A randomized wait-list control trial to evaluate the impact of a mobile application to improve self-management of individuals with type 2 diabetes: a study protocol

Novel 3-arm wait-list controlled trial designs together with mixed-effects analysis improve precision of treatment effect estimators

Clinical trialists have long been searching for approaches to increase statistical power without increasing sample size. Conventional wait-list controlled (WLC) trials are limited to two trial arms and two or three repeated measurements per person. These features limit statistical power. Furthermore, their analysis is usually based on analysis of covariance or mixed effects modelling, with a focus on estimating treatment effect at one time-period after initiation of therapy. We propose two 3-arm WLC trial designs together with a mixed-effects analysis framework. The designs require three or four repeated measurements per person. The analytic framework defines up to three treatment effect estimands, representing the effects at one to three time-periods after initiation of therapy. The precision (inverse of variance) of the treatment effect estimators in the new and conventional trial designs are analytically derived and evaluated in simulations. The results are interpreted in the context of a cognitive training trial in older people. The proposed designs and analysis methods increase the precision level of treatment effect estimators as compared to conventional designs and analyses. Given a target level of statistical power, the proposed methods require a smaller number of participants per trial than the conventional methods, without necessarily increasing the number of measurements per trial. Furthermore, the proposed analytic framework sheds light on the treatment effects at different times after initiation of therapy, which is not usually considered in conventional WLC trial analysis. In situations that a WLC trial is appropriate, the 3-arm designs are useful alternatives to existing 2-arm designs.

Healthcare professionals' and patients' assessments of listed mobile health apps in China: a qualitative study

Background

In recent years, mobile health (mHealth) has gradually developed in China, and intelligent medicine has become an important research topic. However, there are still significant problems in mHealth applications (apps). Although healthcare professionals and patients are the main users, few studies have focused on their perceptions of the quality of mHealth apps.

Objective

This study aimed to (1) understand the respective perceptions of healthcare professionals and patients regarding mHealth apps, (2) assess what barriers exist that influence the user experience, and (3) explore how to improve the quality of mHealth apps and the development of the mHealth market in China. The study aims to promote the standardization of mHealth apps and provide effective information for the improvement and development of mHealth apps in the future.

Methods

Semistructured interviews with 9 patients and 14 healthcare professionals were conducted from January 2022 to April 2022 in the Affiliated Hospital of Xuzhou Medical University. The participants used mHealth apps for more than 3 months, including the "Good Mood" and "Peace and Safe Doctors" apps and apps developed by the hospital that were popular in China. Interview transcripts were analysed using thematic analysis.

Results

The following five themes were extracted: different concerns, hidden medical dangers, distance and insecurity, barriers for older people, and having positive perceptions of mHealth apps. Healthcare professionals prioritized simplicity in regard to mHealth apps, whereas patients rated effectiveness as the most crucial factor. The study also revealed several problems with mHealth apps, including insufficient information about physician qualifications, inaccurate medical content, nonstandard treatment processes, and unclear accountability, which led to a sense of distance and insecurity among participants. Older individuals faced additional obstacles when using mHealth apps. Despite these issues, the participants remained optimistic about the future of mHealth app development.

Conclusion

The utilization, advantages, and obstacles of mHealth applications for healthcare professionals and patients were explored through semistructured interviews. Despite the promising prospects for mHealth apps in China, numerous issues still need to be addressed. Enhancing the safety monitoring system and developing user-friendly mHealth apps for older adult patients are essential steps to bridge the gap between healthcare providers and patients.

Understanding Whether and How a Digital Health Intervention Improves Transition Care for Emerging Adults Living With Type 1 Diabetes: Protocol for a Mixed Methods Realist Evaluation

BACKGROUND

Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to an increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from pediatric to adult care with sufficient self-management capability. While digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which groups of individuals.

OBJECTIVE

This study aims to evaluate the design and implementation of a multicomponent SMS text message-based digital health intervention to support emerging adults living with T1D in real-world settings. The objectives are to identify the intervention components and associated mechanisms that support user engagement and T1D health care transition experiences and determine the individual characteristics that influence the implementation process.

METHODS

We used a realist evaluation embedded alongside a randomized controlled trial, which uses a sequential mixed methods design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and realist interviews. In step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships among "individual-level contextual factors, intervention components and features, mechanisms, and outcomes," with special attention paid to user engagement. Among them, intervention components and features depict 10 core characteristics such as transition support information, problem-solving information, and real-time interactivity. The proximal outcomes of interest include user engagement, self-efficacy, and negative emotions, whereas the distal outcomes of interest include transition readiness, self-blood glucose monitoring behaviors, and blood glucose. In step 2, we plan to conduct semistructured realist interviews with the randomized controlled trial's intervention-arm participants to test the hypothesized "context-intervention-mechanism-outcome" configurations. In step 3, we plan to triangulate all sources of data using a coincidence analysis to identify the necessary combinations of factors that determine whether and how the desired outcomes are achieved and use these insights to consolidate the program theory.

RESULTS

For step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for this realist evaluation was anticipated to start in July 2023 and continue until we reached thematic saturation or achieved informational power.

CONCLUSIONS

Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46115.

Effectiveness of cognitive behavioral therapy with yoga in reducing job stress among university lecturers

Introduction

Job stress is highly prevalent in the workforce worldwide, and tends to threaten employees' physical and mental wellbeing, reducing organizational outcomes. The negative impacts of workplace stress on academics have been found to disproportionately interfere with both institutional research productivity and students' learning outcomes. This study analyzed data from a randomized control trial, to validate the effectiveness of cognitive behavioral therapy combined with yoga in treating job-related stress among lecturers from two Universities in South-East, Nigeria.

Methods

Participants included 93 academic staff members from two Federal Universities in Enugu and Ebonyi States in Nigeria. We assigned participants to Y-CBT (N = 46) and waitlist control (N = 47) groups using random sampling techniques. A 2-h Y-CBT program was delivered weekly for a period of 12 weeks. Two instruments were used to collect data for the study. Single Item Stress Questionnaire (SISQ) was employed to identify the potential participants, while the teachers' Stress Inventory (TSI) was served for data collection at baseline, post-intervention, and follow-up tests. Mean, standard deviations, t-test, statistics, and repeated measures Analysis of Variance, were used to analyze data for the study.

Results

Results revealed that the perception of stressors and stress symptoms reduced significantly at post-test and follow-up assessments following Y-CBT intervention.

Discussion and conclusion

The outcomes of this study support the prior that Y-CBT is valuable for harmonizing mind and body for a stable psychological state. The conclusion was that Y-CBT can minimize the perception of stressors and stress manifestation among university lecturers.

A blended rational emotive occupational health coaching for job-stress among teachers of children with special education needs

BACKGROUND/OBJECTIVES

Heightened stress tends to undermine both teachers' efficacy and students' outcomes. Managing job stress in teachers of children with special education needs is continually recommended due to the increased demands for the teachers to adapt curriculum content, learning materials and learning environments for learning. This study investigated the efficacy of blended Rational Emotive Occupational Health Coaching in reducing occupational stress among teachers of children with special needs in Abia State, Nigeria.

METHOD

The current study adopted a group-randomized waitlist control trial design with pretest, post-test and follow-up assessments. Participants (N = 83) included teachers of children with special education needs in inclusive and specialized schools. The bREOHC group was exposed to intersession face-to-face and online REOC program weekly for twelve (12) weeks. Data were collected using Single Item Stress Questionnaire (SISQ), Teachers' Stress Inventory and Participants' Satisfaction questionnaire (PSQ). Data collected at baseline; post-test as well as follow-up 1 and 2 evaluations were analyzed using mean, standard deviation, t-test statistics, repeated measures ANOVA and bar charts.

RESULTS

Results revealed that the mean perceived stress, stress symptoms and the total teachers' stress score of the bREOHC group at post-test and follow up assessments reduced significantly, compared to the waitlisted group. Participants also reported high level of satisfaction with the therapy and procedures.

CONCLUSION

From the findings of this study, we conclude that blended REOHC is efficacious in occupational stress management among teachers of children with special education needs.

Stress in teachers of children with neuro-developmental disorders: Effect of blended rational emotive behavioral therapy

BACKGROUND/OBJECTIVES

Neuro-developmental disorders impose a wide range of learning barriers on learners, increasing stress among their teachers. Evidence attests to the heightened stress among teachers teaching children with such conditions. This study tested the efficacy of blended Rational Emotive Behavior Therapy in reducing job stress among teachers of children with neuro-developmental disorders in Abia State, Nigeria.

METHOD

The current study adopted a group-randomized waitlist control trial design with pretest, post-test, and follow-up assessments. Participants (N = 83) included teachers of children with neuro-developmental disorders in inclusive and specialized schools. The blended Rational Emotive Behavior Therapy group participated in a 2 h intersession face-to-face and online Rational Emotive Behavior Therapy (REBT) program weekly for 12 weeks. Data were collected using the Single Item Stress Questionnaire, Teachers' Stress Inventory, and Participants' Satisfaction questionnaire. The waitlisted group also received a blended Rational Emotive Behavior Therapy intervention after all data collection. Data collected at baseline; post-test as well as follow-up 1 and 2 evaluations were analyzed using mean, standard deviation, t-test statistics, repeated measures analysis of variance, and charts.

RESULTS

Results revealed that the mean perceived stress, stress symptoms, and the total teachers' stress score of the blended Rational Emotive Behavior Therapy group at post-test and follow-up assessments reduced significantly, compared to the waitlisted group. Participants also reported a high level of satisfaction with the therapy and procedures.

CONCLUSION

From the findings of this study, we conclude that blended Rational Emotive Behaviour Therapy is efficacious in occupational stress management among teachers of children with neuro-developmental disorders.

Closing the Virtual Gap in Health Care: A Series of Case Studies Illustrating the Impact of Embedding Evaluation Alongside System Initiatives

Early decisions relating to the implementation of virtual care relied on necessity and clinical judgement, but there is a growing need for the generation of evidence to inform policy and practice designs. The need for stronger partnerships between researchers and decision-makers is well recognized, but how these partnerships can be structured and how research can be embedded alongside existing virtual care initiatives remain unclear. We present a series of case studies that illustrate how embedded research can inform policy decisions related to the implementation of virtual care, where decisions are either to (1) discontinue (red light), (2) redesign (yellow light), or (3) scale up existing initiatives (green light). Data were collected through document review and informal interviews with key study personnel. Case 1 involved an evaluation of a mobile diabetes platform that demonstrated a mismatch between the setting and the technology (decision outcome: discontinue). Case 2 involved an evaluation of a mental health support platform that suggested evidence-based modifications to the delivery model (decision outcome: redesign). Case 3 involved an evaluation of video visits that generated evidence to inform the ideal model of implementation at scale (decision outcome: scale up). In this paper, we highlight the characteristics of the partnership and the process that enabled success and use the cases to illustrate how these characteristics were operationalized. Structured communication included monthly check-ins and iterative report development. We also outline key characteristics of the partnership (ie, trust and shared purpose) and the process (ie, timeliness, tailored reporting, and adaptability) that drove the uptake of evidence in decision-making. Across each case, the evaluation was designed to address policy questions articulated by our partners. Furthermore, structured communication provided opportunities for knowledge mobilization. Structured communication was operationalized through monthly meetings as well as the delivery of interim and final reports. These case studies demonstrate the importance of partnering with health system decision-makers to generate and mobilize scientific evidence. Embedded research partnerships founded on a shared purpose of system service provided an effective strategy to bridge the oft-cited gap between science and policy. Structured communication provided a mechanism for collaborative problem-solving and real-time feedback, and it helped contextualize emerging insights.

Yoga complemented cognitive behavioral therapy on job burnout among teachers of children with autism spectrum disorders

BACKGROUND/OBJECTIVE

Job burnout is a syndrome of reaction to chronic job-related stress which affects overall health, limits occupational efficacy, and personal accomplishments of employees thereby thwarting organizational outcomes. Burnout symptoms are common among teachers of children with autism spectrum disorders (ASD) and affect the academic progress of the children. This study investigated the effectiveness of Yoga-based cognitive behavioral therapy (Y-CBT) in reducing occupational burnout among teachers of children with autism in Lagos States, Nigeria.

METHODS

A group-randomized control-trial with immediate intervention and waitlist control groups was design was adopted. Participants included 58 teachers of children with autism in public and private special schools in the area. Participants were randomly assigned to Y-CBT (N = 29) and waitlist control (N = 29) groups. The Y-CBT group participated in a 2 hours Y-CBT program weekly for 12 weeks. Three instruments Demographic variable, Single Item Stress Questionnaire (SISQ), and Maslach Burnout Inventory-Educators' Survey (MBI-ES) were used to collect data. Data were collected at baseline; post-test and follow-up evaluations. Data were analyzed using means, standard deviations, t test statistics, repeated measures analysis of variance, and bar charts.

RESULTS

Results revealed that job-burnout reduced significantly at post-test assessment among the Y-CBT group compared to the waitlisted group. The reduction in the participant was sustained across 3months follow-up evaluation.

CONCLUSION

It was concluded that Y-CBT modalities could help to reduce the burnout symptoms among teachers of children with ASD.

Health Information Technology and Diabetes Management: A Review of Motivational and Inhibitory Factors

BACKGROUND

Health information technology helps patients to take better care of themselves and improves health status of patients with chronic diseases, such as diabetes.

OBJECTIVE

This study aimed to identify factors influencing the use of health information technology in diabetes management.

METHODS

This was a review study conducted in 2019. To obtain the related articles, databases, including Scopus, Web of Science, Proquest, and PubMed, were searched and the time frame was between 2010 and 2018. Initially, 1159 articles were retrieved and after screening, 28 articles were selected to be included in the study.

RESULTS

Factors influencing the use of health information technology in diabetes management could be divided into the motivational and inhibitory factors, and each of them could be categorized into five groups of organizational, technical, economic, individual, and ethical/legal factors. The motivational factors included training, system ease of use, economic support, having computer literacy, and maintaining privacy and confidentiality. The inhibitory factors included a lack of long-term planning, technical problems, inadequate financial resources, old age, and concerns over confidentiality issues.

CONCLUSION

Identifying motivational and inhibitory factors can help to make better use of technology for diabetes management. This approach, in turn, can improve the acceptability of the technology and save cost, reduce long-term complications of diabetes, and improve the quality of life in diabetic patients.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

Managing job stress in teachers of children with autism: A rational emotive occupational health coaching control trial

BACKGROUND/OBJECTIVE

Teaching has been found to be 1 of the most stressful occupations worldwide. Stress associated with teaching is more critical among teachers teaching children with special needs in general and those with autism specifically, partly due to the heterogeneous nature of the disorders. The purpose of this study was to investigate the effectiveness of Rational Emotive Occupational Health Coaching (REOHC) in minimizing job stress in teachers of children with autism (CWA).

METHODS

A group-randomized waitlist control-trial design was adopted. A sample of 87 teachers of CWA who participated in the study was randomized into the immediate intervention group (IIG) and waitlist group (WLG). Participants were evaluated on 3 occasions: pretest, post-test and follow-up. Three instruments (Occupational Stress Index, Perceived Occupational Stress Scale and Stress Symptom Scale) were used to measure dimensions of job stress. After the pretest exercise, the IIG participated in a 2-hour REOHC programme weekly for a period of 12 weeks. Post- and follow-up evaluations were conducted respectively at 2 weeks and 3 months after the REOHC programme. Those in WLG were exposed to the REOHC after the follow-up assessment. Data collected were analysed using t-test statistics, repeated measures analysis of variance and bar charts.

RESULTS

Results revealed that the perceived stress and stress symptoms of the REOHC group reduced significantly over WLG at post-test, and follow-up assessments. Changes in the occupational stress index scores across pre-, post- and follow-up measurements were minimal and could not account for a significant difference between the IIG and WLG.

CONCLUSION

It was concluded that REOHC is effective in reducing subjective feelings and physiological symptoms of job stress, even when the objective stressors remain constant among teachers of CWA and other employees who work in stressful occupational environments.

Computerized clinical decision system and mobile application with expert support to optimize management of vertigo in primary care: study protocol for a pragmatic cluster-randomized controlled trial

Vertigo and dizziness are amongst the most common symptoms in medicine and often have a major impact on activities of daily life. Although many causes of vertigo and dizziness can easily be recognized, patients often receive inappropriate and ineffective treatment. The reasons for this are various. Because vertigo/dizziness is an interdisciplinary symptom and there is a lack of standardised diagnostic tools, it is easy to lose the overview of the possible differential diagnoses. There is evidence though, that the management of patients with vertigo/dizziness can be optimized using standardized care pathways with digital support. The present study (within the framework of “PoiSe—prevention, online feedback, and interdisciplinary therapy of acute vestibular syndromes by e-health”) aims to evaluate the implementation of a program with several interlocking components. The three main components are a computerized clinical decision system, a mobile application, a counselling and interdisciplinary educational program developed by the German Center for Vertigo and Balance Disorders (DSGZ). The study is a cluster-randomized controlled trial with a parallel-group design, as well as a detailed process evaluation. Clusters comprise of primary care physician practices in Bavaria, Germany. In the scope of the study the effectiveness, acceptability and efficiency of the intervention will be evaluated. It is anticipated that the intervention will improve the quality and efficiency of the management of dizzy patients. A higher diagnostic accuracy, optimized treatment, and disease progression monitoring is expected to improve patient-relevant outcomes and reduce health-care costs.

Variability in patient sociodemographics, clinical characteristics, and healthcare service utilization among 107,302 treatment seeking smokers in Ontario: A cross-sectional comparison

Background

Since 2005, the Smoking Treatment for Ontario Patients (STOP) program has provided smoking cessation treatment of varying form and intensity to smokers through 11 distinct treatment models, either in-person at partnering healthcare organizations or remotely via web or telephone. We aimed to characterize the patient populations reached by different treatment models.

Methods

We linked self-report data to health administrative databases to describe sociodemographics, physical and mental health comorbidity, healthcare utilization and costs. Our sample consisted of 107,302 patients who enrolled between 18Oct2005 and 31Mar2016, across 11 models operational during different time periods.

Results

Patient populations varied on sociodemographics, comorbidity burden, and healthcare usage. Enrollees in the Web-based model were youngest (median age: 39; IQR: 29–49), and enrollees in primary care-based Family Health Teams were oldest (median: 51; IQR: 40–60). Chronic Obstructive Pulmonary Disease and hypertension were the most common physical health comorbidities, twice as prevalent in Family Health Teams (32.3% and 30.8%) than in the direct-to-smoker (Web and Telephone) and Pharmacy models (13.5%-16.7% and 14.7%-17.7%). Depression, the most prevalent mental health diagnosis, was twice as prevalent in the Addiction Agency (52.1%) versus the Telephone model (25.3%). Median healthcare costs in the two years up to enrollment ranged from $1,787 in the Telephone model to $9,393 in the Addiction Agency model.

Discussion

While practitioner-mediated models in specialized and primary care settings reached smokers with more complex healthcare needs, alternative settings appear better suited to reach younger smokers before such comorbidities develop. Although Web and Telephone models were expected to have fewer barriers to access, they reached a lower proportion of patients in rural areas and of lower socioeconomic status. Findings suggest that in addition to population-based strategies, embedding smoking cessation treatment into existing healthcare settings that reach patient populations with varying disparities may enhance equitable access to treatment.

The role of text messaging intervention in Inner Mongolia among patients with type 2 diabetes mellitus: a randomized controlled trial

Background

Short messages service (SMS) provides a practical medium for delivering content to address patients to adherence to self-management. The aim of study was to design some patient-centered health education messages, evaluate the feasibility of messages, and explore the effect of this model.

Methods

The messages were designed by a panel of experts, and SMS Quality Evaluation Questionnaire was used to evaluate their quality. A two-arm randomized controlled trial was conducted to evaluate the effectiveness of this management model. Participants were randomly divided into an intervention group (IG) who received evaluated messages and a control group (CG) who received regular education. The primary outcomes were changes in plasma glucose and control rates, and the secondary outcomes were improvements in diet control, physical activities, weight control, etc.

Results

A total of 42 messages covering five main domains: health awareness, diet control, physical activities, living habits and weight control were designed, and the average scores of the messages were 8.0 (SD 0.7), 8.5 (SD 0.6), 7.9 (SD 1.0), 8.0 (SD 0.7), and 8.4 (SD 0.9), respectively. In the SMS intervention, 171 patients with an average age of 55.1 years were involved, including 86 in the CG and 85 in the IG. At 12 months, compared with the control group (CG), the decrease of fasting plasma glucose (FPG) (1.5 vs. 0.4, P = 0.011) and control rate (49.4% vs. 33.3%, P = 0.034), the postprandial glucose (PPG) (5.8 vs. 4.2, P = 0.009) and control rate (57.8% vs. 33.7%, P = 0.002) were better in the intervention group (IG). In terms of self-management, improvements in weight control (49.3% vs. 28.2%, P = 0.031), vegetables consumption (87.3% vs. 29.0%, P < 0.001), fruits consumption (27.5% vs. 7.4%, P = 0.022), and physical activities (84.7% vs. 70.0%, P = 0.036) were better in the IG than in the CG.

Conclusions

The overall quality of the messages was high. It was effective and feasible to carry out an SMS intervention to improve the behavioral habits of patients with chronic diseases in remote and undeveloped areas.

Trial registration

Clinicaltrials.gov, ChiCTR1900023445. Registered May 28, 2019--Retrospectively registered.

A Library of Analytic Indicators to Evaluate Effective Engagement with Consumer mHealth Apps for Chronic Conditions: Scoping Review

Background

There is mixed evidence to support current ambitions for mobile health (mHealth) apps to improve chronic health and well-being. One proposed explanation for this variable effect is that users do not engage with apps as intended. The application of analytics, defined as the use of data to generate new insights, is an emerging approach to study and interpret engagement with mHealth interventions.

Objective

This study aimed to consolidate how analytic indicators of engagement have previously been applied across clinical and technological contexts, to inform how they might be optimally applied in future evaluations.

Methods

We conducted a scoping review to catalog the range of analytic indicators being used in evaluations of consumer mHealth apps for chronic conditions. We categorized studies according to app structure and application of engagement data and calculated descriptive data for each category. Chi-square and Fisher exact tests of independence were applied to calculate differences between coded variables.

Results

A total of 41 studies met our inclusion criteria. The average mHealth evaluation included for review was a two-group pretest-posttest randomized controlled trial of a hybrid-structured app for mental health self-management, had 103 participants, lasted 5 months, did not provide access to health care provider services, measured 3 analytic indicators of engagement, segmented users based on engagement data, applied engagement data for descriptive analyses, and did not report on attrition. Across the reviewed studies, engagement was measured using the following 7 analytic indicators: the number of measures recorded (76%, 31/41), the frequency of interactions logged (73%, 30/41), the number of features accessed (49%, 20/41), the number of log-ins or sessions logged (46%, 19/41), the number of modules or lessons started or completed (29%, 12/41), time spent engaging with the app (27%, 11/41), and the number or content of pages accessed (17%, 7/41). Engagement with unstructured apps was mostly measured by the number of features accessed (8/10, P=.04), and engagement with hybrid apps was mostly measured by the number of measures recorded (21/24, P=.03). A total of 24 studies presented, described, or summarized the data generated from applying analytic indicators to measure engagement. The remaining 17 studies used or planned to use these data to infer a relationship between engagement patterns and intended outcomes.

Conclusions

Although researchers measured on average 3 indicators in a single study, the majority reported findings descriptively and did not further investigate how engagement with an app contributed to its impact on health and well-being. Researchers are gaining nuanced insights into engagement but are not yet characterizing effective engagement for improved outcomes. Raising the standard of mHealth app efficacy through measuring analytic indicators of engagement may enable greater confidence in the causal impact of apps on improved chronic health and well-being.

Mobile App for Improved Self-Management of Type 2 Diabetes: Multicenter Pragmatic Randomized Controlled Trial

Background

As the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A_1c (HbA_1c) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear.

Objective

The primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA_1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA_1c levels compared with controls.

Methods

The study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA_1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app.

Results

The results of an analysis of covariance controlling for baseline HbA_1c levels did not show evidence of intervention impact on HbA_1c levels at 3 months (mean difference [ITG−WLC] −0.42, 95% CI −1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA_1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants’ 3-month HbA_1c levels (95% CI −0.03 to −0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51).

Conclusions

The results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA_1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed.

Trial Registration

Clinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343)

Prototypes of User Interfaces for Mobile Applications for Patients with Diabetes

We live in a heavily technologized global society. It is therefore not surprising that efforts are being made to integrate current information technology into the treatment of diabetes mellitus. This paper is dedicated to improving the treatment of this disease through the use of well-designed mobile applications. Our analysis of relevant literature sources and existing solutions has revealed that the current state of mobile applications for diabetics is unsatisfactory. These limitations relate both to the content and the Graphical User Interface (GUI) of existing applications. Following the analysis of relevant studies, there are four key elements that a diabetes mobile application should contain. These elements are: (1) blood glucose levels monitoring; (2) effective treatment; (3) proper eating habits; and (4) physical activity. As the next step in this study, three prototypes of new mobile applications were designed. Each of the prototypes represents one group of applications according to a set of given rules. The most optimal solution based on the users’ preferences was determined by using a questionnaire survey conducted with a sample of 30 respondents participating in a questionnaire after providing their informed consent. The age of participants was from 15 until 30 years old, where gender was split to 13 males and 17 females. As a result of this study, the specifications of the proposed application were identified, which aims to respond to the findings discovered in the analytical part of the study, and to eliminate the limitations of the current solutions. All of the respondents expressed preference for an application that includes not only the key functions, but a number of additional functions, namely synchronization with one of the external devices for measuring blood glucose levels, while five-sixths of them found suggested additional functions as being sufficient.

A Mobile App to Improve Self-Management of Individuals With Type 2 Diabetes: Qualitative Realist Evaluation

BACKGROUND

The increasing use of Web-based solutions for health prevention and promotion presents opportunities to improve self-management and adherence to guideline-based therapy for individuals with type 2 diabetes (T2DM). Despite promising preliminary evidence, many users stop using Web-based solutions due to the burden of data entry, hidden costs, loss of interest, and a lack of comprehensive features. Evaluations tend to focus on effectiveness or impact and fail to evaluate the nuanced variables that may interact to contribute to outcome success (or failure).

OBJECTIVE

This study aimed to evaluate a Web-based solution for improving self-management in T2DM to identify key combinations of contextual variables and mechanisms of action that explain for whom the solution worked best and in what circumstances.

METHODS

A qualitative realist evaluation was conducted with one-on-one, semistructured telephonic interviews completed at baseline, and again toward the end of the intervention period (3 months). Topics included participants' experiences of using the Web-based solution, barriers and facilitators of self-management, and barriers and facilitators to effective use. Transcripts were analyzed using thematic analysis strategies, after which the key themes were used to develop statements of the relationships between the key contextual factors, mechanisms of action, and impact on the primary outcome (glycated hemoglobin, HbA_1c).

RESULTS

Twenty-six interviews (14 baseline, 12 follow-up) were completed with 16 participants with T2DM, and the following 3 key groups emerged: the easiest fit, the best fit, and those who failed to activate. Self-efficacy and willingness to engage with the solution facilitated improvement in HbA_1c, whereas competing priorities and psychosocial issues created barriers to engagement. Individuals with high baseline self-efficacy who were motivated, took ownership for their actions, and prioritized diabetes management were early and eager adopters of the app and recorded improvements in HbA_1c over the intervention period. Individuals with moderate baseline self-efficacy and no competing priorities, who identified gaps in understanding of how their actions influence their health, were slow to adopt use but recorded the greatest improvements in HbA_1c. The final group had low baseline self-efficacy and identified a range of psychosocial issues and competing priorities. These participants were uncertain of the benefits of using a Web-based solution to support self-management, ultimately resulting in minimal engagement and no improvement in HbA_1c.

CONCLUSIONS

Self-efficacy, competing priorities, previous behavior change, and beliefs about Web-based solutions interact to determine engagement and impact on the clinical outcomes. Considering the balance of these patient characteristics is likely to help health care providers identify individuals who are apt to benefit from a Web-based solution to support self-management of T2DM. Web-based solutions could be modified to incorporate the existing screening measures to identify individuals who are at risk of suboptimal adherence to inform the provision of additional support(s) as needed.

Examining Tensions That Affect the Evaluation of Technology in Health Care: Considerations for System Decision Makers From the Perspective of Industry and Evaluators

Virtual technologies have the potential to mitigate a range of challenges for health care systems. Despite the widespread use of mobile devices in everyday life, they currently have a limited role in health service delivery and clinical care. Efforts to integrate the fast-paced consumer technology market with health care delivery exposes tensions among patients, providers, vendors, evaluators, and system decision makers. This paper explores the key tensions between the high bar for evidence prior to market approval that guides health care regulatory decisions and the “fail fast” reality of the technology industry. We examine three core tensions: balancing user needs versus system needs, rigor versus responsiveness, and the role of pre- versus postmarket evidence generation. We use these to elaborate on the structure and appropriateness of evaluation mechanisms for virtual care solutions. Virtual technologies provide a foundation for personalized, patient-centered medicine on the user side, coupled with a broader understanding of impact on the system side. However, mechanisms for stakeholder discussion are needed to clarify the nature of the health technology marketplace and the drivers of evaluation priorities.

A mobile and web-based clinical decision support and monitoring system for diabetes mellitus patients in primary care: a study protocol for a randomized controlled trial

BACKGROUND

Physicians' guideline use rates for diagnosis, treatment and monitoring of diabetes mellitus (DM) is very low. Time constraints, patient overpopulation, and complex guidelines require alternative solutions for real time patient monitoring. Rapidly evolving e-health technology combined with clinical decision support and monitoring systems (CDSMS) provides an effective solution to these problems. The purpose of the study is to develop a user-friendly, comprehensive, fully integrated web and mobile-based Clinical Decision Support and Monitoring System (CDSMS) for the screening, diagnosis, treatment, and monitoring of DM diseases which is used by physicians and patients in primary care and to determine the effectiveness of the system.

METHODS

The CDSMS will be based on evidence-based guidelines for DM disease. A web and mobile-based application will be developed in which the physician will remotely monitor patient data through mobile applications in real time. The developed CDSMS will be tested in two stages. In the first stage, the usability, understandability, and adequacy of the application will be determined. Five primary care physicians will use the developed application for at least 16 DM patients. Necessary improvements will be made according to physician feedback. In the second phase, a parallel, single-blind, randomized controlled trial will be implemented. DM diagnosed patients will be recruited for the CDSMS trial by their primary care physicians. Ten physicians and their 439 patients will be involved in the study. Eligible participants will be assigned to intervention and control groups with simple randomization. The significance level will be accepted as p < 0.05. In the intervention group, the system will make recommendations on patient monitoring, diagnosis, and treatment. These recommendations will be implemented at the physician's discretion. Patients in the control group will be treated by physicians according to current DM treatment standards. Patients in both groups will be monitored for 6 months. Patient data will be compared between 0th and 6th month of the study. . Clinical and laboratory outcomes will be assessed in person while others will be self-assessed online.

DISCUSSION

The developed system will be the first of its kind to utilize evidence based guidelines to provide health services to DM patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02917226 . 28 September 2016.