 1.94% to 7.78 ± 1.51% p < 0.0001. The number of treatment modalities per patient ranged from one to five with several different regimens utilized. The majority of patients maintained the reduction in A1C levels without recidivism over a mean follow-up of 16 months after discharge. Strategies using meal replacements are being implemented to facilitate weight loss.

DISCUSSION

This program resulted in improved A1C levels of patients with diabetes in rural, financially challenged, underserved areas; met recidivism goals; and provided a practical template to reduce the workforce gap of endocrinologists in those areas.

Attrition and social vulnerability during 2-year-long structured care in type 2 diabetes, the ERMIES randomized controlled trial

BACKGROUND

Diabetes self-management education is exposed to attrition from services and structured ambulatory care. However, knowledge about factors related to attrition in educational programs remains limited. The context of social vulnerability due to low income may interfere. The aim of this study was to identify the sociodemographic, clinical, psychometric, and lifestyle factors associated with attrition from the ERMIES multicentre randomized parallel controlled trial (RCT) that was interrupted due to the combination of both slow inclusion and high attrition.

METHODS

The ERMIES trial was performed from 2011 to 2016 on Reunion Island, which is characterized by a multicultural population and high social vulnerability. The original objective of the RCT was to test the efficacy of a2-year structured group self-management education in improving blood glucose in adult patients with nonrecent, insufficiently controlled type 2 diabetes. One hundred participants were randomized to intensive educational intervention maintained over two years (n = 51) versus only initial education (n = 49). Randomization was stratified on two factors: centres (five strata) and antidiabetic treatment (two strata: insulin-treated or not). Sociodemographic, clinical, health-care access and pathway, psychometric and lifestyle characteristics data were collected at baseline and used to assess determinants of attrition in a particular social context and vulnerability. Attrition and retention rates were measured at each visit during the study. Multiple correspondence analysis and Cox regression were performed to identify variables associated with attrition.

RESULTS

The global attrition rate was 26% during the study, with no significant difference between the two arms of randomization (9 dropouts out of 51 patients in the intervention group and 17 out of 49 in the control group). Male gender, multiperson household, low household incomes (< 800 euros), probable depression and history of hospitalization or medical leave at inclusion were associated with a higher risk of attrition from the study in multivariate regression.

CONCLUSIONS

Social context, vulnerability, and health care history were related to attrition in this 2-year longitudinal comparative study of structured care. Considering these potential determinants and biases is of importance in scaling up interventions aimed at the optimization of long-term care in type 2 diabetes mellitus.

TRIAL REGISTRATION

ID_RCB number: 2011-A00046-35, Clinicaltrials.gov number: NCT01425866 (Registration date: 30/08/2011).

SOURCE OF FUNDING

Ministry of Health, France.

Rationale, design, and recruitment outcomes for the Family/Friend Activation to Motivate Self-care (FAMS) 2.0 randomized controlled trial among adults with type 2 diabetes and their support persons

BACKGROUND

Self-care behaviors help reduce hemoglobin A1c (HbA1c) and prevent or delay type 2 diabetes (T2D) complications. Individualized interventions that support goal setting and self-monitoring improve self-care and HbA1c in the short-term; engaging family and friends may enhance and/or sustain effects. Family/Friend Activation to Motivate Self-care (FAMS) is a mobile phone-delivered intervention (i.e., phone coaching and text message support) based on Family Systems Theory which was successfully piloted among diverse adults with T2D.

METHODS

We made improvements to FAMS and conducted iterative usability testing to finalize FAMS 2.0 before evaluation in a randomized controlled trial (RCT). Adult persons with diabetes (PWDs) who enrolled were asked to invite a support person (friend or family member) to participate alongside them. For the RCT, dyads were randomly assigned to FAMS 2.0 or enhanced treatment as usual (control) for the first 9 months of the 15-month trial. Outcomes include PWDs' HbA1c and psychosocial well-being (including diabetes distress) and support persons' own diabetes distress and support burden.

RESULTS

We recruited RCT participants from April 2020 through October 2021 (N = 338 PWDs with T2D; 89% [n = 300] with a support person). PWDs were 52% male, 62% non-Hispanic White, aged 56.9 ± 11.0 years with HbA1c 8.7% ± 1.7% at enrollment; 73% cohabitated with their enrolled support person. Data collection is ongoing through January 2023.

CONCLUSION

Findings will inform the utility of engaging family/friends in self-care behaviors for both PWD and support person outcomes. Using widely available mobile phone technology, FAMS 2.0, if successful, has potential for scalability.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04347291 posted April 15, 2020.

Meeting own needs and supporting ability to care: Family caregivers' and health care professionals' perspectives on professional support provided through a potential mobile application

BACKGROUND

A majority of persons with dementia in Sweden live in their own homes and are often cared for by family members. Caring for a family member may be a positive experience. It may, however, also be a negative experience as symptoms like disturbing behavior and delusions may be difficult to encounter. The burden of being a family caregiver has been shown to affect the caregivers' quality of life.

OBJECTIVE

To explore stakeholders' perspectives on a potential mobile application through which family caregivers could be supported by healthcare professionals in caring for a person with dementia living at home.

METHOD

Eight individual interviews with family caregivers and a focus group with eight healthcare professionals specialized in dementia care were analyzed using content analysis method.

RESULTS

The findings suggest that a mobile application can support family caregivers to meet their own needs in terms of finding structure in everyday life, how to get information and support in their own pace, and how to care for themselves. The findings also suggest the necessity of accessing relevant contact networks to be supported in the ability to care for a family member with dementia.

CONCLUSION

Healthcare and social services mediated support provided through user-friendly mobile application has the potential to support family caregivers both in taking care of a person with dementia and caring for themselves. Moreover, it is important that the information provided to family caregivers is personalized according to the needs of the family caregivers as the family member's dementia advances.

Effectiveness of a nurse-led smartphone-based self-management programme for people with poorly controlled type 2 diabetes: A randomized controlled trial

AIM

To evaluate the effectiveness of a nurse-led smartphone-based self-management programme (NSSMP) on improving self-efficacy, promoting diabetes self-care, increasing health-related quality of life (HRQoL) and decreasing HbA1c, acute complications and unplanned medical consultation for people with poorly controlled type 2 diabetes compared with a nurse-led diabetic service (NDS).

DESIGN

A two-arm randomized controlled trial with repeated measures was conducted.

METHODS

Participants were recruited from June 2018 to September 2020. Eligible participants were assigned to either the intervention or control group randomly. Participants assigned to intervention group received the 6-month NSSMP, while those in the control group received existing NDS provided by the study hospital. Outcomes were measured at baseline, and at 3 and 6 months from baseline.

RESULTS

A total of 114 participants were recruited. There were no significant interactions between group and time for all the outcomes except for blood glucose testing activities (F = 4.742, p = .015). Both groups had reduced HbA1c over 6 months. The intervention group had a lower HbA1c than the control group at follow-ups, but the differences were not statistically significant. None of the participants had acute diabetes complications at follow-up. Similarly, the differences in the number of unplanned medical consultation at 6-month follow-up between two groups were statistically insignificant.

CONCLUSION

The NSSMP is as effective as existing NDS provided by the study hospital in improving most of the outcomes. NSSMP can liberate valuable time for nurses to provide care to critically ill patients and supports healthcare resource constraints in the current COVID-19 pandemic.

IMPACT

The existing diabetes service is labour intensive as nurses are required to deliver education, follow-up telephone calls to trace blood sugar monitoring and provide therapeutic consultations and necessary referrals. The outbreak of COVID-19 pandemic has added further strain on the overworked professionals. NSSMP provides an alternative programme that is just as effective, to reduce nurses' workload by delegating them back to the individuals through self-management strategies. This enables nurses to increase contact time with patients, and individuals to take onus of their disease through increased self-efficacy, facilitated by technology.

CLINICAL TRIAL

This study is registered under clinical registration number NCT03088475.

Regulatory standards and guidance for the use of health applications for self-management in Africa: scoping review protocol

INTRODUCTION

Despite health applications becoming ubiquitous and with enormous potential to facilitate self-management, regulatory challenges such as poor application quality, breach of data privacy and limited interoperability have impeded their full adoption. While many countries now have digital health-related policies/strategies, there is also a need for regulatory standards and guidance that address key regulatory challenges associated with the use of health applications. Currently, it is unclear the status of countries in Africa regarding regulatory standards and guidance that address the use of health applications.This protocol describes the process of conducting a scoping review which aims to investigate the extent to which regulatory standards and guidance address the use of health applications for self-management within the WHO African Region countries.

METHODS

The review will follow the methodological framework for conducting a scoping study by Arksey and O'Malley (2005), and the updated methodological guidance for conducting a Joanna Briggs Institute (JBI) scoping review. Given that regulatory standards and guidance are unlikely to be available in scientific databases, we will search Scopus, Google, OpenGrey, WHO Regional Office for Africa Library (AFROLIB), African Index Medicus (AIM), websites of WHO, ITU and Ministries of Health, repositories for digital health policies. We will also search the reference lists of included documents, and contact key stakeholders in the region. Results will be reported using descriptive qualitative content analysis based on the review objectives. The policy analysis framework by Walt and Gilson (1994) will be used to organise findings. A summary of the key findings will be presented using tables, charts and maps.

ETHICS AND DISSEMINATION

The collection of primary data is not anticipated in this study and hence ethical approval will not be required. The review will be published in a peer-reviewed journal while key findings will be shared with relevant organisations and/or presented at conferences.

Use of motivational techniques to enhance unpaid caregiver engagement in a tailored skills training intervention

OBJECTIVES

The Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES) evaluated a skills training program to support family caregivers of cognitively or functionally impaired persons. HI-FIVES demonstrated sustained improvements in caregivers' and patients' experiences of VA care. The aim of this distinct, secondary qualitative study was to explore the potential processes related to the individual tailored skills-based telephone training underpinning HI-FIVES intervention effects. We explored topics caregivers selected, characteristics of action items created, patterns of action or inaction, and barriers to action item completion across topics.

METHODS

Qualitative data was analysed from 118 dyads randomized into the HI-FIVES intervention which included three weekly facilitated training calls covering five education topics and action items developed by caregivers for each topic. Qualitative analysis of text responses to questions from the training calls was used.

RESULTS

Three of the top four most selected topics were caregiver-oriented and caregivers created an action item most often for self-care topics. Caregiver-oriented topics also had the highest action item completion rates. The majority of action items created met SMART guidelines for goal setting and simple structure. With regard to barriers to action item completion, caregivers commonly reported still contemplating/pending.

CONCLUSION

Our findings identify motivational interviewing as an effective technique to identify critical intervention content and address barriers to achieving caregiving goals. We suggest that caregivers felt more empowered to create and complete an action item when they had more control over completing the action item, such as in topics related to their own self-care.

Healthcare Professionals' Views of Factors Influencing Diabetes Self-Management and the Utility of a mHealth Application and Its Features to Support Self-Care

INTRODUCTION

The perspectives of healthcare professionals (HCPs) are pivotal to co-development of self-management strategies for patients with diabetes. However, literature has been largely limited to perspectives of patients within the context of a Western healthcare setting. This study aims to explore factors influencing diabetes self-management in adult patients with diabetes from the perspectives of HCPs and their views of the value of mHealth application for diabetes self-management.

MATERIALS AND METHODS

We conducted focus group discussions (FGD) with purposively selected HCPs in Singapore. All FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted using NVivo 12.

RESULTS

A total of 56 HCPs participated in the study. Barriers to self-management included limited patient commitment to lifestyle changes, suboptimal adherence to medication and treatment, patient resistance to insulin initiation and insufficient rapport between patients and HCPs. Patients' perceived susceptibility to complications, social support from family and community, multidisciplinary team care and patient's understanding of the benefits of self-care were viewed as facilitating self-management. HCPs saw mHealth apps as a vital opportunity to engage patients in the self-management of conditions and empower them to foster behavior changes. Yet, there were concerns regarding patient's limited digital literacy, lack of integration into routine electronic system and reluctance.

DISCUSSION

We identified a set of factors influencing self-management in adult patients with diabetes and useful app features that can empower patients to manage their conditions. Findings will inform the development of a mHealth application, and its features designed to improve self-care.

Veterans' Interpretation of Diabetes Distress in Diabetes Self-Management: Findings From Cognitive Interviews

PURPOSE

The purpose of this project was to identify additional facets of diabetes distress (DD) in veterans that may be present due to the veteran's military-related experience.

METHODS

The study team completed cognitive interviews with veterans with type 2 diabetes mellitus (T2DM) to examine how they answered the Diabetes Distress Scale (DD Scale), a tool that assesses DD. The DD Scale was used because of its strong associations with self-management challenges, physician-related distress, and clinical outcomes.

RESULTS

The veterans sample (n= 15) was 73% male, mean age of 61 (SD = 8.6), 53% Black, 53% with glycosylated hemoglobin level <9%, and 67% with prescribed insulin. The DD Scale is readily understood by veterans and interpreted. Thematic analysis indicated additional domains affecting DD and T2DM self-management, including access to care, comorbidities, disruptions in routine, fluctuations in emotions and behaviors, interactions with providers, lifelong nature of diabetes, mental health concerns, military as culture, personal characteristics, physical limitations, physical pain, sources of information and support, spirituality, and stigma.

CONCLUSIONS

This study describes how a veteran's military experience may contribute to DD in the context of T2DM self-management. Findings indicate clinicians and researchers should account for additional domains when developing self-management interventions and discussing self-management behaviors with individuals with T2DM.

What matters when exploring fidelity when using health IT to reduce disparities?

BACKGROUND

Implementation of evidence-based interventions often involves strategies to engage diverse populations while also attempting to maintain external validity. When using health IT tools to deliver patient-centered health messages, systems-level requirements are often at odds with 'on-the ground' tailoring approaches for patient-centered care or ensuring equity among linguistically diverse populations.

METHODS

We conducted a fidelity and acceptability-focused evaluation of the STAR MAMA Program, a 5-month bilingual (English and Spanish) intervention for reducing diabetes risk factors among 181 post-partum women with recent gestational diabetes. The study's purpose was to explore fidelity to pre-determined 'core' (e.g. systems integration) and 'modifiable' equity components (e.g. health coaching responsiveness, and variation by language) using an adapted implementation fidelity framework. Participant-level surveys, systems-level databases of message delivery, call completion, and coaching notes were included.

RESULTS

96.6% of participants are Latina and 80.9% were born outside the US. Among those receiving the STAR MAMA intervention; 55 received the calls in Spanish (61%) and 35 English (39%). 90% (n = 81) completed ≥ one week. Initially, systems errors were common, and increased triggers for health coach call-backs. Although Spanish speakers had more triggers over the intervention period, the difference was not statistically significant. Of the calls triggering a health coach follow-up, attempts were made for 85.4% (n = 152) of the English call triggers and for 80.0% (n = 279) of the Spanish call triggers (NS). Of attempted calls, health coaching calls were complete for 55.6% (n = 85) of English-language call triggers and for 56.6% of Spanish-language call triggers (NS). Some differences in acceptability were noted by language, with Spanish-speakers reporting higher satisfaction with prevention content (p = < 0.01) and English-speakers reporting health coaches were less considerate of their time (p = 0.03).

CONCLUSIONS

By exploring fidelity by language-specific factors, we identified important differences in some but not all equity indicators, with early systems errors quicky remedied and high overall engagement and acceptability. Practice implications include: (1) establishing criteria for languge-equity in interventions, (2) planning for systems level errors so as to reduce their impact between language groups and over time; and (3) examining the impact of engagement with language-concordant interventions on outcomes, including acceptability. Trial Registration National Clinical Trials registration number: CT02240420 Registered September 15, 2014. ClinicalTrials.gov.

Autonomy support from informal health supporters: links with self-care activities, healthcare engagement, metabolic outcomes, and cardiac risk among Veterans with type 2 diabetes

This study examined the role of autonomy support from adults' informal health supporters (family or friends) in diabetes-specific health behaviors and health outcomes. Using baseline data from 239 Veterans with type 2 diabetes at risk of complications enrolled in behavioral trial, we examined associations between autonomy support from a support person and that support person's co-residence with the participant's diabetes self-care activities, patient activation, cardiometabolic measures, and predicted risk of a cardiac event. Autonomy support from supporters was associated with significantly increased adherence to healthy lifestyle behaviors (diet, p < .001 and exercise, p = .003); higher patient activation (p < .001); greater patient efficacy in interacting with healthcare providers, and lower 5-year (p = .044) and 10-year (p = .027) predicted cardiac risk. Autonomy support was not significantly associated with diabetes-specific behaviors (checking blood glucose, foot care, or medication taking); or hemoglobin A1c, systolic blood pressure, or non-HDL cholesterol. There was a significant interaction of autonomy support and supporter residence in one model such that lack of autonomy support was associated with lower patient activation only among individuals with in-home supporters. No other interactions were significant. Findings suggest that autonomy support from family and friends may play a role in patient self-management, patient activation, and lower cardiac risk.

Integrating family and friend support, information technology, and diabetes education in community-centric diabetes self-management

OBJECTIVE

Diabetes self-management (DSM) education, social support, and information technology interventions can improve patient engagement and health. A major challenge is animating, integrating, and accessing resources in under-resourced, rural communities. Set in an island community in Hawai'i, this study piloted a program that integrated friend-and-family support, community health services, telehealth-enabled DSM education, and mobile technologies by activating the community's social capital to support the program.

MATERIALS AND METHODS

An action research approach informed the design and implementation of a community-based DSM program that included: friends and family support, telehealth classes, personalized consultations, Bluetooth-enabled blood glucose monitors, and text messaging support. Outcomes were evaluated using biometric data, surveys, interviews, and participant observations.

RESULTS

The study spanned 9 months with 7 dyads, each with 1 individual with type 2 diabetes and a friend or family member. Six of the 7 participants with diabetes experienced reduced hemoglobin A1c percentages, with 3 reducing by more than 1%. The seventh participant maintained a hemoglobin A1c level within American Diabetes Association recommended ranges. DSM knowledge and self-care behaviors improved overall. Interviews and participant observations highlighted program strengths and social challenges associated with the interpersonal relationships between the members of the dyads.

CONCLUSIONS

A community-centric diabetes program can enhance understanding of diabetes etiology, DSM activities, and communication skills for effective disease management support in under-resourced rural communities. Social capital among community members, leveraged with health information technology, can catalyze and integrate limited health system resources for DSM and social support as a cost-effective strategy to develop community-centric chronic healthcare management initiatives.

Text messaging to engage friends/family in diabetes self-management support: acceptability and potential to address disparities

OBJECTIVE

Explore acceptability of engaging family/friends in patients' type 2 diabetes (T2D) self-management using text messaging.

MATERIALS AND METHODS

Participants (N = 123) recruited from primary care clinics for a larger trial evaluating mobile phone support for T2D completed self-report measures and a hemoglobin A1c test and then had the option to invite an adult support person to receive text messages. We examined characteristics and reasons of participants who did/did not invite a support person, responses to the invitation, and feedback from patients and support persons.

RESULTS

Participants were 55.9 ± 10.1 years old, 55% female, 53% minority, and 54% disadvantaged (low income, less than high school degree/GED, uninsured, and/or homeless). Participants who invited a support person (48%) were slightly younger, more likely to be partnered, and reported more depressive symptoms and more emergency department visits in the year prior to study enrollment as compared to participants who did not (all p <.05). Participants' reasons for inviting a support person included needing help and seeing benefits of engaging others, while reasons for not inviting a support person included concerns about being a "burden" and support person's ability or desire to text. Support persons reported the texts increased awareness, created dialogue, and improved their own health behaviors.

DISCUSSION

Patients inviting a support person had higher need and thus may stand to benefit most. Most support persons were open to engagement via text messages.

CONCLUSION

Across race and socioeconomic status, text messaging may engage support persons to increase health-related support-particularly for patients with higher levels of need.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02409329.

The development and testing of a nurse-led smartphone-based self-management programme for diabetes patients with poor glycaemic control

AIMS

To describe a systematic process for the development of a nurse-led smartphone-based self-management programme for type 2 diabetes patients with poor glycaemic control in Singapore.

METHODS

A three-step process involving the application of a theoretical framework, evidence from literature, content validity, and pilot tests were conducted for the content and technical development of the programme. Content experts and lay patients evaluated the appropriateness, relevance, and comprehensibility of the newly developed Care4Diabetes application. A pilot randomized controlled trial was conducted with 40 patients recruited in Singapore. Twenty patients each were randomly allocated to the control and intervention groups. The study outcomes were collected at baseline and at 3 months thereafter.

RESULTS

The nurse-led smartphone-based self-management programme was developed with integration of the Care4Diabetes application and the web-portal system. The pilot results indicated that the effects of this smartphone-based programme on patient's health-related outcomes were comparable with those of the currently available nurse-led diabetes service.

CONCLUSION

The smartphone-based self-management intervention was deemed effective, yet full-scale randomized controlled trials are still ongoing and the results of these may provide strong evidence of the effectiveness of such an approach in improving patient care.

IMPACT

The uniqueness of this study lies in the integrated system used, which offers a clinical platform for diabetes nurses to provide personalized coaching and care to patients remotely, while monitoring patients' progress closely. By adopting such an approach, it would free up more time for nurses to cater to patients who are more critically in need of their direct attention.

mHealth and Engagement Concerning Persons With Chronic Somatic Health Conditions: Integrative Literature Review

Background

Chronic somatic health conditions are a global public health challenge. Being engaged in one’s own health management for such conditions is important, and mobile health (mHealth) solutions are often suggested as key to promoting engagement.

Objective

The aim of this study was to review, critically appraise, and synthesize the available research regarding engagement through mHealth for persons with chronic somatic health conditions.

Methods

An integrative literature review was conducted. The PubMed, CINAHL, and Inspec databases were used for literature searches. Quality assessment was done with the guidance of Critical Appraisal Skills Programme (CASP) checklists. We used a self-designed study protocol comprising 4 engagement aspects—cognitive, behavioral and emotional, interactional, and the usage of mHealth—as part of the synthesis and analysis.

Results

A total of 44 articles met the inclusion criteria and were included in the analysis. mHealth usage was the most commonly occurring engagement aspect, behavioral and emotional aspects the second, cognitive aspects the third, and interactional aspects of engagement the least common aspect in the included articles. The results showed that there is a mix of enablers and barriers to engagement in relation to the 4 engagement aspects. The perceived meaningfulness and need for the solution and its content were important to create and maintain engagement. When perceived as meaningful, suitable, and usable, mHealth can support knowledge gain and learning, facilitate emotional and behavioral aspects such as a sense of confidence, and improve interactions and communications with health care professionals.

Conclusions

mHealth solutions have the potential to support health care engagement for persons with chronic somatic conditions. More research is needed to further understand how, by which means, when, and among whom mHealth could further improve engagement for this population.

mHealth Apps as Effective Persuasive Health Technology: Contextualizing the "Necessary" Functionalities

Persuasive health technology (PHT) is any technology purposely designed to influence, reinforce, change, or shape health-related attitudes or behaviors. Behavioral interventions can be developed for the purpose of maintaining or improving a person’s health status. Delivering behavioral interventions via PHTs is a promising approach for encouraging healthy behaviors among individuals and populations. Important attributes of all PHTs include their functionalities. A functionality refers to any useful features, functions, capabilities, or technologies associated with computer hardware or software. Creating effective PHTs requires a deliberate selection of appropriate functionalities for supporting specific behavioral interventions. The number and types of functionalities necessary to create an effective PHT will be specific to the context of each project, influenced by project objectives, stakeholder goals, behavioral interventions, and a variety of real-world constraints. Selecting appropriate functionalities can be challenging. Fortunately, there are frameworks and models developed specifically for guiding the design of PHTs. The Persuasive Systems Design model describes 4 categories, and 28 design principles for creating effective persuasive interventions. These same design principles could also be useful for guiding the selection of appropriate functionalities.

Dyadic Psychosocial eHealth Interventions: Systematic Scoping Review

Background

Dyadic psychosocial interventions have been found beneficial both for people coping with mental or physical health conditions as well as their family members and friends who provide them with support. Delivering these interventions via electronic health (eHealth) may help increase their scalability.

Objective

This scoping review aimed to provide the first comprehensive overview of dyadic eHealth interventions for individuals of all ages affected by mental or physical illness and their family members or friends who support them. The goal was to understand how dyadic eHealth interventions have been used and to highlight areas of research needed to advance dyadic eHealth intervention development and dissemination.

Methods

A comprehensive electronic literature search of PubMed, EMBASE, Cochrane, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO was conducted for articles published in the English language through March 2019. Eligible records described a psychosocial eHealth intervention that intervened with both care recipients and their support person.

Results

A total of 7113 records were reviewed of which 101 met eligibility criteria. There were 52 unique dyadic eHealth interventions identified, which were tested across 73 different trials. Of the unique interventions, 33 were conducted among dyads of children and their supporting parent, 1 was conducted with an adolescent-young adult care recipient population, and the remaining 18 were conducted among adult dyads. Interventions targeting pediatric dyads most commonly addressed a mental health condition (n=10); interventions targeting adult dyads most commonly addressed cancer (n=9). More than three-fourths of interventions (n=40) required some human support from research staff or clinicians. Most studies (n=64) specified one or more primary outcomes for care recipients, whereas less than one-fourth (n=22) specified primary outcomes for support persons. Where specified, primary outcomes were most commonly self-reported psychosocial or health factors for both care recipients (n=43) and support persons (n=18). Results of the dyadic eHealth intervention tended to be positive for care recipients, but evidence of effects for support persons was limited because of few studies specifying primary outcomes for supporters. Trials of dyadic eHealth interventions were most commonly randomized controlled trials (RCTs; n=44), and RCTs most commonly compared the dyadic eHealth intervention to usual care alone (n=22).

Conclusions

This first comprehensive review of dyadic eHealth interventions demonstrates that there is substantial, diverse, and growing literature supporting this interventional approach. However, several significant gaps were identified. Few studies were designed to evaluate the unique effects of dyadic interventions relative to individual interventions. There was also limited assessment and reporting of outcomes for support persons, and there were no interventions meeting our eligibility criteria specifically targeting the needs of older adult dyads. Findings highlight areas of research opportunities for developing dyadic eHealth interventions for novel populations and for increasing access to dyadic care.

Exploring app features with outcomes in mHealth studies involving chronic respiratory diseases, diabetes, and hypertension: a targeted exploration of the literature

Objectives

Limited data are available on the correlation of mHealth features and statistically significant outcomes. We sought to identify and analyze: types and categories of features; frequency and number of features; and relationship of statistically significant outcomes by type, frequency, and number of features.

Materials and Methods

This search included primary articles focused on app-based interventions in managing chronic respiratory diseases, diabetes, and hypertension. The initial search yielded 3622 studies with 70 studies meeting the inclusion criteria. We used thematic analysis to identify 9 features within the studies.

Results

Employing existing terminology, we classified the 9 features as passive or interactive. Passive features included: 1) one-way communication; 2) mobile diary; 3) Bluetooth technology; and 4) reminders. Interactive features included: 1) interactive prompts; 2) upload of biometric measurements; 3) action treatment plan/personalized health goals; 4) 2-way communication; and 5) clinical decision support system.

Discussion

Each feature was included in only one-third of the studies with a mean of 2.6 mHealth features per study. Studies with statistically significant outcomes used a higher combination of passive and interactive features (69%). In contrast, studies without statistically significant outcomes exclusively used a higher frequency of passive features (46%). Inclusion of behavior change features (ie, plan/goals and mobile diary) were correlated with a higher incident of statistically significant outcomes (100%, 77%).

Conclusion

This exploration is the first step in identifying how types and categories of features impact outcomes. While the findings are inconclusive due to lack of homogeneity, this provides a foundation for future feature analysis.

Feasibility study of automated interactive voice response telephone calls with community health nurse follow-up to improve glycaemic control in patients with type 2 diabetes

BACKGROUND

Thailand has a shortage of community health nurses for supporting the self-management of type 2 diabetes, which is prevalent and poorly controlled.

AIM

This study examined the feasibility and acceptability of a self-care assistance programme for poorly controlled type 2 diabetes mellitus. The SukapapNet programme consisted of automated interactive voice response calls to patients and automated follow-up email notifications to their nurses.

DESIGN

Single-arm pre-post trial.

METHODS

Six nurses and 35 type 2 diabetes patients were recruited from primary care settings in suburban provinces in Thailand. The study was conducted from June 2017 to November 2017. We assessed patients before and after 12 weeks of the SukapapNet intervention.

RESULTS

Mean glycated haemoglobin decreased by 0.9%. Patients reported reduced carbohydrate consumption, increased physical activity, increased medication adherence, improved sleep quality, and more frequent foot care. Patients and nurses both recommended using the intervention, although nurses expressed concerns regarding increased workload.

CONCLUSIONS

The study programme could improve outcomes in Thai type 2 diabetes patients. Further study of the impact of technology upon nurses' workload is warranted.

Impact of mobile health applications on self-management in patients with type 2 diabetes mellitus: protocol of a systematic review

INTRODUCTION

The emergence of mobile health (mHealth) solutions, particularly mHealth applications (apps), has shown promise in self-management of chronic diseases including type 2 diabetes mellitus (T2DM). While majority of the previous systematic reviews have focused on the effectiveness of mHealth apps in improving treatment outcomes in patients with T2DM, there is a need to also understand how mHealth apps influence self-management of T2DM. This is crucial to ensure improvement in the design and use of mHealth apps for T2DM. This protocol describes how a systematic review will be conducted to determine in which way(s) mHealth apps might impact on self-management of T2DM.

METHODS

The following electronic databases will be searched from inception to April 2019: PubMed, MEDLINE, EMBASE, Global Health, PsycINFO, CINAHL, The Cochrane Central Register of Controlled Trials, Scopus, Web of Science, ProQuest Dissertations & Theses Global, Health Management Information Consortium database, Google Scholar and ClinicalTrials.gov. The Cochrane risk of bias tool will be used to assess methodological quality. The primary outcome measures to be assessed will be 'change in blood glucose'. The secondary outcomes measures will be 'changes in cardiovascular risk markers' (including blood pressure, body mass index and blood lipids), and self-management practices. Others will include: health-related quality of life, economic data, social support, harms (eg, death or complications leading to hospital admissions or emergency unit attendances), death from any cause, anxiety or depression and adverse events (eg, hypoglycaemic episodes).

ETHICS AND DISSEMINATION

This study will not involve the collection of primary data and will not require ethical approval. The review will be published in a peer-reviewed journal and a one-page summary of the findings will be shared with relevant organisations. Presentation of findings will be made at appropriate conferences.

TRIAL REGISTRATION NUMBER

CRD42017071106.

The Use of Mobile Health to Assist Self-management and Access to Services in a Rural Community

The purpose of this study was to explore the barriers to and needs for using mobile health technology to assist low-income Asian American and Pacific Islander participants living in rural Hawaii in their healthcare. Three focus groups consisting of patients, family support/significant others, and providers (N = 19) were conducted to assess the unique needs of low-income Asian American and Pacific Islander patients in rural Hawaii. The electronic health literacy scale was also used among participants in the patients and family support/significant other groups. The total electronic health literacy means were 23.57 (SD = 9.71) among participants in the patient group, 34.50 (SD = 7.78) in the family support/significant others group, and 35.67 (SD = 4.56) in the providers group. The qualitative analysis yielded categories with three main themes: value of mobile health, stumbling blocks to mobile health, and mobile health wish list and subthemes. Practice implications include uses of these findings to integrate future versions of mobile health that will promote effective communication and information specifically to diverse low-income populations.

Caregiver-Based Interventions to Optimize Medication Safety in Vulnerable Elderly Adults: A Systematic Evidence-Based Review

OBJECTIVES

To study the effect of caregiver-focused interventions to support medication safety in older adults with chronic disease.

DESIGN

Systematic review.

SETTING

Studies published before January 31, 2017, searched using Ovid Medline, PubMed, EMBASE, Scopus, CINAHL, PsycINFO, and Google Scholar.

PARTICIPANTS

Caregivers with or without a care recipient.

MEASUREMENTS

Inclusion criteria: interventions focused on caregivers aiming to improve medication safety. Studies not focusing on older adults, not evaluating medication safety, failing to include caregivers, or without a comparison group were excluded.

RESULTS

The initial search revealed 1,311 titles. Eight studies met inclusion criteria. The strategies used in randomized trials were a home-based medication review and adherence assessment by a clinical pharmacist (2 home visits 6-8 weeks apart, with pharmacist and physician meeting independently) that found no difference in nonelective hospital admissions (p=.8) but fewer medications (p=.03); a 19-minute educational DVD and an hour-long medication education and training that improved caregiver satisfaction (p<.04); a medication education and adherence intervention (2-3 home visits per care recipient and caregiver dyad over 8 weeks) that found no difference in knowledge, administration, or accessibility of medications (p=.29); and a collaborative case management program (16-month program of assessment, meeting, and monthly follow-up telephone calls) that reduced perceived caregiver burden (p=.03). Quasi-experimental trials included collaborative care transitional coaches, an outpatient collaborative care model, and education and training programs. Of these, educational interventions showed improvements in self-efficacy, confidence, and preparedness. The collaborative care intervention reduced rehospitalizations (p=.04) and improved quality-of-care outcomes.

CONCLUSION

Although some interventions improved caregiver medication knowledge and self-efficacy, effects on clinical outcomes and healthcare use were insufficiently studied. Two studies implementing collaborative care models with medication management components showed potential for improvement in quality of clinical care and reductions in healthcare visits and warrant further study with respect to medication safety. J Am Geriatr Soc 66:2128-2135, 2018.

Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes

Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.

Effectiveness of the mHealth technology in improvement of healthy behaviors in an elderly population-a systematic review

Demographic changes in the 21st century, increased population of the elderly and high prevalence of related diseases call for new healthcare strategies that can change the behavior and lifestyle of elderly individuals. Innovative information and communication technology, such as mobile health (mHealth), can play a significant role. The present study was conducted aiming to assess the effectiveness of mHealth in improving health behaviors among an elderly population. This paper presents a systematic review involving a search of PubMed, Web of Science (ISI), Scopus, Science Direct and Embase databases from [2012-2016]. Our search resulted after initial evaluations 12 articles. Inclusion criteria mostly revolved around interventional studies, other studies were excluded because of their methodology, non-elderly target groups and irrelevant to the subject. Findings showed that mHealth can improve care, self-management, self-efficacy, behavior promotion (quality of sleep, diet, physical activity mental health) and medication adherence. The mHealth technology has proven effective for disease prevention, lifestyle changes, management of cardiovascular disease and diabetes, and is a suitable tool for elderly people. In conclusion, it seems that mHealth can facilitate behavioral changes; although, further research is necessary in this regard.

A Systematic Review: Family Support Integrated with Diabetes Self-Management among Uncontrolled Type II Diabetes Mellitus Patients

The rate of type-2 diabetes mellitus (T2D) is dramatically increasing worldwide. Continuing diabetes mellitus (DM) care needs effective self-management education and support for both patients and family members. This study aimed to review and describe the impacts of diabetes mellitus self-management education (DSME) that involve family members on patient outcomes related to patient health behaviors and perceived self-efficacy on self-management such as medication adherence, blood glucose monitoring, diet and exercise changes, health outcomes including psychological well-being and self-efficacy, and physiological markers including body mass index, level of blood pressure, cholesterol level and glycemic control. Three databases, PubMed, CINAHL, and Scopus were reviewed for relevant articles. The search terms were "type 2 diabetes," "self-management," "diabetes self-management education (DSME)," "family support," "social support," and "uncontrolled glycaemia." Joanna Briggs Institute (JBI) guidelines were used to determine which studies to include in the review. Details of the family support components of DSME intervention and the impacts of these interventions had on improving the health outcomes patients with uncontrolled glycaemia patients. A total of 22 intervention studies were identified. These studies involved different DSME strategies, different components of family support provided, and different health outcomes to be measured among T2D patients. Overall, family support had a positive impact on healthy diet, increased perceived support, higher self-efficacy, improved psychological well-being and better glycemic control. This systematic review found evidence that DSME with family support improved self-management behaviors and health outcomes among uncontrolled glycaemia T2D patients. The findings suggest DSME models that include family engagement can be a useful direction for improving diabetes care.

Phone Messaging to Prompt Physical Activity and Social Support Among Low-Income Latino Patients With Type 2 Diabetes: A Randomized Pilot Study

BACKGROUND

Given disparities in diabetes prevalence, receipt of diabetes education, diabetes knowledge, and self-management behaviors among Latinos, there is a need to provide education and ongoing support to this population. Phone-based interventions have the potential to reach and engage both patients and their family members and friends.

OBJECTIVE

The aim of this study was to investigate the feasibility, perceived usefulness, and potential effectiveness of a short text or voice message (STVM) intervention to activate (1) physical activity (PA) behavior change among urban, low-income Latino adults with type 2 diabetes and (2) supportive behaviors by their family members and friends.

METHODS

A 12-week pilot study randomized 42 participants recruited in person from a safety-net ambulatory care clinic in Los Angeles into one of the 3 study arms: control, phone messaging (PM), and phone messaging plus social support from family members and friends (PM+FF). All participants were prompted to set PA goals and to self-monitor PA behavior using pedometers and walking logs. PM and PM+FF participants received STVMs with reminders to review goals and self-monitor, PA behavior change education, and feedback on performance. Participants in the PM+FF arm also had their family members and friends receiving STVMs with suggestions for how they could support the participant's PA behavior change efforts. Participants completed semistructured assessments in person at baseline, 6 weeks, and 12 weeks. Outcomes were PA (steps/day) and perceived social support from family members and friends.

RESULTS

Among PM and PM+FF participants, those who opted to receive text messages (short message service, SMS) responded to 62.7% (128/204) of SMS text messages requiring a response while those who opted to receive voice messages responded 30% (12/40) of the time. Participants perceived guidance in self-regulation as useful, particularly self-monitoring, goal setting, self-instruction, feedback, and social support. All participants increased PA at 6 weeks, but only the PM and PM+FF arms increased PA at 12 weeks. All study arms experienced an increase in perceived social support from family members and friends at 6 weeks, but only those in the PM+FF arm had an increase in the perception of social support at 12 weeks.

CONCLUSION

Designing an STVM intervention based on self-regulation techniques is feasible and perceived as useful by participants. The STVM intervention has the potential to improve PA in terms of daily steps and perceived social support from family members and friends.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02850770; https://clinicaltrials.gov/ct2/show/NCT02850770 (Archived by WebCite at http://www.webcitation.org/query?id=1495567756845570).

Assessing the Medication Adherence App Marketplace From the Health Professional and Consumer Vantage Points

Background

Nonadherence produces considerable health consequences and economic burden to patients and payers. One approach to improve medication nonadherence that has gained interest in recent years is the use of smartphone adherence apps. The development of smartphone adherence apps has increased rapidly since 2012; however, literature evaluating the clinical app and effectiveness of smartphone adherence apps to improve medication adherence is generally lacking.

Objective

The aims of this study were to (1) provide an updated evaluation and comparison of medication adherence apps in the marketplace by assessing the features, functionality, and health literacy (HL) of the highest-ranking adherence apps and (2) indirectly measure the validity of our rating methodology by determining the relationship between our app evaluations and Web-based consumer ratings.

Methods

Two independent reviewers assessed the features and functionality using a 4-domain rating tool of all adherence apps identified based on developer claims. The same reviewers downloaded and tested the 100 highest-ranking apps including an additional domain for assessment of HL. Pearson product correlations were estimated between the consumer ratings and our domain and total scores.

Results

A total of 824 adherence apps were identified; of these, 645 unique apps were evaluated after applying exclusion criteria. The median initial score based on descriptions was 14 (max of 68; range 0-60). As a result, 100 of the highest-scoring unique apps underwent user testing. The median overall user-tested score was 31.5 (max of 73; range 0-60). The majority of the user tested the adherence apps that underwent user testing reported a consumer rating score in their respective online marketplace. The mean consumer rating was 3.93 (SD 0.84). The total user-tested score was positively correlated with consumer ratings (r=.1969, P=.04).

Conclusions

More adherence apps are available in the Web-based marketplace, and the quality of these apps varies considerably. Consumer ratings are positively but weakly correlated with user-testing scores suggesting that our rating tool has some validity but that consumers and clinicians may assess adherence app quality differently.

Barriers to Remote Health Interventions for Type 2 Diabetes: A Systematic Review and Proposed Classification Scheme

Background

Diabetes self-management involves adherence to healthy daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption.

Objective

The objective of our study was to identify and classify barriers to adoption of remote health for management of type 2 diabetes.

Methods

The following 6 electronic databases were searched for articles published from 2010 to 2015: MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier). The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of 2 to review and extract data from identified papers. Information collected included study characteristics, outcomes, dropout rates, technologies used, and barriers identified.

Results

A total of 53 publications on 41 studies met the specified criteria. Lack of data accuracy due to input bias (32%, 13/41), limitations on scalability (24%, 10/41), and technology illiteracy (24%, 10/41) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations, whereas limitations on scalability were more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. In total, 40.5% (60/148) of identified barrier instances impeded patient engagement, which is manifest in the large dropout rates cited (up to 57%).

Conclusions

The barriers identified represent major challenges in the design of remote health interventions for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high dropout rates, and new interventions are needed to identify and assist those at the greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financial sustainability.

Remotely engaged: Lessons from remote monitoring in multiple sclerosis

OBJECTIVES

Evaluate web-based patient-reported outcome (wbPRO) collection in MS subjects in terms of feasibility, reliability, adherence, and subject-perceived benefits; and quantify the impact of MS-related symptoms on perceived well-being.

METHODS

Thirty-one subjects with MS completed wbPROs targeting MS-related symptoms over six months using a customized web portal. Demographics and clinical outcomes were collected in person at baseline and six months.

RESULTS

Approximately 87% of subjects completed wbPROs without assistance, and wbPROs strongly correlated with standard PROs (r>0.91). All wbPROs were completed less frequently in the second three months (p<0.05). Frequent wbPRO completion was significantly correlated with higher step on the Expanded Disability Status Scale (EDSS) (p=0.026). Nearly 52% of subjects reported improved understanding of their disease, and approximately 16% wanted individualized wbPRO content. Over half (63.9%) of perceived well-being variance was explained by MS symptoms, notably depression (r_s=-0.459), fatigue (r_s=-0.390), and pain (r_s=-0.389).

CONCLUSIONS

wbPRO collection was feasible and reliable. More disabled subjects had higher completion rates, yet most subjects failed requirements in the second three months. Remote monitoring has potential to improve patient-centered care and communication between patient and provider, but tailored PRO content and other innovations are needed to combat declining adherence.

Thinking about the environment and theorising change: how could Life History Strategy Theory inform mHealth interventions in low- and middle-income countries?

BACKGROUND

There is a growing body of literature outlining the promise of mobile information and communication technologies to improve healthcare in resource-constrained contexts.

METHODS

We reviewed the literature related to mobile information and communication technologies which aim to improve healthcare in resource-constrained contexts, in order to glean general observations regarding the state of mHealth in high-income countries (HIC) and low- and middle-income countries (LMIC).

RESULTS

mHealth interventions in LMIC often differ substantively from those in HIC, with the former being simpler, delivered through a single digital component (an SMS as opposed to a mobile phone application, or 'app'), and, as a result, targeting only one of the many factors which impact on the activation (or deactivation) of the target behaviour. Almost as a rule, LMIC mHealth interventions lack an explicit theory of change.

CONCLUSION

We highlight the necessity, when designing mHealth interventions, of having a theory of change that encompasses multiple salient perspectives pertaining to human behaviour. To address this need, we explore whether the concept of Life History Strategy could provide the mHealth field with a useful theory of change. Life History Strategy Theory may be particularly useful in understanding some of the problems, paradoxes, and limitations of mHealth interventions found in LMIC. Specifically, this theory illuminates questions regarding 'light-weight' programmes which solely provide information, reminders, and other virtual 'nudges' that may have limited impact on behaviours governed by extrinsic structural factors.

Home Telehealth and Caregiving Appraisal in Chronic Illness

BACKGROUND

Remote health monitoring applications are being adopted to improve the health of chronically ill individuals. Little work has focused on the effects of these technologies on informal caregivers (CG) of patients with chronic illnesses.

OBJECTIVES

To examine differences in caregiving appraisal between CG of enrolled and nonenrolled Veterans in the home telehealth (HT) program.

METHODS

Cross-sectional survey methodology in 244 dyads (Veteran and CG) from 6 rural Midwestern Veterans Affairs Medical Centers. Survey variables were derived from the 2004 National Alliance for Caregiving survey, along with measures of caregiving strain, burden, and satisfaction.

RESULTS

We found no differences when comparing HT and non-HT CG. In multivariate analyses combining the two groups, CG characteristics associated with CG strain included younger age, providing help with activities of daily living and instrumental activities of daily living, use of coping skills, depressive symptoms, and less use of unpaid help (all p ≤ 0.001). Burden was associated with CG use of coping skills, caregiving confidence, and relationship quality with the Veteran (all p < 0.0001). CG satisfaction was associated with presence of social support (p < 0.0001). High CG strain was associated with Veteran hospitalization in the combined group (p = 0.03). Burden (p = 0.0002) was significantly associated with CG satisfaction.

DISCUSSION

Existing HT infrastructure provides an opportunity to incorporate training and support programs for CG of chronically ill patients. Such programs could improve CG confidence and use of positive coping skills, lower strain and burden, and potentially improve the health of both the care recipient and CG.

Family behaviors and type 2 diabetes: What to target and how to address in interventions for adults with low socioeconomic status

OBJECTIVES

Diabetes-specific family behaviors are associated with self-care and glycemic control among adults with type 2 diabetes. Formative research is needed to inform assessment of these behaviors and interventions to address obstructive family behaviors (sabotaging and nagging/arguing), particularly among racial/ethnic minorities and low-income adults who struggle most with self-care adherence.

METHODS

We conducted a mixed-methods study with adults with type 2 diabetes at a Federally Qualified Health Center to better understand experiences with diabetes-specific family behaviors and willingness to engage family members in diabetes interventions. Participants completed a phone survey (N = 53) and/or attended a focus group (n = 15).

RESULTS

Participants were 70% African American and had low socioeconomic status (96% annual income <US$20K, 51% uninsured). Although 62% lived with family members, only 48% lived with the person providing the most diabetes-specific support. Participants' family living situations were diverse and multigenerational. Most (64%) experienced both supportive and obstructive family behaviors from the same person(s). Some participants (40%) said engaging family in interventions would positively affect all members; others (27%) did not want to involve family.

DISCUSSION

Findings can inform the design and content of interventions targeting family involvement in adults' type 2 diabetes, with implications for assessing family behaviors, intervention modalities, and who to engage.

Social Support for Diabetes Self-Management via eHealth Interventions

eHealth interventions have been increasingly used to provide social support for self-management of type 2 diabetes. In this review, we discuss social support interventions, types of support provided, sources or providers of support, outcomes of the support interventions (clinical, behavioral, psychosocial), and logistical and clinical considerations for support interventions using eHealth technologies. Many types of eHealth interventions demonstrated improvements in self-management behaviors, psychosocial outcomes, and clinical measures, particularly HbA1c. Important factors to consider in clinical application of eHealth support interventions include participant preferences, usability of eHealth technology, and availability of personnel to orient or assist participants. Overall, eHealth is a promising adjunct to clinical care as it addresses the need for ongoing support in chronic disease management.

Hypoglycemia-related information seeking among informal caregivers of type 2 diabetes patients: Implications for health education

•

We examined information seeking and knowledge about hypoglycemia among caregivers.

•

Nearly two thirds of family members and friends actively sought information.

•

Caregivers' knowledge about symptoms and treatments was found to be insufficient.

•

Increased information seeking is associated with higher health literacy levels.

Aims

To examine information seeking and knowledge about hypoglycemia among partners and family of type 2 diabetes patients and to identify associations between information seeking, knowledge and demographic, and disease-related characteristics.

Methods

Caregivers of adults with type 2 diabetes (N = 488) completed surveys assessing information seeking, knowledge of hypoglycemia symptoms and treatment, perceived competence, demographic information, and diabetes-related characteristics. Hierarchical and logistic regressions were used for data analysis.

Results

Nearly two thirds of family members and friends actively sought information about hypoglycemia, while health professionals and print media were reported as the main sources. Many respondents (74.5%) were able to identify at least one correct warning sign. But 32% could not state any correct treatment measures. Health professionals were the main and most helpful source of their knowledge. Education, past experience with hypoglycemia, and comprehension of information were associated with knowledge about treatment. Caregivers' perceived competence about hypoglycemia correlated with medical education, information-seeking, and comprehension of information.

Conclusions

Our results indicate the importance of the hypoglycemia-related information seeking of caregivers in managing incidents of hypoglycemia. These findings suggest the need to consider caregivers' health knowledge when developing health education programs in diabetes care. More attention must be focused on providing interventions that motivate information seeking and improve the comprehension of information. Interventions should inform caregivers about hypoglycemia to enhance their knowledge.

The Impact of Information Technology on Patient Engagement and Health Behavior Change: A Systematic Review of the Literature

Background

Advancements in information technology (IT) and its increasingly ubiquitous nature expand the ability to engage patients in the health care process and motivate health behavior change.

Objective

Our aim was to systematically review the (1) impact of IT platforms used to promote patients’ engagement and to effect change in health behaviors and health outcomes, (2) behavior theories or models applied as bases for developing these interventions and their impact on health outcomes, (3) different ways of measuring health outcomes, (4) usability, feasibility, and acceptability of these technologies among patients, and (5) challenges and research directions for implementing IT platforms to meaningfully impact patient engagement and health outcomes.

Methods

PubMed, Web of Science, PsycINFO, and Google Scholar were searched for studies published from 2000 to December 2014. Two reviewers assessed the quality of the included papers, and potentially relevant studies were retrieved and assessed for eligibility based on predetermined inclusion criteria.

Results

A total of 170 articles met the inclusion criteria and were reviewed in detail. Overall, 88.8% (151/170) of studies showed positive impact on patient behavior and 82.9% (141/170) reported high levels of improvement in patient engagement. Only 47.1% (80/170) referenced specific behavior theories and only 33.5% (57/170) assessed the usability of IT platforms. The majority of studies used indirect ways to measure health outcomes (65.9%, 112/170).

Conclusions

In general, the review has shown that IT platforms can enhance patient engagement and improve health outcomes. Few studies addressed usability of these interventions, and the reason for not using specific behavior theories remains unclear. Further research is needed to clarify these important questions. In addition, an assessment of these types of interventions should be conducted based on a common framework using a large variety of measurements; these measurements should include those related to motivation for health behavior change, long-standing adherence, expenditure, satisfaction, and health outcomes.

The Motivating Function of Healthcare Professional in eHealth and mHealth Interventions for Type 2 Diabetes Patients and the Mediating Role of Patient Engagement

eHealth and mHealth interventions for type 2 diabetes are emerging as useful strategies to accomplish the goal of a high functioning integrated care system. However, mHealth and eHealth interventions in order to be successful need the clear endorsement from the healthcare professionals. This cross-sectional study included a sample of 93 Italian-speaking type 2 diabetes patients and demonstrated the role of the perceived ability of healthcare professionals to motivate patients' initiative in improving the level of their engagement and activation in type 2 diabetes self-management. The level of type 2 diabetes patients' activation resulted also in being a direct precursor of their attitude to the use of mHealth and eHealth. Furthermore, patient engagement has been demonstrated to be a mediator of the relationship between the perceived ability of healthcare professionals in motivating type 2 diabetes patients and patients' activation. Finally, type 2 diabetes patients adherence did not result in being a direct consequence of the frequency of mHealth and eHealth use. Patient adherence appeared to be directly influenced by the level of perceived healthcare professionals ability of motivating patients' autonomy. These results offer important insights into the psychosocial and organizational elements that impact on type 2 diabetes patients' activation in self-management and on their willingness to use mHealth and eHealth devices.

Older Adults' Residential Proximity to Their Children: Changes After Cardiovascular Events

OBJECTIVES

To assess changes in family residential proximity after a first cardiovascular (CV) event among older adults and to identify families most likely to experience such moves.

METHOD

Using a nationally representative longitudinal study of older adults in the United States, we identified respondents with no prior diagnosis of CV disease (CVD). We examined subsequent development of stroke, heart attack, and/or heart failure among these older adults and examined changes in their residential proximity to their closest child before and after the CV event. We then compared the likelihood of changes in proximity between families with and without CV events. Finally, we determined which types of families are most likely to relocate following a CV event.

RESULTS

Having a first CV event increases the 2-year predicted probability of children and adult parents moving in with and closer to each other (relative risk ratio = 1.61 and 1.55, respectively). Families are especially likely to move after a first CV event if the older person experiencing the event is spouseless or has a daughter.

DISCUSSION

CVD is a leading cause of disability, which in turn creates a significant need for personal care among older adults. Assessment of changes in family residential proximity responding to CV events is important to fully understand the consequences of older adults' CV events including the cost of caregiving.

Family interventions to improve diabetes outcomes for adults

Diabetes self-care is a critical aspect of disease management for adults with diabetes. Since family members can play a vital role in a patient's disease management, involving them in self-care interventions may positively influence patients' diabetes outcomes. We systematically reviewed family-based interventions for adults with diabetes published from 1994 to 2014 and assessed their impact on patients' diabetes outcomes and the extent of family involvement. We found 26 studies describing family-based diabetes interventions for adults. Interventions were conducted across a range of patient populations and settings. The degree of family involvement varied across studies. We found evidence for improvement in patients' self-efficacy, perceived social support, diabetes knowledge, and diabetes self-care across the studies. Owing to the heterogeneity of the study designs, types of interventions, reporting of outcomes, and family involvement, it is difficult to determine how family participation in diabetes interventions may affect patients' clinical outcomes. Future studies should clearly describe the role of family in the intervention, assess quality and extent of family participation, and compare patient outcomes with and without family involvement.

Improvements in illness self-management and psychological distress associated with telemonitoring support for adults with diabetes

OBJECTIVE

The objective of this observational open label trial was to characterize changes in diabetes self-management and psychological distress associated with a mobile health (mHealth) interactive voice response (IVR) self-management support program.

METHODS

For 3-6 months, 301 patients with diabetes received weekly IVR calls assessing health status and self-care and providing tailored pre-recorded self-management support messages. Patients could participate together with an informal caregiver who received suggestions on self-management support, and patients' clinicians were notified automatically when patients reported significant problems.

RESULTS

Patients completed 84% of weekly calls, providing 5682 patient-weeks of data. Thirty-nine percent participated with an informal caregiver. Outcome analyses adjusted for study design factors and sociodemographics indicated significant pre-post improvement in medication adherence, physical functioning, depressive symptoms, and diabetes-related distress (all p values <0.001). Analyses of self-management problems indicated that as the intervention proceeded, there were significant improvements in patients' IVR-reported frequency of weekly medication adherence, SMBG performance, checking feet, and frequency of abnormal self-monitored blood glucose readings (all p values <0.001).

CONCLUSIONS

We conclude that the combined program of automated telemonitoring, clinician notification, and informal caregiver involvement was associated with consistent improvements in medication adherence, diabetes self-management behaviors, physical functioning, and psychological distress. A randomized controlled trial is needed to verify these encouraging findings.

Integrating support persons into diabetes telemonitoring to improve self-management and medication adherence

OBJECTIVE

The purpose of this study was to investigate the potential benefits for medication adherence of integrating a patient-selected support person into an automated diabetes telemonitoring and self-management program, and to determine whether these benefits vary by patients' baseline level of psychological distress.

STUDY DESIGN

The study was a quasi-experimental patient preference trial.

METHODS

The study included patients with type 2 diabetes who participated in three to six months of weekly automated telemonitoring via interactive voice response (IVR) calls, with the option of designating a supportive relative or friend to receive automated updates on the patient's health and self-management, along with guidance regarding potential patient assistance. We measured long-term medication adherence using the four-point Morisky Medication Adherence Scale (MMAS-4, possible range 0-4), weekly adherence with an IVR item, and psychological distress at baseline with the Mental Composite Summary (MCS) of the SF-12.

RESULTS

Of 98 initially nonadherent patients, 42% opted to involve a support person. Participants with a support person demonstrated significantly greater improvement in long-term adherence than those who participated alone (linear regression slopes: -1.17 vs. -0.57, respectively, p =0.001). Among distressed patients in particular, the odds of weekly nonadherence tended to decrease 25% per week for those with a support person (p =0.030), yet remained high for those who participated alone (p =0.820).

CONCLUSIONS

Despite their multiple challenges in illness self-management, patients with diabetes who are both nonadherent and psychologically distressed may benefit by the incorporation of a support person when they receive assistance via automated telemonitoring.