a review of mobile terminal-based applications for self-management of patients with diabetes

A Review of Mobile Terminal-Based Applications for Self-Management of Patients with Diabetes

Naoe Tataraa,b, Eirik Årsanda,b, Heidi Nilsena, and Gunnar Hartvigsenb,a

a Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Norway

b Department of Computer Science, University of Tromsø, Norway

eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

Outline

• Introduction• Methods

– Literature search– Inclusion and exclusion criteria

• Results– Data extracted and summarized in 9 categories

• Discussion• Conclusion


Maintain BG level within a safe range

IntroductionHigh preverance of diabetes and the importance of self-management

Regular Blood Glucose (BG) measuremenet

Proper nutrition Physical activity

All images are from Google Image





Leading to additional and complex diseases






Leading to additional and complex diseases

Mobile phones

• Pervasiveness• Portability• Inherent technologies

Promising support device?



Purpose of this study– Identify studies that examined feasibility, acceptability

or effectiveness of mobile terminal-based applications– Review research methods and technologies used– Summarize useful findings by empirical methods

involving prospective users

Literature search

• Data sources– Pubmed, ISI Web of Science, INSPEC, EMBASE, CINAHL, PsycINFO,

Cochrane Library, ACM digital library, IEEExplore, and JMIR

• Search terms– Diabetes AND (mobile OR handheld OR cellular phone OR cell

phone OR PDA)

• June to July 2008• No restriction by year of publication


Inclusion and exclusion criteria

• A mobile terminal-based application is used, examined or developed for supporting diabetes self-management

the health care professionals’ side onlycollection of medical data only

• Qualitative or quantitative results obtained by empirical methods involving subjects or clinical outcome evaluation are concretely described

Reviews without primary dataConcept work or only technological work

• Publications should appear in peer-reviewed journals or reviewed international conference proceedings

Publications written not in English eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

Data extraction categories

• Study design• Targeted population• Terminals used• People involved in the application• Data input by patients and data entry methods• Functions of the applications• Methods used to evaluate feasibility, acceptability or

effectiveness• Methods and results of clinical outcome evaluations• Research findings (positive/negative aspects)

Results of literature search

94 publications

36 publications describing 27 studies

39 publications describing 28 studies

Search results after removal of duplicates: 817 publications

review of titles and abstracts

examination of full texts following inclusion and exclusion criteria

Removal of 3 publications reporting midterm results of clinical evaluation, whose final results were included in newer ones

Addition of 3 publications describing 1 study

Addition of 3 publications relevant to 2 of the studies included


Commercialapplications

: 7Other: 1

Study design

In 25 studies: applications were tested in field settings (inc. 15 studies clinical evaluation were conducted)

In 3 studies: results from usability engineering process were described

Self-developed applications: 20


Targeted population

Other specification of target• Child, adolescent, or young adult patients (8 studies)• Parents of child patients (1 study) • Insulin-treated patients (5 studies)• Newly diagnosed patients (1 study)

Type1 diabetes: 13 Type not specified: 9

Type2 diabetes

: 6


Terminals used

Among the 20 studies where mobile phones are used:• In 5 studies, the participants used their own mobile phones.• In 5/8 studies targeting child or young patients with Type1

diabetes, a mobile phone is used. • In 8 studies, SMS is used for data entry, feedback, or reminder• In 3 studies, WAP is used as an alternative data entry means

besides SMS and a web browser on a PC.

In 10 studies, a PC is used as an additional terminal.

Both mobile phone and PDA: 1

Other: 1Mobile phone: 20 PDA: 8


People involved in the applications

Among the studies where HCPs are involved in applications• In 13 studies: HCPs give manual feedback to the patients• In 3 studies: HCPs can only view the uploaded data by patients• In 2 studies: HCPs are involved at the patients’ regular clinic visits• In 1 study: HCPs participate in usability engineering process

All studies where family of patients are involved are targeting young patients with Type1 diabetes

None: 5Health Care Professionals (HCPs): 20Family of Patients

: 3

Data input methods and data type• Blood glucose data

• Activity data

• Other mannually input datafood intake (15 studies), medication (10 studies), general comments (7 studies), general health (4 studies), other daily measurements (3 studies)

Automatic: 13 Mannual: 14 Not used: 4Both automatic

and mannual: 3

Mannual: 12 Not used: 14Automatic: 2


Functions of the applications

• Data view: in 16 studies– By only using a mobile terminal (6 studies)– By only accessing through a website using a PC (5 studies)– By using more than one terminals (5 studies)

• Automatic feedback: in 8 studies– Alarms are generated according to blood glucose values (4

studies)

• Reminder: in 9 studies• Educational tool: in 6 studies• Communication platform: in 5 studies


Evaluation methods

• Questionnaires (in 24 studies)– The Summary of Diabetes Self-Care Activities (SDSCA) is used in 4

studies– In most of the studies, self-developed questionnaires are used

• Log files (in 18 studies)• Qualitative methods

– Interviews (in 7 studies)– Focus group meetings (in 3 studies)– Feedback through free comments (in 3 studies)– User meeting (in 2 studies)

• Clinical evaluation (in 15 studies)


Clinical evaluations

• The 15 studies vary in design of:– Clinical evaluation (Randomized controlled trial, one group pre-

post intervention study, randomized crossover trial, or a non-randomized parallel group trial)

– Duration of intervention (4 weeks to 12 months)– The number of patients (10 to 203)– Statistical analysis methods– Features of applications

• In 10/15 studies, a significant decrease in HbA1c is shown (inc. 3 studies with certain conditions)


Findings [positive aspects]

• Automatic and wireless data transmission• Ease of use, menu structure, data presentation (fast

analysis, data visualization, no difficulty in reading)• Use of mobile phone > PC

– Participants’ own mobile phone – SMS > WAP– Reminding effect

• Message delivery at a frequency of 1-2 times a day• Better communication and feeling of security• Statistically significant improvement in various aspects of

diabetes self-management

Findings [negative aspects]

• Technical problems– Data transmission failures, difficulties– Hardware (small size of buttons or displays, short battery-life, slow

processors, small memories)– Software (menu structures, data entry methods and little flexibility in

data entry rules)

• Time requried (too time-consuming)• Difficulties in long-term use • Dropping-out users and enthusiastic users


Discussion• Key Assessment points

– Motivation in self-management– Long-term adherence (Dropping-out ratio)– Relationship between patients, HCPs and families– Glycemic control as a result

• Features that applications should consider– Automation, manual operation by patients, and support by HCPs

or patient peers– Time required to use and reflection-in-action– Intuitive and informative user interface


Conclusion• Studies that examined feasibility, acceptability or

effectiveness of mobile terminal-based applications were identified and reviewed.

• Mobile terminal-based applications for self-management of diabetes are generally well accepted by patient users.

• Useful findings in development of such applications were summarized.

• Long-term adherence and enhancing motivation on unmotivated patients are left as future works.


Thank you for your attention!

Questions?

AcknowledgementThis work was supported by the Centre for Research-based Innovation, Tromsø Telemedicine Laboratory (TTL), Norwegian Research Council Grant No.174934


a review of mobile terminal-based applications for self-management of patients with diabetes

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